Ateneo de Zamboanga University

College of Nursing
NURCO-2

Name: __________________________________ Date: ______________

Section: ___________________ Delivs # ____________

Concept/s: ________________________________________________________

CHOLECYSTITIS
Cholecystitis is inflammation of the gallbladder, usually resulting from a gallstone
blocking the cystic duct.

an acute or chronic inflammation of the gallbladder, usually associated with a

gallstone impacted in the cystic duct, causing painful distention of the gallbladder.
The acute form is most common during middle age; the chronic form, among
elderly people. Prognosis is good with treatment.

Causes (Risk Factors):

The exact cause of cholecystitis is unknown; risk factors include:
● a high-calorie, high-cholesterol diet, associated with obesity
● elevated estrogen levels from hormonal contraceptives, postmenopausal
therapy, pregnancy, or multiparity
● diabetes mellitus, ileal disease, hemolytic disorders, liver disease, or
pancreatitis
● genetic factors
● weight-reduction diets with severe calorie restriction and rapid weight
loss.

Patho-physiology
Occlusion of the cystic duct or malfunction of the mechanics of gallbladder
emptying is the pathophysiology of this disease. Gallstones form from various
materials such as bilirubinate or cholesterol. These materials increase the
likelihood of cholecystitis and cholelithiasis in conditions such as sickle cell
disease where red blood cells are broken down forming excess bilirubin and
forming pigmented stones. Patients with excessive calcium such as in
hyperparathyroidism can form calcium stones. Patients with excessive cholesterol
can form cholesterol stones.

Assessment Findings (Subjective & Objective)

Subjective:
Often, there is a specific dietary event leading to the acute attack, e.g., "I ate pork
chops and gravy last night."

Objective:
Right upper quadrant abdominal pain and and rigidity with bloating,
that may radiate to the midsternal area or right shoulder and is associated
with nausea, vomiting, and the usual signs of an acute inflammation The finding
of right upper abdominal pain with deep palpation, Murphy sign, is usually classic
for this disease.

Diagnostic Test Findings (Imaging or Scan & Laboratory Test)

● Radionuclide Imaging or Cholescintigraphy - a radioactive agent is
administered intravenously (IV) which is taken up by the hepatocytes and
excreted rapidly through the biliary tract. The biliary tract is then scanned,
and images of the gallbladder and biliary tract are obtained.
 ● Cholecystogram, Cholangiogram - Visualize gallbladder and bile duct
● Ultrasonography - Show size of abdominal organs and presence of
masses
● Endoscopic Retrograde Cholangiopancreatography - Visualize biliary
structures and pancreas via endoscopy
● Serum Alkaline Phosphatase - in absence of bone disease, to measure
biliary tract obstruction
● Cholesterol Levels - Elevated in biliary obstruction; decreased in
parenchymal liver disease.

Interventions/Management (Surgical Procedures, Treatments, Medications)

● Surgery, usually elective, is the treatment of choice for gallbladder and
duct disease. Procedures may include cholecystectomy, cholecystectomy
with operative cholangiography and, possibly, exploration of the common
bile duct.
● A low-fat diet is prescribed to prevent attacks as well as vitamin K for
itching, jaundice, and bleeding tendencies caused by vitamin K deficiency.
● During an acute attack, treatment may include insertion of an NG tube and
I.V. line as well as antibiotic administration.
● A nonsurgical treatment for choledocholithiasis involves insertion of a
flexible catheter, formed around a T tube, through the sinus tract into the
common bile duct. Guided by fluoroscopy, the doctor directs the catheter
toward the stone. A Dormia basket is threaded through the catheter to
entrap the calculi

Nursing Responsibilities
Before surgery, implement these measures:
• Monitor and, if necessary, help stabilize the patient’s nutritional status and fluid
balance. Such measures may include vitamin K administration, blood
transfusions, and glucose and protein supplements.
• For 24 hours before surgery, give the patient clear liquids only.
• As ordered, administer preoperative medications and insert an NG tube

Follow these steps after laparoscopic surgery:

• Check the small stab wounds; they will be closed with staples or sutures and
may have small dressings.
• Monitor for anesthesia-related nausea and vomiting.
• Apply heat to the patient’s shoulder to alleviate right shoulder pain caused by
phrenic irritation from carbon dioxide under the diaphragm. To decrease
discomfort, place the patient in semiFowler’s position. Early ambulation also
helps.
• Tell the patient a light meal is usually permitted the same evening.
• The day after discharge, place a follow-up phone call to the patient’s home to
check on his progress.

Complications
- Biloma
- Intraabdominal abscess
- Bile duct injury
- Hepatic injury
- Small bowel injury
- Infection
- Retained stones in the bile duct
- Bleeding
Questions:
1. A 42-year-old woman presents with 10 hours of persistent epigastric pain,
nausea, and bloating. She experienced similar symptoms in the past that
resolved without treatment. Her vital signs are within normal limits, and
the physical exam is significant for a positive Murphy sign. Laboratory
results show a slightly elevated white blood cell count. Abdominal
ultrasound demonstrates a thickened gallbladder wall with pericholecystic
fluid and gallstones. What is the most appropriate treatment?
A. Emergent Surgery
B. Surgery within 48 hours of admission
C. IV antibiotics and surgery in 1 week
D. IV antibiotics and surgery in 4 weeks
Rationale: B. Uncomplicated acute cholecystitis is best treated with surgery 24 to
48 hours after admission. There is conflicting data on the administration of IV
antibiotics for uncomplicated acute cholecystitis, and it is not recommended
unless the patient has diabetes mellitus or is immunocompromised or frail.
Surgery is still recommended within 24 to 48 hours after admission.

2. A 56-year-old woman presents with gallstones on abdominal imaging. The

patient denies abdominal pain, discomfort with food intake, dark urine, or
pale stool. The patient's complete blood count (CBC), basic metabolic
panel (BMP), and liver function test (LFT) are unremarkable. What is her
risk of developing acute cholecystitis as a primary presentation, in the next
20 years?
A. 1%
B. 5%
C. 10%
D. 20%
Rationale: A. Only 1% of patients with incidental gallstones are likely to develop
complications, such as acute cholecystitis, without prior symptoms such as biliary
colic. Although 95% of people with acute cholecystitis have gallstones, only 20%
of people found to have gallstones incidentally will develop symptoms in their
lifetime. Because of these findings, prophylactic cholecystectomy is not
warranted in asymptomatic patients.
3. A nurse anticipates that the conservative treatment of a client with acute
cholecystitis will include:
A. A bland diet
B. Administration of anticholinergic medications
C. Placing the client in a supine position with the head of the bed flat
D. Administering laxatives to clear the bowel
Rationale: B. Anticholinergic medications decrease secretion and counteract
smooth muscle spasms. The client should be NPO rather than on a bland diet to
decrease gallbladder stimulations. Laxatives would increase rather than decrease,
gastrointestinal stimulation. Positioning the client with the head of the bed
elevated decreases the pressure of the abdominal contents on the diaphragm and
promotes improved ventilation. (322 Davis)
4. Your patient has severe mid epigastric or right upper quadrant pain
radiating to the back or referred to the right scapula, belching that leaves a
sour taste in the mouth, and flatulence. She most likely has:
A. appendicitis.
B. acute cholecystitis, acute cholelithiasis, or choledocholithiasis.
C. diverticular disease.
 D. acute gastritis.
Rationale: B. These signs and symptoms suggest your patient has acute
cholecystitis, acute cholelithiasis, or choledocholithiasis.
5. When caring for a client with cholecystitis, the nurse would question an
order calling for administration of which drug?
A. Morphine
B. Pro-Banthine
C. Atropine
D. Compazine
Rationale: A. Morphine is not given because it can cause spasms in the muscle of
the ducts. The anticholinergics atropine and Pro-Banthine are used for pain and
antiemetics such as Compazine is used for N&V.
6. When assessing a client with cholecystitis, a report of which type of pain
would the nurse interpret as consistent with the diagnosis?
A. Dull, aching upper right abdominal pain
B. Sharp, crampy periumbilical pain
C. Sharp pain in the back under the shoulder blade
D. Dull upper abdominal and right shoulder pain
Rationale: C. Cholecystitis causes right upper quadrant pain referred to the back
under the shoulder blade. A. is incorrect - Liver cancer causes dull, aching pain in
the right abdomen. B is incorrect - Crampy, sharp periumbilical pain is
characteristic of a variety of intestinal disorders. D is incorrect - an enlarged
spleen can press on the diaphragm and stimulate the phrenic nerve.

7. A woman is seen in the clinic with complaints suggesting cholecystitis or

cholelithiasis. What teaching should the nurse expect to reinforce?
A. Sit up after you eat
B. Avoid carbonated beverages
C. Avoid caffeine
D. Avoid fatty foods
Rationale: D. The woman should avoid fatty foods. Cholecystitis is inflammation
of the gallbladder. The sole function of the gallbladder is to store bile and then
release it when the person eats to help digest fat. Fats make the symptoms worse
because the gallbladder is trying hard to release bile.

8. A client is admitted with a diagnosis of cholecystitis. One of the admitting

orders is for morphine PRN for pain. Why would the nurse question this
order?
A. Morphine is constipating
B. Morphine can cause nausea and vomiting
C. Morphine promotes biliary stone formation
D. Morphine causes spasm of the bile ducts.
Rationale: D. Morphine is contraindicated for clients with cholecystitis because
of the risk of precipitating duct spasm. A, B, and C are incorrect - Morphine,
which is an opioid, does cause constipation and also cause nausea and vomiting
but these are not the reason it is not used in clients with cholecystitis.
9. An adult who has cholecystitis reports clay-colored stools and moderate
jaundice. The nurse knows which is the best explanation for the presence
of clay-colored stools and jaundice?
A. There is an obstruction in the pancreatic duct
 B. There are gallstones in the gallbladder
C. Bile is no longer produced by the gallbladder
D. There is an obstruction in the common bile duct
Rationale: D. Clay-colored stools mean bile is not getting through the duodenum.
The bile duct is obstructed, so bile backs up into the bloodstream, causing
jaundice.
10. A client has an open cholecystectomy with bile duct exploration.
Following the surgery, the client has a T-tube. To evaluate the
effectiveness of the T-tube, the nurse should:
A. Irrigate the tube with 20 mL of normal saline every 4 hours
B. Unclamp the T-tube and empty the contents every day
C. Assess the color and amount of drainage every shift
D. Monitor the multiple incision sites for bile drainage.
Rationale: C. A T-tube is inserted in the common bile duct to maintain patency
until edema from the duct exploration subsides. The bile color should be gold to
dark green and the amount of drainage should be closely monitored to ensure tube
patency.

References:
Saiman, Y. (2024, January 25). Cholecystitis - liver and gallbladder disorders.
MSD Manual Consumer Version.
https://www.msdmanuals.com/home/liver-and-gallbladder-disorders/gallbl
adder-and-bile-duct-disorders/cholecystitis
Jones, M. W. (2023, May 22). Acute cholecystitis. Stat Pearls [Internet].
https://www.ncbi.nlm.nih.gov/books/NBK459171/
Lippincott Williams & Wilkins. (2012). Medical-surgical nursing made incredibly
easy! (3rd ed.). (pp. 461, 469, 514).
Miller, J. (2011). Delmar’s NCLEX-PN review. (2nd ed.). (pp. 556, 567, 535,
546)
Monahan, F. (2008). Review for the NCLEX-RN examination. (pp. 872, 1125,
1128)
Ohman, K. (2010). Davis’s q&a for the NCLEX-RN examination. (p. 332)