Post Operative Care After Gall Stone Removal Essay

Bianca Robinson
Patients who are undergoing operative procedures are required the delivery of ongoing care to optimize their recovery and prevent complications. This delivery of care will enable early identification of circumstances surrounding surgery that may put patients at risk of harm. Mr Whakanna is a 36 year old Polynesian male who has just returned to the ward after having a laparoscopic cholecystectomy. A laparoscopic cholecystectomy is the surgical removal of the gall bladder using laparoscopic technology in a process also known as keyhole surgery (Graham, 2008, p. 47). The aim of this report is to identify and prioritize the problems associated with in the first four hours of Mr Whakaana’s return. It is important for nurses to have an understanding of gallstone disease and the surgical procedure, to ensure that patients are cared for with empathy but also safely and effectively. This report presents the four highest problems that may occur with Mr Whakaana on return to the ward from surgery.Post Operative Care After Gall Stone Removal Essay

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ABCD’s, Vital Signs and Pain
Although different surgical procedures require specific and specialist nursing care, the principles of post-operative care remain the same. It is essential for a structured assessment of Mr Whakaana to be carried out such as that described by Elliot, Aitken & Chaboyer (2007) where Airway, Breathing, Circulation, Disability and Environment are examined. This is known as a primary assessment, and is used to identify any signs of airway obstruction, respiratory failure, circulatory failure or neurological dysfunction (Graham, 2008). In this scenario, the nurse must pay particular attention to Mr Whakaana’s airway due to the fact that he has been administered 8mg of morphine, and morphine can cause respiratory depression (Tiziani, 2010). Bradypnoea is a respiratory rate less than 12 breathes per minute in an adult at rest, and is the first sign of respiratory depression; Mr Whakaana should be monitored closely to prevent this (Tiziani, 2010). Mr Whakaana’s conscious state should also be monitored especially as he is currently scored as 1 on the Glasgow Coma Scale, the nurse must pay particular attention to this to ensure that Mr Whakaana does not go into shock (Elliot, Aitken & Chaboyer, 2007). It is also helpful to include the patency of drainage systems and vascular devices into your primary assessment of Mr Whakaana, and note if any allergies are known (Elliot, Aitken & Chaboyer, 2007).Post Operative Care After Gall Stone Removal Essay

Vital signs should be assessed as often as possible (every half hour/hour) during the first four hours of Mr Whakaana’s return to the ward to determine any signs of deterioration. Vital sign measurements include blood pressure, respirations, pulse, temperature and oxygen saturation levels. Changes in Mr Whakaana’s blood pressure can be used to monitor changes in his cardiac output; pulse assessment can determine Mr Whakaana’s heart rate and rhythm, and can estimate the volume of blood being pumped by his heart (Elliot, Aitken & Chaboyer, 2007). Core body temperature differences can occur in illnesses and an abnormal reading can be an indication of infection; Mr Whakaana’s temperature is 36.5C at present, which is within normal range (REFERENCE). Pulse oximeters give a non-invasive estimate of the arterial haemoglobin oxygen saturation, and measurement should always be above 95% (REFERENCE). The nurse should be aware that Mr Whakaana is currently on 3L per minute of oxygen via nasal prongs, as this could give a false sense of security when recording/documenting Mr Whakaana’s oxygen saturation (Elliot, Aitken & Chaboyer, 2007).Post Operative Care After Gall Stone Removal Essay

Pain and discomfort are also important factors in Mr Whakaana’s postoperative period as good pain control is required for an optimal physical and psychological recovery. Post-operative nausea and vomiting (PONV) is common after laparoscopic cholecystectomy because of peritoneal gas insufflation and manipulation of the bowel (Graham, 2008). There are additional risk factors to consider including the use of peri-operative opioids (REFERENCE). Opioids, such as morphine, are a common cause of PONV and so their use, even during laparoscopic cholecystectomy, should be kept to the required minimum. Pain should be measured using an assessment tool that identifies the quantity and quality experienced of Mr Whakaana’s pain. Patients’ self-reporting of their pain is regarded as the gold standard of pain assessment measurement as it provides the most valid measurement of pain (REFERENCE). Self-reporting can be influenced by numerous factors including mood, sleep disturbances and medications and may result in patients not reporting pain accurately (REFERENCE). For example, Mr Whakaana may not report his pain because of the effects of sedation or lethargy and reduced motivation as a consequence of the surgery.Post Operative Care After Gall Stone Removal Essay

Fluid Balance / Output
Patients following surgery are vulnerable to fluid and electrolyte imbalance due to many factors, including blood loss, fasting for long periods and exposure during surgery (Walker,2003). Therefore an accurate measurement of Mr Whakaana’s fluid balance is an essential factor in evaluating his condition. This should include strict readings of the output of drains as well as urine and vomit, and the measurement of fluid intake (oral, nasogastric and intravenous). Wound drainage sites and the surgical wound itself should be inspected at regular intervals for excessive blood loss, as this may indicate haemorrhage. Other factors that should be taken into account include diarrhoea, sweating and the use of diuretic therapy.

Blood Sugars
Diabetes is associated with an increased requirement for surgical procedures and increased postoperative morbidity and mortality (Dagogo-Jack & Alberti, 2002). Hyperglycaemia impairs leukocyte function and wound healing (Tiziani, 2010). The management goal for Mr Whakaana is to optimize metabolic control through close monitoring, adequate fluid and caloric repletion, and sensible use of insulin (Dagogo-Jack & Alberti, 2002). This assessment is to prevent hyperglycaemia and prevent further complications during Mr Whakaana hospital stay.Post Operative Care After Gall Stone Removal Essay

Infection /Sepsis
Conclusion

Although postoperative care is a daily occurrence within many areas of practice, it is evident that the theory underpinning nursing actions is often forgotten in daily practice and hence actions may not be prioritised as they should be. It is hoped that this paper has enabled the reader to revisit the principles underpinning postoperative care. Such care must be viewed as a priority, and although there are local policies in place to guide nursing staff, the responsibility for understanding the reasons for actions lies with each individual practitioner.Post Operative Care After Gall Stone Removal Essay

The gallbladder is a small sac that holds bile, a digestive juice produced by the liver that is used in the breakdown of dietary fats. The gallbladder extracts water from its store of bile until the liquid becomes highly concentrated. The presence of fatty foods triggers the gallbladder to squeeze its bile concentrate into the small intestine.

Gallstones (biliary calculi) are small stones made from cholesterol, bile pigment and calcium salts, usually in a mixture that forms in the gallbladder. They are a common disorder of the digestive system, and affect around 15 per cent of people aged 50 years and over.Post Operative Care After Gall Stone Removal Essay

Some things that may cause gallstones to form include the crystallisation of excess cholesterol in bile and the failure of the gallbladder to empty completely.

In most cases, gallstones don’t cause any problems. However, you might need prompt treatment if stones block ducts and cause complications such as infections or inflammation of the pancreas (pancreatitis).

Surgeons may remove your gallbladder (called a cholecystectomy) if gallstones (or other types of gallbladder disease) are causing problems. Techniques include laparoscopic (‘keyhole’) cholecystectomy or open surgery. The gallbladder is not a vital organ, so your body can cope quite well without it.Post Operative Care After Gall Stone Removal Essay

Symptoms of gallstones

In approximately 70 per cent of cases, gallstones cause no symptoms. The symptoms of gallstones may include:
pain in the abdomen and back. Pain is generally infrequent, but severe
increase in abdominal pain after eating a fatty meal
jaundice
fever and pain, if the gallbladder or bile duct becomes infected.
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Types of gallstones

There are three main types of gallstones being:
mixed stones – the most common type. They are made up of cholesterol and salts. Mixed stones tend to develop in batches
cholesterol stones – made up mainly of cholesterol, a fat-like substance that is crucial to many metabolic processes. Cholesterol stones can grow large enough to block bile ducts
pigment stones – bile is greenish-brown in colour, due to particular pigments. Gallstones made from bile pigment are usually small, but numerous.Post Operative Care After Gall Stone Removal Essay
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Causes and risk factors for gallstones

Gallstones are more common in women than in men. They are also more common in overweight people and people with a family history of gallstones.

There is no single cause of gallstones. In some people, the liver produces too much cholesterol. This can result in the formation of cholesterol crystals in bile that grow into stones. In other people, gallstones form because of changes in other components of bile or because the gallbladder does not empty normally.

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Diagnosis of gallstones

Doctors diagnose gallstones by using a number of tests, including:
general tests – such as physical examination and x-rays
ultrasound – soundwaves form a picture that shows the presence of gallstones
endoscope test – endoscopic retrograde cholangiopancreatography (ERCP). A thin tube is passed through the oesophagus and injects dye into the bowel to improve the quality of x-ray pictures
hepatobiliary iminodiacetic acid (HIDA) scan – a special type of nuclear scan that assesses how well the gallbladder functions
magnetic resonance cholangiopancreatography (MRCP) – a form of the body-imaging technique magnetic resonance imaging (MRI). The person’s liver, biliary and pancreatic system is imaged using an MRI unit. The image is similar to an ERCP test.
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Complications of gallstones

If gallstones cause no symptoms, you rarely need any treatment.Post Operative Care After Gall Stone Removal Essay

Complications that may require prompt medical treatment include:
biliary colic – a gallstone can move from the body of the gallbladder into its neck (cystic duct), leading to obstruction. Symptoms include severe pain and fever
inflammation of the gallbladder (cholecystitis) – a gallstone blocks the gallbladder duct, leading to infection and inflammation of the gallbladder. Symptoms include severe abdominal pain, nausea and vomiting Post Operative Care After Gall Stone Removal Essay
jaundice – if a gallstone blocks a bile duct leading to the bowel, trapped bile enters the person’s bloodstream instead of the digestive system. The bile pigments cause a yellowing of the person’s skin and eyes. Their urine may also turn orange or brown
pancreatitis – inflammation of the pancreas, caused by a blocked bile duct low down near the pancreas. Pancreatic enzymes irritate and burn the pancreas and leak out into the abdominal cavity
cholangitis – inflammation of the bile ducts, which occurs when a bile duct becomes blocked by a gallstone and the bile becomes infected. This causes pain, fever, jaundice and rigors (shaking)
infection of the liver
cancer of the gallbladder (occurs rarely).Post Operative Care After Gall Stone Removal Essay
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Treatment for gallstones

Gallstones that cause no symptoms, generally don’t need any medical treatment. In certain cases (such as abdominal surgery for other conditions), doctors may remove your gallbladder if you are at high risk of complications of gallstones.

Treatment depends on the size and location of the gallstones, but may include:
dietary modifications – such as limiting or eliminating fatty foods and dairy products
lithotripsy – a special machine generates soundwaves to shatter the gallstones. This treatment is used in certain centres only, for the minority of people with small and soft stones
medications – some medications can dissolve gallstones, but this treatment is only rarely given, due to side effects and a variable success rate
surgery.Post Operative Care After Gall Stone Removal Essay
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Surgical removal of the gallbladder or gallstones

Around 80 per cent of people with gallstone symptoms will need surgery. Surgeons may remove your entire gallbladder (cholecystectomy), or just the stones from bile ducts.

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Techniques to remove the gallbladder include:
laparoscopic cholecystectomy – ‘keyhole’ surgery. The surgeon makes a number of small incisions (cuts) through the skin, allowing access for a range of instruments. The surgeon removes the gallbladder through one of the incisions
open surgery (laparotomy) – the surgeon reaches the gallbladder through a wider abdominal incision. You might need open surgery if you have scarring from prior operations or a bleeding disorder.
Medical factors to consider before cholecystectomy

Before the operation, you need to discuss some things with your doctor or surgeon, including:
your medical history, since some pre-existing conditions may influence decisions on surgery and anaesthetic
any medications you take on a regular basis, including over-the-counter preparations
any bad reactions or side effects from any medications.
Laparoscopic cholecystectomy

The general procedure includes:
The surgeon makes a number of small incisions into your abdomen, so that slender instruments can reach into the abdominal cavity.
A tube blowing a gentle stream of carbon dioxide gas is inserted. This separates the abdominal wall from the underlying organs.
The surgeon views the gallbladder on a TV monitor by using a tiny camera attached to the laparoscope.
Special x-rays (cholangiograms) during the operation can check for gallstones wedged in the bile ducts.
The ducts and artery that service the gallbladder are clipped shut. These clips are permanent.
The gallbladder is cut free using either laser or electrocautery
The gallbladder, along with its load of gallstones, is pulled out of the body through one of the abdominal incisions.
The instruments and the carbon dioxide gas are removed from the abdominal cavity. The incisions are sutured (closed up) and covered with dressings.Post Operative Care After Gall Stone Removal Essay
Open gallbladder surgery

The general procedure is the same as for laparoscopic surgery, except that the surgeon reaches the gallbladder through a large, single incision in the abdominal wall. Sometimes, an operation that starts out as a laparoscopic cholecystectomy turns into open surgery if the surgeon encounters unexpected difficulties, such as not being able to see the gallbladder properly.Post Operative Care After Gall Stone Removal Essay

Immediately after gallbladder surgery

After a gallbladder operation, you can expect to:
feel mild pain in your shoulder from the carbon dioxide gas
receive pain-relieving medications
be encouraged to cough regularly to clear your lungs from the general anaesthetic
be encouraged to walk around as soon as you feel able
stay overnight in hospital, if you had a laparoscopic cholecystectomy
stay up to eight days in hospital, if you had open surgery.
Complications after gallbladder surgery

All surgery carries some degree of risk. Possible complications of cholecystectomy include:
internal bleeding
infection
injury to nearby digestive organs
injury to the bile duct
leakage of bile into the abdominal cavity
injury to blood vessels.
Self-care after gallbladder surgery Post Operative Care After Gall Stone Removal Essay

Be guided by your doctor, but general self-care suggestions include:
Rest as much as you can for around three to five days.
Avoid heavy lifting and physical exertion.
Expect your digestive system to take a few days to settle down. Common short-term problems include bloating, abdominal pains and changes to toilet habits.
Most people recover within one week of laparoscopic surgery.Post Operative Care After Gall Stone Removal Essay