Cholecystitis

Learn how to double up your nursing interventions to manage these twin challenges.

You're working in the medical/surgical unit when the phone at the nurses' station rings.

The clerk in the emergency department wants a bed for Jeanne Wilson, 33, who's being admitted with acute cholecystitis. No problem.. until you hear the words that make your heart sink: "She's 30 weeks pregnant."

Working in a medical/surgical unit, you may find yourself caring for a pregnant woman for various reasons. In this article, I'll explain why pregnancy makes a woman more susceptible to cholecystitis and I'll review the basic skills you need to care for her and her unborn child.

Pregnancy increases risk

Cholecystitis is an acute or chronic inflammation of the gallbladder and the second most common nonobstetric surgical condition in pregnancy (after appendicitis). Acute cholecystitis is usually the result of a gallstone impacted in the cystic duct. In up to 85% of acute cases, bacterial infection is present.

Conditions that predispose someone to gallstone formation include obesity, weight loss, high estrogen levels, and pregnancy. The following gastrointestinal (GI) changes that occur with pregnancy increase the risk of acute cholecystitis:

displaced stomach and intestines. The growing uterus and fetus push them backward and sideways. About halfway through pregnancy, displacement is enough to slow intestinal peristalsis and, stomach emptying and trap bile in the gallbladder, which can change its composition and cause gallstones to form.

changes within the gallbladder. Gallbladder volume and residual volume after eating are twice as great during pregnancy, so emptying may be incomplete. Hormone changes may increase the bile's cholesterol content and contribute to gallstone development.

Assessing your patient

Ms. Wilson arrives in the unit, and you help her get settled in bed. Assess her for signs and symptoms of acute cholecystitis and monitor her for problems related to her pregnancy.

Colicky or stabbing pain in the right upper abdominal quadrant or epigastric area radiating to the interscapular area, right shoulder, or scapula is a hallmark of cholecystitis. A stone obstructing the cystic or common bile duct increases intraluminal pressure and distends the viscus to cause the pain.

Although pregnancy reduces the likelihood of a positive response, assess Ms. Wilson for Murphy's sign: Hook your left thumb or the fingers of your right hand under her right costal margin and ask her to take a deep breath; if she has a sharp increase in tenderness and suddenly stops breathing in, Murphy's sign for cholecystitis is positive.

Anorexia, nausea, and vomiting are common, along with other GI symptoms such as flatulence, bloating, and belching.

Low-grade fever, tachycardia, and tachypnea may be present.

Jaundice is rare but may occur with obstruction of the common duct.

Signs of preterm labor are a key assessment in any pregnant woman who has infection, trauma, medical complication, or surgical intervention. Preterm labor occurs before 37 weeks' gestation. Ms. Wilson's medical record shows the estimated gestational age as 30 weeks. Assess her for labor every shift and auscultate the fetal heart rate and rhythm according to your unit's protocol. (See What to Ask a High-Risk Patient for key questions and Auscultating Fetal Heart Rate to review the technique.) Immediately report any concerns to the health care provider.

Because of her pregnancy, Ms. Wilson's diagnostic testing should be limited. Ultrasound of the gallbladder is the diagnostic test of choice. Other imaging or X-ray studies should be avoided if possible because they could harm the fetus.

Ms. Wilson's blood work should include hemoglobin and hematocrit levels to screen for physiologic anemia of pregnancy, which could be a problem if she needs surgery A white blood cell count of 10,000 to 14,000/mm^sup 3^ isn't unusual in a normal pregnancy, especially near term. Cholecystitis may cause elevated serum transaminase and bilirubin levels, but alkaline phosphatase levels aren't as reliable because they may double during pregnancy

Carrying out the care plan

Your care for a pregnant patient with acute cholecystitis aims to manage her signs and symptoms, protect her and her fetus, and possibly prepare her for surgery. Ms.Wilson will probably have a surgical consult to evaluate her diagnostic test results and determine whether she needs surgery.

If the surgeon takes a wait-and-see approach, you'll administer antiemetics, intravenous (LV) analgesics to manage her pain, maintenance IN fluids for hydration, and prophylactic antibiotics as ordered.

(For safety, check with your facility's pharmacist before giving her any medication.) She may be restricted to bed rest with bathroom privileges until her pain and other symptoms decrease. She'll remain NTO. until she has a nutritional consult, then may slowly start a low-fat diet if her symptoms resolve.

If Ms. Wilson needs surgery, she'll undergo laparoscopic cholecystectomy When she returns to the unit, you'll administer pain medications and prophylactic antibiotics and continue to assess her for preterm labor and perform frequent fetal monitoring. As for any surgical patient, monitor her intake and output, administer IN fluids, assess her wound, and maintain her NTO. status and bed rest as ordered.

Because pregnancy induces hypercoagulability, Ms. Wilson has a higher risk of thromboembolism.

Carefully monitor her for signs and symptoms of deep vein thrombosis and pulmonary embolism. Keep her in a left lateral tilt position, rather than supine. Lying on her back can lead to supine hypotensive syndrome caused by the gravid uterus compressing the vena cava and reducing cardiac output.

As soon as possible after surgery, Ms. Wilson should switch to an oral pain medication, begin modified activities, resume bowel and bladder function, and advance slowly to clear liquids and then a lowfat diet.

What to do about preterm labor

Whether Ms. Wilson has surgery or not, frequently monitor her for preterm labor and thoroughly investigate and report any questionable signs and symptoms. If you're concerned about any aspect of her care, don't hesitate to ask a maternity nurse or an advanced practice obstetric nurse for help. If Ms. Wilson is in labor, the obstetrician may order a tocolytic agent, such as magnesium sulfate, to try halting labor.

If she receives therapy with a tocolytic agent, she must have continuous external fetal and uterine monitoring (EFM) to determine fetal distress. Only staff who have completed EFM competencyvalidated training are qualified to monitor, interpret, and evaluate the EFM tracings, so she should be transferred to the labor and delivery unit. Hopefully, after 24 hours, the signs of preterm labor will subside and the tocolytic therapy will be discontinued. She'll then begin an oral medication to prevent contractions.

Going home

Preparing Ms. Wilson for discharge, you teach her about wound care, pain management, medications, activity and dietary restrictions, signs and symptoms of preterm labor, and when to call the practitioner. Then you document your teaching.

As a medical/surgical nurse, you've applied the basics of preterm labor assessment, medication use, and patient teaching to protect her and her fetus while helping her overcome the effects of cholecystitis.

SELECTED REFERENCES

Burrow, G., and Duffy, T.: Medical Complications during Pregnancy, 5th edition. Philadelphia, Pa., WB. Saunders Co., 1999.

Loudermilk, D., et al.: Maternity and Women's Health Care, 7th edition. St. Louis, Mo., Mosby, 2000.

Mattson, S., and Smith, J.: Core Curriculum for Maternal Newborn Nursing, 2nd edition. Philadelphia, Pa., WB. Saunders Co., 2000. Nursing2002 Drug Handbook, 22nd edition. Springhouse, Pa., Springhouse Corp., 2002.

Susan Brodheim Cordero Is a clinical educator for the women and Children's area at Albert Einstein Medical Center in Philadelphia, Pa.

Copyright Springhouse Corporation Nov 2002
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