A patient undergoing cholecystectomy for gallbladder inflammation with suspected choledocholithiasis presents with fever, jaundice, and elevated lab values indicating systemic involvement. Which nursing intervention is the priority in managing this patient’s condition preoperatively?

A) Administer prescribed antibiotics to address potential infection.

B) Ensure the patient is NPO (nothing by mouth) in preparation for surgery.

C) Monitor vital signs closely for changes indicating sepsis.

D) Educate the patient about the surgical procedure and postoperative care.

A patient undergoing a cholecystectomy presents with fever, jaundice, and right upper quadrant pain. Laboratory results show leukocytosis, elevated liver enzymes, and elevated bilirubin. Which nursing action is most critical to perform preoperatively to address the potential for systemic complications?

B) Initiate antibiotic therapy as prescribed to manage the risk of infection.

A) Administer antiemetics to control nausea and prevent aspiration.

B) Initiate antibiotic therapy as prescribed to manage the risk of infection.

C) Monitor fluid intake and output to prevent dehydration.

D) Educate the patient about postoperative dietary restrictions to prevent complications.

A postoperative patient following cholecystectomy with ERCP is showing signs of hemodynamic instability, characterized by hypotension, tachycardia, and borderline oxygen saturation. Which nursing intervention is the most critical to address first in this scenario?

B) Administer IV fluids to address the hypotension.

A) Increase supplemental oxygen to improve oxygen saturation.

B) Administer IV fluids to address the hypotension.

C) Notify the surgical team about the increased abdominal pain.

D) Reassess vital signs and monitor for changes.

A patient is in the intensive care unit post-cholecystectomy with signs of hemodynamic instability, including a blood pressure of 90/60 mmHg, heart rate of 120 bpm, and oxygen saturation of 92% on supplemental oxygen. The patient also reports increasing abdominal pain and has a rising white blood cell count. Which nursing intervention is the priority to address the patient's current condition?

B) Increase the rate of IV fluid administration to improve blood pressure.

A) Administer prescribed broad-spectrum antibiotics as part of the sepsis protocol.

B) Increase the rate of IV fluid administration to improve blood pressure.

C) Provide supplemental oxygen to improve oxygen saturation levels.

D) Administer pain medication to manage the patient's discomfort.

A patient in the ICU is being treated for hemodynamic instability and potential infection. After initial improvements with interventions, the patient develops jaundice and imaging confirms bile leakage. What is the nurse's priority action in managing this patient's care?

B) Prepare the patient for possible surgical intervention

A) Monitor the patient's vital signs every 2 hours

B) Prepare the patient for possible surgical intervention

C) Administer prescribed antibiotics and document the response

D) Increase oxygen flow to improve respiratory status

A patient in the intensive care unit shows modest improvement in blood pressure but exhibits jaundice and elevated serum bilirubin levels. An abdominal ultrasound and CT scan confirm bile leakage. Which nursing intervention is most crucial at this time to prevent further complications?

B) Prepare the patient for immediate surgical intervention.

A) Administer additional fluids to maintain blood pressure.

B) Prepare the patient for immediate surgical intervention.

C) Increase the oxygen flow rate to improve saturation levels.

D) Adjust the antibiotic regimen to target bile duct infection.

A patient is in the ICU following an exploratory laparotomy and repair of a bile duct leak. The patient's serum bilirubin is elevated, and they are receiving high-flow nasal cannula oxygen therapy. Which nursing intervention is the highest priority to support this patient's stabilization and recovery?

D) Monitor and document bile output from the surgical drain.

A) Adjust the oxygen delivery mode to improve respiratory function.

B) Administer calcium supplements to correct hypocalcemia.

C) Initiate enteral nutrition to prevent metabolic derangements.

D) Monitor and document bile output from the surgical drain.

A patient post-exploratory laparotomy for a bile leak is being monitored in the ICU. The nurse notes an increase in serum bilirubin levels to 5.2 mg/dL. Which of the following nursing interventions is most appropriate to address the patient’s condition?

B) Collaborate with the dietitian to optimize enteral nutrition, focusing on liver-friendly nutrients.

A) Increase the patient's fluid intake to enhance renal clearance of bilirubin.

B) Collaborate with the dietitian to optimize enteral nutrition, focusing on liver-friendly nutrients.

C) Administer a diuretic to promote excretion of excess bilirubin.

D) Encourage early ambulation to improve circulation and promote liver function recovery.

A patient in the ICU on the third postoperative day after abdominal surgery develops a low-grade fever, increased right upper quadrant tenderness, and an increase in surgical drain output. An abdominal ultrasound suggests a small localized fluid collection. Based on these clinical findings, what is the nurse's priority intervention?

C) Administer prescribed broad-spectrum antibiotics and monitor for response.

A) Increase the frequency of vital sign monitoring to every hour.

B) Prepare the patient for immediate surgical intervention.

C) Administer prescribed broad-spectrum antibiotics and monitor for response.

D) Encourage the patient to ambulate to promote drainage of fluid collection.

A patient in the ICU is recovering postoperatively and has developed a low-grade fever and increased tenderness in the right upper quadrant. The surgical drain output has increased, and imaging confirms a small subhepatic abscess. What is the nurse's priority intervention to address these findings?

B) Notify the physician of the changes and collaborate on initiating broad-spectrum antibiotics.

A) Educate the patient on the importance of adhering to antibiotic therapy.

B) Notify the physician of the changes and collaborate on initiating broad-spectrum antibiotics.

C) Increase the frequency of vital sign monitoring to every 30 minutes.

D) Reposition the patient to improve comfort and reduce abdominal pressure.

cholycystectomy - Nursing Case Study

Pathophysiology

• Primary mechanism: Cholecystectomy involves the surgical removal of the gallbladder, primarily due to gallstones obstructing the cystic duct. This obstruction leads to increased pressure and inflammation within the gallbladder, causing pain and potential infection (cholecystitis).

• Secondary mechanism: Without a gallbladder, bile produced by the liver flows directly into the small intestine, which can alter digestion. The gallbladder typically concentrates bile, but its absence may lead to less efficient fat digestion, potentially causing diarrhea or fat malabsorption in some patients.

• Key complication: Post-cholecystectomy syndrome can occur, characterized by persistent abdominal pain and gastrointestinal symptoms due to bile duct injury or alterations in bile flow, emphasizing the need for careful surgical technique and postoperative monitoring.

Patient Profile

Demographics:

45-year-old female, office manager

History:

• Key past medical history: Hypertension, hyperlipidemia

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

• Allergies: Penicillin

Current Presentation:

• Chief complaint: Severe abdominal pain and nausea

• Key symptoms: Right upper quadrant pain, fever, jaundice, vomiting

• Vital signs: Temperature 101.4°F, Heart rate 110 bpm, Blood pressure 150/95 mmHg, Respiratory rate 22 breaths per minute, Oxygen saturation 94% on room air

Section 1

As the surgical team prepared for the cholecystectomy, the patient's initial assessment findings indicated significant concerns that warranted immediate attention. The right upper quadrant pain was consistent with gallbladder inflammation, yet the addition of fever and jaundice suggested a more complex scenario, possibly involving acute cholangitis or choledocholithiasis, where a gallstone obstructs the common bile duct. Given the patient's elevated heart rate and blood pressure, alongside an elevated respiratory rate and borderline oxygen saturation, there was a clear indication of systemic involvement, potentially sepsis, necessitating prompt intervention.

Laboratory tests were ordered to clarify the situation, revealing leukocytosis with a white blood cell count of 16,000/mm³, elevated liver enzymes (AST and ALT above 200 U/L), and a total bilirubin level of 3.5 mg/dL. These findings corroborated the suspicion of common bile duct obstruction and possible liver involvement. An abdominal ultrasound confirmed the presence of gallstones and suggested dilatation of the common bile duct, further complicating the clinical picture. These results emphasized the need for a careful surgical approach and possible intraoperative cholangiography to assess for stones in the common bile duct.

The surgical plan was adjusted to address these complexities, and antibiotics were initiated to manage the infection risk. The team anticipated potential postoperative complications, such as bile leakage or persistent pain due to ductal injury, necessitating vigilant postoperative monitoring. The patient was informed about the potential for these complications and the need for close follow-up after the cholecystectomy to ensure optimal recovery and manage any arising issues effectively.

Section 2

As the surgical team proceeded with the cholecystectomy, the patient's condition remained a focal point of concern due to the potential complications already identified. During the procedure, intraoperative cholangiography was performed, revealing a significant stone lodged in the common bile duct, confirming the initial suspicion of choledocholithiasis. This finding necessitated an additional procedure, an intraoperative endoscopic retrograde cholangiopancreatography (ERCP), to remove the obstructing stone. The ERCP was successful in clearing the obstruction, but it extended the duration of the surgery, which was a crucial factor considering the patient's systemic condition.

Postoperatively, the patient was transferred to the intensive care unit for close monitoring, given the complexity of the case and the potential for new complications. Within the first 24 hours, the patient exhibited signs of hemodynamic instability, with blood pressure dropping to 90/60 mmHg and heart rate increasing to 120 beats per minute. Oxygen saturation remained borderline at 92% on supplemental oxygen, and the patient reported increasing abdominal pain. Laboratory tests indicated a further rise in white blood cell count to 18,500/mm³, suggesting a possible ongoing infectious process or inflammatory response.

The clinical team initiated a sepsis protocol, adjusting antibiotic therapy to cover a broader spectrum while ensuring fluid resuscitation to address the patient's hypotension. The pain was managed with caution, considering the risk of masking any signs of bile leakage or other complications. This situation demanded a multidisciplinary approach, involving the surgical team, intensivists, and infectious disease specialists, to optimize the patient’s recovery trajectory while remaining vigilant for any further complications. The patient's journey now hinged on the effectiveness of these interventions in stabilizing the condition and preventing further deterioration.

Section 3

As the patient continued to be monitored in the intensive care unit, the multidisciplinary team focused on the response to the interventions initiated to address the hemodynamic instability and possible infection. Over the next 12 hours, there was a modest improvement in the patient's blood pressure, which stabilized around 100/65 mmHg following aggressive fluid resuscitation. However, the heart rate remained elevated at 115 beats per minute, indicating a persistent compensatory response. Despite this, the respiratory status showed slight improvement, with oxygen saturation increasing to 94% on high-flow nasal cannula, suggesting better oxygenation.

The laboratory tests, repeated 24 hours post-intervention, revealed that the white blood cell count had slightly decreased to 16,000/mm³, hinting at a potential response to the broad-spectrum antibiotics. However, the patient began to exhibit signs of jaundice, with scleral icterus becoming more pronounced and serum bilirubin levels climbing to 4.5 mg/dL. These findings raised concerns about possible bile duct obstruction or bile leakage, prompting the team to consider imaging studies to assess the biliary tree for any new blockages or leaks.

Given the mixed response to initial interventions and the new development of jaundice, the clinical team decided to conduct an urgent abdominal ultrasound followed by a CT scan with contrast to evaluate for any complications such as bile duct perforation or persistent obstruction. The imaging revealed a moderate amount of free fluid in the abdominal cavity, consistent with bile leakage, necessitating further surgical consultation. This development underscored the need for prompt surgical intervention to address the bile leak, as untreated, it could lead to peritonitis and further complicate the patient's recovery trajectory.

Section 4

As the surgical team reviewed the imaging results, the decision was made to proceed with an exploratory laparotomy to address the bile leak. During the procedure, a small perforation in the cystic duct was identified as the source of the leak. The surgical team successfully repaired the duct and placed a surgical drain to facilitate postoperative monitoring of bile output. Despite the successful intervention, the patient's condition remained fragile.

Postoperatively, the patient was closely monitored in the intensive care unit. Vital signs continued to show a heart rate of 110 beats per minute, while blood pressure remained stable at 105/70 mmHg with ongoing fluid support. Oxygen saturation improved slightly to 96% with high-flow nasal cannula, indicating adequate respiratory compensation. However, laboratory results indicated a further increase in serum bilirubin to 5.2 mg/dL, reflecting continued hepatic dysfunction, potentially exacerbated by the recent surgical stress.

The patient's metabolic panel revealed a corrected calcium level of 7.8 mg/dL, suggesting mild hypocalcemia, which was addressed with calcium supplementation. The multidisciplinary team initiated discussions to optimize the patient's nutritional status and enhance recovery, focusing on enteral nutrition support to prevent further metabolic derangements. As the patient began to stabilize, the team planned for gradual weaning from high-flow oxygen support while ensuring vigilant monitoring for any signs of recurrent infection or bile leak complications. The clinical team recognized the need for ongoing assessment of liver function, anticipating that resolving the bile leak would lead to gradual improvement in bilirubin levels. This careful balancing of interventions and monitoring underscored the complexity of the patient's recovery process, necessitating continued collaborative care to prevent further setbacks.

Section 5

As the patient continued to recover in the intensive care unit, the clinical team remained vigilant for any signs of new complications. On the third postoperative day, the patient developed a low-grade fever of 100.6°F, prompting an immediate assessment for potential sources of infection. Blood cultures were drawn, and the surgical drain output was carefully examined for any changes in character or volume. Despite stable hemodynamics with blood pressure at 110/72 mmHg and heart rate at 100 beats per minute, a sudden increase in drain output to 150 mL over the last 12 hours raised concerns about a possible re-leak or infection. The drain fluid was sent for biochemical analysis to assess the presence of bile or infection-related markers.

In parallel, the patient's abdominal examination revealed increased tenderness in the right upper quadrant, accompanied by mild guarding, which had not been previously noted. Given these findings, the surgical and medical teams considered the possibility of an evolving intra-abdominal infection or abscess formation. An abdominal ultrasound was ordered to investigate the status of the biliary tract and adjacent structures, revealing a small localized fluid collection near the site of the previous repair. This raised the suspicion of a developing abscess, necessitating further imaging with a contrast-enhanced CT scan for better delineation.

The new diagnostic results confirmed the presence of a small subhepatic abscess. In response, the interdisciplinary team promptly initiated broad-spectrum antibiotics to address the potential infectious process and consulted interventional radiology for possible percutaneous drainage. The team held a collaborative discussion to reassess the patient's condition and intervention strategy, weighing the risks and benefits of additional procedures against the need for ongoing conservative management and close monitoring. This dynamic situation highlighted the importance of adaptive clinical reasoning, balancing timely interventions with the patient's overall stability and recovery trajectory.