TRIBHUVAN UNIVERSITY

INSTITUTE OF MEDICINE
MAHARAJGUNJ NURSING CAMPUS
BACHELOR OF NURSING SCIENCE PROGRAM
TEACHING LEARNING PRACTICUM

Lesson Plan for Classroom Teaching

Subject: Adult Health Nursing I (Theory)

Course Number: BSN 9

Unit: 5, Disorders of Gastro- Intestinal System

Topic: Cholelithiasis and Cholecystitis

Date and Time: 2080/5/25 at 11 A.M.

Duration: 60 Minutes

Place: B.Sc. Nursing 2nd Year Classroom, MNC

Level of Learners: B.Sc. Nursing 2nd Year

Number of Learners: 39 Students

Name of the Student Teacher: Binita Das,

Level : B. Sc. Nursing 4th Year

Name of Supervisor : Lecturer, Nisha Bhandari, Asha Sapkota

TU, IOM, MNC

General Objective:
At the end of this session, all the B.Sc.Nursing 2nd Year students will be able to explain about the
Cholelithiasis and Cholecystitis.
S.N Specific Contents Tim T/L T/L Evaluation
objectives e Methods Materials

- Attendance 3min PPT using

Introduction of multimedia
topic projector
- Objectives Brainstormi
At the end of - Pretest ng
this Session,
B.Sc 2nd year
Students will
be able to :
1. introduce Introduction of 5min Interactive PPT using What is Cholelithiasis?
Cholelithiasis Cholelithiasis Lecture multimedia
projector
with images
2. state the Epidemiology 2min Interactive PPT using What is the epidemiology
epidemiology of Cholelithiasis lecture multimedia of Cholelithiasis?
of projector
Cholelithiasis
3. state the Etiology of 6 Interactive PPT using What are the etiological
etiology of Cholelithiasis min lecture multimedia factors of Cholelithiasis?
Cholelithiasis projector
with images
4. describe the Pathophysiolog 6min Interactive PPT using How does Cholelithiasis
pathophysiolog y of lecture multimedia occur?
y of Cholelithiasis projector+
Cholelithiasis Newsprint
6. list the clinical Clinical features 7min Interactive PPT using What are the clinical
features of Cholelithiasis lecture + multimedia features of Cholelithiasis?
of Cholelithiasi Buzz projector
s method with images

7. state the Diagnostic 6min Interactive PPT using Which test are done to
diagnostic procedures of lecture multimedia diagnose Cholelithiasis?
procedures Cholelithiasis projector
of Cholelithiasi with images
s
8. explain the Management 10 Interactive PPT using How can we manage the
management of Cholelithiasis min lecture+ multimedia patient having
of Cholelithiasi Medical/ discussion projector Cholelithiasis?
s Surgical/ with images
Nursing
Management
9. list the Complications 2min Interactive PPT using What are the complication
complications of Cholelithiasis lecture multimedia of Cholelithiasis?
 of projector
Cholelithiasis
10. define Definition of 2 Interactive PPT using What do you mean by
cholecystitis cholecystitis min lecture multimedia cholecystitis?
projector
11. state Epidemiology Interactive PPT using What is the epidemiology
epidemiology of cholecystitis 1 lecture multimedia of cholecystitis?
of cholecystitis min projector
11. state the Classification of 3 Interactive PPT using What are the classification
classifications cholecystitis min lecture multimedia of cholecystitis?
of cholecystitis projector
10. -Summary 3min Discussion PPT using 1.what is Cholelithiasis?
-Home and multimedia 2. What are the main 3
assignment questionnair projector clinical manifestations of
-References e Cholelithiasis and
cholecysttitis?

Cholelithiasis
Introduction
The presence of gallstones in the gall bladder is called cholelithiasis. A gall stones is a crystalline
concentration formed within the gallbladder by accretion of bile components. These calculi are
formed in the gall bladder. Gall stones can vary in size and shape from as small as a grain of
sand to as large as a golf ball. The gall bladder may contain a single large stones or many smaller
ones. Gallstones can occur at anywhere in the biliary tree. When stones form in or migrate to the
common bile duct, the condition is termed as choledocholelithiasis.
On the basis of their composition, gallstones can be divided into three types:
 Cholesterol stones: Cholesterol stones vary in color from light- yellow to dark green or
brown and are oval, 2 to 3 cm in length. It is more common form, which result from bile
supersaturated with cholesterol due to increased synthesis of cholesterol and decreased
synthesis of bile acids that dissolve cholesterol. They contain 80% of cholesterol.
 Pigment stones: Pigment stones are small, dark stones made up of bilirubin and calcium
salts that are found in bile. They contain less than 20% of cholesterol.
 Mixed stones: Mixed gallstones typically contain 20-80% cholesterol. Other common
constitutes are calcium carbonate, palmitate phosphate, bilirubin, and other bile pigments.

Epidemiology
According to world gastroenterology organization (WGO), more than 85% of gallstones are
cholesterol stones in developed countries. About 20 million people in the USA (15% of the
population) have gallstones, while in Europe it is 9-21% with incidence of 0.63/100
persons/year. In South Eastern Asia, the prevalence of gallstones is low. Gallstone disease is
responsible for about 10,000 deaths per year in the United States.
In Nepal, the overall prevalence of gallstone disease is around 2.44%-6.45%. Most common type
of stone was mixed type comprising 78.75%, followed by cholesterol stone 12.5%, brown
pigment stone 7.5% and black pigment stone 1.25%.
Source: Kathmandu University Medical College
They are uncommon in children and young adults but become increasingly prevalent after 40
years of age. They are most common in female than male.
Etiological Factors
The actual cause of cholelithiasis is unknown. The risk factors for gallstones are as following,
they are:
1. Four Fs: Fair skin, Fat, Female, Age after 40 are the risk factors.
2. Dietary Pattern: Excessive fatty consumption, increased cholesterol in the bile.
3. Excessive alcohol consumption: It causes liver damage, disrupts normal cholesterol
metabolism. Results in increased cholesterol production in liver and changes composition
of bile.
4. Obesity: Amount of bile salts in the bile is reduced, resulting in more cholesterol in bile.
Increased cholesterol reduces gallbladder emptying, contribute to stone formation.
5. Oral contraceptives: Alter the hormone level
6. Lipid lowering drugs: That lower cholesterol levels in the blood but actually increase the
amount of cholesterol secreted into bile.
7. Ileal disease/Resection : Bile salts helps to emulsify dietary fats, promote their digestion
and also maintain the solubility of cholesterol in bile. But in the ileal disease, bile salt is
not absorbed due to inflammation, scarring, or damage to ileal lining resulting in bile salt
deficiency. When bile salts are deficient, cholesterol may become supersaturated in the
bile, increasing the risk of cholesterol crystallization and gallstone formation.
8. Multiple pregnancy: Increases the hormone oestrogen which increase the biliary
cholesterol secretions.
9. Rapid weight loss: During rapid weight loss, liver may release more cholesterol into the
bile than can be dissolved. This excess cholesterol can lead to the formation of
cholesterol crystals, leads to rapid development of gallstones

Pathophysiology
Gallstone formation occurs because certain substances (cholesterol, calcium bilirubinate ) in the
bile are present in concentrations that approach the limits of their solubility. When bile is
concentrated in the gallbladder, it can become supersaturated with these substances, which then
precipitate from the solution as microscopic crystals. The crystals are trapped in the gallbladder
mucus, producing gallbladder sludge. Over time, the crystals grow, aggregate, and fuse to form
macroscopic stones. Occlusion of the ducts by sludge and/or stones produces the complications
of gallstone disease. Complications of gallbladder disease include necrosis, empyema, and
perforation of gall bladder causing cholecystitis.

Decreased bile acid synthesis

Increased cholesterol synthesis in the liver

Super saturation of bile with cholesterol

 Formation of precipitates

Gall stones (Cholelithiasis)

Inflammatory changes (Cholecystitis)

Different causes like hemolytic anemia increases heme production. Heme is further broken down
in unconjugated bilirubin by biliverdinreductase enzymes. Unconjugated bilirubin is water
insoluble. So, it needs to be conjugate but during this condition, it mixes with bile in
unconjugated form and increases level of unconjugated bilirubin in bile. Similarly, infection to
liver causes loss of its function to conjugate bilirubin and increases level of unconjugated
bilirubin in bile. Resulting in increase concentration of bile. It can become supersaturated with
these substances, which then precipitate from the solution as microscopic crystals and aggregate
to form small solid particles. Over the time, small particles grow in size and form hard, dark in
color gallstone.

Hemolytic anemia Infection of Liver

Heme and globin

Heme is further broken down into Loses its function to conjugate bilirubin

unconjugated bilirubin

Increase in unconjugated bilirubin

Precipitate out bile and aggregate to form small solid particles

Hard, dark in color gallstones

Clinical Features
1. Gallstones may be asymptomatic, “silent stones”, producing no pain and only mild
gastrointestinal symptoms.
2. Symptoms commonly begin to appear once the stones reach a certain size (>8mm)
3. Localized pain in the right upper quadrant, or epigastric region and may radiates to
right shoulder accompanied by nausea and vomiting, constant or colicky pain.
4. Abdominal pain, rigidity and tenderness.
5. Epigastric distress such as fullness, abdominal distension, and vague upper right
quadrant pain after a high fat meal.
6. Complaints of indigestion after eating high fat foods.
7. Anorexia, nausea, vomiting and flatulence.
8. Fever
9. A positive murphy’s sign is a common finding on physical examination.
10. Jaundice and/ or clay colored stool is an important finding in biliary obstruction.
(choledocholithiasis)
 11. Bleeding tendencies – lack or decreased absorption of vitamin k resulting in
decreased production of prothrombins.

Diagnostic Procedures
1. History taking: Dietary history, Family history of gall bladder disease and pervious
surgery of gall bladder etc.
2. Physical Examination: Findings include fever,tachycardia, Right upper quadrant
tenderness and abdominal rigidity, presence of morphy’s sign etc.
3. Abdominal radiography, Ultrasonography (USG): It is rapid and accurate diagnostic
procedure which can detect calculi in the gallbladder or dilated common bile duct.
4. Endoscopic retrograde cholangiopancreatography (ERCP): Permits direct visualization
of structures to evaluate the presence and location of ductal stones.
5. Percutaneous Transhepatic cholangiography: involves the injection of the dye directly
into the biliary tract for locating stones within bile ducts.
6. Liver function studies: shows an elevation in bilirubin and serum transaminases.
7. WBC counts
8. Magnetic Resonance Cholangiopancreatography (MRC): It is a non-invasive imaging test
that uses magnetic resonance imaging (MRI) to visualize the biliary system, including the
gallbladder and bile ducts. It is particularly useful for detecting bile duct stones.

Management
 Supportive therapy:
 Achieve remission with rest,
 Keep the patient in NPO to allow GI tract and gallbladder to rest.
 Give intravenous fluids, nasogastric suction, and antibiotic agents.
 Low fat liquids with high protein and carbohydrates followed by solid soft foods as
tolerated,
 Avoiding eggs, fatty rich foods, gas forming vegetables and alcohol.

 Pharmacologic Therapy:
 Ursodeoxycholic acid (UDCA) 10-15mg/kg body weight orally used to dissolve small,
radiolucent gallstones composed mainly of cholesterol. 6 to 12 months of therapy are
required in many patients to dissolve stones.
 Chenodeoxycholic acid (CDCA): CDCA is generally not the first-line therapy.
Ursodeoxycholic acid (UDCA) is preferred. If UDCA is not effective or contraindicated,
the dosing and administration of CDCA for gallstone dissolution should be determined by
a healthcare provider on a case-by-case basis.
 Analgesics agents such as meperidine may be required; avoid morphine because it
increase spasm of the sphincter of oddi.

 Non surgical removal of gall stones:

 Dissolving the gall stones by infusion of a solvent ( mono-octanoin or methyl tertiary
butyl ether (MTBE) into the gall bladder. The solvent can be infused through a tube or
catheter inserted percutaneously directly into the gallbladder.
  A catheter and instrument with a basket attached are threaded through the T-tube tract or
fistula formed at the time of T-tube insertion , the basket is used to retrieve and remove
the stones lodged in the common bile duct.

 Lithotripsy: repeated shock waves directed at gallstones in the gall bladder or common
bile duct (CBD) to fragment the stones. It is done for the patients with only a few stones.

Surgical Management
Goal of surgery is to relieve persistent symptoms, remove the cause of colic. Following surgical
procedures are performed to remove gall stones. They are:
1. Open Cholecystectomy or Laparoscopic Cholecystectomy: This is the treatment of choice
,It is the removal of gallbladder. The gallbladder along with cystic duct, vein and artery
are ligated.
2. Cholecystotomy: Incision of gallbladder for removal of stones.
3. Choledocholithotomy: Incision to common bile duct for removal of stones.
The lack of a gallbladder may have no negative consequences in many people. However, there is
a portion of the population ( between 10 and 15%) may develop a condition called post-
cholecystectomy syndrome which may cause gastrointestinal distress and persistent pain in the
upper- right abdomen, as well as 10% chance of developing chronic diarrhea.

Pre-operative nursing management

 Explain patient and visitor about the present condition, requirement of surgical
procedure, associated complications clearly
 Keep NPO after midnight
 Obtain written informed consent
 Collect required reports of investigations such as ultrasound, blood reports, x-rays etc.
 Make skin preparation (pre-op bath)
 Check pre-op list for completeness.
 Check for blood arrangement
 Remove jewelries, false teeth, nail paint, contact lenses etc and put on hospital gown
 Assess the patient’s level of anxiety by listening and observing.
 Provide detail information about the surgical procedures including post-operative care for
example, Positioning deep breathing and coughing exercise, ambulation, diet etc.
 Provide pre-operative medicines as prescribed.
 Put identification tag
Post-operative Nursing Management
 Monitoring of vital signs, level of consciousness, pain intensity, and bowel sound.
 Assess the incision site for soakage and bleeding
 Maintain NPO until bowel function returns
 Give analgesics for the first two to three days. Meperidine is the drug of choice to
minimize spasm in the bile ducts.
 Place the patient in low-fowler’s position, assist to change position frequently.
 Assess level of anxiety and knowledge regarding disease condition and self care
needs.
  Urge patient for deep breathing at regular intervals (every 1 to 2 hours) and to cough
if secretions are present until ambulating well. Encourage use of incentive spirometer.
 Nutritional management and drug therapy
 Encourage early ambulation in the first post-operative day.
 Monitor intake and output including wound drainage, vomiting or nasogastric
suctioning.
 Monitor signs of surgical complications and report immediately

Nursing Management
Assessment:
 Obtain a thorough medical history to identify risk factors and symptoms related to
cholelithiasis.
 Perform a physical examination, with a focus on abdominal tenderness, jaundice, and
signs of infection.
 Monitor vital signs, including temperature, blood pressure, heart rate, and respiratory
rate.
 Assess psychological status
Nursing Diagnosis:
 Acute pain and discomfort related to surgical incision.
 Impaired gas exchange related to high abdominal surgical incision.
 Impaired skin integrity related to altered biliary drainage after surgical incision.
 Imbalanced nutritional related to inadequate bile secretion.
 Deficient knowledge about self-care activities related to incisional care, dietary
modifications (if needed), medication, reportable signs or symptoms (fever, bleeding,
vomiting)
Nursing Interventions:
 Relieving pain
 Assess the pain level by using pain intensity scale, characteristics of pain, its aggravating
factors and alleviating factors
 Instruct patient to use a pillow to splint incision.
 Administer analgesics agents as ordered.
 Engage the patient in diversional activities, such as deep breathing exercises, or
relaxation techniques, to help distract from the pain and promote relaxation.
 Improving Respiratory status
Teach and encourage the patient to perform deep breathing and coughing exercises hourly to
maintain lung function and prevent atelectasis (partial lung collapse). Instruct them to take slow,
deep breaths and exhale fully.
 Encourage the patient to sit up or elevate the head of the bed to a semi-Fowler's
position. This position can help improve lung expansion and oxygenation.
 Ensure the patient remains well-hydrated to maintain thin respiratory secretions,
making it easier to cough and clear the airways.
 Encourage to use incentive spirometer
 Monitor elderly and obese patients most closely for respiratory problems.
 Maintain pulmonary hygiene ( cough deep breath, ambulate, turn and position
incentive spirometer).
  Promoting skin care and biliary drainage
 Connect tubes to drainage receptacle and secure tubing to avoid kinking (elevate
above abdomen)
 Place drainage bag in patient’s pocket when ambulating.
 Observe for indications of infection, leakage of bile, obstruction of bile drainage,
clay colored stool, and change in vital signs.
 Observe for jaundice (check the sclera)
 Note and report right upper quadrant pain, nausea and vomiting.
 Change dressing frequently, using ointment to protect skin from irritation.
 Keep careful record of intake and output.
 Measure bile collected every 24 hours; document amount color and character of
drainage.
 Monitoring and Managing complications
 Bleeding : Assess periodically for increased tenderness and rigidity of abdomen
and report; instruct patient and family to report change in color of stool. Monitor
vital signs closely. Inspect incision for bleeding.
 Gastrointestinal symptoms: Assess for loss of appetite, vomiting, pain
distension of abdomen, and temperature elevation; report promptly and instruct
patient and family to report symptoms promptly; provide written reinforcement of
verbal instructions.

Complications
1. Cholecystitis: Sudden inflammation of the gall bladder.
2. Cholangitis: An infection or inflammation of the common bile duct
3. Choledocholithiasis: Gallstones in the common bile duct.
4. Pancreatitis: Infection or inflammation of the pancreas.
Cholecystitis
Definition
Cholecystitis is an inflammation of the gallbladder wall and nearby abdominal lining that occurs
most commonly because of an obstruction of the cystic duct by gallstones arising from the
gallbladder (cholelithiasis).

Epidemiology
Among 10%-20% of Americans have gallstones, and as many as one third of these people
develop acute cholecystitis. The incidence of acute cholecystitis is approximately 6,300 per
100,000 in individuals under 50 years age and 20,900 per 100,000 in individuals over 50 years
age.
Source: National organization for rare disorders (NORD)

Classification
Cholecystitis is classified as
1. Acute cholecystitis
2. Chronic cholecystitis
3. Calculus cholecystitis
4. Acalculus cholecystitis
 1. Acute cholecystitis: is a sudden inflammation of the gallbladder that causes severe
abdominal pain. More than 90% of patients with acute cholecystitis have gall stones.

2. Chronic cholecystitis: Occurs when the gallbladder becomes thickend, rigid, fibrotic and
functions poorly that result from repeated attacks of cholecystitis, calculi or chronic
irritation. The gallbladder usually contains sludge (microscopic particles of materials
similar to those in gallstones) or gallstones that block its opening into the cystic duct or
reside in the cystic duct itself

3. Calculus cholecystitis: In calculus cholecystitis, gallbladder stone obstructs bile outflow.

Bile remaining in the gallbladder intiates a chemical reaction, autolysis and edema occur;
and the blood vessels in the gallbladder are compressed, compromising its vascular
supply. Gangrene of the gallbladder with perforation may result. Bacteria play a minor
role in acute chocystitis.

4. Acalculus cholecystitis: Acute inflammation of the gallbladder without obstruction of

the gallbladder.Acalculus cholecystitis occurs after major surgical procedures, severe
trauma or burns. It is also caused by alteration in fluid and electrolytes and increased
viscosity of bile.

Etiology
It can be caused by an obstruction, gallstone or a tumor. 90% of all cases caused by gallstones.
Also caused by secondary infection by gut organisms, predominantly E.coli and Bacteroides
species.

Pathophysiology:
Calculus Cholecystitis

Gall bladder stone

Obstruction of cystic duct

Distention of gall bladder

Impaired lymphatic and venous drainage

Proliferation of bacteria

Localized cellular irritation

Area of ischemia developed

Gangrene or necrosis

Fibrosis of gall bladder wall

 Acalculus Cholecystitis

Different etiological factors like infections, severe trauma or burns

Viscosity of bile increases

Bile stasis

Formation of precipitates

Gall stones (Cholelithiasis)

Inflammatory changes

Cholecystitis
Clinical featrures: Same as cholelithiasis
Diagnostic procedures: Same as cholelithiasis
Management
Treatment of the cholecystitis depends on the severity of the condition and the presence or
absence of complications.
In acute cholecystitis, The initial treatment includes
 Hospitalization with bed rest in fowler’s position reduces intra-abdominal pressure.
 Keep NPO and maintain nasogastric suction helps to removes secretions that stimulates
release of cholecystokinin and gallbladder contractions.
 Initial fluid management to maintain hydration of the patient.
 administration of antibiotics to fight infection such as piperacillin-tazobactom,
ampicillin-sulbactam or meropenem.
 Low fat diet ( when food can be tolerated)
 Analgesics to manage pain.
In chronic cholecystitis,
 Use medicine that dissolves gallstones over a period of time.
 May need emergency surgery if patient have gangrene, perforation, pancreatitis, or
inflammation of the common bile duct.

Nursing Management: Same as cholelithiasis

Summary
The presence of gallstones in the gall bladder is called cholelithiasis. A gall stones is a crystalline
concentration formed within the gallbladder by accretion of bile components. These calculi are
formed in the gall bladder. Cause of cholelithiasis is unknown but the risk factors are 4 ‘fs’, they
are fair skin, fat, female and forty. The major clinical features of cholelithiasis are pain in right
upper quadrant, or epigastric region, Anorexia, nausea and vomiting, morphy’s sign positive.
The supportive therapy for cholelithiasis are to achieve remission with rest,NPO to allow GI tract
and gallbladder to rest. Cholecystitis is an inflammation of the gallbladder wall and nearby
abdominal lining that occurs most commonly because of an obstruction of the cystic duct by
gallstones arising from the gallbladder (cholelithiasis). It is classified as acute, chronic, calculus
and acalculus cholecystitis.

References
Suzanne, C.S. and Brenda (2010) Brunner and Suddarth’s Textbook of medical surgical
Nursing, (12th ed), Wolters Kluwer health
Basavanthapa B.T. (2003), Medical surgical Nursing,(1st ed), Jaypee brothers’ medical
publishers (p) ltd.
Mandal G.N (2014). Textbook of Medical Surgical Nursing (3rded). Makalu Publication
House
Sharma M, Paudel K., Gautam R (2020), Essential Textbook of Medical
Surgical Nursing (3rd ed.). Samiksha Publication
Black J.M., Hawks J.H. (2009), Medical Surgical Nursing (1st ed). Reed Elsevier India
private limited
Ignatavicius, Donna D. Workman, Linda M. Rebar, Cherie (2013).“Medical –Surgical
Nursing (9th ed).
Kluwer,W.(2018).Lippincott manual of nursing practice.(11thed.).Wolters luwer(india) pvt ltd
TRIBHUVAN UNIVERSITY
INSTITUTE OF MEDICINE
MAHARAJGUNJ NURSING CAMPUS
BACHELOR OF NURSING SCIENCE PROGRAM
TEACHING LEARNING PRACTICUM
Sample Questions

Subject: Adult health NursingI Full Marks: 15

Level : B.Sc.Nursing 2nd Year Pass Marks: 7
Time : 25 mins

Candidates are required to give their own words as far as possible.

The Figures in the margin indicate full marks.

1.Multiple Choice Questions

Choose the one alternative that best completes the statement or answers the question:
1. Another word for gallstones disease is…. (1)
a. Cholelithiasis
b. Cholecystitis
c. Urolithiasis
d. Hepatitis
2. Which of the following surgery used to treat gallstones? (1)
 a. Cholecystography
b. Cholecystitis
c. Cholecystectomy
d. Lithotripsy

Long Answer

1. What do you mean by cholelithiasis? How do you care a patient with cholelithiasis. (2+5)
2. What do you mean by cholecystitis? What are the types of cholecystitis? (2+4)