A patient with untreated cholecystitis is showing signs of systemic infection and possible progression towards sepsis. Which nursing intervention is most critical to prioritize at this time?

D) Initiating a fluid resuscitation protocol to maintain hemodynamic stability

A) Administering broad-spectrum intravenous antibiotics immediately

B) Preparing the patient for possible surgical intervention

C) Monitoring the patient's oxygen saturation and providing supplemental oxygen

D) Initiating a fluid resuscitation protocol to maintain hemodynamic stability

A patient with suspected progression towards sepsis due to untreated cholecystitis is being closely monitored. Which nursing intervention is most critical in preventing further deterioration of the patient's condition?

A) Administering prescribed broad-spectrum intravenous antibiotics as scheduled

B) Encouraging the patient to ambulate as tolerated to prevent complications of immobility

C) Providing the patient with oral fluids to maintain hydration and electrolyte balance

D) Applying supplemental oxygen to maintain oxygen saturation levels above 95%

A patient with a suspected gallbladder perforation is being prepared for an emergent laparoscopic cholecystectomy. Which nursing intervention is most critical to prioritize preoperatively to prevent further deterioration in the patient's condition?

C) Monitoring and maintaining the patient's hemodynamic stability through fluid resuscitation.

A) Administering analgesics to manage the patient's pain effectively.

B) Ensuring the patient remains NPO to prevent aspiration during surgery.

C) Monitoring and maintaining the patient's hemodynamic stability through fluid resuscitation.

D) Educating the patient and family about the surgical procedure to alleviate anxiety.

A patient with suspected gallbladder perforation is being prepared for an emergent laparoscopic cholecystectomy. The nurse notes the patient's blood pressure is 115/75 mmHg, heart rate is 125 bpm, and oxygen saturation is 92% on supplemental oxygen. Which is the most appropriate initial nursing intervention to optimize the patient's pre-surgical condition?

A) Increase the rate of IV fluid administration to improve blood pressure and perfusion.

B) Administer an additional dose of antibiotic to address potential infection.

C) Elevate the head of the bed to improve respiratory status and oxygenation.

D) Notify the surgical team to expedite the patient's transfer to the operating room.

A postoperative patient who underwent an open cholecystectomy is in the intensive care unit with a decreased urine output of 20 mL/hr, elevated lactate levels, and is on vasopressors. Which nursing intervention should be prioritized to address the potential risk of acute kidney injury?

A) Increase the rate of intravenous fluid administration

B) Administer a diuretic to promote urine output

C) Monitor daily weight to assess fluid retention

D) Adjust antibiotic therapy based on culture results

A postoperative patient who underwent an open cholecystectomy is admitted to the ICU with a diagnosis of early-stage sepsis. Which nursing intervention is the priority to prevent further complications?

A) Administer broad-spectrum antibiotics as prescribed

B) Monitor the patient's urine output closely

C) Assess the surgical site for signs of infection

D) Maintain the patient's blood pressure with vasopressors

A patient in the ICU with confirmed E. coli sepsis is experiencing persistent hypotension despite vasopressor support, oliguria, and a high lactate level. Which nursing intervention is most critical in addressing the patient's current condition?

C) Increase the rate of intravenous fluid administration.

A) Administer a diuretic to increase urine output.

B) Initiate continuous renal replacement therapy immediately.

C) Increase the rate of intravenous fluid administration.

D) Adjust the patient's oxygen delivery to a non-rebreather mask.

A patient in the ICU with sepsis from a biliary source is receiving vasopressor support, but continues to have hypotension, elevated heart rate, and low urine output. Which nursing intervention is most appropriate to address the current clinical findings?

C) Initiate additional fluid resuscitation to optimize cardiac output and kidney perfusion.

A) Increase the rate of the vasopressor infusion to improve blood pressure.

B) Administer a diuretic to enhance urine output and relieve potential fluid overload.

C) Initiate additional fluid resuscitation to optimize cardiac output and kidney perfusion.

D) Prepare the patient for immediate dialysis to address acute kidney injury.

A patient in the ICU develops signs of abdominal compartment syndrome after aggressive fluid resuscitation for cholecystitis. Which of the following nursing interventions is most critical in managing the patient's condition at this time?

C) Monitor intra-abdominal pressure and collaborate with the healthcare team regarding potential surgical intervention.

A) Increase the rate of fluid resuscitation to maintain blood pressure.

B) Position the patient in a high Fowler's position to reduce abdominal pressure.

C) Monitor intra-abdominal pressure and collaborate with the healthcare team regarding potential surgical intervention.

D) Administer additional analgesics to manage increased abdominal pain.

A patient in the ICU is developing signs of abdominal compartment syndrome following aggressive fluid resuscitation for cholecystitis. Which nursing intervention is the priority to address her current condition?

D) Position the patient to optimize respiratory function and monitor closely

A) Increase the rate of fluid resuscitation to improve perfusion

B) Administer analgesics to manage escalating abdominal pain

C) Prepare for a decompressive laparotomy to relieve intra-abdominal pressure

D) Position the patient to optimize respiratory function and monitor closely

cholecystitis - Nursing Case Study

Pathophysiology

• Primary mechanism: Gallstone obstruction in the cystic duct, leading to bile accumulation and increased pressure within the gallbladder, which initiates inflammation of the gallbladder wall.

• Secondary mechanism: Bacterial infection (commonly by E. coli) can develop due to stagnant bile, exacerbating the inflammatory process and potentially leading to pus formation and further gallbladder wall damage.

• Key complication: Untreated cholecystitis can progress to gallbladder necrosis or perforation, leading to peritonitis, a life-threatening condition requiring immediate medical intervention.

Patient Profile

Demographics:

45-year-old female, office manager

History:

• Key past medical history: Hypertension, Hyperlipidemia

• Current medications: Lisinopril 10 mg once daily, Atorvastatin 20 mg once daily

• Allergies: Penicillin

Current Presentation:

• Chief complaint: Severe right upper quadrant abdominal pain

• Key symptoms: Nausea, vomiting, fever, and jaundice

• Vital signs: Temperature 101.3°F, Heart rate 110 bpm, Blood pressure 145/90 mmHg, Respiratory rate 22 breaths per minute, Oxygen saturation 94% on room air

Section 1

As the case progresses, the patient's condition starts to show signs of deterioration, indicating the development of new complications. Over the course of several hours, her abdominal pain intensifies, and she begins to exhibit signs of systemic infection. Her vital signs reveal a concerning trend: her heart rate has increased to 120 bpm, her blood pressure has dropped to 130/85 mmHg, and her temperature has risen further to 102.5°F. Respiratory rate has increased to 24 breaths per minute, and oxygen saturation has decreased to 91% on room air. These changes suggest a possible progression towards sepsis, a serious complication of untreated cholecystitis.

Laboratory results further support this clinical suspicion. Her white blood cell count is markedly elevated at 17,000/mm³, indicating a significant inflammatory response or infection. Liver function tests show elevated bilirubin levels, confirming the presence of jaundice and suggesting that the bile duct obstruction is affecting hepatic function. An ultrasound of the abdomen reveals thickening of the gallbladder wall and the presence of pericholecystic fluid, suggesting inflammation and possible empyema formation. These findings necessitate urgent surgical consultation to evaluate the need for cholecystectomy and to prevent further complications such as gallbladder perforation.

The care team initiates broad-spectrum intravenous antibiotics, taking into account the patient's penicillin allergy, and provides supportive care including intravenous fluids to address potential sepsis. Despite these interventions, the patient's condition remains tenuous, prompting the healthcare team to closely monitor her hemodynamic status and laboratory markers. A decision must be made regarding the timing of surgical intervention, balancing the risks of further delaying the procedure against the potential for stabilization with medical therapy. This critical juncture requires careful clinical reasoning and collaboration among the multidisciplinary team to optimize patient outcomes.

Section 2

As the team continues to monitor the patient, new diagnostic results provide more clarity on the extent of her condition. A CT scan of the abdomen is performed to further evaluate the gallbladder and surrounding structures. The results reveal not only a distended gallbladder with a thickened wall and pericholecystic fluid, but also a small amount of free air in the abdominal cavity, suggestive of early gallbladder perforation. This finding is particularly concerning as it indicates that the inflammatory process has progressed beyond simple cholecystitis, posing a risk for generalized peritonitis and sepsis if not promptly addressed.

In light of these findings, the surgical team is consulted and they agree that immediate surgical intervention is necessary. The risk of delaying surgery now outweighs the benefits of continued medical management, given the potential for rapid deterioration. The patient is prepared for an emergent laparoscopic cholecystectomy, with the surgical team ready to convert to an open procedure if necessary, depending on intraoperative findings.

Meanwhile, the healthcare team remains vigilant in managing the patient's hemodynamic status. Despite ongoing fluid resuscitation and antibiotic therapy, her vital signs continue to show signs of instability. Her blood pressure has now dropped to 115/75 mmHg, and her heart rate remains elevated at 125 bpm. Oxygen saturation is maintained at 92% with supplemental oxygen. These parameters underscore the urgency of the situation and the need for a seamless transition to surgical care. The multidisciplinary team collaborates to ensure that the patient is optimized for surgery, with continuous monitoring and adjustment of therapies as needed to support her through this critical period.

Section 3

As the patient is wheeled into the operating room for the emergent laparoscopic cholecystectomy, the surgical team reviews the latest preoperative laboratory results that reveal new concerns. The patient's white blood cell count has risen to 18,000/mm³, indicative of a worsening inflammatory response, and her lactate level is elevated at 3.2 mmol/L, suggesting tissue hypoperfusion and a heightened risk for sepsis. These laboratory findings corroborate the clinical picture of a patient in the early stages of sepsis, emphasizing the urgency of surgical intervention to prevent further systemic deterioration.

Intraoperatively, the surgical team encounters significant inflammation around the gallbladder, confirming the CT findings of a thickened gallbladder wall and pericholecystic fluid. Additionally, small perforations in the gallbladder are identified, with localized bile leakage into the abdominal cavity, explaining the free air observed on imaging. The decision is made to convert to an open cholecystectomy to ensure thorough exploration and cleaning of the abdominal cavity. The surgical team successfully resects the gallbladder and irrigates the area to minimize the risk of peritoneal contamination and subsequent infection.

Postoperatively, the patient is transferred to the intensive care unit for close monitoring. Despite the successful surgery, her condition remains precarious. Her blood pressure is maintained with vasopressors, and she is started on broad-spectrum antibiotics to combat any potential peritoneal infection. The healthcare team continues to assess her fluid status and renal function, as her urine output has decreased to 20 mL/hr, raising concerns about acute kidney injury secondary to sepsis. The management plan includes titrating medications and fluid therapy to stabilize her hemodynamic status while monitoring her closely for any signs of further complications, such as persistent infection or organ dysfunction.

Section 4

As the first few hours in the ICU unfold, the patient's condition presents new challenges. Her vital signs are closely monitored, showing a persistent low blood pressure of 85/50 mmHg despite vasopressor support, and a heart rate that remains elevated at 115 beats per minute, indicative of continued systemic stress. Respiratory rate is slightly increased at 24 breaths per minute, and her oxygen saturation is stable at 95% on 2 liters of nasal cannula. However, her temperature rises to 38.7°C, pointing to a possible infectious process still at play. Her urine output continues to be concerning, with only 25 mL over the last two hours, reinforcing the suspicion of acute kidney injury.

New laboratory diagnostics reveal a further increase in her white blood cell count to 20,200/mm³, and a repeat lactate level remains high at 3.0 mmol/L, suggesting ongoing tissue hypoperfusion. Blood cultures drawn preoperatively have returned positive for Escherichia coli, confirming a biliary source of sepsis. These findings prompt an adjustment in her antibiotic regimen to more specifically target this organism, transitioning from broad-spectrum coverage to a more focused approach with piperacillin-tazobactam.

In response to these developments, the healthcare team intensifies her fluid resuscitation efforts, carefully balancing the risk of fluid overload given her compromised renal function. Diuretics are withheld for the time being, and nephrology is consulted for further assessment of her renal status. The interdisciplinary team considers the possibility of continuous renal replacement therapy if her renal function does not improve with optimized hemodynamic support. The focus remains on stabilizing her condition and preventing further organ dysfunction, while also preparing for potential adjustments in her management plan based on her evolving clinical status. This stage is critical in determining her trajectory towards recovery or further complications.

Section 5

As the team continues to manage the patient's condition, a new complication emerges that requires immediate attention. Over the next several hours, the patient begins to exhibit signs of abdominal compartment syndrome, a potential consequence of aggressive fluid resuscitation and underlying inflammation from her cholecystitis. Her abdomen becomes increasingly distended and tense, and she reports escalating abdominal pain, despite being on a continuous infusion of analgesics. The nursing staff notes a decrease in bowel sounds, and her respiratory rate increases further to 28 breaths per minute, suggesting diaphragmatic compromise due to the increased intra-abdominal pressure.

In light of these developments, an urgent bedside ultrasound is performed, revealing significant ascites and confirming the suspicion of abdominal compartment syndrome. The team assesses the need for decompressive laparotomy to relieve the pressure and prevent further deterioration of her organ function. This decision is weighed carefully, considering her current hemodynamic instability and the risk of additional surgical intervention. The patient's lactate level, now elevated at 3.5 mmol/L, further underscores the urgency of addressing the compromised perfusion.

As the healthcare team deliberates the next steps, they prioritize optimizing her hemodynamic status and monitoring closely for any further signs of organ dysfunction. The potential need for surgical intervention is balanced against the risks, and preparations are made for rapid escalation of care if necessary. This phase of her treatment highlights the complexity of managing critical complications in the ICU setting and underscores the importance of timely, coordinated interventions to guide her towards recovery.