Post Operative Care after Cholecystectomy - Literature review Example

Running Head: Report on a Clinical Scenario Post Operative Care after Cholecystectomy Name Institution Date Cholecystectomy is the surgical removal of the gall bladder.Cholecystectomy is now the first choice management option for the inflammation of the gall bladder and symptomatic gall stones. The risk for the development of the gall stones increases with age and also the body mass index with the women being more predisposed to gall stones formation. Gall stones tend to develop as a result of an imbalance in the chemical constituents of bile (Etolen, 2011). When gall stones are formed, they bring about pain on blocking the outlet of the gall bladder, the stones can also lead to pancreatitis as it passes down the bile duct and thee stones will manage to cause irritation of the opening of the pancrease.Jaundice will ensure due to the gall stone bringing about the obstruction to the flow of bile this will be exhibited by the yellowness of the skin, itching of the skin and the passage of darker urine. There are various methods of managing the gall stones which include dissolving of the stones or operation to remove the gall bladder (cholecystectomy). Various complications could arise when cholecystectomy is conducted. This will include, the Infection of both the wounds, bleeding that could occur after the surgery at the site of the wound, the leakage of bile could also occur from the site of the incision and the patients will tend to have pain in the abdomen and the tips of the shoulders (Etolen, 2011). The pain at the shoulder tip that was exhibited by the patient, at other instances the pain could be located in the lower abdomen or even the patient could manifest with back pains. The patient in the case study had the pains located at the tip of the shoulder and it had a score of 6.this means that the pain is severe in nature. The pain tends to be caused by the insufflaction of the abdomen when laparatomy is being conducted by gas or fluid so that the endoscope can be able to visualize the abdominal contents without the direct contact with the abdominal viscera or tissues. The pain will be caused as a result of the irritation of the diaphragm by the carbon dioxide gas (Etolen, 2011). The shoulder tip pain tends to occur in most patients. The pain is felt greatest after operation and will decrease to a low level within 24hours after which the pain will be at its peak. The shoulder pain would be more significant one day after undergoing surgery (Fannin, 2011). The mechanism of pain after laparatomy will be due to a rapid distention of the peritoneum that will be associated by the tearing and rapture of blood vessels, traction of the nerves is also experienced during this period and this will also be characterized by the release of the inflammatory mediators. The shoulder pain will occur when the phrenic nerve is excited. This shoulder pain is most often associated with pneumoperitoneum that is persistent. The pain could also be due to excessive traction of the triangular ligament and over stretching of diaphragmatic fibers due to insufflation (Fannin, 2011). Nursing care for this post cholecystectomy patient will be usually for a short term basis. Nursing priorities in this case will be on the maintenance of the patient’s fluid as well as the electrolyte balance to be within the normal limits. The nurse should also provide the wound care to facilitate healing of the wound without any complications. The reliving of the patients pain will also be a priority. The appropriate nutritional requirements of the patient should also be met (Rodts, 2011).Clinical care and assessment will encompass the checking of the vital signs four hourly within the first twenty four hours and eight hourly in the next twenty four hours. The observation of the patient for the early and the late warning signs is done. The vital signs to be taken will include the temperature, the pulse, respiratory rate and the blood pressures. This will enable planning of the care for the patient. The early and late warning signs will also enable the provision of adequate interventions at the right time. The patient will also be assessed for the eight general parameters which include pallor, dehydration, edema, pallor, cyanosis, jaundice, oral thrush and finger clubbing (Rodts, 2011). The nurse should also initiate the appropriate protocol for the management of the pain that the patient is having at the shoulder. The assessment of the intensity, character and the quality of the pain has to be considered (Jensen et al, 2007). The nurse will have to rate the pain every now and then to ascertain the effectiveness of the planned intervention for the pain. Nurses must rely solely on the patient's verbal and nonverbal cues to determine the level of discomfort (Levett-jones et al, 2009). The patient will be assessed and the pain will be scored from 1- 10, with 10 being the most severe pain. The nurse should therefore give the appropriate pain relieving regiment. The patient will be given the anti inflammatory analgesics which will help in the relieving of the shoulder pain (Maxwell , 2007). Other methods to be used include the injection of the wound with the local anesthetics while the patient is still asleep. Also the Giving of intravenous bolus of 2.5mg morphine and wait for 5-10 minutes to confirm that the desired effect has been achieved and the consciousness of the patient still maintained (Rona et al, 2011). Fluid management and electrolyte levels will also be of importance. The intravenous fluids will be administered to the patient if found to be dehydrated, the fluid intake and output will also be monitored four hourly .the patient should be maintained on intravenous fluids up to when they will be able to tolerate the oral intake. This is so because during surgery the intravascular volume of patients is usually depleted (Turkistani et al, 2009). General assessment for complains of nausea and vomiting should also be assessed for and the anti emetics will be administered. The patient should be on oral sips for about 12 hours and will only be allowed to resume the normal diet. The patient should be encouraged to take oral sips and will resume normal diet after the confirmation of the bowel sounds returning.ths will mostly occur after 2 to three days. The patient should also be encouraged to walk eight hours after surgery and will be discharged after 3-5 days to come again after six weeks after the procedure. They should be able maintaining low-fat diet to avoid development of diarrhea (Mehrvarz et al, 2011). Wound care will involve the use a white gauze to cover the site of the wound under them we will have the steri strips. The gauze can be removed a day after surgery has been done while the steri strips will be left until they fall off by themselves which normally occurs two weeks after surgery. The dressing should be done in such away to facilitate early and proper wound healing. The patient should also to be discouraged from smoking during this period to allow for early wound healing since smoking tends to make wound healing process to take a longer time. Wound care will be centered at enhancing the good healing of the wound and also to manage the complications of wound healing such as wound dehiscence in case they arise. Site of incision should be assessed for the changes in color such as erythema, palpation should also be done at the site of the wound to confirm if there is presence of warmth or if there is edema. The wound area should also be inspected for purulent discharge. The normal discharge will be observed from the incision site (Allvin et al, 2008). The normal discharge will typically be thin and watery and reddish in colour.The wound will be assed for infection which will be evidenced by the discharge being corpius or green in coulor.The formation of a hematoma or even the evisceration. The bleeding of the site of incision should also be assessed. The care of the wound will involve the dressing of the wound will involve the cleaning of the wound daily, application of the antibiotics and the dressing of the wound (Clarke, 2011). The care for the y tube or the t tube should also be considered. Drainage tubes are normally inserted during the cholecystectomy procedure in the common bile duct. The tube normally acts like a safety valve because after surgery the duct usually becomes edematous and thus blocks the flow of bile into the duodenum. The tubes are attached to a drainage bag and they are used to measure the amount of bile being removed (Massoumi et al, 2007). Measurement of the drained bile is done periodically i.e. eight hourly.Asceptic techniques must be used while emptying the bag. But when the tubes are not connected directly to the drainage bag, they will normally drain directly on the surgical dressings from the operative site. If this occurs then additional care has to be given on the surgical dressings and the skin at that area since bile causes irritation of the skin around the site of incision (Manouras et al, 2009). The nursing care plan for the t tube or y tube will involve the taking into account of the three major problems that could arise. This will include the presence of infections setting in, the obstruction of the t tube or the y tube and finally the dislodgement of the tube. The monitoring of infections will involve the constant taking of the temperature readings of the patient and also the inspection of the site for features such as erythema or redness, the swelling of the site, the presence of warmth and the presence of a discharge from the site that will be purulent in color. Eight hourly measurement of the amount of drainage from the tube will be done and the decrease in the amount of drained fluid will be indicative of the dislodgement of the t tube or the y tube. The patient will also be examined for the features of jaundice, the patient feeling nauseated, vomiting and passing of dark urine will be indicative of the obstruction of the common bile duct (Beuran et al, 2008). The nurse should also be observant for the features of the effects of anesthesia as they tend to manifest in the post operative period. Anesthetic agents tend to depress the respiratory functions, they have their effect in the cardiovascular system by bringing about the lowering of the cardiac output and unstable blood pressures.th patients could also have altered of the genitourinary system functions for instance they might exhibit the retention of urine (Young, 2008). Breathing of the patient also be checked since the patients who have under gone cholecystectomy will tend to have difficulties in rbreathing.Their breathing will tend to be shallow due to the effect of the anesthesia. The shallow breathing could also be due to the pain which normally caused by the proximity of the site of operation to the respiratory muscles and hence the patients would be a bit reluctant to take deep breaths (Karayiannakis A et al 2011). The patient will also be shown how to offer support to the site of incision while either breathing in or coughing. The patients should also be encouraged to expectorate secretions and adopt effective breathing techniques. Patients should assume the fowlers position to achieve adequate lung expansion and breathing (Osman et al 2011). Promotion of cardiovascular function is encouraged through the promotion of early ambulation and this will go in the long run to prevent the complications such as deep venous thrombosis and also bring about peristalsis. Deep venous thrombosis is likely to occur in patients who have under gone cholecystectomy due to clots forming in the veins.Larascopic surgery tends to increase the risk for one developing deep venous thrombosis or pulmonary embolism. Therefore the patients should be given thinning agents to decrease the risk of the development of deep venous thrombosis, they should also be encouraged to wear the compressions stockings (Clarke M, 2011). In Conclusion, management of a patient after cholecystectomy is very much centered on the prevention of the complications arising. The care will mainly comprise of the checking of the vital signs, the control of the pain, fluid management, and the care of the tube. Nurses should be able to use their clinical reasoning in being able to identify the intensity of the patients complains for example pain. Clinical reasoning will enable the appropriate care to be given to the patients by the nurses. Reference Levett-jones T. et al (2009). 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