Nursing 213

N213: Health Differences Across the Lifespan 3 Study Guide

Signs and symptoms of cholecystitis: • Pain • Tenderness • Rigidity in the right upper abdomen • Pain with deep inspiration (Murphy’s sign) • Dyspnea Signs and symptoms of cholelithiasis: • Mild gastrointestinal symptoms • Abdominal distention • RUQ pain after a high-fat meal • Gall bladder distention/infection • Fever

Belching Flatulence Nausea Vomiting Jaundice Biliary colic Jaundice

• • • • •

Abdominal mass Vitamin deficiencies Clay colored stools/dark urine

• • • • •

Nursing assessment for gall bladder disease: • Full abdominal assessment: inspection, auscultation, percussion, and palpation • History of abdominal pain and factors that cause episodes • Assess breath sounds and visualize respiratory efforts; guarding may cause atelectasis • Review laboratory and radiology reports: o CBC: WBC, leukocytes, and neutrophils may be elevated o Electrolytes o Liver panel: Bilirubin and cholesterol will be elevated o X-ray o Ultrasound o Hepatobiliary scan: Checks patency of biliary system o Radionuclide scan Nursing diagnosis for gall bladder disease: • Pain related to tissue trauma/muscle spasms, secondary to infection, obstruction, and surgery • Altered nutrition with less than body requirements related to vomiting or an inability to eat • Knowledge deficit related to disease process, dietary modifications, surgery, and treatment

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