Nursing Management of Cholelithiasis

Cholelithiasis, or gallstone disease, affects up to 20% of adults in Western countries and is a leading cause of biliary tract disorders. Gallstones may remain asymptomatic or precipitate biliary colic, cholecystitis, and life-threatening complications such as cholangitis and pancreatitis. Skilled nursing management—encompassing comprehensive assessment, targeted interventions, patient education, and collaborative care—optimizes recovery and fosters long-term health.

1. Definition and Epidemiology

• Definition: Formation of crystalline concretions within the gallbladder or biliary ducts, typically composed of cholesterol, bilirubin, or mixed constituents.
• Prevalence: 10–20% in adult populations; risk increases with age, female sex, obesity, multiparity, and rapid weight loss.
• Stone Types:
• Cholesterol stones (75–90%)
• Pigment stones (black—hemolysis; brown—infection)
• Mixed stones

2. Pathophysiology and Risk Factors

• Cholesterol Supersaturation: Imbalance in bile acids, phospholipids, and cholesterol leads to crystal precipitation.
• Gallbladder Stasis: Hypomotility in obesity, pregnancy, or prolonged fasting promotes nucleation.
• Inflammation & Infection: Mucin hypersecretion and bacterial enzymes accelerate stone growth.
• Genetic and Metabolic: Family history, hemolytic disorders, cirrhosis, and rapid weight loss.

3. Clinical Presentation

• Asymptomatic: Incidental ultrasound finding.
• Biliary Colic: Episodic right upper quadrant or epigastric pain, often postprandial, lasting 30–60 minutes.
• Acute Cholecystitis: Persistent pain, fever, leukocytosis, positive Murphy’s sign.
• Complications: Jaundice, clay-colored stools, dark urine, cholangitis (Charcot triad), gallstone pancreatitis.

4. Nursing Assessment

4.1 Subjective Data

• Pain characteristics: onset, intensity (0–10 scale), location, radiation, triggers, relief measures.
• Gastrointestinal symptoms: nausea, vomiting, bloating, intolerance to fatty foods.
• Past medical history: prior biliary episodes, comorbidities (diabetes, liver disease).
• Lifestyle: dietary patterns, alcohol intake, rapid weight changes.

4.2 Objective Data

• Vital signs: fever, tachycardia, hypotension.
• Abdominal exam: RUQ tenderness, Murphy’s sign, abdominal distention.
• Laboratory studies: WBC, liver function tests (AST, ALT, ALP), bilirubin, amylase/lipase.
• Diagnostic imaging: ultrasound (stones, sludge, gallbladder wall thickening), HIDA scan, MRCP/ERCP when indicated.

5. Nursing Diagnoses

1. Acute Pain related to gallbladder distension and inflammation.
2. Risk for Infection related to biliary stasis and surgical interventions.
3. Imbalanced Nutrition: Less than Body Requirements related to dietary restrictions and postoperative fasting.
4. Anxiety related to impending surgery and potential complications.

6. Nursing Interventions

6.1 Preoperative Care

• Provide emotional support; use clear, empathetic communication to explain diagnosis and surgical plan (laparoscopic vs. open cholecystectomy).
• Enforce NPO status; administer IV fluids and maintain electrolyte balance.
• Optimize nutrition: encourage high-protein, low-fat diet until preoperative period.
• Prepare for surgery: verify lab results, administer prophylactic antibiotics, ensure informed consent.

6.2 Postoperative Care

• Pain Management: Assess pain regularly; administer prescribed analgesics (PCA, NSAIDs) and employ nonpharmacologic measures (positioning, relaxation techniques).
• Respiratory Care: Encourage deep breathing, incentive spirometry, and early ambulation to prevent atelectasis.
• Gastrointestinal Management: Advance diet from clear liquids to low-fat meals as tolerated; monitor bowel sounds and abdominal distention.
• Drain and T-Tube Care: Maintain patency; record drainage output, color, and consistency; perform aseptic dressing changes and skin protection.
• Mobility and DVT Prevention: Assist with early mobilization; apply compression stockings or sequential compression devices.
• Monitoring: Check vital signs q4h, monitor for signs of infection, bile leak, or pancreatitis; assess fluid balance and I&O.

7. Patient Education

• Dietary Guidance: Adopt a low-fat diet rich in fruits, vegetables, and lean protein; avoid greasy, fried, and spicy foods.
• Activity Recommendations: Gradually resume daily activities; avoid heavy lifting for 4–6 weeks.
• Wound Care: Instruct on incision care, signs of infection, and when to seek medical attention.
• Self-Monitoring: Educate on recognizing complications such as fever, persistent RUQ pain, jaundice, and changes in stool or urine color.
• Follow-Up Plan: Schedule postoperative visits for wound assessment, laboratory tests, and T-tube removal if applicable.

8. Evaluation

• Pain score consistently ≤3/10 with stable vital signs.
• No evidence of surgical site infection or postoperative complications.
• Patient demonstrates correct wound care techniques and dietary adjustments.
• Patient expresses confidence in managing symptoms and adhering to follow-up care.

References

1. Working Party of the British Society of Gastroenterology. Guidelines on the management of cholelithiasis. Gut. 2018.
2. Strasberg SM. Clinical practice of laparoscopic cholecystectomy. Ann Surg. 2020.
3. Portincasa P, et al. Cholesterol gallstone pathogenesis. Gastroenterology. 2020.
4. SAGES Guidelines for laparoscopic gallbladder removal. Surg Endosc. 2019.