Download Gallbladder Cancer (Cont`d)

Focus on Disorders of the Biliary
Tract
(Relates to Chapter 44, “Nursing Management: Liver,
Pancreas, and Biliary Tract Problems” in the textbook)
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Gallbladder Disease
• Cholelithiasis
 Most common disorder of biliary
system
 Stones in the gallbladder
• Cholecystitis
 Inflammation of the gallbladder
 Usually associated with cholelithiasis
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Gallbladder Disease (Cont’d)
• Common health problem in U.S.
• 8%-10% of adults have cholelithiasis
• Incidence of cholelithiasis
 Higher in women, multiparous
women, and persons over 40 years of
age
 Estrogen therapy ↑ risk
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Gallbladder Disease (Cont’d)
• Other risk factors
 Sedentary lifestyle
 Familial tendency
 Obesity
• More common in whites than Asian
and African Americans
• ↑ incidence in Navaho and Pima
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Etiology and Pathophysiology
• Cholecystitis
 Most commonly associated with
obstruction
• Gallstones or biliary sludge
 In absence of obstruction
• Occurs in older adults and those who have
trauma, extensive burns, or recent
surgery
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Etiology and Pathophysiology
• Cholecystitis (cont’d)
 Causes
• Bacteria
• Escherichia coli is most common cause
• Other factors include
•
•
•
•
Adhesions
Neoplasms
Anesthesia
Opioids
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Etiology and Pathophysiology
• Cholecystitis (cont’d)
 Inflammation
• Major pathophysiologic condition
• Confined to mucous lining or entire wall
• Gallbladder is edematous and hyperemic
• May be distended with bile or pus
• Cystic duct may become occluded
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Etiology and Pathophysiology
• Cholecystitis (cont’d)
 Gallbladder is scarred after acute
attack
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Etiology and Pathophysiology
• Cholelithiasis
 Cause of gallstones unknown
 Develops when balance that keeps
cholesterol, bile salts, and calcium in
solution is altered
• Precipitation of these substances occurs
• Causes include infection and disturbances
in metabolism of cholesterol
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Etiology and Pathophysiology
• Cholelithiasis (cont’d)
 Bile in gallbladder is supersaturated
with cholesterol
 Precipitation of cholesterol results
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Etiology and Pathophysiology
• Cholelithiasis (cont’d)
 Other components of bile that
precipitate into stones include
• Bile salts
• Bilirubin
• Calcium
• Protein
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Etiology and Pathophysiology
• Cholelithiasis (cont’d)
 Stones that are primarily cholesterol
are the most common
 Immobility, pregnancy, and
inflammatory or obstructive lesions of
biliary system ↓ bile flow
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Etiology and Pathophysiology
• Cholelithiasis (cont’d)
 Stones may remain in gallbladder or
migrate to cystic or common bile duct
 Cause pain as they pass through ducts
• May lodge in ducts and produce an
obstruction
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Gallstones in Gallbladder
Fig. 44-17
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Etiology and Pathophysiology
• Cholelithiasis (cont’d)
 If blockage occurs in cystic duct
• Bile can continue to flow into the
duodenum directly from liver
• When bile in gallbladder cannot escape
stasis of bile, may lead to cholecystitis
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Clinical Manifestations
• Varies from
 Indigestion
 Moderate to severe pain
 Fever
 Jaundice
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Clinical Manifestations (Cont’d)
• Initial symptoms of acute
cholecystitis
 Indigestion
 Pain
 Tenderness in right upper quadrant
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Clinical Manifestations (Cont’d)
• Acute cholecystitis
 Pain may be acute
• May be accompanied by nausea,
vomiting, restlessness, and diaphoresis
 Inflammation manifestations
• Leukocytosis
• Fever
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Clinical Manifestations
• Acute cholecystitis (cont’d)
 Physical findings
• Right upper quadrant tenderness
• Abdominal rigidity
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Clinical Manifestations
• Chronic cholecystitis
 Symptoms
• History of
•
•
•
•
Fat intolerance
Dyspepsia
Heartburn
Flatulence
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Clinical Manifestations (Cont’d)
• Cholelithiasis
 May produce severe symptoms or
none at all
• “Silent cholelithiasis”
 Severity depends on
• Presence of obstruction
• Whether stones move or not
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Clinical Manifestations
• Cholelithiasis (cont’d)
 Stones lodged in ducts or moving may
cause spasm
• Can produce severe pain
• Termed biliary colic, although more
steady than colicky
• Pain could be accompanied by
tachycardia, diaphoresis, and prostration
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Clinical Manifestations
• Cholelithiasis (cont’d)
 Pain may last an hour
• When it subsides, tenderness in right
upper quadrant develops
 Attacks of pain occur 3-6 hours after a
heavy meal or after lying down
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Clinical Manifestations
• Cholelithiasis (cont’d)
 Total obstruction symptoms
• Jaundice
• Dark amber urine
• Clay-colored stools
• Pruritus
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Clinical Manifestations
• Cholelithiasis (cont’d)
 Total obstruction symptoms (cont’d)
• Intolerance to fatty foods
• Bleeding tendencies
• Steatorrhea
• No urobilinogen in urine
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Complications
• Cholecystitis
 Gangrenous cholecysitis
 Subphrenic abscess
 Pancreatitis
 Cholangitis
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Complications
• Cholecystitis (cont’d)
 Biliary cirrhosis
 Fistulas
 Gallbladder rupture
• Bile peritonitis
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Complications
• Cholecystitis (cont’d)
 Most common complication in older
patients and those with diabetes
• Gangrenous cholecystitis
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Complications
• Cholelithiasis
 Cholangitis
 Biliary cirrhosis
 Carcinoma
 Peritonitis
 Choledocholithiasis
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Diagnostic Studies
• History and physical examination
• Ultrasound
• Laboratory tests
 Liver function studies
 WBC count
 Serum bilirubin
 Serum amylase
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Diagnostic Studies (Cont’d)
• ERCP
• Percutaneous transhepatic
cholangiography
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Diagnostic Studies (Cont’d)
• Ultrasound
 Commonly used
 90%-95% accurate in detecting stones
 Useful in patients with jaundice or
allergic to contrast
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X-ray of Gallbladder with Gallstones
Fig. 44-18
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Diagnostic Studies
• Liver function
 ↑ AST
 ↑ ALT
 ↑ Alkaline phosphatase
• WBC count
 ↑ due to inflammation
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Diagnostic Studies (Cont’d)
• Serum bilirubin
 ↑ direct
 ↑ indirect
 ↑ urinary bilirubin
• If obstruction present
• Serum amylase
 ↑ if pancreatic involvement
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Diagnostic Studies (Cont’d)
• ERCP
 Allows visualization of gallbladder,
cystic duct, common hepatic duct, and
common bile duct
 Bile collected sent for culture
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Diagnostic Studies (Cont’d)
• Percutaneous transhepatic
cholangiography
 Used to diagnose obstructive jaundice
and locate stones within bile ducts
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Collaborative Care
Conservative Therapy
• Cholecystitis
 Acute episode focus on
• Pain control
• Antibiotic treatment
• Maintenance of fluid and electrolyte
balance
 Treatment supportive and
symptomatic
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Collaborative Care
Conservative Therapy
• Cholecystitis (cont’d)
 Treatment
• Gastric decompression
• If nausea/vomiting are severe
• Anticholinergics
• ↓ secretion
• Counteract smooth muscle spasms
• Analgesics
• Pain management
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Collaborative Care
Conservative Therapy
• Cholelithiasis
 Treatment
• ↑ use of laparoscopic surgical removal
• Two nonsurgical approaches for stone
removal
• Endoscopic sphincterotomy
• Mechanical lithotripsy
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Collaborative Care
Conservative Therapy
• Cholelithiasis (cont’d)
 Endoscopic sphincterotomy
• Effective in removing common bile duct
stones
• Endoscope passed to duodenum
• Sphincter of Oddi is widened
• Basket is used to retrieve stone
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Endoscopic Sphincterotomy
Fig. 44-19
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Collaborative Care
Conservative Therapy
• Cholelithiasis (cont’d)
 Mechanical lithotripsy
• Used if stone is too large to pass
• Endoscopist crushes the stone
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Collaborative Care
Conservative Therapy
• Cholelithiasis (cont’d)
 Other options
• Cholesterol solvents
• Oral drugs
• Endoscopic sphincterotomy
• Extracorporeal shock-wave lithotripsy
• Surgery
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Collaborative Care
Surgical Therapy
• Cholelithiasis
 Laparoscopic cholecystectomy
• Treatment of choice
• Removal of gallbladder thorough four
puncture holes
• Minimal postoperative pain
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Collaborative Care
Surgical Therapy
• Cholelithiasis (cont’d)
 Laparoscopic cholecystectomy (cont’d)
• Discharged day or next day
• Injury to common bile duct is the main
complication
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Collaborative Care
Surgical Therapy
• Cholelithiasis (cont’d)
 Open cholecystectomy
• Removal of gallbladder through right
subcostal incision
• T-tube inserted into common bile duct
• Ensures patency of the duct
• Allows excess bile to drain
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Placement of T Tube
Fig. 44-20
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Collaborative Care
Transhepatic Biliary Catheter
• Used preoperatively in
 Biliary obstruction
 Hepatic dysfunction
• Used when
 Inoperable liver, pancreatic, or bile
duct carcinoma obstructs bile flow
 Endoscopic drainage is unsuccessful
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Collaborative Care
Transhepatic Biliary Catheter
(Cont’d)
• Inserted percutanously
• Allows for decompression of
obstructed extrahepatic bile ducts
• After insertion, catheter is
connected to drainage bag
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Collaborative Care
Transhepatic Biliary Catheter
(Cont’d)
• Skin care
 Catheter insertion site cleaned daily
with antiseptic
 Observe for bile leakage
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Collaborative Care
Drug Therapy
• Most common
 Analgesics
 Anticholinergics
 Fat-soluble vitamins
 Bile salts
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Collaborative Care
Drug Therapy (Cont’d)
• Others
 Morphine
 NSAIDs
• Cholestyramine (Questran) may be
given for pruritus
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Collaborative Care
Drug Therapy (Cont’d)
• Medical dissolution therapy
 Recommended in those with
• Small radiolucent stones
• Mildly symptomatic
• Poor surgical risks
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Collaborative Care
Drug Therapy
• Medical dissolution therapy (cont’d)
 May take 6 months to 2 years for
dissolution
 Low-dose therapy recommended to
prevent recurrence
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Collaborative Care
Drug Therapy
• Medical dissolution therapy (cont’d)
 Examples
• Ursodeoxycholic acid (UDCA)
• Ursodiol (Actigall)
• Chenodeoxycholic acid (CDCA)
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Collaborative Care
Nutritional Therapy
• Diet modifications
 Major
• Low-fat diet
• Avoid diary products, fried foods, rich
pastries, gravy, nuts
 Reduced-calorie diet if obese
 Eat small, more frequent meals
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Collaborative Care
Nutritional Therapy
• Diet modifications (cont’d)
 After laparoscopic cholecystectomy
• Liquids for day
• Light meals for several days
 After incisional cholecystectomy
• Liquids to bland diet after return of bowel
sounds
• Restrict fats for 4-6 weeks
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Nursing Management
Nursing Assessment
• Subjective Data
 Past medical history
• Obesity, infection, cancer, pregnancy
 Medication use
• Estrogen, oral contraceptives
 Surgical history
• Previous abdominal surgery
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Nursing Management
Nursing Assessment
• Subjective Data (cont’d)
 Positive family history
 Anorexia
 Weight loss
 Indigestion
 Nausea and vomiting
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Nursing Management
Nursing Assessment
• Subjective Data (cont’d)
 Fat intolerance
 Clay-colored stools
 Dark urine
 Pain in right upper quadrant
 Pruritus
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Nursing Management
Nursing Assessment
• Objective Data
 Fever
 Restlessness
 Jaundice
 Tachypnea
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Nursing Management
Nursing Assessment
• Objective Data (cont’d)
 Tachycardia
 Abnormal liver enzymes
 Abnormal gallbladder ultrasound
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Nursing Management
Nursing Diagnoses
• Acute pain
• Ineffective therapeutic regimen
management
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Nursing Management
Planning
• Overall Goals
 Relief of pain and discomfort
 No complications postoperatively
 No recurrent attacks of cholecystitis or
cholelithiasis
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Nursing Management
Nursing Implementation
• Health Promotion
 Recognize predisposing factors in
general health screening
• Disease more common in Native
Americans
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Nursing Management
Nursing Implementation
• Acute Intervention
 Nursing objectives
• Relieve pain
• Relieve nausea and vomiting
• Provide comfort and emotional support
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Nursing Management
Nursing Implementation
• Acute Intervention (cont’d)
 Nursing objectives (cont’d)
• Maintaining fluid and electrolyte balance
and nutrition
• Making accurate assessments
• Observing for complications
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Nursing Management
Nursing Implementation
• Acute Intervention (cont’d)
 Assessment of pain and administration
of pain medications
 Provide clean bed, comfortable
positioning, and oral care
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Nursing Management
Nursing Implementation
• Acute Intervention (cont’d)
 Nausea and vomiting
• May need gastric decompression
• Oral hygiene
• Care of nares
• Accurate intake and output
• Antiemetics
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Nursing Management
Nursing Implementation
• Acute Intervention (cont’d)
 Pruritus
• Relief measures
•
•
•
•
•
Baking soda or calamine lotion
Soft linen
Control of temperature
Shorten nails
Teach patients to scratch with knuckles
rather than nails
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Nursing Management
Nursing Implementation
• Acute Intervention (cont’d)
 Observe for signs of obstruction
• Jaundice
• Clay-colored stools
• Dark, foamy urine
• Fever
• ↑ WBC
• Steatorrhea
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Nursing Management
Nursing Implementation
• Acute Intervention (cont’d)
 Watch for bleeding
• Common sites—mucous membranes
• If present
• Small gauge needles with gentle pressure
• Know patient’s prothrombin time
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Nursing Management
Nursing Implementation
• Acute Intervention (cont’d)
 Assess for infection
• Temperature elevation with chills and
jaundice may indicate choledocholithiasis
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Nursing Management
Nursing Implementation
• Postoperative care
 Laparoscopic cholecystectomy
• Monitoring for complications
• Common problem
• Shoulder pain from irritation of phrenic nerve
and diaphragm due to retained CO2
• Place patient in Sim’s position
• Encourage deep breathing
• Pain medications
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Nursing Management
Nursing Implementation
• Postoperative care (cont’d)
 Incisional cholecystectomy
• Maintain adequate ventilation
• Prevent respiratory complications
• Follow general postop nursing care
• If T tube present
• Maintain bile drainage
• Observe function and drainage
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Nursing Management
Nursing Implementation
• Ambulatory and Home Care
 Dietary teaching
 Fat-soluble vitamin supplements
 Instructions to patient regarding
observations indicating obstruction
 Stress significance of continued health
care
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Nursing Management
Nursing Implementation
(Cont’d)
• Ambulatory and Home Care
 Laparoscopic cholecystectomy
• Home care instructions
• Teaching essential
 Open-incision cholecystectomy
• Discharged in 2-3 days
• No heavy lifting for 4-6 weeks
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Nursing Management
Evaluation
• Expected Outcomes
 Appear comfortable and verbalize pain
relief
 Verbalize knowledge of activity level
and dietary restrictions
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Gallbladder Cancer
• Primary cancer of gallbladder is
uncommon
• Majority are adenocarcinomas
• Relationship exists between
gallbladder cancer and chronic
cholecystitis and cholelithiasis
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Gallbladder Cancer (Cont’d)
• Early symptoms
 Insidious
 Similar to cholecystitis and
cholelithiasis
• Late symptoms
 Usually those of biliary obstruction
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Gallbladder Cancer (Cont’d)
• Diagnosis and staging
 EUS
 Transabdominal ultrasound
 CT
 MRI
 MRCP
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Gallbladder Cancer (Cont’d)
• Usually not detected until disease
advanced
• If found early, can be curative
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Gallbladder Cancer (Cont’d)
• Factors influencing successful
surgical outcomes
 Depth of cancer invasion
 Extent of liver involvement
 Presence of venous or lymphatic
invasion
 Lymph node metastasis
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Gallbladder Cancer (Cont’d)
• If surgery is not an option
 Endoscopic stenting of biliary tree to
reduce jaundice
• Adjuvant therapies
 Radiation therapy
 Chemotherapy
• Poor prognosis overall
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Gallbladder Cancer (Cont’d)
• Nursing Management
 Supportive care
• Nutrition
• Hydration
• Skin care
• Pain relief
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Case Study
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Case Study
• 35-year-old female presents to
emergency department complaining
of acute abdominal pain
• She points to the pain in the right
upper quadrant
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Case Study (Cont’d)
• She describes the pain as a 7 out of
10
• Lab values show elevated WBCs and
bilirubin
• Ultrasound confirms gallstones
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Discussion Questions
1. What is her priority of care?
2. What are her treatment options?
3. What can you teach her about
avoiding complications or
recurrences?
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