NURSING NR 228 Nutrition Week 7 edapt - Nutrition and Biliary Health- nutrition for gastrointestinal

Nutrition and Biliary Health Wellness is influenced by the function of the body organs. Physical health is crucially dependent on the liver, pancreas, and gallbladder; one malfunction can devastate nutritional status. The biliary system is comprised of the:  gallbladder  the hepatic, cystic, and common bile ducts In this learning module, you will explore the nutritional therapies for clients with alterations in their biliary system.

Six Dimension of GI health There are six dimensions of health. Although each dimension can have a significant impact on an individual's health, intellectual

health strategies are needed to help clients as they try to find food combinations and textures that are aesthetically pleasing as they are forced to restrict the consumption of problematic foods such as gluten in celiac disease.

Physical health is most affected when a gastrointestinal (GI) disorder is chronic and intensive. Eventually, weight loss and nutrient deficiencies pose health risks in addition to the primary disorder. Intellectual health is tested as the patient tries to find food combinations and textures that are aesthetically pleasing. Some disorders require constant vigilance to restrict inadvertent consumption of problematic foods (e.g., gluten in celiac disease). Emotional health is taxed when patients struggle with acceptance of their dietary or physical limitations. Poorly managed symptoms diminish psychological well-being and overall quality of life.

Social health strategies are needed to help patients handle the personal ramifications of colostomies, dumping syndrome, and other disorders.

Spiritual health can be enhanced through yoga and meditation, which are tied to mind and body wellness. For those with GI disorders that may cause unexpected need for access to a bathroom, the environmental health dimension of facilities at home, at work, and during commuting or traveling may alter the sense of wellness.

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Gallbladder Larry is experiencing inflammation of his gallbladder due to a high fat and high carbohydrate diet. Which of the following is the correct medical term for this disease?

Cholangitis Gallbladderitis Cholecystectomy Cholecystitis

Two diets have the most evidence for their protective qualities: the traditional Mediterranean diet and the DASH (Dietary Approaches to Stop Hypertension) diet to support biliary health. 1800 ADA diet was created to help control diabetes and the pureed diet is used to control dysphagia or difficulty swallowing.

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Celiac Disease Celiac disease is a chronic autoimmune disorder in which the mucosa of the small intestine is inflamed when foods containing gluten are consumed. A gluten-free diet is recommended for clients with celiac disease. Which of the following foods should the client remove from their diet? Select all that apply.

Rye Barley Wheat Rice Celiac disease is a chronic autoimmune disorder in which the mucosa of the small intestine is inflamed when foods containing gluten are consumed. Gluten is a protein found in rye, barley and wheat. Rice is gluten free.

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Six Dimensions of Health Review the six dimensions of health below.

Biliary Colic & Low Carbohydrate Diets Bile and digestive enzymes are carried by the bile ducts from the liver, gallbladder, and pancreas to the small intestine. The bile carries away wastes from the liver and plays a role in the digestion of fats. The gallbladder stores a portion of the bile. After an individual eats a meal, the gallbladder contracts, emptying the gallbladder’s contents into the small intestine.

When a person has a gallstone that is blocking the bile duct, they can develop biliary colic with clinical manifestations such as:  A sharp cramp or dull ache in the middle to upper right quadrant of the abdomen  Fever  Jaundice Biliary colic is thought to be increased by diets that are high in calories, fat, and carbohydrates. Modification of diet, to include reducing high-calorie foods, low fat and a low carbohydrate diet, contributes to the prevention of biliary colic.

Mediterranean Diet The healthcare provider has recommended the Mediterranean diet for a client with biliary colic. When shopping for groceries for this diet, which of the following oils would the client purchase?

Avocado oil

Extra-virgin olive oil Coconut oil Canola oil Extra-virgin olive oil (EVOO) is a special food with multiple plant chemicals (phytochemicals) that reduce inflammation. EVOO is a fundamental food in the world's healthiest diet—the Mediterranean diet. Canola oil, avocado oil, and coconut oil do not have the anti-inflammatory properties that EVOO has.

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Risk of Acute Inflammation Nonalcoholic fatty liver disease (NAFLD) has become the most common form of liver disease in the United States and is one of the most common comorbidities associated with overweight and metabolic syndrome. It is unclear why certain individuals accumulate and deposit more fat in their liver (Mayo, 2020).

For some people, the excess fat deposited acts as a toxin to liver cells, causing the liver to become inflamed and scar tissue to develop in the liver. This can progress to cirrhosis.

A calorie-controlled diet limiting fats, fructose, and alcohol may be ordered. Adequate tracking of glucose and lipid levels will be needed.

Whatever the cause, proper nutrition in the form of a well-balanced diet is important in reversing fatty infiltration.

References Mayo Clinic (2020). Nonalcoholic fatty liver disease. Mayo Clinic. https://www.mayoclinic.org/diseases-conditions/nonalcoholic-fattyliver-disease/symptoms-causes/syc-20354567

Nonalcoholic Fatty Liver Disease For some individuals with nonalcoholic fatty liver disease, excess fat deposited in the liver acts as a toxin, causing the liver to become inflamed and scar tissue to develop in the liver.

Nonalcoholic fatty liver disease (NAFLD) has become the most common form of liver disease in the United States and is one of the most common comorbidities associated with overweight and metabolic syndrome. It is

unclear why certain individuals acculumate and deposit more fat in their liver (Mayo Clinic, 2020). For some people, the excess fat deposited acts as a toxin to liver cells, causing the liver to become inflamed and scar tissue to develop in the liver. This can progress to cirrhosis. Estrogen, cholesterol and carbohydrates are not deposited in the liver.

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Nonalcoholic Fatty Liver Disease Which of the following diets are recommended for clients with nonalcoholic fatty liver disease?

Gluten-free diet Calorie-controlled diet 1800 ADA diet Celiac diet A calorie-controlled diet limiting fats, fructose, and alcohol may be ordered. Adequate tracking of glucose and lipid levels will be needed.

Whatever the cause, proper nutrition in the form of a well-balanced diet is important in reversing fatty infiltration. The other diets do not apply.

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Gluten-Free Diet to Support Biliary Health Celiac disease is a chronic autoimmune disorder in which the mucosa of the small intestine is damaged when food containing gluten is consumed; impacting the body's ability to absorb nutrients. It is a disease of malabsorption (nutrients are not absorbed) and an abnormal immune

reaction to gluten. The recommended treatment for celiac disease is to adhere to a diet that is gluten-free.

Malnutrition is one of the most common complications linked to untreated celiac disease since the condition results in serious intestinal malabsorption. One of the most effective ways of treating malnutrition in individuals with celiac disease is to identify the cause-products containing gluten. Individuals with celiac disease should consume a gluten-free diet to decrease inflammation and support biliary health. With an increase in the number of individuals experience celiac disease, gluten-free products are now easier to find in stores, restaurants, and at special food companies.

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Anti-Inflammatory Diet When teaching a client to consume an anti-inflammatory diet to support biliary health, the choices would include the following food groups and the items within each group:

whole grains like oatmeal and brown rice; and legumes like chickpeas, beans, and lentils; pecans and other nuts. fiber-rich whole grains

salmon, tuna, mackerel, and sardines.

omega-3 fatty acids

avocado, artichokes, mango, tomatoes, grapes, avocado, blueberries, cherries strawberries, raspberries, cherries. Foods that are rich in carotenes, vitamins C and E, and selenium. fruits and vegetables

extra-virgin olive oil, and nuts. mono and polyunsaturated fat

Anti-inflammatory diets include the following recommendations to support biliary health:  Fruits and vegetables like avocado, artichokes, mango, tomatoes, grapes, avocado, blueberries, cherries strawberries, raspberries, cherries. Foods that are rich in carotenes, vitamins C and E, and selenium.  Fiber-rich whole grains like oatmeal and brown rice; and legumes like chickpeas, beans, and lentils; pecans and other nuts.  Healthy fats containing mono and polyunsaturated fat such as extravirgin olive oil, and nuts.  Omega-3 fatty acids are found in fish like salmon, tuna, mackerel, and sardines

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DASH Diet When following the DASH diet to support biliary health, the healthcare provider asks the client to add foods rich in carotenes, vitamins C and E, and selenium. The client would respond by choosing which of the following foods? Select all that apply.

Sugar-sweetened beverages Mango Tomatoes Avocado When following the DASH diet, one would identify the following foods are rich in carotenes, vitamins C and E, and selenium, an individual would choose avocados, mangos and tomatoes. It is recommended that one avoids sugar-sweetened beverages.

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Celiac Disease Celiac disease is the most common disease for which dietary modification remains the main treatment to support biliary health. Individuals who have a diagnosis of celiac disease, who are not following a gluten-free diet; experience altercations in the speed in which food is moved through the small intestine (Anderson, 2020). The lining of the small intestine is damaged which leads to a limited cholecystokinin production. This increases the risk of gallbladder issues due to the delay in the gallbladder emptying; especially after a fatty meal.

Hepatitis Hepatitis is inflammation of the liver. Acute hepatitis can occur as the result of infectious mononucleosis, cirrhosis, toxic chemicals, or viral infection. There are five types of hepatitis: A, B, C, D, E. Individuals with a diagnosis of hepatitis usually do not require a special diet. It has found that eating healthy, maintaining a healthy weight, and avoiding alcohol are simple steps that individuals with a diagnosis of hepatitis can take to prevent complications.

Other than nutritional considerations, risk factors for contracting hepatitis include men who have sex with men, illegal drug users sharing needles, and persons who visit developing countries.

Dietary Consumption and Hepatitis Everything you eat and drink passes through your liver. Your liver changes food into stored energy and chemicals necessary for life. Your liver makes nutrients available so your body can use them to build cells, give you energy, and maintain normal body functions.

A good diet can improve liver health and lower the risks associated with hepatitis. If you have hepatitis, you usually do not need a special diet.

Recommendations for those with hepatitis are:      

Eat regular, balanced meals Maintain healthy calorie intake Eat whole-grain cereals, breads, and grains Eat lots of fruits and vegetables Get adequate protein Limit fatty, salty, and sugary foods

 Drink enough fluids  Reach and maintain a healthy weight  Avoiding alcohol The goal is to eat healthy, maintain a healthy weight, and avoid alcohol consumption.

Hepatitis Health If you have hepatitis, you usually don't need a special diet.

Recommendations for those with hepatitis are:     

Eat regular, balanced meals Maintain healthy calorie intake Eat whole-grain cereals, breads, and grains Eat lots of fruits and vegetables Get adequate protein

 Limit fatty, salty, and sugary foods  Drink enough fluids The goal is to eat healthy, maintain a healthy weight, and avoid alcohol consumption.

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Gallstones & Risk Assessment

Yo ur gallbladder is a small, pear-shaped organ on the right side of your abdomen, beneath your liver. The gallbladder holds a digestive fluid that gets released into your small intestine called bile. Cholecystitis is inflammation of the gallbladder, usually caused by gallstones blocking bile from leaving your gallbladder. The other causes of cholecystitis include bile duct problems, tumors, serious illness and certain infections.

Treatment for cholecystitis often involves gallbladder removal. However, diets high in fat and low in fiber may increase the risk of gallstones. To lower your risk, choose a diet:  High in fruits  High in vegetables  Whole grain foods Increased bilirubin can occur if the gallbladder is blocked and can't drain properly. Increased cholesterol, can cause a development of gallstones.

The white blood cells would be elevated indicating infection and the bilirubin blood levels would be increased.

Populations at risk for gallstones include:    

Adults age 60 and older Pregnant women Women using hormone replacement therapy or oral contraceptives Native Americans and Mexican Americans.

Gallstones to Pancreatitis Gallstone pancreatitis is a type of pancreatitis caused by a blockage of the pancreas duct by a gallstone. If a stone blocks the opening of the bile duct into the small intestine, it could block the flow of material from the liver and pancreas. This could result in inflammation and could turn into a lifethreatening disease. When this occurs, material from the liver and pancreas is obstructed.

When this condition is diagnosed, the client is instructed to:  Avoid food and fluids until the inflammation subsides.  Intravenous fluids are provided during the initial phases.  In the cases of severe pancreatitis and ongoing inflammation, intravenous delivery of nutrients is started.

 Causes of Pancreatitis  Acute Pancreatitis Symptoms

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Nonalcoholic Fatty Liver Disease When caring for a client with nonalcoholic fatty liver disease (NAFLD), it is important to educate the client on consuming a diet that limits which of the following? Select all that apply.

Fructose Fats Alcohol Protein A calorie-controlled diet limiting fats, fructose, and alcohol may be ordered. Adequate tracking of glucose and lipid levels will be needed.

Whatever the cause, proper nutrition in the form of a well-balanced diet is important in reversing fatty infiltration. Protein is not restricted.

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Biliary Diseases At a well visit appointment, the client mentions to the primary care provider that each time they consume wheat or rye products, they experience abdominal pain and diarrhea. Based on these clinical manifestations, the provider is concerned about?

Irritable bowel syndrome Celiac disease Chronic pancreatitis Pancreatic cancer Celiac disease is a chronic autoimmune disorder in which the mucosa of the small intestine is damaged when food containing gluten are consumed; impacting the body's ability to absorb nutrients. Gluten is a protein found in wheat, rye, and barley.

Celiac disease affects each person differently. Symptoms may occur in the digestive system, or in other parts of the body. One person might have diarrhea and abdominal pain, while another person may be irritable or depressed. Irritable bowel syndrome, pancreatic cancer, and chronic

pancreatitis are not stimulated with the consumption of wheat or rye bread.

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Gallstones Which of the following would most likely occur as a result of a gallstone obstructing a duct leaving the gall bladder?

Increased levels of cholesterol Decreased levels of bilirubin Increased levels of red blood cells Increased levels of bilirubin Increased bilirubin can occur if the gallbladder is blocked and can't drain properly. Increased cholesterol, can cause a development of gallstones.

The white blood cells would be elevated indicating infection and the bilirubin would be increased, not decreased.

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Healthy Diet for Gallbladder Treatment for cholecystitis often involves gallbladder removal. However, diets high in fat and low in fiber may increase the risk of gallstones.

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Gallbladder Disease Risk To lower your risk of gallbladder disease, choose a diet that includes which of the following? Select all that apply.

High in fruits High in vegetables Whole grain foods High in fats To lower your risk of gallbladder disease, choose a diet:  High in fruits  High in vegetables  Whole grain foods A high fat diet is not recommended.

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Gallstone Pancreatitis The healthcare provider is caring for a client that has been diagnosed with gallstone pancreatitis. The healthcare provider understands that this type of pancreatitis is caused by a blockage of the pancreatic duct by a gallstone. When this occurs, material from which organs are obstructed?

Select all that apply.

Trachea Colon Liver Pancreas Appendix The healthcare provider is caring for a client that has been diagnosed with gallstone pancreatitis. The healthcare provider understands that this type of pancreatitis is caused by a blockage of the pancreatic duct by a gallstone. When this occurs, material from the liver and pancreas are obstructed. The other options do not apply.

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Who is at Risk for Gallstones?

A seasoned healthcare provider is orientating a new healthcare provider in the emergency department. In discussing individuals who are at risk for gallstones, the new healthcare provider would indicate an understanding that individuals at greater risk for gallstones include which of the following? Select all that apply.

People with rheumatoid or osteoarthritis Pregnant women or women using hormone replacement therapy or oral contraceptives Native Americans and Mexican Americans Adults age 60 and older As a new healthcare provider in the emergency department, it is important to recognize that some populations are at greater risk of developing gallstones. These include adults age 60 and older, pregnant women or women using hormone replacement therapy or oral contraceptives and Native Americans and Mexican Americans.

Rheumatoid arthritis or osteoarthritis does not increase the risk of gallstones.

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Acute Pancreatitis & Diet The healthcare provider is caring for a client with a diagnosis of acute pancreatitis. The client is asking the healthcare provider what to expect regarding dietary changes. The healthcare provider would inform the client that they need to avoid food and fluids until the inflammation subsides.

When gallstone pancreatitis is diagnosed, the client is instructed to avoid food and fluids until the inflammation subsides. Intravenous (IV) fluids are provided during the initial phases. In the cases of severe pancreatitis and ongoing inflammation, intravenous delivery of nutrients is started. You do not want to increase fluid, solid or protein intake.

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Diet Support for a Healthy Liver A good diet can improve liver health and lower the risks associated with hepatitis. Which of the following diet recommendations would you teach your client to support a healthy liver? Select all that apply.

Diet Support for a Healthy Liver A good diet can improve liver health and lower the risks associated with hepatitis. Which of the following diet recommendations would you teach your client to support a healthy liver? Select all that apply.

Avoiding alcohol Increase fatty, salty, and sugary foods Eat whole-grain cereals, breads, and grains Eat regular, balanced meals Get adequate protein Eat lots of fruits and vegetables A good diet can improve liver health and lower the risks associated with hepatitis. There is no special diet to prevent hepatitis, however supporting recommendations, to include; eat regular, balanced meals; maintain healthy calorie intake; eat whole-grain cereals, breads, and grains; eat lots of fruits and vegetables; get adequate protein; fatty, salty, and sugary

foods in moderation (not increase intake); drink enough fluids; reach and maintain a healthy weight, and avoiding alcohol.

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Nursing Application – Nursing and Biliary Health When caring for patients with alterations in their biliary health, the healthcare provider must monitor the gastrointestinal parameters. As you complete this unit, you will gain the knowledge and skills needed to:  Apply principles of nutrition and biliary health  Implement the nursing process in caring for clients with alternations in biliary health  Demonstrate clinical decision making as it pertains to biliary health and nutrition

Diet and Cholecystitis When caring for a client with a recent diagnosis of cholecystitis, what dietary choices should the nurse encourage the client to eat? Select all that apply.

Frozen yogurt or sorbet Grilled, skinless chicken breast Baked red potato slices Bacon cooked in the microwave As a healthcare provider focusing on client nutrition, you will encourage the client to avoid fatty meats, fried foods and high-fat foods. You would

further instruct the client to consume low-fat foods. Bacon is high in fat and should be avoided. Grilled chicken without skin, baked potato slices, and frozen yogurt or sorbet are low fat, low calorie, and not fried.

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Food for Biliary Health A healthcare provider is providing client teaching in how to modify their diet to reduce the incidence of gallbladder disease. Which of the following foods should be avoided?

Lean meat, poultry, and fish Fresh fruits and vegetables Whole grains High fat dairy products

Certain foods have been studied for their potential to prevent gallbladder problems or reduce symptoms. Fresh fruits, vegetables, whole grains and lean meats are beneficial to the diet to prevent gallbladder disease. High fat dairy products, low fiber foods, and high fat meats can contribute to alterations in gallbladder function.

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High–Fat Foods A client with gallbladder disease has been advised to limit the consumption of high-fat foods. Which foods should the client avoid? Select all that apply.

Deli roast beef Ice cream Skim Milk French fries Changing your diet won't get rid of gallstones that are already there, but eating a healthy, balanced variety of nutrients and limiting the amount of saturated fats and cholesterol-heavy foods you eat may help ease your symptoms.

Try to avoid or limit these high-fat foods in your diet:  Fried foods  Highly processed foods (doughnuts, pie, cookies, and some deli meats)  Whole-milk dairy products (cheese, ice cream, butter)  Fatty red meat

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Right Upper Quadrant Pain Yolanda Rodriguez, a 62 –year-old Hispanic female presenting at the emergency department with complaints of right upper quadrant pain radiating to the right shoulder lasting for more than 12 hours. She has been experiencing nausea and vomiting, fever, and tenderness to the right upper quadrant. Labs have been completed (see below). Abdominal ultrasound confirms gallstone presence. She is scheduled for gallbladder removal (cholecystectomy).

Laboratory tests to evaluate for presence of gallbladder disease include:  Complete blood count (CBC)—evaluates blood cells; a high white blood cell count can indicate inflammation, infection, an abscess, or a ruptured gallbladder.

 C-reactive protein (CRP) or erythrocyte sedimentation rate (ESR)— elevated results indicate inflammation.  Liver panel—if someone has gallstones that block bile ducts, results for bilirubin may be high due to bile backing up into the liver. Liver enzymes, especially alkaline phosphatase (ALP), may be elevated in severe cases of gallbladder inflammation.  Lipase (the preferred test) or amylase—these pancreatic enzymes may be elevated if gallbladder disease has also caused pancreatitis.

Gallbladder Assessment Healthcare Provider Concerns Match the appropriate result with the laboratory test for a client with gallbladder disease.

Complete Blood Count (CBC) high leukocytes

C-reactive Protein (CRP) elevated inflammatory marker

Liver Panel high bilirubin

Lipase elevated enzyme

Laboratory tests supporting diagnosis of gallbladder disease include:  Complete blood count (CBC)—evaluates blood cells; a high white blood cell count can indicate inflammation, infection, an abscess, or a ruptured gallbladder.  CRP (C-reactive protein, the preferred test) or ESR (erythrocyte sedimentation rate)—elevated results indicate inflammation.  Liver panel—if someone has gallstones that block bile ducts, results for bilirubin may be high due to bile backing up into the liver. Liver enzymes, especially alkaline phosphatase (ALP), may be elevated in severe cases of gallbladder inflammation.  Lipase (the preferred test) or amylase—these pancreatic enzymes may be elevated if gallbladder disease has also caused pancreatitis.

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Nursing Diagnoses Clients with biliary alterations can have the following nursing diagnoses (hypotheses):

 Acute pain related to cholecystitis or cholelithiasis and subsequent surgical intervention  Alteration in nutrition: less than body requirements due to gastrointestinal (GI) disturbances related to gallbladder disease  Fluid volume deficit related to nausea and vomiting  Knowledge deficit related to risk factors, aggravating behaviors, and poor dietary choices  Risk for infection following surgical intervention Think about ones that you would prioritize for your client? Are they urgent, likely to happen, or is your client at-risk?

Priority Nursing Diagnosis Considering Yolanda's situation, what is the priority nursing diagnosis?

Acute pain Risk for infection

Knowledge deficit Risk for imbalanced nutrition: less than body requirements Nursing care planning and management for patients with cholecystitis include relieving pain and promoting rest, maintaining fluid and electrolyte balance, preventing complications, and provision of information about disease process, prognosis, and treatment. In this case, pain is the priority, as it is the most prominent symptom of gallbladder disease and is often severe. Nutritional imbalances would need to be addressed as well as the lack of knowledge in caring for self. Finally risk for infection is important, but only after surgical intervention.

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Intervention The healthcare provider informs Yolanda that she needs to have her gallbladder removed. Before this can occur, the client needs to have nothing by mouth (NPO) for at least 6 hours, may need placement of a nasogastric tube for stomach decompression, antibiotic administration if infection is present, intravenous fluids to replace volume and electrolytes, medications for nausea and vomiting, and mouth care.

Removal of the gallbladder can be performed with either an open cholecystectomy (via laparotomy) or laparoscopic cholecystectomy.

Recovery time depends upon the type of surgical intervention.

Immediately after an open laparotomy cholecystectomy, clients generally can NPO or remain on a clear liquid diet until bowel sounds are auscultated. Once GI motility is present, clients can transition to a regular diet as tolerated.

The patient who undergoes a laparoscopic cholecystectomy procedure may consume a regular diet immediately after surgery and oral fluids are well tolerated.

Both procedures can require time for the body to adapt to lack of the gallbladder. Therefore, some patients need to follow a low-fat diet for several weeks after surgery. This prevents gastrointestinal upset, especially diarrhea.

Laparotomy

Laparoscopic Cholecystectomy

Nursing Implications Nursing implications for clients who have experienced alterations in biliary health with gallbladder disease include the following:  Management of pain and discomfort due to gallstones, inflammation, or both  Administration of antiemetics for nausea related to disease process  Monitoring fluid and electrolytes and hydration status due to GI distress  Administer intravenous fluids for adequate hydration and to restore electrolytes as needed  Evaluate nutritional status related to GI distress and alteration in absorption  Evaluate client knowledge regarding diagnosis and provide teaching as needed  Assess client diet and instruct client about appropriate modifications  Evaluate surgical wound for signs and symptoms of infection (redness, edema, fever, pain, increased WBC count, etc.)

Diet Teaching

The nurse is teaching Yolanda about her diet after the cholecystectomy.

Although there isn't a required post-surgical diet, the following tips may help minimize problems with diarrhea.

Limit Fats Increase Fiber in the Diet Eat Smaller, More-Frequent Meals

Dietary Goals The nurse is speaking with Yolanda about dietary choices in the future, post cholecystectomy. It is important for the nurse to emphasize the importance of making healthy food choices. The client verbalizes understanding of the dietary education received with which statements?

Select all that apply.

"I will eat small, frequent meals.”

"I will increase my caffeine consumption after a week.” ”High fiber is essential for gastrointestinal (GI) health.” ”Fatty and fried foods should not be chosen.”

Although there isn't a set gallbladder removal diet, the following tips may help minimize problems with diarrhea after gallbladder removal  Go easy on the fat. Avoid high-fat foods, fried and greasy foods, and fatty sauces and gravies for at least a week after surgery. Instead, choose fat-free or low-fat foods. Low-fat foods are those with no more than 3 grams of fat a serving. Check labels and follow the serving size listed.  Increase the fiber in your diet. This can help normalize bowel movements. Add soluble fiber, such as oats and barley, to your diet.

But be sure to increase the amount of fiber slowly, such as over several weeks, because too much fiber at first can make gas and cramping worse.  Eat smaller, more-frequent meals. This may ensure a better mix with available bile. A healthy meal should include small amounts of lean protein, such as poultry, fish or fat-free dairy, along with vegetables, fruits and whole grains.

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Recommended vs. Limited Food Options Yolanda has consulted with a dietician. Place the foods into the correct columns to identify what food is recommended and what should be limited.

Foods

Recommended

Limited

chicken yogurt with skim milk raw nuts whole grain bread, pasta blueberries water avocadoes

steak cookies alcohol soda chocolate coffee full-fat yogurt

When choosing foods to eat after gallbladder removal, it is important that one avoid high-fat foods, fried and greasy foods, and fatty sauces and gravies for at least a week after surgery. Instead, choose fat-free or low-fat foods. Low-fat foods are those with no more than 3 grams of fat a serving.

Check labels and follow the serving size listed.

To help normalize bowel movements; Add soluble fiber, such as oats and barley, to your diet. But be sure to increase the amount of fiber slowly, such as over several weeks, because too much fiber at first can make gas and cramping worse.

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Low-Fat Diet Yolanda was discharged from the hospital without complications. Ten days later she is following up with her healthcare provider. She does not have the pain she did before her surgery, but is complaining about gas, bloating and diarrhea. Yolanda states that she has slightly modified her diet, "loves hamburgers and french fries", and has decreased her visits to fast food restaurants. She is upset that she must modify her diet and cannot eat the convenient and high calorie foods that she loves.

While speaking with the dietician, Yolanda is reminded that when the gallbladder is removed, bile is less concentrated and drains more continuously into the intestines, where it can have a laxative effect. It is

important that Yolanda considers the amount of fat she consumes at one meal. Additionally, smaller amounts of fat are easier to digest, while larger amounts can remain undigested and cause gas, bloating and diarrhea. The dietician can also work with the client on meal planning and preparation to allow for quick meals that can be planned at home.

Dietary Complications Yolanda expresses concern at the post-operative visit about the presence of gas, bloating and diarrhea. Yolanda said she thought that after the surgery, she would not have any other symptoms. She asks the health care provider what she can do to prevent future symptoms from occurring. How should the provider reply?

"Eat larger amounts of fat during meals.” ”When eating, select smaller amounts of fat.”

"Decrease the amount of fiber you are eating during meals.”

"Increase the amount of protein intake during meals.”

The amount of fat you eat at one time also plays a role. Smaller amounts of fat are easier to digest, while larger amounts can remain undigested and cause gas, bloating and diarrhea.

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Clinical Manifestations – Recognizing Cues For the client with a diagnosis of cholecystitis, the pain is located in the right upper quadrant and radiates to the epigastric region, directly over the stomach and inferior to the sternum.

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Clinical Manifestations – Analyzing Cues Laboratory values are collected for Yolando and are as follows: Complete blood count shows a white blood cell (WBC) count of 17,000/mm3.  Serum chemistry studies show the following:  total bilirubin 0.9 mg/dL  direct bilirubin 0.8 mg/dL  alkaline phosphatase 112 U/L  aspartate transaminase (AST) 47 U/L  alanine transaminase (ALT) 39 U/L 

Which laboratory value provided above indicates a possible risk for infection?

white blood cell (WBC) count of 17,000/mm3 total bilirubin 0.9 mg/dL alanine transaminase (ALT) 39 U/L aspartate transaminase (AST) 47 U/L A complete blood count (CBC), which looks at levels of different types of blood cells such as white blood cells. A high white blood cell count may indicate infection. If there is inflammation caused by gallstones, the white blood cell count is usually elevated (higher). In this situation, the patient will often have a fever.

A liver function test checks the enzyme and protein levels in the blood.

Enzymes found in the liver and other parts of the body include alanine transaminase (ALT), aspartate transaminase (AST), alkaline phosphatase (ALP), and gamma-glutamyl transpeptidase (GGT). High levels of these enzymes could mean damage to the liver or bile duct.

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Interventions - Generate Solutions During Yolanda's initial presentation to the emergency department, she was experiencing an increase in pain and nausea. The attending physician was notified and ordered an abdominal ultrasound.

The result of the ultrasound revealed a thickened gallbladder wall, common bile duct (CBD) diameter of 4.3 mm, and presence of multiple 12mm stones in the gallbladder

Yolanda receives a diagnosis of cholecystitis. As the primary nurse caring for Yolanda, what would be appropriate interventions? Select all that apply.

Intravenous (IV) fluid administration Complete bed rest Increase fat consumption Nothing by mouth (NPO) Prepare for transfer to the operating room With a diagnosis of cholecystitis, you are anticipating that Yolanda will have surgical removal of the gallbladder. With a focus on Yolanda's nutritional needs and in preparation for the possibility of a surgical procedure, you would keep the patient NPO, begin intravenous fluids and keep the patient at rest to ensure comfort. You would also not want to feed the client to prevent aspiration during surgery. Additionally, preparation for transfer to the operating room is appropriate as well.

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Urinary Changes – Analyzing Cues After Yolanda has been admitted, she is placed nothing by mouth (NPO) and started on intravenous fluids. To appropriately monitor her urine output, a foley catheter was inserted. The urine that is obtained is dark colored. What does the dark urine suggest?

glycosuria constipation anorexia

blocked bile duct Dark or orange colored urine can indicate a blockage in the bile duct.

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Post Procedure Diet When Yolanda returns to her room after an open cholecystectomy, she asks when she can eat or drink. What diet would the nurse expect to be prescribed for this client?

Remain nothing by mouth (NPO) Begin full liquids Resume a regular diet Start on a pureed diet Immediately after an open laparotomy cholecystectomy, patients may receive either nothing orally or clear liquids until bowel sounds resume.

After that time, they can proceed as tolerated to a regular diet. The patient who undergoes laparoscopic cholecystectomy may consume a regular diet immediately after surgery.

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Nursing Interventions – Generate Solutions A client who has been recently diagnosed with cholecystitis calls the nurse to report continued nausea with eating any type of foods. What intervention can the nurse recommend?

Choose small frequent meals throughout the day Select high fat meals to increase gastrointestinal motility Drink fruit juices to stimulate gastric secretions Increase activity before and after eating all meals Small meals throughout the day can help prevent nausea, as the smaller amount of bile is needed to break down fats. Larger, fatty meals are more difficult to digest and require more bile.

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After surgery, it is not unusual for clients to vomit once, but if they tolerate fluids well afterwards, they can progress diet. After changing positions for the first time, the client may experience slight dizziness. IF this does not resolve, or additional symptoms occur, additional evaluation would be warranted. It is also common for clients to be hungry after surgery. The concerning finding is the bleeding at the incision site along with report of pain. While this can be normal incisional pain and slight bleeding, but the dressing needs to be removed to evaluate the incision site.

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Role of The Dietitian The health care provider made a referral to a dietitian to help improve Yolanda's post-surgical dietary health. What is the role of the consulting dietitian?

Provide client teaching on nutritional therapy Assess client's intake and output and daily weight Manage all prescribed medications Monitor and evaluate client's activity status The role of the dietitian in the care of patient with gallbladder removal is to assess and interpret data to provide appropriate teaching and medical nutritional therapy for each patient. They work as part of the multidisciplinary team in the care of clients needing nutritional support.

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