Now, let's talk about an open or incisional cholecystectomy.
Now, that's a pretty graphic picture if you think about that being your body.
Now, this gallbladder is removed through an incision right in the abdominal wall.
You see them holding back the incision so the surgeon can visualize the gallbladder.
Now, a T-tube is used. Why is it called a T-tube? Well, it's actually shaped like a letter T.
Okay, it's also a transhepatic biliary catheter. So, that will help you remember both ways.
So, we're talking about a T-tube. See the picture there?
We may place that in the common bile duct.
Why would we put a tube in there after an open chole?
Well, you put it in the common bile duct to keep that duct open, okay?
So, because remember, we're choosing to do an open chole
because this was a little more complicated procedure.
Probably it was extra scarring, other variables,
and so, the physician chose an open cholecystectomy as the safest option for your patient.
So, there's going to likely be some edema and other challenges to draining while it's healing.
So, you put a T-tube in, a transhepatic biliary catheter,
put it right in the common bile duct to keep that duct open
while you're dealing with edema, manipulation after surgery.
Okay, so, the T-tube is placed in the common bile duct
and then it is threaded outside of the body to allow for drainage.
Now, we've got a closeup for that T-tube so let's zero in and take a look at it.
Now, you see the liver, follow that down, look, you see where we've got the cystic duct clipped off
or tied off, then you see where the T-tube directly where it's inserted.
See how the short part of the T is in that duct.
The long part or the leg of the T exits out the incision
so we can connect it to a drainage bag outside of the body.
So, you're with me? See, this is actually a really brilliant solution.
Pretty simple but it gets the job done. Initially, your body has gone through a lot of trauma
and things are gonna be swollen and that duct may be difficult for things to pass through.
So, you're gonna have a lot more drainage at the very beginning.
So, normally, it drains up to about 500 mL in the first 24 hours after surgery.
Your job as a nurse is to watch the amount of drainage, look at that incision,
make sure you know any changes in color and amount.
Be sure to document the entire amount of drainage that's put out into that drainage bag.
So, what are we looking for? About 500 mL in the first 24 hours after surgery.
Now, drainage, as everything begins to heal, should decrease.
Why do you think that is?
Well, initially, that tube is pretty swollen and edematous
so a fair amount of drainage from the liver is gonna get diverted into the bag.
But now as that tube heals, things open up again, more of the bile is gonna drop
right on down into the small intestine where it should.
So, drainage should decrease to less than 200 mL is 2-3 days.
First 24 hours, 500. It'll decrease to 200 mL in the first 2-3 days.
Now, after that, the drainage should be minimal. Initially, the drainage may be blood tinged.
Remember, pretty traumatic procedure going on here, but then it will change to green-brown.
Okay, change. That's something we're always watching for as nurses.
Why is it initially blood tinged and then it changes to green-brown?
Well, initially, it went through the surgery and the trauma,
that's why it should be blood-tinged.
Not frank bleeding, not bright red bleeding, just little tinges or smidges of blood in it.
As things progress and heal, then what's gonna be going into the bag is green-brown
because it's just gonna be straight bile.
Okay, so you know your role as a nurse.
Keep an eye in the incision, keep an eye on the tube,
make sure you're looking at the amount that's coming out, and the color.
We would expect it to become less and less in the bag as time progresses.
In fact, many patients, when they go home, no longer have a drainage bag.
So, what I want you to encourage the patient about the T-tube
is that they're gonna replace the amount of fluid drained in the T-tube with electrolyte-rich fluids.
Now, I'm not gonna give you any brand names here, but we're talking about sports drinks.
So, think about something like a sports drink.
So, if the first day, my patient puts out 500 mL of drainage into their T-tube drainage bag,
then I'm gonna encourage them to drink 500 mL of a sports drink or an electrolyte-rich liquid.
Now, I'm gonna keep an eye on that skin around the catheter site.
Remember, it should be cleansed daily with antiseptic and then looking for any signs of infection.
So, is it reddened outside of what you would normally see with an incision.
Is it extra red? Is it warm? Is it oozing anything from the incision?
I'm watching closely for signs of infection because if I see any signs of infection or bile leakage,
I need to contact the healthcare provider.
We need to do something else to address that
and always be on the lookout for signs of a blocked or malfunctioning T-tube.
Remember that I've said an abdominal pain, nausea, fever, or chills.
Same things when they experience a gallstone.
So let's talk about the open cholecystectomy's priorities.
Okay, you're not really impressed with that title, are you?
Now, let's see how you respond. I've got care plan gold for you.
Got a care plan due in a couple hours? Let me show you what are priorities.
So, if you were taking care of a patient after they've had an open chole, these are your top priorities.
Watch them for signs of bleeding, watch them for signs of bile leaking, T-tube obstruction, or infection.
Right there. I've given you four of the most important things
to be looking for postop after a cholecystectomy.
Now, you're gonna monitor the patient's pain.
I know in NCLEX world, pain is a psychosocial need.
However, if it's my body that's been butchered, I definitely am gonna want pain control.
Now, fluid and electrolyte balance is a little wonky cuz I don't feel good as a patient,
I've got stuff exiting my body maybe earlier than I intended it to do, we've got to replace that fluid.
So, watch my fluid and electrolyte balance very closely.
Encourage your patients to be active. We want them up and moving around.
That is the best for anyone after a surgery or a procedure.
They see our last point for your care plan.
It's talking about slowly introducing clear liquids and then progress the diet as it's ordered or appropriate.
So, what does that mean? Well, the physician will have some very specific things.
The patient has bowel sounds? We'll start with clear liquids.
If they tolerate the clear liquids, we'll bump it up a little bit.
Maybe we'll get real crazy and add some pudding.
They tolerate that, then we'll move to soft foods, and back to their regular diet.
So, that's what it means when you see an order that says progress diet as ordered.