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 Plan

C. Drug Study

CHAPTER IV – IMPLEMENTATION

A. Discharge Planning

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 to

thank Mandaluyong City Medical Center. And also to our Clinical Instructor, Ma’am

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

this is the first time that we’ve encountered a case like this in our entire rotation.

CHAPTER II – ASSESSMENT

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 extraction

Attending Physician: Dr. Buelva

PAST MEDICAL HISTORY

The patient is a smoker and alcohol drinker but stopped 2 years ago. The patient stated that he was confined at Mandaluyong City Medical Center because of jaundice and stomachache. Then after 4 hours in the operating room, he was transferred to UERM.

PRESENT MEDICAL HISTORY

- The patient was admitted December 31, 2007 at 3pm with a chief complaint of abdominal pain.- 1 day PTA, the patient developed fever and vomiting with abdominal pain; epigastric area radiating to RUQ area.- Patient consulted at the Emergency Room, Patient was managed at ER and subsequently admitted.

FAMILY HEALTH HISTORY

The patient stated that his family has a history of liver cirrhosis. He also stated that they don’t have a history of Diabetes, Tuberculosis and other hereditary disease.

B. PHYSICAL ASSESSMENT

VITAL SIGNS

Normal Finding Outcome Analysis

Body Temperature

37°C 37.7°C Increase in temp. indicates infection

Pulse Rate (80) 60-100 bpm 103 bpm Increased pulse rate indicates 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

Skin

Uniform color with slightly warmer than normal temperature, dry and

smooth. No scars and hairs are evenly distributed.

Nails

Pale and Clean

Head and Face

The skull is proportionate to body size, no tenderness and there is a scar.

Hair is oily, thick and evenly distributed. Face is symmetrical with

symmetrical facial movement.

Eyes

The client has straight normal eye condition; with yellowish sclera. Pupil is

black in color and equal in size. Have thin eyebrows.

Nose

The nasal septum is in the midline, mucosa is moist.

Mouth

The lips are pale and dry, symmetrical, pale mucosa, tongue is in midline.

Neck

The skin is uniform in color. Neck muscles are equal in size. No tenderness

and masses upon palpation.

Breast and Axilla

No masses and tenderness upon palpation

Abdomen

Uniform in color. There is a wound dressing at RUQ, dry and intact.

Upper Extremities

There is resistance for muscle strength.

Lower Extremities

*Not done because of present condition*

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 infection that cause anemia

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

DIFFERENTIAL COUNTNEUTROPHILS (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

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 full blood 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's blood. A Medical technologist performs the requested testing and provides the requesting Medical Professional with the results of the CBC. A CBC is also known as a "hemogram".The cells that circulate in the bloodstream are generally divided into three types: white blood cells (leukocytes), red blood cells (erythrocytes), and platelets or thrombocytes. Abnormally high or low counts may indicate the presence 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 body’s 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 lungs and 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. (Low hemoglobin is called anemia.)

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

WHITE BLOOD CELLS (LEUKOCYTES):Are cells of the immune system which defend the body against both infectious disease and foreign materials. All the white cell types are given as a percentage and as an absolute number per litre.

A complete blood count with differential will also include:

NEUTROPHILS: This is the main defender of the body against infection and antigens. High levels may indicate an active infection.May indicate bacterial infection. May also be raised in acute viral infections.

LYMPHOCYTES:Is a type of blood cell in the vertebrate immune system.Elevated levels may indicate an active viral infections. Higher with some viral infections such as glandular fever and. Also raised in lymphocytic leukaemia CLL.

MONOCYTES:

May be raised in bacterial infection Is a leukocyte, part of the immune system that protects against bloodborne pathogens 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 for combating 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 and chondroitin), 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 the formation of blood clots. Dysfunction or low levels of platelets predisposes to bleeding, while high levels, although usually asymptomatic, may increase the risk 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 per mm³ of blood (150–400 x 109/L). 95% of healthy people will have platelet counts in this range. Some will have statistically abnormal platelet counts while having no abnormality, although the likelihood increases if the platelet count is either very low or very high. Low platelet counts are generally not corrected by transfusion unless the patient is bleeding or the count has fallen below 5 x 109/L; it is contraindicated in thrombotic thrombocytopenic purpura (TTP) as it fuels the coagulopathy. In patients having surgery, a level below 50 x 109/L) is associated with abnormal surgical bleeding, and regional anaesthetic procedures such as epidurals are avoided for levels below 80-100.

RED BLOOD CELL MORPHOLOGY:Also known as Blood Smear, and Manual differential.Was once prepared on nearly everyone who had a complete blood count (CBC) performed. With the automated blood cell counting instruments currently used, an automated differential is also provided. However, if the presence of abnormal WBCs, RBCs, or platelets is suspected, a blood smear examined by a trained eye is still the best method for definitively evaluating and identifying immature and abnormal cells.Findings from the blood smear evaluation are not always diagnostic in themselves and more often indicate the presence of an underlying condition

and its severity and suggest the need for further diagnostic testing. Blood smear findings may include: RBC, WBC and differential count.

PERIPHERAL SMEAR:- A Peripheral smear is a blood test that gives information about the number and shape of blood cells.

URINALYSIS REPORT

PHYSICAL EXAMINATION: Color- amber Transparency- turbid PH- 6.0 sp.gr- 1.020

CHEMICAL EXAMINATION: Leukocytes- Albumin- negative Ketons- Billirubin- positive (+++) Nitnte- Sugar- negative Urobilinogen- Blood-

MICROSCOPIC EXAMINATION: Epithelial cells- occasional Mucus thread- Amorphous urates- PUS or WBC- 0-1/hpf RBC- Casts- Crystals- Bacteria- moderate

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

Sodium 129.50 135-148mmol/L 129.50 135-148meg/LPotassium 4.54 3.5-5.3mmol/L 4.54 3.5-5.3meg/L

ELECTROLYTES

Result Ref. ValuesSodium 138.8 135-145mmol/LPotassium 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 slightly dilated. No evidence of lithiasis & filling defects are noted.

ULTRA SOUND

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

The liver is normal in size and outline. The hepatorenal interface is intact. Parenchumal echogenicity is increased w/ no focal mass or calcifications seen. Intrahepatic duct are dilated. The common bile duct has diameter of 1.2cm.

The gallbladder is normal in size & configuration, the wall is smooth & not thickened. There are two shadowing hypere chor foci seen in the area of gallbladder neck/cystic duct measuring about 1.1cm & 0.9cm.The pancreas is not well visualized in this study due to abundant bowel gas obscuring it.

IMPRESSION:1) Fatty infiltrative changes of the liver considered.2) Biliary tract obstruction most likely secondary to lithiasis formation. Exact

location not well determined.3) Lithiase formation in the gallbladder neck/cystic duct.

BLOOD TRANSFUSION

Patient blood type: “O”Donor’s serial no.: 2002-206631Donor’s blood type: “O”Donor’s Rh type: Rh (+) positiveBlood bank source: PNRC

Donor’s screening result:Malaria- Negative HIV testing- non reactiveRPR/VDRL- Non negative HCV testing- non reactive

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

COMPLETE BLOOD GLUCOSE (CBG)Done and recorded

D. ANATOMY AND PHYSIOLOGY

Removal of the Gallbladder?

In some cases, the gallbladder must be removed. The surgery to

remove the gallbladder is called a cholecystectomy (pronounced co-lee-sist-

eck-toe-mee). In a cholecystectomy, the gallbladder is removed through a 5-

to 8-inch long cut in your abdomen.

Once the gallbladder is removed, bile is delivered directly from the

liver ducts to the upper part of the intestine.

Function of liver

The liver has many functions. Some of the functions are: to produce

substances 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

duodenum. The duodenum wall is composed of a very thin layer of cells that

form the muscularis mucosae. The duodenum is almost entirely

retroperitoneal. The pH in the duodenum is approximately six. It also

regulates the rate of emptying of the stomach via hormonal pathways.

Function of pancreas

The pancreas is a small organ located near the lower part of the

stomach and the beginning of the small intestine. This organ has two main

functions. It functions as an exocrine organ by producing digestive enzymes,

and as an endocrine organ by producing hormones, with insulin being the

most important hormone produced by the pancreas.

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 as

vitamin K.

C. DRUG STUDY

Name of Drug: CeftriaxonePhil. Brand: Rocephin, PatrixonTherapeutic Class: Anti-infectiveIndication: Treatment of susceptible infections including chancroid,

gastroenteritis (invasive salmonellosis, shegilosis), lyme disease, meningitis (including meningococcal magnetism prophylaxis), syphilis, typhoid fever, whipple’s disease. Pre-operative prophylaxis to reduce chance of post-operative surgical infections.

Dosage: Adult usual dosage – 1g/day in a single injection and up to 2g/day once daily according to the infection severity and the patient’s body weight.

Contraindication: Ceftriaxone is contraindicated in patients with hypersensitivity 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 and leukopenia

Nursing Responsibilities: Use with caution in patients with history of gastrointestinal disease

Name of Drug: KetorolacPhil. Brand: Acular, Kortezor, ToradolTherapeutic Class: AnalgesicIndication: Short term management of moderate to severe acute post

operative painDosage: IM injection – adult less than 35 yrs: 60mg, greater than 35

yrs:30mg. IV injection - adult less than 65 yrs: 30mg. Adults more than 65 yrs: 15mg

Contraindication: Active peptic ulcer disease, recent gastrointestinal bleeding or perforatin, moderate to severe renal impairment, hypovolemia or dehydration

Adverse Reaction: Gastrointestinal ulceration, bleeding and perforation, post-operative bleeding. Hypertension, pruritus, rash, GI disturbances, nausea, dyspepsia, diarrhea, headache, drowsiness, dizziness, sweating, edema

Nursing Responsibilities: Check if the client takes the medication. Check for the doctor’s order and if it is the right patient. Observe for any effect and if any side effects occur inform physician.

Name of Drug: TramadolPhil. 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 daily

dosage by mouth should not exceed 400 mg.Contraindication: Hypersensitivity. Acute intoxication with alcohol, hypnotics,

centrally acting analgesics, opioids, or psychotropic agents.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 dosage interval by patient response

Name of Drug: RanitidinePhil. Brand: Ceranid, Cygran, Drug Maker’s Biotech Ranitidine, Incid, Pharex

Ranitidine, Ramadine, Raxide, Ulcin, Zantac/Zantac FRZantac 75/Zantac Ampule

Therapeutic 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 150mg twice a day or 300mg at bedtime for 4 wks. Maintenance 150mg at bedtime. NSAID-associated peptic ulcer 150mg twice a day or 300mg 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 of 0.9% D5W, NaCl over 5 mins or more

Contraindication: Hypersensitivity. History of acute porphyria. Long-term therapy.

Adverse Reaction: Cardiac arrhytmias, bradycardia. Headache, somnolence, fatigue, dizziness, hallucinations, depression, insomnia.

Nursing Responsibilities: Advice patient to not take any new medication during therapy without consulting a physician. Allow 1hr between any other antacids and ranitidine.

CHAPTER IV – IMPLEMENTATION

DISCHARGE PLANNING

M – MEDICINE- Advice patient to continue taking his prescribed medicines like

Ceftriaxone 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- Encourage patient to increase protein intake for tissue repair- Advice patient to eat smaller-than-normal amounts of food at

mealtime.

S – SPIRITUALITY- Encourage patient to communicate with God.- Encourage patient to communicate with other people.

CHAPTER III - PLANNING

A. LIST OF PRIORITIZED NURSING DIAGNOSISPriority: 1. Acute pain

2. Anxiety

B. NURSING CARE PLAN

Assessment Nursing Diagnosis

Planning Nursing Intervention

Rationale Evaluation

Subjective:

“Samasakit ang tahi ko sa tiyan”as verbalized by the patient.

Objective:

>Temp. 37.7°c>RR: 36 cpm>PR: 103 bpm>BP: 120/80

>(+)Facial Grimace

>Irritable

Pain Scale:>5/10

Pain discomfort, related to surgical incision.

> After 3hrs. of Nursing Intervention the pain will be lessen.

Pain scale> 5/10 to 3/10

> Monitor v/s of the patient

> Encourage verbalization of feelings about pain.

> Provide non- pharmacologicalTherapies ex.: Radio, Books, Socialization w/ others.

> Provide calm activities.

> If all the above doesn’t work, Administer analgesic.

> To obtain baseline data

> To lessen the pain of the patient.

> To relax & provide comfort to the patient.

> To lessen the pain of the patient.

> Analgesic can lessen the pain.

> After 3hrs. of Nursing Intervention the pain will be lessen.

Pain Scale> 5/10 to 3/10

ASSESSMENT NURSING DIAGNOSIS

PLANNING NURSING INTERVENTION

RATIONALE EVALUATION

Subjective:“Nahihirapan ako ngayon sa sakit ko”. As verbalized by the patient.

Objective:Vital signs taken and recorded:

BP: 120/80PR: 103 BPMRR: 36 CPMTemp: 37.7°C

Anxiety related to change in health status, as evidence by fear of specified consequence.

Short term:At the end of 5Hrs. of nursing intervention patient will be able to reduce anxiety.

Long term:After two weeks of nursing care, patient will be able to accept changes in health status.

> Assess patient’s level of anxiety.

> Place patient in comfortable position.

> Provide non- pharmacologicalTherapies such as:T.V, Radio, Books, Socialization w/ others.

> Provide calm activities.

> Provide health teaching about hepatitis disease.

> To establish baseline data.

> To help the patient have adequate period of rest and sleep.

> To relax & provide comfort to the patient.

> Can lessen the anxiety of the patient.

> To give more information about his health status.

Short term:At the end of 5Hrs. of nursing intervention patient was able to reduce feeling of anxiety.

Long term:After two weeks of nursing care, patient was able to accept /understand his health status.

E. PATHOPHYSIOLOGY

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

pancreatitis, diabetes mellitus

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

Major constituents are cholesterol and pigment

Cholecystectomy

Removal of the gallbladder after

ligation of the cystic duct

Gallstone in bile duct

Bile stasis

Body will return to normal function

Recovery

Bile accumulates in the liver

Cholestatic

Biliary cirrhosis

Bacterial proliferation

Gallbladder and duct infection

Rupture of gallbladder

Cholecystitis if

Peritonitis Death

Abnormal fat digestion

Diarrhea

Pain Fever Nausea and vomiting

Gastric irritation

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

values

Jaundice

Increase bilirubin

There is inflammation due to infection

If not treated