Predisposing Factors: Precipitating Factors:

>Female, Fertile, >High fat, high cholesterol diet

Overweight (BMI= 28.2), >appendectomy 4 years ago
Age of 40 and above (45 (Kim et al., 2020) (Chung et al.,
years old) 2016)
LEGEND References:
Chung, S. D., Huang, C. C., Lin, H. C., Tsai, M. C., & Chen, C. H. (2016).
Predisposing Medical Nursing Increased Risk of Clinically Significant Gallstones following an
Factor Diagnosis Diagnosis Appendectomy: A Five-Year Follow-Up Study.PloS one,11(10), e0165829.
https://doi.org/10.1371/journal.pone.0165829
Supersaturation
of Bile
Precipitating Doenges, M.E., Moorhouse, M.F., & Geissler-Murr, A. C. (2012) Nurse's
Clinical Pathophysiology Pocket Guide: Diagnoses, Interventions, and Rationales. 9th Edition.
Factor Manifestations F.A. Davis Company. Philiadelphia

Increased Jones, M.W., Gnanapandithan, K., Panneerselvam, D., et al. (2021).

Presence of Impaired gallbladder Chronic Cholecystitis. In: StatPearls [Internet]. Treasure Island (FL):
cholesterol relative to Diagnostics/ Nursing
gallbladder proteins (Mucin contractility (gallbladder Medications StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK470236/
Metoclopramide 4 mg SIVP q8° PRN bile acid solubizing Medical Intervention Intervention
Indication: To prevent postoperative nausea and vomiting and Immunoglobulins) hypomotility)
agent
Mechanism of Axn: Metoclopramide blocks dopaminergic receptors in the Kim, S. Y., Lim, H., Park, B., Lim, H., Kim, M., Kong, I. G., & Choi, H. G.
chemoreceptor trigger zone that helps reduce feelings of sickness (2020). Increased risk of gallstones after appendectomy: A longitudinal
(nausea) and helps stop vomiting. follow-up study using a national sample cohort.Medicine,99(20), e20269.
Side Effect: Frequent: Drowsiness, restlessness, fatigue, lethargy. https://doi.org/10.1097/MD.0000000000020269
Decreased mixing of
Occasional: Dizziness, anxiety, headache, insomnia, breast tenderness, Increased nucleation gallbladder contents,
Cholelithiasis
altered menstruation, constipation, rash, dry mouth, galactorrhea, points, physically facilitating Increased residence time for
(presence of gallstones
gynecomastia. Rare: Hypotension, hypertension, tachycardia. gallstone crystallization stone growth within the
in the gallbladder)
Nursing Responsibilities: Assess for nausea, vomiting, abdominal gallbladder
Ketomed (Ketorolac) 30 mg IV q 6 hours x 4 doses RTC; 1st dose given at 7 AM distention, bowel sounds. Assess skin for rash. Monitor renal function, B/P,
Indication: short-term management of moderate to severe acute post-op pain heart rate. Raise side rails of bed, assist client when ambulating and when
Mechanism of Action: Ketorolac inhibits key pathways in prostaglandin synthesis going to bathroom. Instruct to avoid tasks that require alertness, motor
which is crucial to it's mechanism of action. Although ketorolac is non-selective and skills until response to drug is established. Evaluate for therapeutic
inhibits both COX-1 and COX-2 enzymes, it's clinical efficacy is derived from it's response from gastroparesis (nausea, vomiting, bloating).
COX-2 inhibition. The COX-2 enzyme is inducible and is responsible for converting Abdominal
arachidonic acid to prostaglandins that mediate inflammation and pain. By blocking Ultrasound: multiple
this pathway, ketorolac achieves analgesia and reduces inflammation. gallstones
Side Effect: Gastrointestinal discomfort, nausea, diarrhea. Headache, vertigo,
dizziness, nervousness, tinnitus, depression, drowsiness, insomnia. Fever,
Post-operative nausea Gallstone blocks cystic Gallstones causing
angioedema, bronchospasm, rashes, nephrotoxicity
and vomiting duct, backing up bile into the physical trauma to gallbladder
Nursing Responsibilities: Monitor BP upon administration. <90 /80never
administer. Refer to doctor; Assess first the patient before administering this drug: gallbladder wall
know the history (e.g. allergies, renal impairment, etc.) and physical condition of the
patient (reflexes, ophthalmologic and audiometric evaluation, orientation, clotting
times, serum electrolytes, etc.); Assess pain (note type, location, and intensity) prior Acute pain related to s/p
to and 1-2 hr following administration. open cholecystectomy

Mechanical and chemical Irritates visceral

irritation of the gallbladder's peritoneum, stimulates
Aeknil (Paracetamol) 600 mg IV q 6 hours PRN for pain not relieved by Ketomed IV
or celecoxib tablet epithelial mucosa (gall foregut autonomic nerves
Indication: help to relieve mild to moderate pain bladder wall) (T5-T8)
Mechanism of Action: It produces analgesia by elevation of the pain threshold and GOAL:
antipyresis through action on the hypothalamic heat regulating centers. Paracetamol -Patient describes satisfactory pain control at a level of less
may act predominantly by inhibiting prostaglandin synthesis in the central nervous than 3 to 4 on a rating scale of 0 to 10; Patient displays
system and to a lesser extent through a peripheral action by blocking pain impulse improved well-being such as baseline levels of BP, pulse,
generation. The peripheral action may also be due to inhibition of prostaglandin respirations, and relaxed muscle tone or body posture; Patient Increased gallbladder -RUQ abdominal pain
synthesis or inhibition of the synthesis or actions of other substances that sensitize demonstrates the use of diversional and relaxation activities; lumen pressure spreading to her right
pain receptors to mechanical or chemical stimulation. DX: shoulder
Side Effect: Minimal GI upset, drowsiness, nausea, vomiting, shortness of breath,
-Evaluate pain regularly (noting characteristics, location, and
weakness
Nursing Responsibility: Assess for pain response; Monitor vital signs especially intensity (0?10 scale).
blood pressure -Assess vital signs, noting tachycardia, hypertension, and
increased respiration. Decreased blood flow to
-Evaluate the patient?s response to pain and management the gallbladder
strategies.
TX: Post-operative pain
Nubain 10 mg SIVP q 4 hours PRN for persistent pain still not relieved by both -Administer medications as prescribed.
Ketomed IV and Aeknil IV -02 inhalation at 2-3 LPM/NC while in PACU as ordered
Indication: For the relief of moderate to severe pain. -Provide a therapeutic environment with proper temperature Open Chronic Calculus
Mechanism of Action: Binds with and stimulates mu and kappa opiate receptors in and humidity. Warm blankets should be provided when the Cholecystectomy Cholecystitis
the spinal cord and higher levels in the CNS. In this way, nalbuphine alters the patient is cold.
perception of and emotional response to pain. S/P Open
EDX:
Side Effects: Frequent: Sedation. Occasional: Diaphoresis, cold/clammy skin, Cholecystectomy
nausea, vomiting, dizziness, vertigo, dry mouth, headache. Rare: Restlessness, -Once fully awake, teach patient about non -pharmacological
pain management: relaxation techniques such as deep under SAB (09/20/2021
emotional lability, paresthesia, flushing, paradoxical reaction. Inflammation
CBC: Leukocytosis - WBC
Nursing Responsibility: breathing exercises, guided imagery, and provisions of 8:15 AM)
self-perpetuates was elevated (13,700
Obtain vital signs before giving medication. If respirations are shallow or rate is below distraction such as TV or radio cell/L).
12 breaths/minute withhold dose and notify prescriber. Monitor circulatory and
respiratory status, bladder and bowel function. Assess onset, type, location, duration
of pain, Reassess patient?s level of pain at least 15 and 30minutes after
administration.
GOAL:
Patient would not display signs of infection as evidenced by
serousangenous wound drainage, pinkish granulation, reduced
swelling days after the surgery.
After RTC IV doses of Ketomed, start celecoxib 200 mg/tab BID
DX:
IIndication: used to treat symptoms of acute pain or inflammation Ischemia,
-Inspect the wound for swelling, unusual drainage, odor Bacterial invasion leads
Mechanism of Action: Selectively inhibits the enzymatic activity of gallbladder necrosis,
redness, or separation of the suture lines to transmural inflammation of
cyclooxygenase-2 (COX-2), the enzyme needed to convert arachidonic acid to loss of gallbladder
-Monitor and report any signs and symptoms of infection such as gall bladder
prostaglandin. Prostaglandins are responsible for mediating the inflammatory structural integrity
redness, swelling, elevated temperature, and WBC count. Risk for infection related
response and causing local vasodilation, swelling, and pain. Prostaglandins also -Assess mental status, orientation, and level of consciousness Possible post-operative
play a role in peripheral pain transmission to the spinal cord. By inhibiting COX-2 to surgical incision infection
(LOC) as frequently as needed.
activity and prostaglandin production, this NSAID reduces inflammatory symptoms TX:
and relieves pain. -Stress proper hand washing technique Trrigers cytokine Increased
Side effect: Frequent : Diarrhea, dyspepsia, headache, upper respiratory tract infection. -Maintain strict asepsis for dressing changes, wound care release intra-gallbladder
Occasional: Abdominal pain, flatulence, nausea, back pain, peripheral edema, dizziness, -Administer antibiotics on time as ordered pressure
insomnia and rash
EDX:
Nursing Responsibility: Assess onset, type, location, duration of pain/inflammation.
-Demonstrate and allow return demonstration of all high-risk
Assess for allergy to sulfa, aspirin, or NSAIDs (contraindicated). Monitor liver function test
procedures that the patient and significant others will do after
results. Monitor BUN and serum creatinine levels in elderly patients; patients taking Irritation of parietal
discharge, such as dressing changes.
diuretics, ACE inhibitors, or angiotensin II receptor antagonists; and patients with heart Fever (37.8 C), peritoneum
failure, impaired renal function, or hepatic dysfunction. Assess patient?s skin regularly for -Teach the patient and family the signs and symptoms of Multiple episodes of
Tachycardia (PR: 104
signs of rash or other hypersensitivity reaction. Avoid using celecoxib with a non-aspirin infections and when to report them to the health care provider. nausea and vomiting
bpm)
NSAID, regardless of the dose. Instruct patient to swallow celecoxib capsules whole with -Instruct the patient not to touch the wound.
a full glass of water and with food or milk to prevent stomach upset. Advise patient to
notify prescriber if pain continues or is poorly controlled. Urge patient to avoid smoking Stimulates somatic
and alcohol consumption during celecoxib therapy because they may increase the risk of nerves
adverse GI reactions.
Ciprofloxacin 500mg/tab, 1 tab BID po in AM Hyperthermia related to
Risk for Imbalanced Nutrition:
Indication: Treatment of susceptible infections due to E. coli, K. pneumoniae, E. cloacae, increased metabolic rate
Less Than Body Requirements
P. mirabilis, P. vulgaris, P. aeruginosa, H. influenzae, M. catarrhalis, S. pneumoniae, S. as evidenced by a
related to nausea and vomiting
aureus (methicillin susceptible), S. epidermidis, S. pyogenes, C. jejuni, Shigella spp., S. temperature of 37.8 C
secondary to cholecystitis -Severe RUQ
typhi including intra-abdominal, bone, joint, lower respiratory tract, skin/skin structure secondary to cholecystitis A three-day history
(Persistent) of RUQ tenderness,
infections. accompanied by
Mechanism of Action: Inhibits the enzyme DNA gyrase, which is responsible for the abdominal pain (9/10)
Positive Murphy's Sign
unwinding and supercoiling of bacterial DNA before it replicates. By inhibiting this enzyme,
ciprofloxacin causes bacterial cells to die.
Side Effects: Nausea, diarrhea, dyspepsia, vomiting, constipation, flatulence, confusion,
crystalluria, abdominal pain/ discomfort, headache, rash. altered taste, dizziness, confusion, Ibuprofen (Advil) q 4 hrs
Acute pain related to inflammation
tremors, hallucinations, hypersensitivity reaction, insomnia, dry mouth, paresthesia. Indication: To relieve mild to moderate pain
GOAL: The patient will report relief of of the gallbladder as evidenced by
Hypersensitivity reaction (rash, pruritus, blisters, edema, burning skin), photosensitivity. Mechanism of Axn: Blocks activity of cyclooxygenase, the
GOAL: Patient will maintain body temperature nausea/vomiting and will emonstrate pain score of 9/10, verbalization of
Nursing Responsibilities: Obtain urinalysis for microscopic analysis for crystalluria prior to enzyme needed to synthesize prostaglandins, which mediate
within normal value 36.5-37.5° C (102.2° F) and progression toward desired weight gain or RUQ abdominal pain, and
and during treatment. Evaluate food tolerance. Monitor daily pattern of bowel activity, stool inflammatory response and cause local vasodilation,
BP and HR within normal limits. maintain weight as individually appropriate. Murphy's sign swelling, and pain. By inhibiting prostaglandins, this NSAID
consistency. Encourage hydration (reduces risk of crystalluria). Monitor for dizziness,
DX: DX: reduces inflammatory symptoms and relieves pain.
headache, visual changes, tremors. Assess for chest, joint pain. Do not skip doses; take full
- Assess for signs of hyperthermia. - Evaluate total daily food intake. Ibuprofen?s antipyretic action probably stems from its effect
course of therapy. Sugarless gum, hard candy may relieve bad taste. Avoid caffeine. Report
- Assess for signs of dehydration as a result of - Assess weight and BMI. on the hypothalamus, which increases peripheral blood flow,
tendon pain or swelling. Avoid exposure to sunlight/artificial light (may cause
hyperthermia. - Consult with patient about likes and dislikes, foods causing vasodilation and encouraging heat dissipation.
photosensitivity reaction). Report persistent diarrhea.?
- Monitor the patient?s heart rate and blood that cause distress, and preferred meal schedule. Goal: The patient will demonstrate and Side Effect: Occasional: Nausea, vomiting, dyspepsia,
pressure. - Assess for abdominal distension, frequent verbalize relief of pain as evidenced by pain dizziness, rash.
- Monitor fluid intake and urine output. belching, guarding, reluctance to move. score of 0/10. Rare: Diarrhea or constipation, flatulence, abdominal cramps
TX: TX: DX: or pain, pruritus, increased B/P.
- Loosen or remove excess clothing and covers. - Provide oral hygiene before meals. - Assess level of pain and characteristics; Nursing Responsibilities: Assess onset, type, location,
- Provide hypothermia blankets or cooling blankets - Provide a pleasant atmosphere at mealtime; - Assess and monitor vital signs; duration of pain for baseline assessment. Monitor for
when necessary. remove noxious stimuli. TX: evidence of nausea, dyspepsia. Monitor CBC, renal function,
- Provide a tepid bath or sponge bath. - Plan with the client her desired meals. - Administer pain medication as prescribed; LFT. Assess skin for rash and increased b/p. Observe for
- Adjust and monitor environmental factors like - Consult with dietitian or nutritional support team - Provide quiet and calm environment; bleeding, bruising, occult blood loss. Give hard candy for
room temperature and bed linens as indicated. as indicated. - Assist to a comfortable position; nausea, raise side rails of bed, instruct to avoid rigorous
- Raise the side rails and lower the bed at all times. EDX: - Raise the side rails of the bed; activities while taking the medication, encourage to increase
- Start D5LRS 1L x 120cc/hr as indicated. - Emphasize importance of well-balanced, nutritious - Prepare for surgery as ordered water intake to prevent dehydration, to eat fiber-rich foods,
EDX: intake. provide information regarding individual EDX: and to avoid fatty/spicy foods. Instruct to avoid aspirin and
- Encourage adequate fluid intake. nutritional needs and ways to meet these needs - Encourage verbalization of thoughts and feelings; alcohol (increases risk of GI bleeding). Evaluate for
- Educate patient on preventive measures include within financial constraints. - Instruct on how to do breathing exercise therapeutic response: relief of pain.
minimizing time spent outdoors, use of air - Instruct client to avoid caffeinated beverages. - Instruct to call nurses station if in need of assistance;
conditioning, use of fans, increasing fluid intake, - Encourage small frequent feeding. - Instruct to maintain side rails up when in bed
taking frequent rest periods, limiting physical
activity, cool baths, and showers.