HOLY ANGEL UNIVERSITY

College of Nursing

CHOLECYSTECTOMY

Submitted to:
Carina Del Rosario RN, MAN
Submitted by:
N-402/Group 4
Cherisse Anne Sicat
Gerald Soriano
John Carlo Suarez
Miraflor Sunga
Pamela Tayag
Jerwin Torres
Anajane Tuazon
Rina Tuazon
Francis Jay Ventura
Janine Vergara
Riah Lyn Yumul

January 15, 2011

 INTRODUCTION

Cholecystectomy is the surgical removal of the gallbladder, a small pear-shaped sac that
is located directly beneath the liver in the upper right side of the abdomen. The gallbladder's
main function is to store bile, which is produced by the liver, and to release it as needed for
digestion. The gallbladder's function is important, but it is not an essential organ.
Surgical removal is the most common therapy for gallbladder disorders. Gallstones
(small, solid formations composed of cholesterol and bile salts) can cause problems in the
gallbladder and the entire biliary system, including the pancreas. A common digestive disorder
worldwide, the annual overall cost of cholelithiasis or gallstones is approximately $5 billion in
the United States, where 75-80% of gallstones are of the cholesterol type, and approximately 10-
25% of gallstones are bilirubinate of either black or brown pigment. In Asia, pigmented stones
predominate, although recent studies have shown an increase in cholesterol stones in the Far
East. They are often responsible for very painful and potentially serious inflammation of the
gallbladder called acute cholecystitis. Cholecystectomy is the treatment of choice for this
condition. Over 500,000 of these procedures are performed each year in the United States.
Risk factors associated with development of gallstones include heredity, Obesity, rapid
weight loss, through diet or surgery, age over 60, Native American or Mexican American racial
makeup, female gender-gallbladder disease is more common in women than in men. Women
with high estrogen levels, as a result of pregnancy, hormone replacement therapy, or the use of
birth control pills, are at particularly high risk for gallstone formation, Diet-Very low calorie
diets, prolonged fasting, and low-fiber/high-cholesterol/high-starch diets all may contribute to
gallstone formation.
Sometimes, persons with gallbladder disease have few or no symptoms. Others,
however, will eventually develop one or more of the following symptoms; frequent bouts of
indigestion, especially after eating fatty or greasy foods, or certain vegetables such as cabbage,
radishes, or pickles; Nausea and bloating; Attacks of sharp pains in the upper right part of the
abdomen. This pain occurs when a gallstone causes a blockage that prevents the gallbladder from
emptying (usually by obstructing the cystic duct); Jaundice (yellowing of the skin) may occur if
a gallstone becomes stuck in the common bile duct, which leads into the intestine blocking the
flow of bile from both the gallbladder and the liver. This is a serious complication and usually
requires immediate treatment.
Two procedures are utilized to surgically remove the gallbladder: open cholecystectomy
and laparoscopic cholecystectomy. The laparoscopic method is utilized more frequently, but
some patients, particularly if they are obese, have a bleeding disorder, are pregnant and near the
due date, or have extensive scarring from previous abdominal surgeries are not candidates. The
choice of procedure is made on an individual basis.
The current trends in performing the cholecystectomy procedures are SILC or Single
Incision Laparoscopic Cholecystectomy and Robotic Cholecystectomy. The SILC technique with
a two-trocar technique is safe, feasible, and reproducible. The operating times are reasonable and
can be lessened with experience. Even complex cases can be managed with this technique. The
SILC procedure is becoming the standard of care for most of the authors’ elective patients with
gallbladder disease that requires single incision only unlike in the previous practice Laparoscopic
cholecystectomy requires several small incisions in the abdomen to allow the insertion of
operating ports, small cylindrical tubes approximately 5-10 mm in diameter, through which
surgical instruments and a video camera are placed into the abdominal cavity . Clinical trials are
warranted before the SILC technique is adopted universally.
In general surgery, advanced robotics will likely find its place in the most complex
laparoscopic procedures where the enhanced dexterity and superior visualization will extend the
feasibility of the minimally invasive approach, particularly in patients requiring advanced
suturing and precise tissue dissection. They hypothesized that robot-assisted laparoscopic
cholecystectomy would be a safe and effective bridge to advanced robotics in general surgery.
Laparoscopic cholecystectomy is a prime operation with which to begin robot applications for
several reasons. First, gallstone disease is the most common of all abdominal diseases for which
patients are admitted to hospital in developed countries,6 making it the most commonly
performed laparoscopic procedure.7 Moreover, it is an operation with a very standardized
approach to prevent complications.

OBJECTIVES:
Upon conducting this study, the student nurses will be able to:
• Recognize the disease condition, understand the risk factors, signs & symptoms and its
underlying complications;
• Identify the diagnostic procedures and treatment for the disease;
• Formulate nursing diagnoses related to the disease condition;
• Identify nursing interventions to relieve signs & symptoms;
• Identify perioperative nursing care for cholecystectomy and
• Educate people regarding the ways on how to prevent cholelithiasis.
Laboratory Studies

• A retrospective study attempted to determine a set of clinical and laboratory parameters

that could be used to predict the outcome of hepatobiliary scintigraphy (HBS) in all
patients with suspected acute cholecystitis.5
o The results of the study showed that, in 40 patients with pathologically confirmed
acute cholecystitis, fever and leukocytosis were absent at the time of presentation
in 36 (90%) and 16 (40%) of the patients, respectively.
o The study also found that no combination of laboratory or clinical values was
useful in identifying patients at high risk for a positive HBS finding.
• Although laboratory criteria are not reliable in identifying all patients with cholecystitis,
the following findings may be useful in arriving at the diagnosis:
o Leukocytosis with a left shift may be observed in cholecystitis.
o Alanine aminotransferase (ALT) and aspartate aminotransferase (AST) levels are
used to evaluate the presence of hepatitis and may be elevated in cholecystitis or
with common bile duct obstruction.
o Bilirubin and alkaline phosphatase assays are used to evaluate evidence of
common duct obstruction.
o Amylase/lipase assays are used to evaluate the presence of pancreatitis. Amylase
may also be elevated mildly in cholecystitis.
o An elevated alkaline phosphatase level is observed in 25% of patients with
cholecystitis.
o Urinalysis is used to rule out pyelonephritis and renal calculi.
o All females of childbearing age should have pregnancy testing.

Imaging Studies

• Radiography (without contrast)

o Gallstones may be visualized in 10-15% of cases. This finding only indicates
cholelithiasis, with or without active cholecystitis.
 o Subdiaphragmatic free air cannot originate in the biliary tract, and, if present, it
indicates another disease process.
o Gas limited to the gallbladder wall or lumen represents emphysematous
cholecystitis, usually because of gas-forming bacteria, such as Escherichia
coli and clostridial and anaerobic streptococci species. Emphysematous
cholecystitis is associated with an increased mortality rate and occurs most
commonly in males with diabetes and with acalculous cholecystitis.
o A diffusely calcified gallbladder (ie, porcelainized) most commonly is associated
with carcinoma, although one retrospective study by Towfigh found no
association between partial calcification of the gallbladder and carcinoma.6
o Other findings may include renal calculi, intestinal obstruction, or pneumonia.
• Ultrasonography
o Ultrasonography provides greater than 95% sensitivity and specificity for the
diagnosis of gallstones more than 2 mm in diameter. Ultrasonography is 90-95%
sensitive for cholecystitis and is 78-80% specific. Studies indicate that emergency
clinicians require minimal training in order to use right upper quadrant
ultrasonography in their practice.
o Ultrasonographic findings that are suggestive of acute cholecystitis include the
following: pericholecystic fluid, gallbladder wall thickening greater than 4 mm,
and sonographic Murphy sign. The presence of gallstones also helps to confirm
the diagnosis.
o Ultrasonography is performed best following a fast of at least 8 hours because
gallstones are visualized best in a distended bile-filled gallbladder.
• Hepatobiliary scintigraphy (hepatoiminodiacetic acid [HIDA]/diisopropyl iminodiacetic
acid [DISIDA])
o HBS has been found to be up to 95% accurate in diagnosing acute cholecystitis.
The reported sensitivities and specificities of biliary scintigraphy are in the range
of 90-100% and 85-95%. (See the following 2 images.)
o

Cholecystitis.
Normal finding
on

hepatoiminodiacetic acid (HIDA) scan.

Cholecystitis. Abnormal finding on hepatoiminodiacetic acid (HIDA) scan.

o In a typical study, the gallbladder, common bile duct, and small bowel fill within
30-45 minutes.
o If the gallbladder is not visualized, intravenous morphine administration can
improve the accuracy of HBS by increasing resistance to flow through the
sphincter of Oddi, resulting in filling of the gallbladder if the cystic duct is patent.
The addition of morphine also reduces the number of false-positive scan results
observed in patients who are critically ill and immobilized with viscous bile.
• CT scan and MRI
o The sensitivity and specificity of CT scan and MRI for predicting acute
cholecystitis have been reported to be greater than 95%.7 Spiral CT scan and MRI
(unlike endoscopic retrograde cholangiopancreatography [ERCP]) have the
advantage of being noninvasive, but they have no therapeutic potential and are
most appropriate in cases where stones are unlikely.
o Findings suggestive of cholecystitis include wall thickening (>4 mm),
pericholecystic fluid, subserosal edema (in the absence of ascites), intramural gas,
and sloughed mucosa.
o CT scan and MRI are also useful for viewing surrounding structures if the
diagnosis is uncertain.
Procedures

• Endoscopic retrograde cholangiopancreatography

o ERCP may be useful in patients at high risk for common duct gallstones if signs
of common bile duct obstruction are present.
o A study performed by Sahai et al found that ERCP was preferred over endoscopic
ultrasound and intraoperative cholangiography for patients at high risk for
common duct stones undergoing laparoscopic cholecystectomy.8
o ERCP allows visualization of the anatomy and may be therapeutic by removing
stones from the common bile duct.
o Disadvantages include the need for a skilled operator, high cost, and
complications such as pancreatitis, which occurs in 3-5% of cases.
• Endoscopic ultrasound-guided transmural cholecystostomy: Studies indicate that this
procedure may be safe as initial, interim, or definitive treatment of patients with severe
acute cholecystitis who are at high operative risk for immediate cholecystectomy.9
• Mutignani et al investigated the efficacy of endoscopic gallbladder drainage as a
treatment for acute cholecystitis.10 The authors, who conducted the study on 35 patients
with the condition and with no residual common bile duct obstruction, found that
endoscopic gallbladder drainage was technically successful in 29 patients and, after a
median period of 3 days, clinically successful in 24 of them. Four patients died within 3
days after the procedure as a result of septic complications, while a fifth patient
accidentally removed a nasocholecystic drain 24 hours after the operation. At follow-up
(on 21 patients, after a median period of 17 months), the investigators found that 4
patients had suffered a relapse of either acute cholecystitis (2 patients) or biliary pain (2
patients). Mutignani et al concluded that endoscopic gallbladder drainage appears to be
an effective, but temporary, means of resolving acute cholecystitis.
Histologic Findings

Edema and venous congestion are early acute changes. Acute cholecystitis is usually
superimposed on a histologic picture of chronic cholecystitis. Specific findings include fibrosis,
flattening of the mucosa, and chronic inflammatory cells. Mucosal herniations known as
Rokitansky-Aschoff sinuses are related to increased hydrostatic pressure and are present in 56%
of cases. Focal necrosis and an influx of neutrophils may also be present. Advanced cases may
show gangrene or perforation.

SURGICAL MANAGEMENT

• Laparoscopic Cholecystectomy

Indications
Laparoscopic cholecystectomy has become the treatment of choice for symptomatic
gallbladder disease. The procedure is suitable for most clients, even those with acute
cholecystitis, because there is minimal trauma to the abdominal wall. This makes it possible for
clients to go home within 24 hours after the procedure and return to work within a few days
instead of a few weeks, as is the case with a cholecystectomy performed with an abdominal
incision.
With the client under general anesthesia, carbon dioxide is used to create
pneumoperitoneum through a needle inserted near the umbilicus. Near the umbilicus, an
endoscope is inserted through a small incision to view the gallbladder and to determine the
feasibility of success associated with this procedure. Three other small incisions are created: one
for grasping the gallbladder, one for suction and irrigation, and one for dissection instruments
and applying clips.
Contraindications
Laparoscopic cholecystectomy is contraindicated if stones are known to exist in the
common bile duct. Laparoscopic cholecystectomy does not allow exploration or removal of
stones from the common bile duct.
Complications
Possible complications of surgery or anesthesia include pneumonia or atelectasis, deep
vein thrombosis or pulmonary embolism, and damage to the biliary tract and hemorrhage.
Operative cholangiography is a protective procedure for complications of cholecystectomy. The
advantages of small scars and a short hospital stay, however, have influenced surgeons to opt for
this procedure more often. Clients who undergo this procedure are at less risk because they are
ambulatory sooner and usually require only oral analgesia. Because of the carbon dioxide
pressing the diaphragm, nausea, vomiting, and shoulder pain are more frequent if the client’s
head and torso are elevated too soon after the surgery.
Outcomes
Most clients are discharged on the day of the surgery or the day after. In most cases, they
can resume normal activities and return to work after 3 to 4 days.

• Cholecystectomy

Indications
A cholecystectomy consists of excising the gallbladder from the posterior liver wall and
ligating the cystic duct, vein, and artery. The surgeon usually approaches the gallbladder through
a right upper paramedian or upper midline incision. If necessary, the common duct may be
explored through this incision. When stones are suspected in the common duct, operative
cholangiography may be performed (if it has not been ordered preoperatively). The surgeon may
dilate the common duct if it is not already dilated as a result of a pathologic process. Dilation
facilitates stone removal. The surgeon passes a thin instrument into the duct to collect the stones,
either whole or after crushing them.
After exploring a common duct, the surgeon usually inserts a T tube to ensure adequate
bile drainage during duct healing (choledochostomy) . the T tube also provides a route for
postoperative cholangiography or stone dissolution, when appropriate.
A conventional open cholecystectomy is indicated when a laparoscopic cholecystectomy
does not allow for retrieval of as tone in the common bile duct and when the client’s physique
does not allow access to the gallbladder. Occasionally, when a client is very obese, the
gallbladder is not retrievable via laparoscopic instruments. Further, a surgeon may have
difficulty accessing the gallbladder in an adult with a small frame and may need to perform the
conventional open cholecystectomy.
Contraindications
A client’s physical condition may not be able to withstand the stress of surgery, including
loss of fluids and electrolytes and the stress of anesthesia. Cholecystotomy , incision, and
drainage of the gallbladder may be performed as an alternative procedure.
Complications
After cholecystectomy, monitor the client for the usual postoperative complications, such
as hemorrhage, pneumonia, thrombophlebitis, urinary retention, and ileus. The risk of bile
leakage into the abdominal cavity is more applicable to surgeries involving the gallbladder. With
hemorrhage and bile leakage, the client feels severe pain and tenderness in the right upper
quadrant, abdominal girth increases, bile or blood may leak from the wound, blood pressure
drops and tachycardia develops,
Outcomes
Cholecystectomy results I immediate cessation of pain in most clients and prevents
development of complications such as acute cholecystitis, choledocholithiasis, and cholangitis.
Persistence of manifestations after removal of the gallbladder indicates (1) a possible
misdiagnosis or functional bowel disorder, such as esophagitis, peptic ulceration, pancreatitis, or
irritable bowel syndrome; (2) technical error; (3) a retained or recurrent common bile duct stone;
or (4) spasm of the sphincter of Oddi. Clients must be hospitalized for about 3 days before
dismissal. They may be sent home with a T tube in place for 1 to 2 weeks. When stones are
present in the common bile duct, research indicates that both complications and cost can be
saved if preoperative ERCP performed for suspicion of uncomplicated common bile duct stones
is replaced by intraoperative cholangiography (IOC).
Preoperative Care
Preoperative care of the client facing gallbladder or biliary surgery involves careful
monitoring for early clinical findings that may indicate the onset of complications from infection
or obstruction. For laparoscopic cholecystectomy, preoperative preparation involves the same
measures taken for other clients going to surgery. They include (1) NPO status after midnight,
(2) skin preparation, (3) occasionally an enema to reduce colon mass and to reduce the chance of
incontinence contaminating the operative field, and (4) sometimes an antibiotic.
Postoperative Care
Respiratory status is carefully monitored after the surgery of the gallbladder or biliary
tract because of the potential for development of atelectasis and pneumonia. Closely monitor
drainage from all biliary tubes and drainage from the incision site, for amount, character, and
color. Carefully assess cardiovascular status and manifestations of hemorrhage or shock.
Hemorrhage, although rare, can occur if an inflamed gallbladder has adhered to the liver.
Analgesia for pain management is important and should be given on a regular basis to promote
comfort and rest as well as to enhance the client’s ability to cough and deep breathe.
Maintain hydration and fluid balance IV until the client is no longer on NPO status and
can receive fluids orally. When the client is allowed oral intake, the amount of fluid and food
should be sufficient and well balanced enough to maintain renal function and body weight.
Clients are generally allowed to progress to a regular diet, with fat content included as tolerated.
Procedure

Traditional open cholecystectomy is a major abdominal surgery in which the surgeon

removes the gallbladder through a 4- to 7-inch (10 to 18 cm) incision. Patients usually remain in
the hospital for about three to seven days and may require several additional weeks to recover at
home.

Anaesthesia
Commonly:
Endotracheal Sedation.

Simplified steps:
Step I Incision.
Types of Incision:
• Upper Right SubCostal
Incision.
• Kocher's Incision.
• Modified Kocher's
Incision.
• Transverse Incision.

Step II: Exposure of the gallbladder:

Retraction of the liver
The dome of the gallbladder is initially scored with
electrocautery, and a tonsil clamp is used to establish
a plane in the thickened gallbladder in proximity to
the gallbladder wall itself. The cautery is then used
to incise the peritoneal surface of the entire dome.
FIGURE 1

Step III: Removal of the Gallbladder:

The fundus of the gallbladder is removed from the liver bed with blunt and sharp dissection.
Care should be taken in mobilizing the infundibulum of the gallbladder to be certain that it is not
adherent to the common bile duct. The cystic artery and its extension are usually encountered on
the medial surface of the gallbladder. The cystic artery can be temporarily controlled with a clip
on the surface of the gallbladder prior to its formal ligation. The gallbladder is then completely
mobilized from the liver bed until it is attached only by the
cystic duct.

. Required instruments, devices, supplies, equipment,

and facilities.
 Basic Set
 Mosquito
 Kelly curves
 Allis
 Babcock
 Needle holder
 Tissue forcep
 Thumb forcep
 Army navy
 Kidney basin
 Towel clips
 Straight clamp
 Mixter

Laparotomy Set
 Deaver
A retractor is a surgical instrument that separates the edges of a surgical incision or
wound, and holds back underlying organs and tissues, so that body parts under the incision may
be accessed. They are available in many shapes, sizes, and styles.

Malleable

A retractor that can be changed in size and shape by curving because it consist of metal
that can be easily bent and curved.
Richardson retractor

A retractor is a surgical instrument that separates the edges of a

surgical incision or wound, and holds back underlying organs and tissues, so
that body parts under the incision may be accessed. They are available in
many shapes, sizes, and styles.
 Mayo-Hegar needle holder

Needle holders are surgical instruments, similar to a hemostat, used to hold a suturing
needle for suturing tissue during surgical procedures. They lock to hold the needle in a manner
which allows the operator to maneuver the needle through the various tissues.
Foester sponge forceps

Sponge Forceps (SF) are used simply to hold a 4 x 4 gauze (sponge)

that will be used to mop up fluids inside the body cavity. They are also called
Ring Forceps. Some have serrated jaws and some do not.

Straight Kocher clamp

 A heavy, straight haemostat with interlocking teeth on the tip.

Mixter Adson hemostat forceps

A hemostat is commonly used in both surgery and emergency medicine to control

bleeding, especially from a torn blood vessel, until the bleeding can be repaired by sutures or
other surgical techniques. The process of halting bleeding is called hemostasis.

Babcock

Forceps with loop blades which are also semicircular in sagittal cross-
section. Designed to hold a short length of intestine without compressing it.

Allis
 Forceps with inward-curving toothed blades and a ratcheted handle. Designed for
grasping fascia and tendons.
Curved Crile

Standard type of hemostats with box joint, ratchet catch, long blades with cross ridging
on the blade face.
Mosquito Clamp

A small hemostatic forceps

Straight Kelly
 A clamp is a fastening device to hold or secure objects tightly together
to prevent movement or separation through the application of inward
pressure.

A hemostat without teeth, introduced for gynecologic surgery.

Curve Mayo and Straight Mayo Scissors

Heavy-duty surgical sissors with narrowed but blunt pointed blades,

which may be straight or curved. These scissors are used to cut and trim
braces and splints as they begin to harden. They have curved blades, which
can cut to the right or the left. The stainless steel scissors are available in
right-hand or left-hand versions.

Metzenbaun

Metzenbaun scissors are used to cut tissues during surgical procedures

No. 3 and 4 knife handles

A scalpel is a very sharp knife used for surgery, anatomical dissection, and
various arts and crafts. Scalpels may be disposable or re-usable. Re-usable
scalpels can have attached, resharpenable blades or, more commonly, non-
attached, replaceable blades. Disposable scalpels usually have a plastic
handle with an extensible blade (like a utility knife) and are used once, then
the entire instrument discarded.

Adson forceps with teeth and Russian

This forcep is designed for grasping skin during oculoplastic surgery.

The tips have teeth set at right angle to each other.

Smooth tissue Forceps with and without teeth

Forceps are a handheld, hinged instrument used for

grasping and holding objects. Forceps are used when fingers are too large to grasp small objects
or when many objects need to be held at one time while the hands are used to perform a task.
Thumb forceps are commonly held between the thumb and two or three fingers of one
hand, with the top end resting on the anatomical snuff box at the base of the thumb and index
finger. Spring tension at one end holds the grasping ends apart until pressure is applied. This
allows one to quickly and easily grasp small objects or tissue to move and release it or to grasp
and hold tissue with easily variable pressure. Thumb forceps are used to hold tissue in place
when applying sutures, to gently move tissues out of the way during exploratory surgery and to
move dressings or draping without using the hands or fingers.

SUPLLIES:
Basin set
Blades no. 1 and no. 15
Hemoclips
Dissectors
T- Tube (when cholecystectomy is done)

EQUIPMENTS
 Suction
 Electrosurgical unit

Medical Management of Physiologic Outcomes

 Fluid Therapy
Before the procedure, an IV fluid is infused for the patient’s hydration and for the
administration of medications. Post-operatively, fluids are given intravenously for 24-48
hours, until the patient's diet is gradually advanced as bowel activity resumes. Fluid therapy
is given to replace fluid and electrolyte loss, maintain patient’s hydration, nutritional status
and fluid balance. It is used to supply the necessary nutrients to the patient while the patient
is not on his/her regular diet yet.

 Pharmacologic Therapy

General anesthesia is used during gallbladder surgery. The surgery begins with the
administration of an IV sedative to relax the patient. Once the drug takes effect, the
anesthesia provider inserts a breathing tube, or endotracheal tube, through the patient’s
mouth into the windpipe. Antibiotics are given prior to the procedure as prophylaxis and after
to prevent infection also. Some of the medications prescribed after the surgery include
vitamins, anticholinergics, antidiarrheal, antispasmodics, as well as analgesics.

Analgesics are given for post operative pain, same with antispasmodics which are also
used for acute exacerbations of pain whenever necessary or as ordered. The client may
experience frequent bowel movements after the surgery or diarrhea. This is managed with the
use of antidiarrheals such as Loperamide and also anticholinergics which act by decreasing
gastrointestinal motility. Since pain medications may cause constipation, stool softeners may
also be prescribed, depending on your physician.
Omeprazole(Ulsek) - It is an anti-ulcer agent which acts to diminish accumulation of acid
in the gastric lumen and is useful when patient is on NPO to prevent heartburn and
epigastric pain.
Meperidine HCl(Demerol) - Relief of moderate to severe pain
Paracetamol(Acetaminophen) - It binds to bacterial cell wall causing cell death, thus acts
as anti-infectives.
Cefoxitin - It inhibits the synthesis of prostaglandins that may serve as mediators of pain
and fever, primarily in the CNS. It is indicated for mild pain and for fever.
Ampicillin + Sulbactam - Ampicillin exerts bactericidal action on both e and gram-
negative organisms. Sulbactam inhibits - lactamases and extends the spectrum of
ampicillin to include -lactamase producing pathogens. This combination is more
effective than Amoxicillin + Clavulanic Acid against -lactamase producing strains of
H influenzae and Acinetobacter.

 Diet Therapy
The diet is usually limited to low-fat liquids. These may include skim milk with
powdered supplements such as those which are high in protein and carbohydrates. Once (+)
flatus, the patient may have a soft diet. Rice, cooked fruits, lean meats, mashed potato, bread,
coffee or tea, may be added as tolerated. Eggs, cream, pork, fried foods, cheese, rich
dressings, alcohol and gas-forming vegetables should be avoided because this may bring an
episode of cholecystitis.
  Activity or Exercise
The patient is generally encouraged to walk 8 hours after surgery and discharged from the
hospital within three to five days, with return to work approximately four to six weeks after
the procedure. Ambulation is encouraged to prevent thromboembolism, facilitate voiding
and stimulate peristalsis. Strenuous activities such as lifting heavy objects and bending
should be avoided for the first weeks after the surgery. Deep breathing and coughing
exercises should be practiced by the patient as taught and assisted by the nurse. Proper
splinting of the abdominal incision should be done by the patient to decrease pain. Activities
may be gradually increased and sexual activity may return whenever patient is ready. No
running or contact sports for two weeks and no swimming or submersion of surgical incision
in water for one week are also advised.

For acute cholecystitis, initial treatment includes bowel rest, intravenous hydration,
analgesia, and intravenous antibiotics. For mild cases of acute cholecystitis, antibiotic therapy
with a single broad-spectrum antibiotic is adequate. Some options include the following:

• The current Sanford guide recommendations include piperacillin/tazobactam (Zosyn,

3.375 g IV q6h or 4.5 g IV q8h), ampicillin/sulbactam (Unasyn, 3 g IV q6h), or
meropenem (Merrem, 1 g IV q8h). In severe life-threatening cases, the Sanford Guide
recommends imipenem (500 mg IV q6h).
• Alternative regimens include a third-generation cephalosporin plus Flagyl (1 g IV loading
dose followed by 500 mg IV q6h).
• Bacteria that are commonly associated with cholecystitis include E coli and Bacteroides
fragilis andKlebsiella, Enterococcus, and Pseudomonas species.
• Emesis can be treated with antiemetics and nasogastric suction.
• Because of the rapid progression of acute acalculous cholecystitis to gangrene and
perforation, early recognition and intervention are required.
• Supportive medical care should include restoration of hemodynamic stability and
antibiotic coverage for gram-negative enteric flora and anaerobes if biliary tract infection
is suspected.
• Daily stimulation of gallbladder contraction with intravenous CCK has been shown by
some to effectively prevent the formation of gallbladder sludge in patients receiving
TPN.
 CONCLUSION and RECOMMENDATION

There is an edge that says learning never ceases. Through this, the world tells us that
learning, even when age has already taken its toll upon us all, will still crease our already
wrinkled foreheads. We are being screwed around with the thought that we could never escape
learning, similar to that of change. Yet, there is quite a significant difference between those you
have learned in your early years, and the formation you will be gathering once you are required
to use wooden stick in walking.
The knowledge we reap today, in our so-called “wonder years”, is supposed to benefit us
in our journey towards the nest step. Perhaps it is even more correct if we refer it to as the next
step, since the world we will be facing after all this quite unnerving. Either way, all education we
have gone, will aid us in our case, life as a nurse.
This case study does not purge away the thought that has been lying around written upon
this piece of paper. This presentation is still a part of that never-ending education. Perhaps it is
keen observation that through this case study, we will only be learning a tiny bit of nursing
profession that lies ahead of us. But it is the assimilation of these tiny bits and pieces of
information that actually makes a difference in being a successful and downright caring nurse
profession. Yes, an undergraduate case presentation still provides insufficient information
regarding a specific condition. We agree. But what makes this tiny piece of data important to us,
is that through this, we have been supplied with at least the basic nursing care, if not more, of
that certain disease. These “basics”, so to speak are the media by which optimum care is
provided to a client.