A 45-year-old female patient with a diagnosis of severe cholecystitis and possible cholangitis is being closely monitored. Her laboratory results show elevated white blood cell count and liver function tests point towards obstructive jaundice. She is febrile and increasingly tender in the right upper quadrant. Based on this clinical presentation, what is the nurse's priority intervention to prevent further complications?

A) Administer broad-spectrum intravenous antibiotics as prescribed.

B) Encourage the patient to ambulate to improve circulation.

C) Offer the patient oral fluids to maintain hydration.

D) Apply a heating pad to the right upper quadrant to alleviate pain.

A 45-year-old female with cholecystitis is experiencing increasing tenderness in the right upper quadrant and a fever of 38.7°C (101.7°F). Her lab results show elevated WBC count and liver enzymes. An ultrasound shows multiple gallstones and a thickened gallbladder wall with pericholecystic fluid. Which nursing intervention is the most important to prevent further complications in this patient?

B) Monitor vital signs and administer prescribed intravenous antibiotics promptly.

A) Encourage oral intake to maintain hydration and support immune function.

B) Monitor vital signs and administer prescribed intravenous antibiotics promptly.

C) Assist the patient with ambulation to prevent deep vein thrombosis.

D) Apply a warm compress to the abdomen to relieve discomfort.

A patient with suspected biliary obstruction and evolving abscess is being prepared for percutaneous cholecystostomy. The nurse knows that which of the following changes in the patient's condition would require immediate notification of the healthcare provider?

C) A sudden drop in blood pressure to 80/50 mmHg.

A) A decrease in white blood cell count.

B) An increase in urine output.

C) A sudden drop in blood pressure to 80/50 mmHg.

A patient with a suspected biliary obstruction and bacterial infection is exhibiting signs of jaundice, dark urine, pale stools, fever, tachycardia, and hypotension. Which nursing intervention is the highest priority to address the patient's current condition?

C) Initiate intravenous fluid therapy to address hypotension and prevent septic shock.

A) Administer the prescribed antibiotics to target the identified Escherichia coli infection.

B) Prepare the patient for percutaneous cholecystostomy to relieve the biliary obstruction.

C) Initiate intravenous fluid therapy to address hypotension and prevent septic shock.

D) Monitor the patient's vital signs and laboratory results closely to detect changes in condition.

A patient with biliary obstruction has undergone a percutaneous cholecystostomy and is showing initial signs of improvement. Which nursing intervention is most crucial at this stage to prevent further complications?

C) Monitor vital signs and drainage output closely to detect signs of bile leakage or infection.

A) Administer oral antibiotics to ensure continued infection control.

B) Encourage early ambulation to promote circulation and prevent deep vein thrombosis.

C) Monitor vital signs and drainage output closely to detect signs of bile leakage or infection.

D) Provide a high-protein diet to support liver function and healing.

A patient with biliary obstruction and systemic infection underwent a percutaneous cholecystostomy. Following the procedure, the patient's blood pressure improved slightly, but jaundice and elevated bilirubin levels persist. Which nursing intervention is most appropriate to monitor for potential complications post-procedure?

A) Monitor for signs of bile leakage and assess abdominal pain.

B) Increase fluid intake to aid in flushing the biliary system.

C) Administer additional antibiotics to prevent further infection.

D) Encourage early mobilization to improve circulation.

A patient with a history of percutaneous cholecystostomy is showing signs of respiratory distress with ABG results indicating respiratory acidosis and hypoxemia. The healthcare team suspects fluid overload. Which nursing intervention should be prioritized to address the patient's respiratory status?

B) Administer prescribed diuretics to reduce fluid overload.

A) Increase the rate of intravenous fluids to improve circulation.

B) Administer prescribed diuretics to reduce fluid overload.

C) Encourage deep breathing exercises to increase oxygenation.

D) Place the patient in a supine position to facilitate lung expansion.

A patient who recently underwent a percutaneous cholecystostomy is now exhibiting signs of respiratory distress, with arterial blood gas analysis indicating respiratory acidosis and hypoxemia. Which of the following nursing interventions is most appropriate to address the patient's current respiratory condition?

C) Initiate non-invasive positive pressure ventilation (NIPPV) to improve gas exchange

A) Increase the rate of intravenous fluid administration to maintain blood pressure

B) Position the patient in a supine position to facilitate breathing

C) Initiate non-invasive positive pressure ventilation (NIPPV) to improve gas exchange

D) Administer high-flow oxygen therapy via a nasal cannula

A patient with a history of liver dysfunction is showing signs of jaundice and elevated liver enzymes. An abdominal ultrasound reveals a dilated common bile duct. The healthcare team plans for an ERCP. As a nurse, what is the priority action to prepare the patient for this procedure?

A) Ensure the patient has fasted for at least 8 hours before the procedure

B) Administer prescribed antibiotics to prevent potential infection

C) Educate the patient about post-procedure dietary restrictions

D) Arrange for a follow-up liver function test post-procedure

A patient with a history of heart failure is being treated for fluid overload and suspected biliary obstruction. After receiving diuretics and NIPPV, the patient's respiratory status improves, but jaundice persists. What is the most appropriate nursing intervention to prioritize before the planned ERCP procedure?

B) Monitor the patient for signs of respiratory distress due to possible sedation during ERCP.

A) Encourage the patient to increase fluid intake to prevent dehydration.

B) Monitor the patient for signs of respiratory distress due to possible sedation during ERCP.

C) Educate the patient about dietary changes to manage jaundice symptoms.

D) Prepare the patient for possible liver biopsy during the ERCP.

choleycistitis - Nursing Case Study

Pathophysiology

• Primary mechanism: Cholecystitis primarily occurs due to gallstone obstruction in the cystic duct, leading to bile stasis and increased intraluminal pressure within the gallbladder. This pressure reduces blood flow, causing ischemia and inflammation of the gallbladder wall.

• Secondary mechanism: The inflammatory process is exacerbated by the proliferation of bacteria, commonly E. coli and Klebsiella, within the stagnant bile. This bacterial infection further intensifies the inflammatory response, contributing to tissue damage and edema.

• Key complication: If untreated, the inflammation can progress to gangrene or perforation of the gallbladder, potentially leading to peritonitis or cholecystenteric fistula, which are serious complications requiring urgent medical intervention.

Patient Profile

Demographics:

45-year-old female, office manager

History:

• Key past medical history: Hypertension, Type 2 Diabetes

• Current medications: Lisinopril, Metformin

• Allergies: Penicillin

Current Presentation:

• Chief complaint: Severe abdominal pain

• Key symptoms: Nausea, vomiting, fever, right upper quadrant tenderness, jaundice

• Vital signs: Temperature 38.5°C (101.3°F), heart rate 110 bpm, blood pressure 140/90 mmHg, respiratory rate 22 breaths per minute

Section 1

As the medical team continues to monitor the 45-year-old female patient with cholecystitis, new diagnostic results reveal a concerning shift in her condition. Laboratory tests show elevated white blood cell count at 16,000/µL, suggesting an ongoing inflammatory or infectious process. Liver function tests indicate elevated bilirubin at 3.2 mg/dL, alkaline phosphatase at 150 U/L, and transaminases, AST at 75 U/L and ALT at 82 U/L, pointing towards obstructive jaundice and possible liver involvement. An ultrasound of the abdomen confirms the presence of multiple gallstones within the gallbladder and a thickened gallbladder wall, measuring 5 mm, which is indicative of significant inflammation. Additionally, a small pericholecystic fluid collection is noted, raising the suspicion of a developing abscess or localized perforation.

These findings suggest a progression of the patient's condition towards a more severe form of cholecystitis, with the potential for complications such as gangrene or perforation. The presence of jaundice and the altered liver enzymes also indicate that the bile duct may be obstructed, leading to cholangitis, which can further complicate the clinical picture. The patient remains febrile with a temperature of 38.7°C (101.7°F) and is experiencing increasing tenderness in the right upper quadrant, exacerbating her discomfort and raising concerns about the potential for systemic infection or sepsis.

Given the evolving situation, the healthcare team decides to escalate care by initiating broad-spectrum intravenous antibiotics to target possible bacterial pathogens and prevent further infectious complications. The patient is also prepared for an urgent consultation with a surgical team to evaluate the need for an emergent cholecystectomy or possible percutaneous cholecystostomy to manage the gallbladder inflammation and obstruction. The team continues to closely monitor the patient's vital signs, laboratory results, and overall clinical status, ready to adjust treatment plans as necessary to address any further complications that may arise.

Section 2

As the healthcare team continues to manage the patient, new diagnostic results provide further insight into her deteriorating condition. A follow-up abdominal CT scan reveals an increase in the size of the pericholecystic fluid collection, now more suggestive of an evolving abscess. Additionally, the scan shows dilated intrahepatic bile ducts, reinforcing the suspicion of biliary obstruction. Concurrently, blood cultures return positive for Escherichia coli, confirming a bacterial infection that explains the persistent fever and elevated white blood cell count.

Clinically, the patient exhibits signs of worsening jaundice, with her skin and sclera appearing more icteric, and she reports dark urine and pale stools, indicative of impaired bile flow. Her vital signs reveal a continued febrile state with a temperature of 38.9°C (102°F), tachycardia with a heart rate of 110 beats per minute, and hypotension with a blood pressure of 95/60 mmHg, raising concerns for potential sepsis. These findings necessitate an urgent reassessment of her management plan to address the risk of systemic infection and to relieve the biliary obstruction.

In response to these developments, the surgical team expedites the patient's preparation for a potential percutaneous cholecystostomy to drain the abscess and alleviate the obstruction. Meanwhile, the antibiotic regimen is adjusted based on the sensitivity profile of the cultured bacteria to ensure effective coverage. The medical team emphasizes the importance of ongoing monitoring for signs of systemic inflammatory response syndrome (SIRS) and organ dysfunction, given the patient's trajectory towards sepsis. This careful coordination aims to stabilize her condition and prevent further complications, paving the way for definitive surgical intervention once she is clinically stable.

Section 3

As the healthcare team implements the revised management plan, the patient's response to interventions is closely monitored. Within 24 hours of initiating the adjusted antibiotic regimen, there is a noticeable, albeit gradual, reduction in her fever, with her temperature decreasing to 38.2°C (100.8°F). Her heart rate stabilizes slightly at 100 beats per minute, yet her blood pressure remains a concern at 90/55 mmHg, indicating persistent hypotension. Despite these marginal improvements, the patient continues to exhibit significant jaundice, with her bilirubin levels climbing to 6.5 mg/dL, further corroborating the severity of her biliary obstruction.

Lab results reveal that the patient's liver function tests show aggravated transaminase levels, with AST and ALT elevated to 220 U/L and 270 U/L, respectively. These findings suggest ongoing hepatic stress and potential liver dysfunction due to biliary obstruction and systemic infection. The patient's renal function remains within normal limits, but her lactate level has risen to 3.5 mmol/L, hinting at the early stages of tissue hypoperfusion and raising concerns about her progression towards septic shock.

Given the patient's evolving condition and the critical need to relieve the biliary obstruction, the surgical team proceeds with a percutaneous cholecystostomy under ultrasound guidance. The procedure successfully drains a significant volume of purulent fluid, providing initial relief. Post-procedure, the patient's vital signs are closely monitored, and there is a cautious optimism as her blood pressure begins to show signs of improvement, rising to 100/65 mmHg. However, the team remains vigilant for any new complications, such as potential bile leaks or further septic episodes, as they plan for her recovery and eventual definitive surgical intervention once her condition stabilizes.

Section 4

Following the percutaneous cholecystostomy, the healthcare team observes the patient's response to the intervention closely. Over the next 12 hours, her vital signs show a trend toward stabilization, with her heart rate decreasing to 88 beats per minute and her blood pressure maintaining at 105/68 mmHg. Despite these promising indicators, her jaundice persists, and repeat liver function tests reveal continued elevation of bilirubin at 5.8 mg/dL, alongside slightly reduced but still elevated AST and ALT levels at 200 U/L and 230 U/L, respectively. These findings reflect ongoing hepatic stress, though the gradual improvement in bilirubin levels suggests partial alleviation of biliary obstruction.

However, a new complication arises as the patient begins to exhibit signs of respiratory distress. Her respiratory rate increases to 24 breaths per minute, and she reports mild dyspnea. Arterial blood gas analysis reveals a pH of 7.32, partial pressure of carbon dioxide (PaCO2) at 50 mmHg, and partial pressure of oxygen (PaO2) at 70 mmHg, indicating respiratory acidosis and hypoxemia. A chest X-ray is performed, revealing bilateral infiltrates suggestive of pulmonary edema. The team suspects fluid overload as a contributing factor, possibly exacerbated by aggressive fluid resuscitation during initial management.

In response to these developments, the healthcare team adjusts the patient's management plan to address her respiratory status. Diuretics are administered to manage fluid overload, and non-invasive positive pressure ventilation (NIPPV) is initiated to support her breathing and improve gas exchange. The patient is monitored closely for signs of improvement in her respiratory status, with the goal of preventing progression to acute respiratory distress syndrome (ARDS) and ensuring her stability for potential surgical intervention. This cautious approach aims to balance the resolution of existing complications while preventing new ones, setting the stage for the next phase of her recovery.

Section 5

As the healthcare team continues to monitor the patient closely, her response to the interventions begins to unfold. Over the next 12 hours, the administration of diuretics and non-invasive positive pressure ventilation (NIPPV) shows promising results. The patient's respiratory rate gradually decreases to 18 breaths per minute, and she reports a slight reduction in dyspnea. Repeat arterial blood gas analysis indicates an improvement, with a pH of 7.35, PaCO2 of 45 mmHg, and PaO2 of 78 mmHg, suggesting partial correction of the respiratory acidosis and enhanced oxygenation.

Despite these improvements, the team remains vigilant for any signs of deterioration. A repeat chest X-ray shows a slight reduction in pulmonary infiltrates, confirming a positive response to the management of fluid overload. However, the persistence of jaundice and elevated liver enzymes prompts further investigation. An abdominal ultrasound is performed, revealing a dilated common bile duct, raising concerns about possible choledocholithiasis or other underlying biliary pathology that may require endoscopic intervention.

To address the potential biliary obstruction, the team plans for an endoscopic retrograde cholangiopancreatography (ERCP) to further evaluate and possibly relieve the obstruction. This decision is made in the context of the patient's improving respiratory status, allowing for a cautious advancement towards addressing the underlying biliary issues. The healthcare team prepares for this procedure, prioritizing the stabilization of her condition while anticipating possible complications that may arise from this next step in her treatment journey.