postoperative care of patients undergoing same-day laparoscopic

CONTINUING EDUCATION

Postoperative Care of PatientsUndergoing Same-Day LaparoscopicCholecystectomy 3.0 www.aorn.org/CE

PATRICIA BRENNER, BSN, RN, CCRN;DONALD D. KAUTZ, PhD, RN, CRRN, CNE, ACNS-BC

Continuing Education Contact Hoursindicates that continuing education (CE) contact hours are

available for this activity. Earn the CE contact hours by readingthis article, reviewing the purpose/goal and objectives, andcompleting the online Examination and Learner Evaluation athttp://www.aorn.org/CE. A score of 70% correct on the exami-nation is required for credit. Participants receive feedback onincorrect answers. Each applicant who successfully completesthis program can immediately print a certificate of completion.

Event: #15523Session: #0001Fee: Members $24, Nonmembers $48

The CE contact hours for this article expire July 31, 2018.Pricing is subject to change.

Purpose/GoalTo provide the learner with knowledge specific to caring forpatients undergoing same-day laparoscopic cholecystectomy.

Objectives1. Discuss gallbladder disease.2. Explain abdominal insufflation during laparoscopic

cholecystectomy.3. Describe recovery from anesthesia.4. Define postoperative pain management.5. Identify checklists used to determine readiness for

discharge.6. Describe issues with patients requiring an extended stay

after laparoscopic cholecystectomy.7. Discuss effective methods of providing postoperative

discharge teaching.

AccreditationAORN is accredited as a provider of continuing nursingeducation by the American Nurses Credentialing Center’sCommission on Accreditation.

ApprovalsThis program meets criteria for CNOR and CRNFA recerti-fication, as well as other CE requirements.

AORN is provider-approved by the California Board of RegisteredNursing, Provider Number CEP 13019. Check with your stateboard of nursing for acceptance of this activity for relicensure.

Conflict-of-Interest DisclosuresMs Brenner and Dr Kautz have no declared affiliations thatcould be perceived as posing a potential conflict of interest inthe publication of this article.

The behavioral objectives for this program were created byRebecca Holm, MSN, RN, CNOR, clinical editor, withconsultation from Susan Bakewell, MS, RN-BC, director,Perioperative Education. Ms Holm and Ms Bakewell have nodeclared affiliations that could be perceived as posing potentialconflicts of interest in the publication of this article.

Sponsorship or Commercial SupportNo sponsorship or commercial support was received for this article.

DisclaimerAORN recognizes these activities as CE for RNs. Thisrecognition does not imply that AORN or the AmericanNurses Credentialing Center approves or endorses productsmentioned in the activity.

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Postoperative Care of PatientsUndergoing Same-Day LaparoscopicCholecystectomy 3.0 www.aorn.org/CE

PATRICIA BRENNER, BSN, RN, CCRN;DONALD D. KAUTZ, PhD, RN, CRRN, CNE, ACNS-BC

ABSTRACTElective laparoscopic cholecystectomies are common outpatient surgical procedures. After brieflydiscussing cholecystectomy and its indications, best practices in phase I, phase II, and phase III re-covery are discussed. Typical pharmaceutical regimens for controlling pain and postoperative nauseaand vomiting are summarized. By implementing best practices, nurses can prevent and recognizecomplications. The criteria for discharge, extended recovery, and inpatient admission are discussed,along with the required patient discharge teaching using the teach-back technique, as well as patientand family teaching needs in the immediate postoperative period. Nurses can optimize the patient’ssurgical experience and promote safety by implementing best practices in all phases of recovery fromlaparoscopic cholecystectomy. AORN J 102 (July 2015) 16-29. ª AORN, Inc, 2015. http://dx.doi.org/10.1016/j.aorn.2015.04.021

Key words: elective laparoscopic cholecystectomy, outpatient surgical procedures, best practices.

Laparoscopic cholecystectomy is removal of the gall-bladder using a laparoscopic technique. Most peoplerequiring a laparoscopic cholecystectomy are experi-

encing choledocholithiasis (ie, gallstones in the bile duct),cholelithiasis (ie, cholesterol stones), or acute cholecystitis (ie,inflammation of the gallbladder wall). The most common gall-bladder disorder is acute cholecystitis; 90% of individuals whohave this also have cholelithiasis. Clinical manifestations ofcholecystitis are nausea, vomiting, fever, malaise, right upperquadrant abdominal pain, or epigastric pain radiating to the back.Risk factors for cholelithiasis are female sex, Native Americanethnicity, obesity, and rapid weight loss in an obese individual.1

In the United States, laparoscopic cholecystectomy is thesecond most frequently performed general surgery procedure.2

Typically, the surgeon performs laparoscopic cholecystectomyon a same-day or outpatient basis in an ambulatory oroutpatient setting. The laparoscopic approach is minimally

invasive and decreases risk of infection, length of surgicaltime, and recovery time.3

The preoperative nurse admits the patient and performs apreoperative nursing assessment. After the patient changes intoa hospital gown, the preoperative nurse inserts an IV andplaces sequential compression device stockings, which the RNcirculator will continue intraoperatively, to prevent deep veinthrombosis.4

After setting up the OR with the scrub person, the RNcirculator meets the patient in the preoperative area. The RNcirculator reviews the patient’s medical record for the historyand physical examination and laboratory results. After assess-ing the patient, the RN circulator develops a nursing care planspecific to the patient (Table 1).

The surgeon reassesses the patient in the preoperative area andmarks the surgical site cooperatively with the patient after

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Table 1.Nursing Care Plan for a Patient Undergoing Laparoscopic Cholecystectomy

Diagnosis Nursing Interventions Interim Outcome Statement Outcome Statement

Risk of injury � Confirms patient identity.� Verifies operative procedure,surgical site, and laterality.

� Manages culture specimencollection.

� Manages specimen handlingand disposition.

� Evaluates correct processeshave been performed forspecimen handling anddisposition.

� Cultures and tissue specimens arecorrectly labeled.

� Culture and tissue specimens aresuccessfully transported to thelaboratory.

� The patient’s specimen(s) ismanaged in the appropriatemanner.

Risk ofimbalancedbodytemperature

� Assesses risk of normothermiaregulation.

� Assesses risk of inadvertenthypothermia.

� Assesses risk of inadvertenthyperthermia.

� Identifies physiological status.� Implements thermoregulationmeasures.

� Monitors body temperature.� Monitors physiologicalparameters.

� Evaluates response tothermoregulation measures.

� The patient’s temperature is greaterthan 36� C (96.8� F) at time ofdischarge from the operating orprocedure room.

� The patient is at or returning tonormothermia at theconclusion of the immediatepostoperative period.

Risk ofimbalancedfluid volume

� Identifies factors associated withan increased risk of hemorrhageor fluid and electrolyteimbalance.

� Identifies physiological status.� Reports deviation in diagnosticstudy results.

� Establishes vascular access.� Implements hemostasistechniques.

� Monitors physiologicalparameters.

� Administers prescribedsolutions.

� Collaborates in fluid andelectrolyte management.

� Administers electrolyte therapyas prescribed.

� Evaluates response toadministration of fluids andelectrolytes.

� The patient’s urinary output is withinexpected range at discharge fromthe OR, procedure room, orpostanesthesia care unit.

� The patient’s fluid, electrolyte,and acid-base balances aremaintained at or improvedfrom baseline levels.

Risk ofperioperativepositioninginjury

� Assesses baseline skincondition.

� Identifies baseline tissueperfusion.

� Identifies baselinemusculoskeletal status.

� Identifies physical alterationsthat require additional

� The patient has full return ofmovement of extremities at time ofdischarge from the OR or procedureroom.

� The patient is free from pain ornumbness associated with surgicalpositioning.

� The patient is free from signsand symptoms of injury relatedto positioning.

� The patient is free from signsand symptoms of injury causedby extraneous objects.

(continued)

July 2015, Vol. 102, No. 1 Outpatient Laparoscopic Cholecystectomy



Table 1. (continued)


precautions for procedure-specific positioning.

� Positions the patient.� Implements protectivemeasures to prevent skin/tissueinjury due to mechanicalsources.

� Applies safety devices.� Uses supplies and equipmentwithin safe parameters.

� Maintains continuoussurveillance.

� Evaluates tissue perfusion.� Evaluates musculoskeletalstatus.

� Evaluates for signs andsymptoms of physical injury toskin and tissue.

Ineffectivebreathingpattern;impaired gasexchange

� Identifies baseline respiratorystatus.

� Identifies physiological status.� Reports deviation in diagnosticstudy results.

� Reports deviation in arterialblood gas studies.

� Monitors physiologicalparameters.

� Monitors changes in respiratorystatus.

� Uses monitoring equipment toassess respiratory status.

� Evaluates respiratory status.

� The patient’s SaO2 and respiratoryrate are within expected range atdischarge from the postoperativecare unit.

� The patient’s respiratory statusis maintained or improved frombaseline levels.

Risk of infection � Assesses susceptibility forinfection.

� Classifies surgical wound.� Implements aseptic technique.� Protects from cross-contamination.

� Initiates traffic control.� Administers prescribedprophylactic treatments.

� Administers prescribedmedications.

� Administers prescribedantibiotic therapy as ordered.

� Performs skin preparations.� Monitors for signs andsymptoms of infection.

� Minimizes the length of invasiveprocedure by planning care.

� Maintains continuoussurveillance.

� Administers care to wound sites.

� The patient’s wound is free fromsigns or symptoms of infection andpain, redness, swelling, drainage, ordelayed healing at time of discharge.

� The patient is free from signsand symptoms of infection.

BrennerdKautz July 2015, Vol. 102, No. 1



completing the informed consent process. The anesthesiaprofessional arrives to assess the patient, discuss the plan to usegeneral anesthesia for the procedure, and explain that use ofanesthesia ensures the patient’s lack of awareness of the sur-gery, reduces pain, and minimizes nausea.5

The anesthesia professional and RN circulator transport thepatient to the OR and help the patient move to the OR bed.After inducing anesthesia, the anesthesia professional admin-isters muscle relaxants to the patient to optimize surgicalvisualization and improve surgical access.5

The RN circulator completes perioperative skin antisepsis.The surgeon creates four port sites (ie, small keyhole incisionseach approximately 1.5 cm in length)6 and fills the patient’sabdominal cavity with carbon dioxide (CO2) via aninsufflator to improve visualization and allow easier access totarget areas. Carbon dioxide is nonflammable when usedwith electrical instruments. There is a very low risk of airembolism when CO2 is introduced into the bloodstreambecause the CO2 is absorbed by red blood cells after theyrelease fresh oxygen to the cells.7 The red blood cells thentransport the CO2 to the lungs, where it is released inexchange for fresh oxygen. In spite of the small incisions,suctioning, cutting, obtaining the specimen, and suturing are

all possible with laparoscopic instruments and magnification.The surgeon uses the instruments to isolate the gallbladderwith electrosurgery and then removes the gallbladderthrough one of the port sites, commonly the umbilical site.3

The surgeon deflates the patient’s abdomen to remove mostof the CO2 gas. A small amount of CO2 gas remains in theabdomen postoperatively. When the procedure is completed,the surgeon applies a tissue adhesive to the approximatedincisions.6 Typically, postoperative drains are not placed inuncomplicated laparoscopic procedures.

When surgery is complete but beforemoving the surgical patientto the postanesthesia care unit (PACU), the anesthesia profes-sional wakes the patient from anesthesia and removes theendotracheal tube. Patient goals during emergence includeadequate reversal from muscular paralytic agents, spontaneousrespirations to maintain saturations near the patient’s baselinewith supplemental oxygen, and an end-tidal CO2 level near thepatient’s baseline. Emergencemarks the entry of the patient intophase I of the recovery period. The anesthesia professional andRN circulator transport the patient to the PACU.

PHASE I RECOVERYThe anesthesia professional and RN circulator provide thePACU RN with a thorough hand over, transfer-of-care report.8

Table 1. (continued)


� Administers care to invasivedevice sites.

� Encourages deep breathing andcoughing exercises.

� Evaluates factors associatedwith increased risk forpostoperative infection at thecompletion of the procedure.

� Evaluates progress of woundhealing.

� Evaluates for signs andsymptoms of infection through30 days following theperioperative procedure.

Acute pain � Assesses pain control.� Identifies cultural and valuecomponents related to pain.

� Implements pain guidelines.� Implements alternative methodsof pain control.

� Collaborates in initiatingpatient-controlled analgesia.

� Evaluates response to painmanagement interventions.

� The patient verbalizes control of pain.� The patient’s vital signs at dischargefrom the OR are equal to orimproved from preoperative values.

� The patient demonstratesand/or reports adequate paincontrol.




The goal of nursing care in the PACU is to identify any potentialanesthesia or surgical problems and intervene whenappropriate.9 The PACU RN performs an initial airway,breathing, and circulation assessment, along withidentification of the patient’s electrocardiogram (ECG)rhythm, level of consciousness, vital signs, pain, surgical siteincisions, IV access, and medication given and ordered for usein the PACU.

Supplemental oxygen requirements in phase I recovery dependon the patient’s respirations and oxygen saturation level. ThePACU RN monitors for deviations in the patient’s ECG,blood pressure, and temperature from the preoperative base-line status. The goal is to restore normothermia and monitorfor complications, such as shivering, bleeding, altered medi-cation metabolism, pain, infection, and late signs of rare ma-lignant hyperthermia (eg, fever).9

The PACU RN also assesses the patient’s surgical site tomonitor for signs of drainage, hematoma, hemorrhage, ordehiscence. The PACU RN then evaluates the patient’sgastrointestinal status to assess for bowel sounds and abdom-inal distention. When clinically appropriate, the PACU RNplaces the patient into a semi-Fowler’s or high Fowler’s posi-tion. This improves respiration and facilitates the movementof CO2 from the patient’s peritoneum into ascending portionsof the body, such as the shoulders.6

Typical Management of PostoperativePainA major goal in the PACU is management of pain. The patientrates the level of his or her postoperative pain on a scale of zero to10; the PACURN appropriately treats the patient’s postoperativepain based on what the patient defines his or her pain to be. Thegoal of postoperative pain management is to achieve a tolerablelevel of discomfort.Managing the patient’s pain adequately allowsthe nurse to encourage earlymobility and deep breathing exerciseswith coughing, thus improving the patient’s postoperative out-comes. The PACU RN administers the postoperative painmedications ordered by the anesthesia professional, which typi-cally includes analgesic medications such as fentanyl, morphine,ketorolac, and hydrocodone with acetaminophen. The PACURN also provides nonpharmacological interventions such as ice,heat, massage, repositioning, and touch therapy.

Typical Management of PostoperativeNausea and VomitingApproximately one-third of surgical patients experience post-operative nausea and vomiting (PONV).10 Risk factors for

PONV include female sex, history of PONV or motionsickness, nonsmoking status, age younger than 50 years,intraoperative use of volatile anesthetics and nitrous oxide,longer duration of general anesthesia, and postoperative opioiduse.11 Hypovolemia from fasting and gastrointestinal ischemiaprecipitates PONV.12 Chatterjee et al13 reported that PONVcan be caused when CO2 gas places pressure on the vagus nerveand transmits information to the vomiting center of the brain,which may explain why PONV is one of the most commonpatient complaints after laparoscopic cholecystectomy.12

The goal in managing nausea and vomiting is to avoid dehy-dration, improve symptoms, maintain adequate urine output,and ensure that the patient tolerates oral hydration. Intravenousfluid hydration is readily available or already infusing before thepatient arrives in phase I recovery. Further, research has shownthat preoperative fluid management may decrease PONV.12

Effective alternative therapies used in conjunction withpharmacological modalities for PONV include P6 stimulationacupuncture (neuromuscular stimulation or pressure placedover the median nerve) and administration of 1 g of ginger bymouth one hour before induction of anesthesia.11

Managing PONV requires knowledge of emetogenic pathwaysand the correct timing and combination of antiemetics. In2013, the Society for Ambulatory Anesthesia (SAMBA)14

published research-based PONV guideline updates forchoosing appropriate antiemetic regimens for patients withPONV. Despite the growing number of emetogenicpathway neurotransmitters that have been identified,multiple pharmacological modalities used in combinationprovide better outcomes than single treatments or notreatment.15 Antiemetic medication selection also dependson efficacy, cost, safety, and ease of dosing.14

Postoperative nausea and vomiting are triggered by four mainreceptors in the body: histamine (H1), serotonergic (5-HT3),dopaminergic (D2), and opiate (ie, mu, delta, kappa).10 Theefficacy of antiemetic medications is related to their bindingaffinity for specific receptors and antagonizing effects.

� Scopolamine is a histamine antagonist that works in thevomiting center of the brainstem; it can be used beforesurgery in the form of a transdermal patch.

� Ondansetron, granisetron, and palonosetron have antago-nistic effects on serotonergic 5-HT3 receptors, resulting inimproved gastric stasis.

� Haloperidol and droperidol are potent dopamine antagoniststhat are also used to manage PONV.16

� The emetogenic mechanism involved for an opiate receptordepends on multiple and complex mechanisms; for example,




the specificity of the opioid receptor (mu opioid receptoragonists are directly associated with nausea and vomiting)and more than one receptor may be active in any one pa-tient. The relationship between opioid use and the incidenceof nausea and vomiting is complex.17

Aprepitant, a selective neurokinin-1 (NK1R) receptor agonist,prevents the binding of substance P (ie, a neuropeptide mainlyfound in the vomiting center of the brain) to the NK1R. Thiscan mediate the induction of vomiting pathways in thebrainstem. Dexamethasone, a corticosteroid, is also effective asa treatment for PONV,11 although the mechanism of action isunclear. Antiemetics ordered for postoperativecholecystectomies include ondansetron, promethazine,dexamethasone, and droperidol.18 Intravenous promethazinerequires verification of IV catheter placement to avoidextravasation and other complications.19

PHASE II RECOVERYThe transition into phase II recovery begins after the PACURN has managed the patient’s pain, nausea, and vomiting withone or more pharmacological interventions or alternativemodalities while simultaneously monitoring for potentiallyharmful side effects (eg, respiratory depression, allergic re-actions). The patient must meet transfer criteria before thePACU RN can move the patient to phase II recovery (eg, mustbe easily arousable and oriented, must be able to toleratesitting without signs or symptoms of orthostatic hypotension).The phase II RN focuses on getting the patient out of bed andinto a chair to facilitate respiration. Early mobility andambulation in the PACU helps decrease postoperativeabdominal pain as well as facilitate movement of CO2 gas outof the peritoneum.20

CRITERIA FOR OUTPATIENT DISCHARGEThe Aldrete Scoring System and the Post-AnestheticDischarge Scoring System (PADSS) are two of the toolsavailable to help the surgical team ensure that outpatients areready for discharge. The Aldrete score is used to objectivelyassess the patient during the recovery process (Figure 1).21 TheAldrete score has five categories: respiration, color,consciousness, circulation, and activity; each category has ascoring range from zero to two. The PACU nurse transfersthe patient to phase II recovery after the patient receives anAldrete score of 10. Health care facilities vary in dischargescoring based on the tool used, such as the Aldrete ScoringSystem or the modified Aldrete score (Post-AnesthesiaRecovery Score for Ambulatory Patients [PARSAP]). Apatient remains in phase II recovery for at least 30 minutesafter administration of oxygen has been stopped and after

the last IV medications (eg, opioid, antiemetic, antihypertensive)have been administered.

The PADSS is a checklist used to determine readiness fordischarge from phase II recovery (Figure 2).22 The checklistassesses whether the patient is stable in the following categories:

� vital signsdis normothermic, maintains and protects airway,and vital signs and blood glucose levels (of patients withdiabetes) are within a 20% range of baseline;

� activity and mental statusdwalks without difficulty and hasminimal dizziness, is easily arousable and oriented, or returnsto preprocedural status;

� pain, nausea, and/or vomitingdpain and nausea are absentor at a tolerable level;

� surgical bleedingdis not excessive; and� intake and outputdis adequate to maintain oral hydration.

CRITERIA FOR EXTENDED RECOVERYOR ADMISSIONPostoperative pain, nausea, and vomiting are the main reasonsfor failure to discharge a patient on the day of surgery.23 TheAmerican Society of Anesthesiologists (ASA) has developed aclassification system to predict patient mortality based onhealth status before undergoing surgery (Figure 3). This toolalso is used to indicate the probable length of stay aftersurgery.24 Reasons for NOT immediately discharging apatient after same-day surgery include

� having an ASA classification score of 3 or higher,� being older than 50 years,� not having a caretaker at home,� having multiple morbidities (eg, obstructive sleep apnea,diabetes, renal insufficiency),

� experiencing uncontrolled pain, and� requiring supplemental oxygen to maintain oxygen satura-tion greater than 90% to 92%.25

The postoperative period may be extended for patients withobstructive sleep apnea who have been administered narcoticsbecause they require monitoring for hyperanalgesia, somno-lence, and respiratory compromise.25 Patients who haveobstructive sleep apnea also may have increasedaccumulation of anesthetic gases in adipose tissue, whichprolongs medication clearance time and leads to furtherepisodes of sleep apnea.26 Patients with diabetes mellitusrequire monitoring and control of blood glucose levels thatare out of range postoperatively. Nurses should also closelymonitor patients who have diabetes for dehydration andrisks associated with hyperosmolar hyperglycemic nonketoticsyndrome (HHNS) or diabetic ketoacidosis.27 Patients with




renal insufficiency have decreased medication clearance times,requiring observation for anesthetic and narcotic side effects.9

Male gender is a risk for adverse outcomes because of delayedpresentation of symptomatic cholelithiasis with advancedinflammation and fibrosis, increased incidence of conversionfrom laparoscopic to open surgery, and psychological andsocial factors.28

During the extended recovery stay, nurses must be aware ofthe complications associated with laparoscopic cholecystec-tomy. These include paralytic ileus, pneumoperitoneum,perforated or necrotic bowel, internal bleeding, intractablenausea and vomiting, deep vein thrombosis, dehydration,urinary retention, and surgical site infection.29

PATIENT DISCHARGE TEACHINGAfter the patient has met discharge criteria, the PACU nurseidentifies the patient’s chosen responsible adult who will

accompany the patient during the surgical recovery period,which typically lasts approximately 24 hours. The responsibleadult must be

� able to show understanding of the discharge instructions,� aware of signs and symptoms of problems or complications,and

� capable of obtainingmedical assistance if adverse events occur.30

Preoperatively, patients are required to identify a responsibleadult to take them home after surgery for phase II discharge.Failure to do so contributes to extended recovery stays andday-of-surgery cancellations.31 During recovery, patientssometimes ask to sleep overnight in the extended recoveryunit because they have unreliable transportation or lack aresponsible adult to be present with them after recovery.Failure to secure a responsible adult is related toambivalence, working hours of the responsible party, or themisconception that being discharged from the PACU is

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Figure 1. The Aldrete Scoring System is used to assess the patient during the recovery process. A score of 10indicates the patient is ready for transfer to phase II recovery.




equivalent to meaning that you are ready to take care ofyourself and do not need a responsible adult. According toChung et al,32 50% of patients who did not have aresponsible adult claimed that they did before surgery.

False claims about having identified a responsible adultresult in delays in the PACU. The nurse must notify thesurgeon and anesthesia professional, and when the surgeonis available, transfer orders must be initiated. The chargenurse must be notified of the change in destination for thepatient and a request made for an extended recovery bed.The nurse must continue to monitor the patient in phaseII recovery until a bed is available. As of October 2015,ICD-10 will pose a financial challenge when a responsibleadult is not secured for home discharge from phase IIrecovery.33 Health insurance reimbursement may bedenied if the only reason a patient requires extendedrecovery is because the patient failed to ensure the

presence of a responsible adult for the first 24 hoursafter surgery rather than having met medical criteria forextended recovery. The patient who is transferred toextended recovery must continue to receive nursing careuntil discharge criteria are met.

The surgeon completes an after-visit summary, which containsdetailed home instructions, contact phone numbers, pre-scriptions, and follow-up appointment information. Thepostoperative nurse is responsible for ensuring that all aspectsof the after-visit summary are understood by the responsibleadult and the patient, if possible. The National QualityForum34 and The Joint Commission35 recommend using anevidence-based, teach-back method for all patient teaching.For example, when providing discharge instructions to a49-year-old woman who just underwent laparoscopiccholecystectomy, the RN informs the patient andresponsible adult:

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Figure 2. The Post-Anesthetic Discharge Scoring System is a checklist used to determine the patient’s readiness fordischarge from phase II recovery. The score required for discharge varies according to each work setting. Adischarge criteria policy is addressed in consultation with the anesthesia department.




I am going to talk to you about when you need to call thesurgeon. You should call your doctor if you have a fever greaterthan 101� F; the surgical site has redness, swelling, ordrainage; your pain medication is not working; you cannot eator drink because of nausea or vomiting; you have jaundice; oryou are unable to urinate. I want to be sure that I did a goodjob of teaching you about how to stay safe after you go home.Could you please tell me in your own words the reasons youshould call the surgeon?

This teaching method allows the nurse to immediately correctany misunderstanding if the patient or a responsible adult hasforgotten or confused some of the content. Evidence showsthat all patients, regardless of educational level, race, or age,benefit from the use of the teach-back method and teach-backis effective in preventing hospital readmissions.36

Medications, activity, wound care, diet, and signs of infectionare the main components of discharge instructions. The nursealso provides the patient and his or her support person withcontact phone numbers and reinforces the expectations ofrecovery. For patients undergoing laparoscopic cholecystec-tomy, the nurse also describes postoperative CO2 gas pain andits brevity. The nurse discusses smoking cessation, withparticular emphasis on the adverse effects of smoking onpostoperative tissue healing. The nurse performs a medicationreconciliation. The nurse reinforces the importance of avoid-ing alcohol during the postoperative period and when using

narcotics. Driving is prohibited during the first 24 hours andwhen using narcotics. The nurse emphasizes the importance ofavoiding legal decisions during the first 24 hours after surgeryand when using narcotics.

Drowsiness, slow reflexes, sore throat, and forgetfulness arecommon after laparoscopic cholecystectomy and generalanesthesia.30 The postoperative nurse must reassure thepatient and responsible adult that a perception of weaknessor malaise is expected during the immediate postoperativeperiod and provide education on specific clinicalmanifestations that necessitate physician or hospitalintervention. The next day, patients frequently tell nursesduring the postoperative follow-up phone call that they hadno idea they would “feel this bad, and wish they had beenable to stay a day in the hospital.” Thus, the postoperativenurse must also be able to distinguish between

� a patient who needs hospitalization for further monitoring oflevel of consciousness, pain, hydration, and stability of vitalsigns; and

� a stable patient who is experiencing expected side effects ofmedications and postoperative surgical discomfort and isready to be discharged home.

EXPECTATIONS AT HOMEPhase III recovery begins in the patient’s home after surgicaldischarge. The responsible adult assumes the care of the

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Figure 3. The American Society of Anesthesiologists (ASA) Physical Status Classification Scoring System is used topredict surgical mortality based on a patient’s preoperative health status.




PATIENT EDUCATIONLaparoscopic Cholecystectomy

OVERVIEWThe gallbladder is an organ in your right upper abdomen (belly).It stores bile to help digest food. Youmay need your gallbladderremoved if it is inflamed, if gallstones (hardened bile) haveformed, or if gallstones are blocking the common bile duct.

WHAT ARE SYMPTOMS OF GALLBLADDERDISEASE?Gallbladder disease may cause sharp right upper abdominalpain, bloating, nausea, or jaundice (yellow skin).

HOW IS GALLBLADDER DISEASE DIAGNOSED?Gallbladder disease is diagnosed by blood tests, anultrasound, a nuclear medicine imaging test, or an ERCP(a test using a scope with X-rays).

WHAT ARE YOUR TREATMENT OPTIONS?If you have gallstones and symptoms, you may need surgeryto remove your gallbladder. The gallbladder is usuallyremoved through a laparoscope incision.

WHAT WILL THE PREOPERATIVE CARE INCLUDE?

� Do not eat or drink anything six hours before surgery.� Ask your doctor whether to take your current medicationsthe morning of surgery.

� While in the preoperative holding area, a nurse will mea-sure your vital signs and ask questions about your currentand past health history.

WHAT HAPPENS DURING LAPAROSCOPICCHOLECYSTECTOMY?Your doctormakes small incisions onyour abdomen and inflatesyour abdomen with carbon dioxide gas to make it easier to see

inside. Your doctor puts a laparoscope with a camera andother instruments through the incisions to remove yourgallbladder. Afterward, your doctor closes the incisions.

WHAT WILL POSTOPERATIVE CARE INCLUDE?

� It is normal to have shoulder pain from the gas put intoyour abdomen and also belly pain after surgery. A nursewill watch you closely and help you treat pain and nausea.You may not need to stay overnight.

� Do breathing exercises to prevent pneumonia.� Before you go home, a nurse will teach you

o how to control pain with medicine,o how to care for the incisions;o what to eat (high-fiber diet) and drink (8 to 10 glasses ofwater each day) to help ease bowel movements; and

o how to slowly increase activity and not lift anything heavierthan 10 lb or do strenuous activity for 4 to 6 weeks aftersurgery.

WHAT ARE POSSIBLE PROBLEMS OF THISSURGERY?

� Although rare, bile may leak from the gallbladder into yourabdomen during surgery. Your doctor will watch for feverand do other tests if needed.

� Other possible complications include common bile ductinjury, jaundice, infection, kidney problems, or bleeding.

WHAT HAPPENS AFTER I GO HOME?

� Eat healthy and stay active (like walking around the house),but be sure to plan to rest.

� Use pain medicine as instructed. Activities like guidedimagery (focusing on happy, peaceful thoughts and places)or listening to music can help control pain.

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postoperative patient; therefore, it is imperative that this per-son understands all instructions and has contact phonenumbers readily available if any questions or concerns arise.Anesthesia effects last for approximately 24 hours post-operatively, so the patient needs a responsible adult to bepresent at all times for at least 24 hours after surgery. Woundcare assessments performed at home include assessing for thepresence of red streaks, redness, foul-smelling drainage,excessive swelling, and separation of the wound. Chuanget al31 reported that risk factors for surgical site infectionsinclude diabetes mellitus, both low and elevated serumalbumin levels, positive bile culture, smoking, and acutecholecystitis. Bile duct leak is the most serious complication

of laparoscopic cholecystectomy. A significant bile leak mayoccur in up to 1% of patients undergoing laparoscopiccholecystectomy, with signs and symptoms presenting sevento 30 days after the procedure.37 Clinical manifestations of asignificant bile leak are persistent abdominal tenderness,generalized malaise, and anorexia; therefore, the nurseinstructs the patient to monitor his or her temperature andfor signs and symptoms of a bile leak. A bile leak isdefinitively diagnosed with magnetic resonance imaging.37

POSTOPERATIVE CALLSThe nurse should make a 24-hour postoperative call to thepatient and ask specific questions as listed in Figure 4. If

� To decrease the pain before coughing or moving, splintyour abdomen by holding a pillow to your stomach.

CALL YOUR DOCTOR IMMEDIATELY IF YOUEXPERIENCE ANY OF THE FOLLOWINGPOSTOPERATIVE COMPLICATIONS:

� shortness of breath or dizziness or weakness that does notgo away;

� increased redness, swelling, or drainage at your incisionsites;

� fever greater than 101� F (38.3� C);� nausea or vomiting that is not relieved with medication;� abdominal swelling;� pain that is not controlled with medication; or� no bowel movement by two to three days after surgery.

ResourcesCholecystectomy: surgical removal of the gallbladder.

American College of Surgeons. https://www.facs.org/w/media/files/education/patient%20ed/cholesys.ashx.Accessed January 30, 2015.

Cholecystectomy. Johns Hopkins Medicine. http://www.hopkinsmedicine.org/healthlibrary/test_procedures/

gastroenterology/cholecystectomy_92,P07689. AccessedJanuary 30, 2015.

www.aornjournal.org

PATIENT EDUCATION –continued

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a patient concern is identified (whether clinical orinformational), the nurse should reinforce the dischargeinstructions or contact the surgeon.38 If the nurse is unableto reach a patient, a voice message should be left or a cardmailed to the home. In the event the patient cannot bereached, 24-hour postoperative calls may be made to thepatient’s emergency contact person.

During a 24-hour surgical follow-up call, the nurse assesses for thepresence of fever, sore throat, pain, surgical site infection, nausea,and vomiting. The nurse also should determine whether thepatient called the surgeon, visited the surgeon, or visited theemergency department. If a problem is identified during a post-operative follow-up call, the nurse makes further inquiries, re-inforces discharge teaching, and documents the teaching on thepatient’s electronic record, whichmay be viewed by the surgeon’sclinical personnel to see what was discussed. If electronic chartingis unavailable, the nurse should instruct the patient to contact thesurgeon’s office to discuss the problem, or the nurse should notifythe surgeon of any change in the patient’s status.

CONCLUSIONBest practices for the postoperative care of patients under-going outpatient laparoscopic cholecystectomy are aimed atoptimizing the surgical experience while maintaining safetyand providing compassionate care. The standards of nursingcare for patients recovering from laparoscopic cholecystec-tomy are comprehensive and include monitoring, evaluation,and treatment. Nurses who provide postoperative care musthave knowledge of the implications of the procedure, clinicalmanifestations of complications, and risk factors. Identifyingpatients at high risk for adverse outcomes allows the nurse toanticipate the needs of the patient and provide a less stressfulpostoperative experience. Efficient nursing care is importantduring recovery. Nurses must be prepared to prevent post-operative complications, rather than waiting to treat them.Nurses can provide excellent care if they are able to anticipatea patient’s needs, intervene early when symptoms first appear,provide reassurance to alleviate patients’ unease duringthe recovery process, and educate patients to alleviate un-necessary anxiety related to discharge expectations. �

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Figure 4. Postanesthesia care unit nurses can use this evidence-based, standard list of questions when callingpatient 24 hours after discharge. Positive responses indicate a need for further teaching or a referral back to thesurgeon or emergency department for additional care.




Acknowledgment: The authors thank Elizabeth Tornquist, MA,FAAN, independent editorial consultant, Durham, NC, for hereditorial assistance with this manuscript and Dawn Wyrick, LeadAdministrative Specialist, University of North Carolina atGreensboro School of Nursing, Greensboro, NC, for her wonderfulassistance in preparing this manuscript.

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6. Jaffe RA, Samuels SI. Anesthesiologists Manual of SurgicalProcedures. Philadelphia, PA: Lippincott Williams & Wilkins;2004.

7. Cheng Y, Lu J, Xiong X, et al. Gases for establishing pneumo-peritoneum during laparoscopic abdominal surgery. CochraneDatabase Syst Rev. 2013;1:CD009569.

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13. Chatterjee S, Rudra A, Sengupta S. Current concepts in themanagement of postoperative nausea and vomiting. AnaesthiosolRes Pract. 2011;2011:748031.

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18. Wilding JR, Manias E, McCoy DG. Pain assessment andmanagement in patients after abdominal surgery from PACU tothe postoperative unit. J Perianesth Nurs. 2009;24(4):233-240.

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22. Phillips NM, Street M, Kent B, Haesler E, Cadeddu M. Post-anaesthetic discharge scoring criteria: key findings from a sys-tematic review. Int J Evid Based Healthc. 2013;11(4):275-284.

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28. Kanakala V, Borowski DW, Pellen MG, et al. Risk factors inlaparoscopic cholecystectomy: a multivariate analysis. Int J Surg.2011;9(4):318-323.

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31. Chuang SC, Lee KT, Chang WT, et al. Risk factors for woundinfection after cholecystectomy. J Formos Med Assoc. 2004;103(8):607-612.

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33. ICD-10 compliance date: October 1, 2015. Centers for Medicareand Medicaid Services. http://www.cms.gov/Medicare/Coding/ICD10/index.html?redirect¼/icd10. Accessed February 13, 2015.

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37. Mungai F, Berti V, Colagrande S. Bile leak after elective laparo-scopic cholecystectomy: role of MR imaging. J Radiol Case Rep.2013;7(1):25-32.

38. van Boxel GI, Hart M, Kiszley A, Appleton S. Elective day-caselaparoscopic cholecystectomy: a formal assessment of the needfor outpatient follow-up. Ann R Coll Surg Engl. 2013;95(8):e142-e146.

Patricia Brenner, BSN, RN, CCRN, is a staff nursein the postanesthesia care unit at Wake Forest BaptistHealth, Winston-Salem, NC.Ms Brenner will be attendingthe Raleigh School of Nurse Anesthesia in August2015. She can be reached at [email protected] Brenner has no declared affiliation that could beperceived as posing a potential conflict of interest inthe publication of this article.

Donald D. Kautz, PhD, RN, CRRN, CNE, ACNS-BC,is an associate professor of nursing at The Universityof North Carolina at Greensboro. Dr Kautz can bereached at [email protected]. Dr Kautz has no declaredaffiliation that could be perceived as posing a potentialconflict of interest in the publication of this article.



http://www.cms.gov/Medicare/Coding/ICD10/index.html?redirect=/icd10



















mailto:[email protected]

mailto:[email protected]


EXAMINATION

Continuing Education:Postoperative Care of PatientsUndergoing Same-Day LaparoscopicCholecystectomy 3.0 www.aorn.org/CE

PURPOSE/GOALTo provide the learner with knowledge specific to caring for patients undergoing same-day laparoscopiccholecystectomy.

OBJECTIVES1. Discuss gallbladder disease.2. Explain abdominal insufflation during laparoscopic cholecystectomy.3. Describe recovery from anesthesia.4. Define postoperative pain management.5. Identify checklists used to determine readiness for discharge.6. Describe issues with patients requiring an extended stay after laparoscopic cholecystectomy.7. Discuss effective methods of providing postoperative discharge teaching.

The Examination and Learner Evaluation are printed here for your convenience. To receivecontinuing education credit, you must complete the online Examination and Learner Evaluationat http://www.aorn.org/CE.

QUESTIONS1. Acute inflammation of the gallbladder wall is

a. choledocholithiasis. b. cholecystokinasis.c. cholecystitis. d. cholesteatoma.

2. The risk of air embolism is very high when CO2, used forabdominal insufflation, is absorbed into the bloodstream.a. true b. false

3. Emergence marks the entry of the patient into phase____ of the recovery period.a. I b. IIc. III d. IV

4. The PACU RN treats the patient’s postoperative painbased ona. what the RN providing care witnesses.b. what the patient defines his or her pain to be.

c. the degree of abnormal variation in the patient’s vitalsigns.

d. the magnitude of the patient’s body language.

5. The Post-Anesthetic Discharge Scoring System (PADSS)is a checklist used to determine readiness for dischargefrom phase ____ recovery.a. I b. IIc. III d. IV

6. Reasons for not immediately discharging a patient aftersame-day surgery include1. being older than 50 years.2. experiencing uncontrolled pain.3. having an ASA classification score of 3 or higher.4. having multiple morbidities.5. not having a caretaker at home.





a. 4 and 5 b. 1, 2, and 3c. 1, 2, 3, and 4 d. 1, 2, 3, 4, and 5

7. In patients who have obstructive sleep apnea, the effectsof increased accumulation of anesthetic gases in adiposetissue include1. episodes of further sleep apnea.2. increased risk of surgical site infections.3. poor clotting times.4. prolonged medication clearance time.

a. 1 and 4 b. 2 and 3c. 1, 2, and 4 d. 1, 2, 3, and 4

8. During the extended recovery stay, nurses must be awareof the complications associated with laparoscopic chole-cystectomy, which include1. deep vein thrombosis.2. dehydration.3. internal bleeding.4. intractable nausea and vomiting.5. paralytic ileus or perforated bowel.

6. pneumoperitoneum.a. 1, 3, and 5 b. 2, 4, and 6c. 2, 3, 5, and 6 d. 1, 2, 3, 4, 5, and 6

9. Health insurance reimbursement may be denied if theonly reason a patient requires extended recovery isbecause the patient failed to ensure the presence of aresponsible adult for the first 24 hours after surgery ratherthan having met medical criteria for extended recovery.a. true b. false

10. The teach-back method for patient teaching1. allows the nurse to immediately correct any misun-

derstanding the patient may have.2. is an effective teaching method for all patients

regardless of educational level, race, or age.3. is effective in preventing hospital readmissions.4. requires administration of a written exam when the

teaching session is complete.a. 1 and 3 b. 2 and 4c. 1, 2, and 3 d. 1, 2, 3, and 4




LEARNER EVALUATION

Continuing Education:Postoperative Care of PatientsUndergoing Same-Day LaparoscopicCholecystectomy 3.0 www.aorn.org/CE

This evaluation is used to determine the extent towhich this continuing education programmet yourlearning needs. The evaluation is printed here for

your convenience. To receive continuing education credit, youmust complete the online Examination and Learner Evaluationat http://www.aorn.org/CE. Rate the items as described below.

OBJECTIVESTo what extent were the following objectives of thiscontinuing education program achieved?1. Discuss gallbladder disease.

Low 1. 2. 3. 4. 5. High

2. Explain abdominal insufflation during laparoscopiccholecystectomy.Low 1. 2. 3. 4. 5. High

3. Describe recovery from anesthesia.Low 1. 2. 3. 4. 5. High

4. Define postoperative pain management.Low 1. 2. 3. 4. 5. High

5. Identify checklists used to determine readiness fordischarge.Low 1. 2. 3. 4. 5. High

6. Describe issues with patients requiring an extended stayafter laparoscopic cholecystectomy.Low 1. 2. 3. 4. 5. High

7. Discuss effective methods of providing postoperativedischarge teaching.Low 1. 2. 3. 4. 5. High

CONTENT8. To what extent did this article increase your knowledge

of the subject matter?Low 1. 2. 3. 4. 5. High

9. To what extent were your individual objectives met?Low 1. 2. 3. 4. 5. High

10. Will you be able to use the information from thisarticle in your work setting?1. Yes 2. No

11. Will you change your practice as a result of readingthis article? (If yes, answer question #11A. If no,answer question #11B.)

11A. How will you change your practice? (Select all that apply)1. I will provide education to my team regarding why

change is needed.2. I will work with management to change/imple-

ment a policy and procedure.3. I will plan an informational meeting with physi-

cians to seek their input and acceptance of theneed for change.

4. I will implement change and evaluate the effect ofthe change at regular intervals until the change isincorporated as best practice.

5. Other: _________________________________

11B. If you will not change your practice as a result ofreading this article, why? (Select all that apply)1. The content of the article is not relevant to my

practice.2. I do not have enough time to teach others about

the purpose of the needed change.3. I donot havemanagement support tomake a change.4. Other: _________________________________

12. Our accrediting body requires that we verify the timeyou needed to complete the 3.0 continuing educationcontact hour (180-minute) program: ____________





postoperative care of patients undergoing same-day laparoscopic

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