A patient with suspected emphysematous cholecystitis is being prepared for an emergent cholecystectomy. Which nursing intervention is the highest priority to prevent further complications in this scenario?

B) Monitoring the patient's blood pressure and adjusting IV fluids accordingly.

A) Administering broad-spectrum IV antibiotics as prescribed.

B) Monitoring the patient's blood pressure and adjusting IV fluids accordingly.

C) Preparing the patient for surgery by ensuring informed consent is obtained.

D) Educating the patient and family about the surgical procedure and postoperative care.

A patient with suspected emphysematous cholecystitis is being prepared for an emergent cholecystectomy. Which nursing intervention is most critical in the preoperative period to prevent further deterioration of the patient's condition?

A) Administering prescribed broad-spectrum IV antibiotics immediately.

B) Initiating a low-fat diet to reduce gallbladder stimulation.

C) Applying warm compresses to the abdomen to alleviate discomfort.

D) Encouraging deep breathing exercises to prevent atelectasis.

A patient undergoing emergent management for septic shock with complications from a cholecystectomy presents with progressive hypotension, tachycardia, and signs of acute kidney injury. Despite fluid resuscitation and vasopressor therapy, the patient’s condition remains unstable. As the nurse in the intensive care unit, what is the most critical next step in managing this patient’s care?

C) Collaborate with the multidisciplinary team to reassess the timing of surgical intervention.

A) Increase the rate of norepinephrine infusion to further elevate blood pressure.

B) Initiate renal replacement therapy to address acute kidney injury and metabolic acidosis.

C) Collaborate with the multidisciplinary team to reassess the timing of surgical intervention.

D) Administer a higher concentration of supplemental oxygen to optimize respiratory status.

A patient undergoing preparation for an emergent cholecystectomy exhibits signs of septic shock and acute kidney injury. Despite aggressive fluid resuscitation, the patient's hemodynamics remain unstable. Which nursing intervention is the highest priority to implement immediately to address the patient's current condition?

B) Initiate norepinephrine infusion to stabilize blood pressure.

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

B) Initiate norepinephrine infusion to stabilize blood pressure.

C) Administer supplemental oxygen via a nasal cannula to improve oxygenation.

D) Prepare the patient for immediate intubation to address respiratory distress.

A patient in the ICU is diagnosed with ARDS secondary to sepsis and is now on mechanical ventilation. The latest ABG shows a pH of 7.28, PaCO2 of 55 mmHg, and PaO2 of 60 mmHg. The patient is also receiving CRRT due to acute renal failure. Which of the following actions should the nurse prioritize to optimize the patient's respiratory status and prevent further deterioration?

C) Implement prone positioning to improve ventilation-perfusion matching.

A) Increase the FiO2 setting on the ventilator to improve oxygenation.

B) Contact the physician to discuss increasing the tidal volume setting on the ventilator.

C) Implement prone positioning to improve ventilation-perfusion matching.

D) Administer sodium bicarbonate to correct the acid-base imbalance.

A patient in the intensive care unit is diagnosed with acute respiratory distress syndrome (ARDS) secondary to sepsis and is receiving mechanical ventilation with lung-protective strategies. The patient also shows signs of worsening renal function and fluctuating levels of consciousness. Which nursing intervention is most critical to perform first to optimize the patient's overall condition?

A) Increase the tidal volume on the ventilator to improve oxygenation.

B) Administer a bolus of intravenous fluids to improve renal perfusion.

C) Monitor neurological status closely and prepare for potential CT imaging.

A patient with sepsis-associated encephalopathy and septic cardiomyopathy is receiving mannitol to manage cerebral edema and dobutamine to improve cardiac output. Given the ongoing treatment, which nursing intervention is most critical to prioritize to prevent further complications?

A) Monitor urine output every 2 hours to assess renal function.

B) Adjust norepinephrine dosage based on blood pressure readings every 15 minutes.

C) Evaluate lung sounds hourly to detect early signs of pulmonary edema.

D) Perform a neurologic assessment every 4 hours to monitor for changes in consciousness.

A patient with sepsis-associated encephalopathy and septic cardiomyopathy is being managed with mannitol, norepinephrine, and dobutamine. The nurse observes a new onset of petechiae and prolonged PT. What is the nurse's priority action considering the patient's complex condition?

A) Administer fresh frozen plasma to address potential DIC.

B) Increase norepinephrine to manage hypotension.

C) Reduce mannitol dosage to prevent renal impairment.

D) Prepare for emergent intubation due to hypoxemia.

A patient in the ICU with acute respiratory distress syndrome (ARDS) and acute kidney injury (AKI) secondary to sepsis is receiving lung-protective mechanical ventilation and continuous renal replacement therapy (CRRT). During your assessment, you note increasing abdominal distension and tenderness. Which intervention should the nurse prioritize to address this new finding?

C) Prepare the patient for an urgent CT scan of the abdomen to assess for potential complications.

A) Increase the PEEP settings to improve oxygenation.

B) Administer a bolus of intravenous fluids to improve renal perfusion.

C) Prepare the patient for an urgent CT scan of the abdomen to assess for potential complications.

D) Adjust the CRRT settings to enhance fluid removal and reduce abdominal distension.

A critically ill patient in the ICU has developed acute respiratory distress syndrome (ARDS) and acute kidney injury (AKI) secondary to sepsis. The patient is on a lung-protective ventilation strategy and continuous renal replacement therapy (CRRT). During your assessment, you observe increased abdominal distension and tenderness. Which nursing action should take priority to address these findings?

B) Contact the healthcare provider to discuss the possibility of abdominal compartment syndrome.

A) Increase the PEEP settings on the ventilator to improve oxygenation.

B) Contact the healthcare provider to discuss the possibility of abdominal compartment syndrome.

C) Administer a diuretic as prescribed to reduce fluid overload.

D) Reposition the patient to improve abdominal blood flow and comfort.

cholecysectomy - Nursing Case Study

Pathophysiology

• Primary mechanism: Gallstone formation leads to obstruction of the cystic duct, causing increased intraluminal pressure and bile stasis, resulting in inflammation and infection of the gallbladder, known as cholecystitis.

• Secondary mechanism: Chronic inflammation induces fibrosis and thickening of the gallbladder wall, impairing its function and potentially leading to complications such as gallbladder perforation or abscess formation.

• Key complication: Untreated cholecystitis can progress to gangrenous cholecystitis, where necrosis of the gallbladder wall occurs, increasing the risk of perforation, peritonitis, and sepsis, necessitating urgent surgical intervention such as cholecystectomy.

Patient Profile

Demographics:

58-year-old female, retired nurse

History:

• Key past medical history: Hypertension, Type 2 Diabetes, Previous myocardial infarction

• Current medications: Metformin, Lisinopril, Aspirin, Atorvastatin

• Allergies: Penicillin

Current Presentation:

• Chief complaint: Severe abdominal pain radiating to the back

• Key symptoms: Nausea, vomiting, fever, jaundice

• Vital signs: Blood pressure 90/60 mmHg, Heart rate 130 bpm, Respiratory rate 28 breaths per minute, Temperature 102.2°F, Oxygen saturation 86% on room air

Section 1

New Diagnostic Results:

Following the initial assessment, the patient was swiftly transferred to the emergency department for further evaluation and stabilization. Blood tests revealed a marked leukocytosis with a white blood cell count of 18,000 cells/mm³, indicating a significant inflammatory response. Liver function tests showed elevated bilirubin levels at 5.2 mg/dL, alkaline phosphatase at 350 U/L, and transaminases significantly raised, consistent with obstructive jaundice. An urgent abdominal ultrasound confirmed the presence of multiple gallstones with a severely thickened gallbladder wall, measuring over 5 mm, and pericholecystic fluid, suggesting the development of complicated cholecystitis. A subsequent CT scan of the abdomen and pelvis revealed air within the gallbladder wall, a concerning sign of emphysematous cholecystitis, a rare and serious form of gallbladder inflammation caused by gas-forming organisms. This finding heightened the suspicion of impending perforation and sepsis.

In tandem with imaging, a blood culture was obtained, and preliminary results indicated growth of Escherichia coli, a common culprit in biliary infections, yet the presence of gas-forming bacteria highlighted the possibility of a mixed infection involving Clostridium species. The patient’s blood pressure continued to trend downward to 85/55 mmHg, despite fluid resuscitation, indicating a progression towards septic shock. Her lactate level was elevated at 4.5 mmol/L, further corroborating the severity of the infection and tissue hypoperfusion. Given these alarming diagnostic results, the decision was made to prepare the patient for an emergent cholecystectomy under intensive monitoring, while broad-spectrum IV antibiotics, including a carbapenem due to her penicillin allergy, were initiated to cover anaerobic and gram-negative organisms.

This complex diagnostic picture emphasizes the urgent need for surgical intervention and highlights the criticality of timely, evidence-based clinical reasoning in preventing further complications such as gallbladder perforation and generalized peritonitis. The healthcare team must now strategize precise perioperative management to optimize outcomes, taking into account the patient's comorbidities and potential for adverse reactions, while maintaining vigilant monitoring for any new complications that may arise in this fragile clinical scenario.

Section 2

As the surgical team prepared for the emergent cholecystectomy, the patient's condition rapidly deteriorated, presenting new complications that required immediate attention. Despite aggressive fluid resuscitation, the patient's blood pressure continued to plummet, reaching a critical level of 78/50 mmHg. Her heart rate soared to 128 beats per minute, indicating a compensatory response to the profound hypotension. The respiratory rate increased to 32 breaths per minute, accompanied by labored breathing and a decreased oxygen saturation of 88% on room air, necessitating supplemental oxygen via a non-rebreather mask. The patient's mental status began to fluctuate, with episodes of confusion and disorientation, suggesting worsening cerebral hypoperfusion.

In response to these alarming changes, the healthcare team swiftly implemented advanced hemodynamic support. A central venous catheter was placed to facilitate the administration of vasopressors, starting with norepinephrine, to stabilize her blood pressure and improve tissue perfusion. Continuous monitoring revealed a further drop in urine output to less than 20 mL/hour, a sign of acute kidney injury likely secondary to septic shock. Repeat blood work showed a worsening metabolic acidosis with a bicarbonate level of 15 mEq/L and a base deficit of -8, necessitating careful titration of bicarbonate therapy alongside vasopressors.

The evolving clinical picture demanded a reassessment of the surgical plan. The anesthesiology team expressed concerns regarding the patient's ability to tolerate general anesthesia given her unstable hemodynamics and declining respiratory status. A multidisciplinary discussion ensued, weighing the risks of proceeding with surgery against the potential for further decompensation. The decision was made to continue aggressive medical management in the intensive care unit while maximizing stabilization efforts, with the surgical intervention to be revisited once the patient’s condition showed signs of improvement. This precarious balance required meticulous coordination and constant reassessment, as the team worked to avert further complications and guide the patient toward recovery.

Section 3

As the intensive care team continued to monitor the patient closely, new diagnostic results added further complexity to the case. A portable chest X-ray revealed bilateral infiltrates suggestive of acute respiratory distress syndrome (ARDS), likely secondary to systemic inflammatory response syndrome (SIRS) and progressive sepsis. Concurrently, an arterial blood gas analysis showed a pH of 7.28, PaCO2 of 55 mmHg, and PaO2 of 60 mmHg, confirming respiratory acidosis and hypoxemia despite supplemental oxygen. These findings necessitated immediate escalation in respiratory support. After a thorough risk-benefit analysis, the team decided to initiate mechanical ventilation with careful attention to lung-protective strategies to minimize barotrauma.

Further complicating the clinical picture, new laboratory results revealed a rising white blood cell count of 22,000/mm³ and elevated lactate levels of 6 mmol/L, indicating worsening sepsis and poor tissue oxygenation. Blood cultures obtained earlier returned positive for gram-negative rods, prompting the infectious disease team to adjust the antibiotic regimen to include broad-spectrum coverage with meropenem and vancomycin. The nephrology team was consulted due to the patient's deteriorating renal function, as evidenced by a creatinine level of 2.8 mg/dL and further reduction in urine output, raising concerns for acute tubular necrosis. A decision was made to initiate continuous renal replacement therapy (CRRT) to manage fluid overload and support renal function.

Amidst these developments, the patient's mental status remained a key concern. Despite improved mean arterial pressure with norepinephrine titration, she continued to exhibit fluctuating levels of consciousness, with a Glasgow Coma Scale score ranging between 10 and 12. Neurological assessment revealed sluggish pupillary responses and an upward drift of the left arm, suggesting possible central nervous system involvement. A CT scan of the head was ordered to rule out any acute intracranial events. This multifaceted situation required the healthcare team to engage in dynamic and integrated critical thinking, balancing immediate life-sustaining interventions with ongoing reassessment and anticipation of further potential complications.

Section 4

As the multidisciplinary team continued to manage the patient's complex condition, a new complication emerged. The CT scan of the head revealed no acute intracranial hemorrhage, but the presence of diffuse cerebral edema was noted, likely secondary to systemic inflammatory response and sepsis-associated encephalopathy. This finding explained the patient's fluctuating level of consciousness and prompted the neurology team to recommend the administration of mannitol to reduce intracranial pressure, alongside careful monitoring of the patient's fluid status to prevent exacerbation of her compromised renal function.

However, shortly after initiating mechanical ventilation, the patient began to exhibit signs of hemodynamic instability. Her blood pressure dropped to 80/50 mmHg despite ongoing norepinephrine support, and her heart rate increased to 130 beats per minute. The team performed a point-of-care ultrasound, which revealed a severely reduced left ventricular ejection fraction, suggesting septic cardiomyopathy. This new development required the introduction of dobutamine to improve cardiac output and optimize perfusion. Furthermore, the critical care team decided to reduce the tidal volume on the ventilator to further protect the lungs, given the additional strain on the heart and the risk of exacerbating barotrauma.

As the team adjusted the interventions, they remained vigilant for further complications such as disseminated intravascular coagulation (DIC), as the patient presented with a new onset of petechiae and a prolonged prothrombin time (PT) of 18 seconds. This necessitated the commencement of fresh frozen plasma and close monitoring of coagulation parameters. Throughout these developments, the team engaged in continuous reassessment and interdisciplinary collaboration, utilizing advanced clinical judgment to navigate the complex interplay of the patient's critical conditions, while preparing for potential escalation in care as new challenges unfolded.

Section 5

As the critical care team continued to manage the patient's complex condition, a new complication arose, further challenging their clinical acumen. The patient developed acute respiratory distress syndrome (ARDS), likely secondary to both the ongoing sepsis and the systemic inflammatory response. This was evidenced by worsening hypoxemia despite high-flow oxygen, with arterial blood gases revealing a PaO2 of 55 mmHg and a PaCO2 of 60 mmHg on a FiO2 of 0.9. The chest X-ray showed bilateral pulmonary infiltrates, consistent with ARDS. The team decided to institute a lung-protective ventilation strategy with low tidal volume and increased PEEP, while closely monitoring for signs of barotrauma or pneumothorax given the patient's fragile state.

In parallel, the patient's renal function continued to deteriorate. The latest laboratory results indicated a sharp increase in creatinine to 3.5 mg/dL and a decrease in urine output to less than 0.5 mL/kg/hr. These findings pointed to acute kidney injury, compounded by the hemodynamic instability and potential nephrotoxic effects of the medications. The nephrology team recommended the initiation of continuous renal replacement therapy (CRRT) to manage fluid overload and electrolyte imbalances, while ensuring careful titration of medications to minimize further renal insult.

Despite the aggressive interventions, the patient's condition remained precarious. The team noted a subtle increase in abdominal distension and tenderness, raising concerns about potential abdominal compartment syndrome or ongoing intra-abdominal infection. An urgent repeat CT scan of the abdomen was ordered to assess for any new intra-abdominal pathology, including abscess formation or bowel ischemia, which could further complicate the clinical picture. This step underscored the importance of dynamic reassessment and the need for prompt diagnostic clarity to guide further therapeutic decisions in this critically ill patient.