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Jose Rizal University

College of Nursing

A case study of a patient with Cholelithiasis

In Partial Fulfillment of the Requirement for


Nursing Care Management 102
Related Learning Experience
Mandaluyong City Medical Center - Surgical Ward

Submitted By:
Group II – A314

Fritz Adriane Gocela


Gaudencio De Vera
Mary Blaise Enosario
Mark Anthony Devera

Submitted To:
Mrs. Virginia Rey
Clinical Instructor
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 37°C 37.7°C Increase in temp.


Temperature 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
COUNT
NEUTROPHILS 0.38 – 0.68 0.70 Slightly increase because of WBC elevation
(segmenters)
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 Values Conventional Values


Result Ref. Values Result 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 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.: 2002-206631
Donor’s blood type: “O”
Donor’s Rh type: Rh (+) positive
Blood bank source: PNRC

Donor’s screening result:


Malaria- Negative HIV testing- non reactive
RPR/VDRL- Non negative HCV testing- non reactive

Blood component: WB/PRBC


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

Broad spectrum compatibility testing result:


Saline phase- compatibility
Protein 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: Ceftriaxone


Phil. Brand: Rocephin, Patrixon
Therapeutic Class: Anti-infective
Indication: 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: Ketorolac


Phil. Brand: Acular, Kortezor, Toradol
Therapeutic Class: Analgesic
Indication: Short term management of moderate to severe acute post
operative pain
Dosage: 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: Tramadol


Phil. Brand: Dolotral, Milador, Peptrad, Sivedol, Tradonal, Tramal
Therapeutic Class: Analgesic
Indication: Used for moderate to severe pain
Dosage: 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: Ranitidine


Phil. Brand: Ceranid, Cygran, Drug Maker’s Biotech Ranitidine, Incid, Pharex
Ranitidine, Ramadine, Raxide, Ulcin, Zantac/Zantac FR
Zantac 75/Zantac Ampule
Therapeutic Class: Gastrointestinal Drug
Indication: 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 DIAGNOSIS


Priority: 1. Acute pain
2. Anxiety

B. NURSING CARE PLAN

Assessment Nursing Planning Nursing Rationale Evaluation


Diagnosis Intervention

Subjective: Pain discomfort, > After 3hrs. of > Monitor v/s of > To obtain > After 3hrs. of
related to Nursing the patient baseline data Nursing
“Samasakit ang surgical incision. Intervention the Intervention the
tahi ko sa pain will be pain will be
tiyan”as lessen. > Encourage > To lessen the lessen.
verbalized by the verbalization of pain of the
patient. Pain scale feelings about patient. Pain Scale
> 5/10 to 3/10 pain. > 5/10 to 3/10
Objective:
> Provide non- > To relax &
>Temp. 37.7°c pharmacological provide comfort
>RR: 36 cpm Therapies ex.: to the patient.
>PR: 103 bpm Radio, Books,
>BP: 120/80 Socialization w/
others.
>(+)Facial
Grimace > Provide calm > To lessen the
activities. pain of the
>Irritable patient.

Pain Scale: > If all the above > Analgesic can


>5/10 doesn’t work, lessen the pain.
Administer
analgesic.
ASSESSMENT NURSING PLANNING NURSING RATIONALE EVALUATION
DIAGNOSIS INTERVENTION

Subjective: Anxiety related to Short term: > Assess > To establish Short term:
“Nahihirapan ako change in health At the end of patient’s level of baseline data. At the end of
ngayon sa sakit status, as 5Hrs. of nursing anxiety. 5Hrs. of nursing
ko”. As verbalized evidence by fear intervention intervention
by the patient. of specified patient will be > Place patient in > To help the patient was able
consequence. able to reduce comfortable patient have to reduce feeling
Objective: anxiety. position. adequate period of anxiety.
Vital signs taken of rest and sleep.
and recorded:
> Provide non- > To relax &
BP: 120/80 Long term: pharmacological provide comfort Long term:
PR: 103 BPM After two weeks Therapies such to the patient. After two weeks
RR: 36 CPM of nursing care, as: of nursing care,
Temp: 37.7°C patient will be T.V, Radio, Books, patient was able
able to accept Socialization w/ to accept
changes in health others. /understand his
status. health status.
> Provide calm
activities. > Can lessen the
anxiety of the
patient.
> Provide health
teaching about > To give more
hepatitis disease. information about
his health status.
E. PATHOPHYSIOLOGY

Middle age (female > male before age 50),


obesity, infection, pregnancy, hormonal
contraceptive, celiac disease. Cirrhosis,
pancreatitis, diabetes mellitus

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

Major constituents are cholesterol and


pigment

Cholecystectomy Gallstone in bile Pain Fever Nausea and Jaundice


duct vomiting

Removal of the There is inflammation Increase


gallbladder after Bile stasis due to infection Gastric irritation bilirubin
ligation of the
cystic duct

Bile accumulates Bacterial Abnormal fat


Body will return to in the liver proliferation digestion There is restlessness
normal function and Increase in RR,
temp, PR and WBC
values
Gallbladder and Diarrhea
Recovery Cholestatic duct infection

Biliary
cirrhosis Rupture of Cholecystitis If not treated
gallbladder if

Peritonitis Death