35298229 case study cholelithiasis

8/2/2019 35298229 Case Study Cholelithiasis

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Cholelithiasis

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TABLE OF CONTENTS

CHAPTER I OBJECTIVES AND INTRODUCTION

CHAPTER II ASSESSMENT

A. Nursing Health History

Personal Data

Past Medical History

Present Medical History

Family Health History

B. Physical Assessment

C. Laboratory Exams

D. Anatomy and Physiology

E. Pathophysiology

CHAPTER III - PLANNING

A. List of Prioritized Nursing Diagnosis

B. Nursing Care PlanC. Drug Study
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CHAPTER I

OBJECTIVES

We did this case study for us to enhance our knowledge and to

understand more information about Cholecystectomy, thus to give us an idea of

how we could give proper nursing care for our clients with this condition, and so

that we could apply them on our future exposures as students and eventually as

nurses. We also did this case study as a part of our requirement in our clinical

exposure.

INTRODUCTION

We, group 2 of A314, students of Jose Rizal University would like tothank Mandaluyong City Medical Center. And also to our Clinical Instructor, Maam

Virginia Rey, for her patience in teaching us and making sure we learn the most

from our clinical exposure.

The purpose of this case study is to be familiar with a patient that

undergo Cholecystectomy; How it start, what are the causes and what are the signs

and symptoms; especially how to prevent, treat and manage the patient by giving

medication for treatment and providing rapport. We chose this case study because
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A. NURSING HEALTH HISTORY

PERSONAL DATA

Name: L. M.

Age: 24 years old

Sex: Male

Address: Mandaluyong City

Civil Status: Married

Nationality: Filipino

Religion: Roman Catholic

Birth Place: Pampanga

Admission:

Date: December 31, 2007

Time: 3pm at ER

Admitting Diagnosis:

- T/C Ascending Cholangitis

Choledolithiasis cystic duct stones

- S/P Papillotomy with stone extractionAttending Physician: Dr. Buelva


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The patient stated that his family has a history of liver cirrhosis. He also

stated that they dont have a history of Diabetes, Tuberculosis and otherhereditary disease.

B. PHYSICAL ASSESSMENT

VITAL SIGNS

Normal Finding Outcome Analysis

Body

Temperature

37C 37.7C Increase in temp.

indicates infection

Pulse Rate (80) 60-100 bpm 103 bpm Increased pulse rateindicates Tachycardia

Respiration (16) 12-20 cpm 36 cpm Increased respiration

indicates Tachypnea

Blood Pressure 120/80 mmHg 120/80 mmHg Normal

HEAD TO TOE ASSESSMENT
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C. LABORATORY EXAMINATIONS

COMPLETE BLOOD COUNT

HEMATOLOGY NORMAL VALUES RESULT INTERPRETATION

HEMOGLOBIN 120 170 g/L 53 Decreased protein production causing jaundice

HEMATOCRIT 0.37 0.54 0.18 Decreased because the patient have a bile infection

RED BLOOD CELL 4.0 6.0 x 1012L 1.96 Decreased oxygen production due to bile infectionthat cause anemia

WHITE BLOOD CELL 4.5 10 x 109L 33.2 Increase because infection started

DIFFERENTIALCOUNT

NEUTROPHILS(segmenters)

0.38 0.68 0.70 Slightly increase because of WBC elevation

LYMPHOCYTES 0.22 0.53 0.30 Normal range

EOSINOPHILS 0.01 - 0.07 NOT DONE NOT DONE

MONOCYTES 0.05 - 0.12 NOT DONE NOT DONE

BASOPHILS 0.002 - 0.01 NOT DONE NOT DONE

STABS 0.0 - 0.05 NOT DONE NOT DONE
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DEFINITION OF TERMS INDICATED IN THE LABORATORY EXAMINATION

COMPLETE BLOOD COUNT (CBC):

A complete blood count (CBC), also known as full blood count (FBC) or fullblood exam (FBE) or blood panel, is a test requested by a doctor or other

medical professional that gives information about the cells in a patient'sblood. A Medical technologist performs the requested testing and provides

the requesting Medical Professional with the results of the CBC. A CBC is alsoknown as a "hemogram".

The cells that circulate in the bloodstream are generally divided into threetypes: white blood cells (leukocytes), red blood cells (erythrocytes), andplatelets or thrombocytes. Abnormally high or low counts may indicate thepresence of many forms of disease, and hence blood counts are amongst the

most commonly performed blood tests in medicine.

RED BLOOD CELLS (ERYTHROCYTES):Are the most common type of blood cells and the vertebrate bodys principal

means of delivering oxygen from the lungs or grills to body tissue via blood.The number of red cells is given as an absolute number per litre.

HEMOGLOBIN:

Is a protein that is carried by the red cells. It picks up oxygen in the lungsand delivers it to the peripheral tissues to maintain the viabilty of the cells.

The amount of hemoglobin in the blood, expressed in grams per litre. (Lowhemoglobin is called anemia.)

HEMATOCRIT OR PACKED CELL VOL. (PCV):This is the fraction of whole blood volume that consists of red blood cells.
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MONOCYTES:

May be raised in bacterial infectionIs a leukocyte, part of the immune system that protects against bloodbornepathogens and moves quickly to sites of infections in the tissue.Elevated levels may indicate an allergic reactions or parasites.

EOSINOPHILS:

Are white blood cells of the immune system that are responsible forcombating infection by parasites in vertebrates. They are granulocytes that

develop in the bone marrow before migrating into blood.Increased in parasitic infections.High levels are found in allergic reactions.

BASOPHILS:Circulates vhite blood cells.

Basophils degranulate to release histamine, proteoglycans (e.g. heparin andchondroitin), and proteolytic enzymes (e.g. elastase and lysophospholipase).

They also secrete lipid mediators like leukotrienes, and several cytokines.

PLATELET COUNT:Platelets or thrombocytes are the cell fragments circulating in the blood that

are involved in the cellular mechanisms of primary hemostasis leading to theformation of blood clots. Dysfunction or low levels of platelets predisposes to

bleeding, while high levels, although usually asymptomatic, may increase therisk of thrombosis.

Functions of Platelets can be generalised into a number of categories:Adhesion, Aggregation, Clot retraction, Pro-Coagulation, Cytokine signalling,Phagocytosis.A normal platelet count in a healthy person is between 150,000 and 400,000
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examined by a trained eye is still the best method for definitively evaluatingand identifying immature and abnormal cells.

Findings from the blood smear evaluation are not always diagnostic inthemselves and more often indicate the presence of an underlying conditionand its severity and suggest the need for further diagnostic testing. Bloodsmear findings may include: RBC, WBC and differential count.

PERIPHERAL SMEAR:

- A Peripheral smear is a blood test that gives information about the numberand shape of blood cells.

URINALYSIS REPORT

PHYSICAL EXAMINATION:Color- amber

Transparency- turbidPH- 6.0

sp.gr- 1.020

CHEMICAL EXAMINATION:Leukocytes-

Albumin- negativeKetons-

Billirubin- positive (+++)Nitnte-

Sugar- negativeUrobilinogen-Blood-
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LABORATORY MEDICINE (CLINICAL CHEMISTRY I)

Test SI ValuesResult Ref. Values

Conventional ValuesResult Ref. Values

Urea nitrogen 8.30 1.70-8.30mmol/L 49.84 10-50mg/dL

Creatinine 116.30 80-115umol/L 1.31 0.9-1.29mg/dL

Sodium 129.50 135-148mmol/L 129.50 135-148meg/L

Potassium 4.54 3.5-5.3mmol/L 4.54 3.5-5.3meg/L

ELECTROLYTES

Result Ref. Values

Sodium 138.8 135-145mmol/L

Potassium 4.48 3.5-5.3

X-RAY

Endoscopic Retrograde Cholangiopancreatogram

Plain film is unremarkable. ERCP shows good filling of the common, right &

left hepatic ducts. The common bile duct & common hepatic duct are slightlydilated. No evidence of lithiasis & filling defects are noted.

ULTRA SOUND

EXAMINATION 4 ORGANS: (Liver, Gallbladder, Biliary tree, and Pancreas)
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BLOOD TRANSFUSION

Patient blood type: ODonors serial no.: 2002-206631Donors blood type: ODonors Rh type: Rh (+) positive

Blood bank source: PNRC

Donors screening result:Malaria- Negative HIV testing- non reactive

RPR/VDRL- Non negative HCV testing- non reactive

Blood component: WB/PRBCExtraction date: 01-04-08

Date/time packed: 01-04-08Expiration date: 24 Hrs. after packing

Broad spectrum compatibility testing result:Saline phase- compatibilityProtein phase- Antihuman globulin phase-

Direct Antiglobulin test- Inderict Antigobulin test-

ELECTROCARDIOGRAM (ECG)Done & recorded
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D. ANATOMY AND PHYSIOLOGY
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Function of liver

The liver has many functions. Some of the functions are: to producesubstances that break down fats, convert glucose to glycogen, produce urea

(the main substance of urine), make certain amino acids (the building blocks

of proteins), filter harmful substances from the blood (such as alcohol),

storage of vitamins and minerals (vitamins A, D, K and B12) and maintain a

proper level or glucose in the blood. The liver is also responsible fore

producing cholesterol. It produces about 80% of the cholesterol in your body.

Function of gall bladder

The function of the gallbladder is to store bile and concentrate. Bile is

a digestive liquid continually secreted by the liver. The bile emulsifies fats

and neutralizes acids in partly digested food. A muscular valve in the

common bile duct opens, and the bile flows from the gallbladder into the

cystic duct, along the common bile duct, and into the duodenum (part of the

small intestine).

Function of duodenum

The duodenum is largely responsible for the breakdown of food in the

small intestine. Brunner's glands, which secrete mucus, are found in the


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The pancreas secretes its digestive enzymes, through a system of

ducts into the digestive tract, while it secretes its variety of hormones

directly into the bloodstream.

Abnormal pancreatic function can lead to pancreatitis or diabetes

mellitus.

Function of cystic duct

Bile can flow in both directions between the gallbladder and the

common hepatic duct and the (common) bile duct.

In this way, bile is stored in the gallbladder in between meal times and

released after a fatty meal.

Function of transverse colon

The large intestine comes after the small intestine in the digestive

tract and measures approximately 1.5 meters in length. Although there are

differences in the large intestine between different organisms, the large

intestine is mainly responsible for storing waste, reclaiming water,

maintaining the water balance, and absorbing some vitamins, such asvitamin K.
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C. DRUG STUDY

Name of Drug:CeftriaxonePhil. Brand: Rocephin, PatrixonTherapeutic Class: Anti-infective

Indication: Treatment of susceptible infections including chancroid,gastroenteritis (invasive salmonellosis, shegilosis), lyme disease,meningitis (including meningococcal magnetism prophylaxis),

syphilis, typhoid fever, whipples disease. Pre-operativeprophylaxis to reduce chance of post-operative surgical infections.

Dosage: Adult usual dosage 1g/day in a single injection and up to 2g/dayonce daily according to the infectionseverity and the patients body weight.

Contraindication:Ceftriaxone is contraindicated in patients withhypersensitivity to cephalosporins and penicillins, lidocaine

or any other local anesthetic product of the amide type.

Adverse Reaction: Pain, induration, phlebitis after IV administration, rash,

diarrhea, eosinophilia, casts in urine, thrombocytosis andleukopenia

Nursing Responsibilities: Use with caution in patients with history of

gastrointestinal disease

Name of Drug: KetorolacPhil. Brand: Acular, Kortezor, Toradol

Therapeutic Class: AnalgesicIndication: Short term management of moderate to severe acute post

operative pain

Dosage: IM injection adult less than 35 yrs: 60mg greater than 35
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Phil. Brand: Dolotral, Milador, Peptrad, Sivedol, Tradonal, TramalTherapeutic Class: Analgesic

Indication: Used for moderate to severe painDosage: Usual dose by mouth are 50 to 100 mg every 4-6 hrs. Total dailydosage by mouth should not exceed 400 mg.

Contraindication: Hypersensitivity. Acute intoxication with alcohol,

hypnotics, centrally acting analgesics, opioids, or psychotropicagents.

Adverse Reaction: Vasodilation; dizziness/vertigo, headache, somnolence,stimulation, anxiety, confusion, coordination disturbances,

euphoria, nervousness, sleep disorder, seizures.Nursing Responsibilities: Give with antiemetic for nausea, vomiting.Administer when pain is beginning to return; determine dosageinterval by patient response

Name of Drug: RanitidinePhil. Brand: Ceranid, Cygran, Drug Makers Biotech Ranitidine, Incid, Pharex

Ranitidine, Ramadine, Raxide, Ulcin, Zantac/Zantac FRZantac 75/Zantac AmpuleTherapeutic Class: Gastrointestinal DrugIndication: Used in the management of various gastrointestinal disorders

such as dyspepsia, gastro-esophageal reflux disease (GERD),peptic ulcer, and Zollinger-Ellison syndrome.

Dosage: Tablet/Fast-release (FR) tablet: Adult duodenal/gastric ulcer 150mgtwice a day or 300mg at bedtime for 4 wks. Maintenance 150mg

at bedtime. NSAID-associated peptic ulcer 150mg twice a day or300mg at bedtime for 8-12 wks. For children, 2-4mg/kg 3x a day.Route: Oral; may be given with or without meals. Give antacids 1hr before or

1hr after this drug. IV: give by direct IV after diluting 50mg/20mL
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DISCHARGE PLANNING

M MEDICINE

- Advice patient to continue taking his prescribed medicines likeCeftriaxone and Tramadol.

E ENVIRONMENT AND EXERCISE

- Maintain a quiet, pleasant, environment to promote relaxation.- Provide clean and comfortable environment.- Encourage walking everyday.

T TREATMENT- Continue home medications.

- Teach patient about wound care- Encourage patient to take multivitamins for immunity

H HEALTH TEACHING- Provide written and oral instructions about wound care, activity,

diet recommendations, medications, and follow-up visits.

- Instruct patient to limit his activity for 24 to 48 hrs after discharge.

O OUT PATIENT FOLLOW-UP- Patient will be advised to go back in the hospital in a specific date

to have a follow-up check up after discharge.- Consult doctor for are any problems or complications encountered.

D DIET
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19/21

CHAPTER III - PLANNING

A. LIST OF PRIORITIZED NURSING DIAGNOSIS

Priority: 1. Acute pain2. Anxiety

B. NURSING CARE PLAN

Assessment Nursing

Diagnosis

Planning Nursing

Intervention

Rationale Evaluation

Subjective:

Samasakit angtahi ko sa

tiyanas

verbalized by thepatient.

Objective:

>Temp. 37.7c>RR: 36 cpm

>PR: 103 bpm>BP: 120/80

>(+)Facial

Grimace

>Irritable

Pain Scale:>5/10

Pain discomfort,related tosurgical incision.

> After 3hrs. ofNursingIntervention thepain will be

lessen.

Pain scale> 5/10 to 3/10

> Monitor v/s ofthe patient

> Encourage

verbalization offeelings aboutpain.

> Provide non-

pharmacologicalTherapies ex.:

Radio, Books,Socialization w/

others.

> Provide calmactivities.

> If all the abovedoesnt work,Administeranalgesic.

> To obtainbaseline data

> To lessen the

pain of thepatient.

> To relax &

provide comfortto the patient.

> To lessen thepain of thepatient.

> Analgesic canlessen the pain.

> After 3hrs. ofNursingIntervention thepain will be

lessen.

Pain Scale> 5/10 to 3/10
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20/21

ASSESSMENT NURSING

DIAGNOSIS

PLANNING NURSING

INTERVENTION

RATIONALE EVALUATION

Subjective:Nahihirapan ako

ngayon sa sakit

ko. Asverbalized by thepatient.

Objective:

Vital signs takenand recorded:

BP: 120/80

PR: 103 BPM

RR: 36 CPMTemp: 37.7C

Anxiety related tochange in health

status, as

evidence by fearof specifiedconsequence.

Short term:At the end of

5Hrs. of nursing

interventionpatient will beable to reduce

anxiety.

Long term:After two weeks

of nursing care,

patient will beable to acceptchanges in healthstatus.

> Assesspatients level ofanxiety.

> Place patient incomfortableposition.

> Provide non-pharmacologicalTherapies suchas:

T.V, Radio,Books,Socialization w/others.

> Provide calmactivities.

> Provide health

teaching abouthepatitis disease.

> To establishbaseline data.

> To help thepatient haveadequate periodof rest and sleep.

> To relax &provide comfortto the patient.

> Can lessen theanxiety of thepatient.

> To give moreinformation about

his health status.

Short term:At the end of5Hrs. of nursing

interventionpatient was ableto reduce feelingof anxiety.

Long term:After two weeksof nursing care,

patient was ableto accept/understand hishealth status.
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21/21

E. PATHOPHYSIOLOGY

Middle age (female > male before age 50),obesity, infection, pregnancy, hormonalcontraceptive, celiac disease. Cirrhosis,

pancreatitis, diabetes mellitus

CholelithiasisRefers to the formation of calculi(e.g. gallstones in the gallbladder)

Major constituents are cholesterol andpigment

Cholecystectomy

Removal of thegallbladder afterligation of the

cystic duct

Gallstone in bileduct

Bile stasis

Body will return tonormal function

Recovery

Bile accumulatesin the liver

Cholestatic

Biliarycirrhosis

Bacterialproliferation

Gallbladder andduct infection

Rupture ofgallbladder

Cholecystitisif

Peritonitis Death

Abnormal fatdigestion

Diarrhea

Pain FeverNausea and

vomiting

Gastric irritation

There is restlessnessand Increase in RR,temp, PR and WBC

values

Jaundice

Increasebilirubin

There is inflammationdue to infection

If not treated
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35298229 case study cholelithiasis

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