The patient is a 45-year-old female presenting with sudden abdominal pain for 3 hours in her epigastric and right upper quadrant areas. She reports one episode of vomiting and a subjective fever. Her vital signs show elevated blood pressure, heart rate, and temperature. Physical exam reveals tenderness in the epigastric and right upper quadrants. Based on her history and exam findings, she is suspected to have acute cholecystitis.

1. TOMORROW
Do not wait for tomorrow,
Because Tomorrow
Does not wait for you.
Therefore Tomorrow always
Comes Tomorrow

3. CASE SENARIO
A 45-year-old female presents with a C/O sudden abdominal
pain for past 3 hours; one episode of vomiting, and a
subjective fever.. She localizes the pain to her epigastric
area and states that it radiates to her right upper quadrant.
She notes that it became markedly worse after eating dinner
last night. She recalls a past history of similar pain, but has
never had any diagnostic workup. K/C/O hyper tension ;
Undergone hysterectomy 1 year ago. No ill habits
 BP 155/90, HR 110, RR 14, T 100.6, SpO2 98%
 On P/E Her chest and cardiovascular exams are normal
except for mild tachycardia. Her abdominal exam is
significant for tenderness to palpation to her epigastric
and right upper quadrants without rebound tenderness.
Bowel sounds are normal.

4. By
Rexy Jenita J.
MSc (N),
Medical Surgical Nursing,
SRIHER (DU)

5. ANATOMY
 The gallbladder is a
pear shape-shaped
sac that is located in a
depression of the
posterior surface of
the liver.
 It is 7-10cm long and
typically hangs from
the anterior inferior
margin of the liver.

7. PARTS
 Fundus – Projects
inferior beyond the
inferior border of the
liver
 Body- Central portion
 Neck- Tapered
portion
 Body and neck
projects superiorly

8. CAPACITY OF GALLBLADDER
 40 – 60ml

9. BLOOD SUPPLY - ARTERY

10. VEIN

11. NERVE SUPPLY
 Celiac nerve plexus (sympathetic and
visceral afferent [pain] fibers)
 The vagus nerve (parasympathetic)
 The right phrenic nerve (actually somatic
afferent fibers).

12. FUNCTIONS
 Reservoir for bile
 Concentration of the bile by up to 10 -15 fold,
by absorption of water through the wall of the
gallbladder
 Release of
stores bile.

13. DEFINITION
 Inflammation of the gallbladder. Usually
associated with cholelithiasis.

14. INCIDENCE
 Gallbladder disease is common health
problem in India. It is estimated that 7% of
North Indians and 2% of South Indians have
gallstones. Cholecystectomy is most
common surgical procedure performed in
India.

15. TYPES OF CHOLECYSTITIS
 Acute cholecystitis
 Acute calculous cholecystitis
 Acute Acalculous cholecystitis
 Chronic cholecystitis

16. ACUTE CHOLECYSTITIS DEFINITION-
 Acute cholecystitis refers to acute
inflammation of the gallbladder wall.

17. ETIOLOGY OF ACUTE CHOLECYSTITIS
 Gall stone in cystic duct
 Obstruction in cystic
duct
 Bacterial infection (gram
positive and gram
negative aerobes and
anaerobes:- E. Coli,
klebsiella, Clostredium
and streptococcus)

18. RISK FACTORS ACUTE CHOLECYSTITIS
BOOK PICTURE PATIENT PICTURE
Sedentary lifestyle
obesity

19. PATHOPHYSIOLOGY
DUE TO ETIOLOGICAL FACTORS
VENOUS AND LYMPHATIC DRAINAGE
IMPAIRED
CELLULAR IRRITATION AND INFLAMMATION
PROLIFERATION OF BACTERIA TAKES
PLACE
ACUTE CHOLECYSTITIS

20. PROGRESSION OF ACUTE CHOLECYSTITIS
 Gallbladder has a grayish appearance & is
edematous. -There is an obstruction of the
cystic duct and the gallbladder begins to
swell. - It no longer has the "robin egg blue"
appearance of a normal gallbladder.

21. PROGRESSION OF ACUTE CHOLECYSTITIS
 As acute cholecystitis progresses, the
gallbladder begins to become necrotic and
gets a speckled appearance as the wall
begins to die.

22. PROGRESSION OF ACUTE CHOLECYSTITIS
 Gallbladder undergoes gangrenous change
and the wall becomes very dark green or
black. - This is the stage when perforation
occurs.

23. CLINICAL MANIFESTATION
BOOK PICTURE PATIENT PICTURE
Complain of pain
• In right upper quadrant
• In epigastric region
• In right subscapular
Complain of pain
• In right upper quadrant
Onset sudden Onset sudden
Peak in 30min
Nausea and vomiting Nausea and vomiting
Low grade fever Fever temperature -100*F
Mild jaundice

24. CHRONIC CHOLECYSTITIS DEFINITION-
 Repeated inflammation and infection of
gallbladder

25. SIGNS AND SYMPTOMS OF CHRONIC
CHOLECYSTITIS
BOOK PICTURE PATIENT PICTURE
Epigastric pain
Indigestion
Fat intolerance
Heart burn
Fibrosis of gall tissues
Inability to concentrate bile

26. DIAGNOSTIC STUDIES
BOOK PICTURE PATIENT PICTURE
USG Cholecystitis
ERCP
Percutaneous Transhepatic
Cholangiography
LFT
WBC
Serum Billirubin

27.  https://www.youtube.com/watch?v=2T0XUQ1
M-x0

28. MEDICAL MANAGEMENT
GOAL
 To treat symptomatic causes
 To prevent complication

29. MEDICAL MANAGEMENT
BOOK PICTURE PATIENT PICTURE
IV fluids IV fluids
Antiemetic Antiemetic
NPO with NG Tube NPO with NG Tube
Antibiotic therapy
Ampicillin
Ureidopenicillins – piperacillin or mezlocillin
Third generation cephalosporins-
Ceftriaxone, cefixime, Cefotaxime
Aminoglycosides – Gentamicin, Amikacin,
Neomycin
Inj Augmentin 625 mg IV BD

30. MEDICAL MANAGEMENT
BOOK PICTURE PATIENT PICTURE
Transhepatic Biliary catheter
ERCP with sphincterotomy
ExtraCorporeal shock-wave lithotripsy

31. ERCP WITH SPHINCTEROTOMY

32. SURGICAL MANAGEMENT
BOOK PICTURE PATIENT PICTURE
Laparoscopic Cholecystectomy
Open Cholecystectomy Open Cholecystectomy

33. OPEN CHOLECYSTECTOMY

35. TRANSHEPATIC BILIARY CATHETER

36. PATIENT AND CARE GIVER TEACHING
 Avoid weight lifting for 4 to 6 weeks
 Remove the bandage on the puncture sites
the day after the surgery and you can shower
 Notify the physician if
• Redness, swelling, bile coloured drainage or
pus from any incision
• Sever abdominal pain, nausea, vomiting,
chills, fever

37. PATIENT AND CARE GIVER TEACHING
 Gradually resume normal activity
 Return to work within 1 wk of surgery
 Resume usual diet, but a low fat diet is
usually better tolerated for several weeks (4-
6 weeks)after surgery

38. NURSING DIAGNOSIS

39. THEORY APPLICATION
VERGINA HENDERSON’S
“THE NEED THEORY”
Henderson identified 14 basic needs that form
the component of nursing care. The nurse help
the patient to meet the need.
ROLE OF NURSE
1. Substitute(doing for the person)
2. Supplementary(helping the person)
3. Complementary(working with the person)

40. 1 Breath normally C/O dyspnea on
mechanical ventilation,
ascitis
Risk for ineffective
breathing r/t secretion.
Comfortable position ,
airway clearance,
administer O2
2 Eat and drink
adequately
On NG tube , NPO
status due to surgery,
fluid restriction
Risk for imbalance
nutrition less than body
requirement r/t
inadequate intake.
Give diet and fluid plan
plan , give q2h NG
feed. Ask for patients
likes and dislikes
3 Eliminate body
waste
On continuous bladder
drainage, prolong bed
rest
Risk for altered bowel
elemination,or impaired
urinary elimination r/t
inability to attain bowel
and bladder control

41. 4 Move and maintain
desirable position
On restricted movement
and prolong bed rest
Impaired physical
mobility r/t liver surgery
and prolong bed rest
Ambulate and teach
exercise
5 Sleep and rest Has complaints of
sleeplessness due to
dyspnea due to ascites
Sleep disturbance r/t
pain, dyspnea and
anxiety
Provide comfortable
environment and
encourage bed time
rituals
6 Select suitable dress On hospital patient gown Situational Low esteem
r/t hospitalization . Ask
patient preference

42. 7 Maintain body
temperature
Post operative
patient, hepatitis
Risk for hyperthermia r/t
infection Hygiene, aseptic
technique, monitor vital
signs
8 Maintain bodily
cleanliness
Inability to do activity
in daily living and self
care
Self care deficit r/t bed
rest and pain
Administer analgesic ,
assist in ADL
9 Avoid dangerous in
the environment
Has imbalance
mobility
Risk for injury r/t unsafe
environment
Provide fall free
environment , assist in
ambulation

43. 10 Communicates with
others to express
emotion, needs fears and
opinion
Looks dull due to
health condition , poor
socialization
Anxiety r/t to health
condition,
hospitalization
Give psychological
support encourage
patient to express
ideas
11 Worship according one’s
faith
Looks depressed Ask for their need and
give priority. Also ask
for chapliancy if
needed
12 Work in a way that
provides a sense of
accomplishment
Powerlessness, tired Enhanced self esteem
r/t encouragement of
the care giver

44. 13 Participate in various
forms of recreation
Looks bored and
alone
Risk for impaired
socialization r/t health
condition
Encourage caregiver to
be with the patient, give
music therapy, ask for
patient interest, give
newspaper, book
14 Learn , discover , or
satisfy the curiosity that
leads to normal
development and health
and use the available
facilities
Poor knowledge
about the available
facility
Explain about the
social facility and follow
up to the hospital

45. JOURNAL INFORMATION

46. ABSTRACT
Background and Objectives:
Percutaneous cholecystostomy is currently
indicated for patients with cholecystitis who
might be poor candidates for operative
cholecystectomy. We performed a study to
evaluate the long-term outcome of patients
undergoing emergent tube cholecystostomy

47. METHODS
This study was a retrospective chart review of
patients who underwent tube cholecystostomy
from July 1, 2005, to July 1, 2012.

48. RESULTS:
During the study period, 82 patients underwent 125 cholecystostomy
tube placements. Four patients (5%) died during the year after tube
placement. The mean hospital length of stay for survivors was 8.8
days (range, 1–59 days). Twenty-eight patients (34%) required at
least 1 additional percutaneous procedure (range, 1–6) for
gallbladder drainage. Twenty-nine patients (34%) ultimately
underwent cholecystectomy. Surgery was performed a mean of 7
weeks after cholecystostomy tube placement. Laparoscopic
cholecystectomy was attempted in 25 operative patients but
required conversion to an open approach in 8 cases (32%). In
another 4 cases, planned open cholecystectomy was performed.
Major postoperative complications were limited to 2 patients with
postoperative common bile duct obstruction requiring endoscopic
retrograde cholangiopancreatography, 1 patient requiring a return to
the operating room for hemoperitoneum, and 2 patients with bile
leak from the cystic duct stump.

49. CONCLUSIONS
In high-risk patients receiving cholecystostomy
tubes for acute cholecystitis, only about one
third will undergo surgical cholecystectomy.
Laparoscopic cholecystectomy performed in
this circumstance has a higher rate of
conversion to open surgery and higher
hepatobiliary morbidity rate.

50. REFERENCE
1. Lewis Medical Surgical Nursing 3rd edition 2nd
volume
2. Brunner and Suddarths Text Book of Medical
Surgical Nursing 13th edition
3. Taylor Fundamental of nursing 7th edition
4. Mosby’s 2021 Nursing drug reference 4th south Asia
edition
5. Tortara and Derrickson principle of Anatomy and
Physiology 13th edition
6. Comprehensive Textbook of Pathophysiology for
Nurses
7. Mahapatra Essential of Medical Physiology
8. Robbinsons Basic Pathology 9th edition

51. NET REFERENCE
 https://www.slideshare.net/AnshuYadav31/ch
olecystitis-cholelithiasispresentation-
88122604
 https://nurseslabs.com/cholecystectomy-
nursing-care-plans/
https://www.youtube.com/watch?v=2T0XUQ1M
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