CHOLELITHIASIS

PRESENTED BY:
07DIN0232
GROUP 33 ( 2/2007 )
 LEARNING OBJECTIVE

 At the end of my case study I will be able to :

1.Explain the Anatomy & Physiology of gall bladder.

2.State the definition of cholelithiasis.
3.Describe Statistic of cholelithiasis.
4.State the Etiology of cholelithiasis .
5.Explain the Risk Factors of cholelithiasis.
6.Explain the Pathophysiology of cholelithiasis.
7. Explain the Clinical Manifestation of cholelithiasis.
8. State the Complication of cholelithiasis.
9. State the Investigation of cholelithiasis.
10. Explain the Treatment of cholelithiasis.
11. Described the care of cholelithiasis patient by using
the nursing process.
12. Explain the health education to the patient with open
cholecystectomy
INTRODUCTION
 ON ADMISSION
My patient is Mr.A from Pulau Pangkor was
admitted to Ipoh Specialist Hospital on 25 May
2009 @ 8.25 pm under Dr.K (general surgeon). He
is a 40 years old malay man. He is a contractor. He
is married and he is very friendly, cheerful person.
Mr.A had admitted because complaint of pain on & off at
right upper quadrant of abdomen since 1day. This problem
had disturb his activity daily living for sometimes and at
last he decided to do operation as suggested by Dr.K
where he was suspected with cholelithiasis.
 NURSING
ASSESSMENT
 PATIENT’S PERSONAL DATA
Name : Mr A
MRN : 23456
Bed No : 7xx
Age : 40year
I/C No : 69xxxx-08-xxxx
Race : Malay
Religion : Islam
Occupation : Contractor
Language Spoken : B.Malaysia
Tel No : 012-5yyxxxx
Next of Kin : Mrs S
Relationship : Wife
 Cont..
Consultant : Dr K
Date/Time of Admission : 25/5/09 @ 8.25pm
Reason For Admission :c/o pain at right upper
quadrant of abdomen on
and off x1/7
Diagnosis : Cholelithiasis
Medical History : Diabetic Mellitus <1years
Surgical History : Nil
Family Medical History : Mother-Hypertension
Current Medication : Gliclazide 80mg daily
Allergies : Nil
 Cont…
• Mode on Admission : Walk in
• Mental Status : Orientated
• Level of Conciousness : Concious
• Emotional Status : Anxious
Physical Examination

Pain on and off at

the right upper
quadrant

FRONT BACK
PICTURE 1:PHYSICAL EXAMINATION
 ACTIVITIES OF DAILY LIVING
 BREATHING
Do not have any problem in breathing.

 ELIMINATION BOWEL
Do not have any problem in open bowel and
no changes noted.
Also do not take any medication for bowel
movement.
 Cont….
BLADDER
Do not have any problem in passing urine and
do not get up frequently at night to pass urine.

EATING AND DRINKING

Do not have any allergies and do not have
problem with eating and drinking.

PERSONAL HYGIENE
Able to maintain his person hygiene
 Cont….
MOBILITY
Able to move around.

COMMUNICATION, HEARING AND VISION

Can communicate as well during the interview.
Able give feedback beside his hearing and
visions are Normal.

SLEEPING
Do no have any problem in sleeping
 ANATOMY AND
PHYSIOLOGY
OF
GASTROINTESTINAL
SYSTEM
PICTURE 2:THE ORGAN OF THE DIGESTIVE SYSTEM
 GALL BLADDER
 A small
 pear-shaped sac attached to
the posterior surface of the
liver by connective tissue
 that is located under the liver.

 Gall bladder is divided into 3

parts:
 1)Fundus or expanded end
 2) Body or main part
 3) neck

PICTURE 3:PICTURE OF GALLBLADDER

 Functions Of The Gall Bladder

 Reservoir for bile

 Concentration of the bile by up to 10 or 15 fold, by absorption of water through the
walls of the gall bladder
 Release of stored bile.
 When the muscle wall of the gall bladder contracts bile passes through the bile
ducts to the duodenum.
 Contraction is stimulated by:

- The hormone Cholecystokinin (CCK), secreted by the duodenum

- The presence of fat and acid chyme in the duodenum.
- Relaxation of the hepatopancreatic sphincter (of Oddi) is caused by CCK and is a
reflex response to contraction of the gall bladder.
Composition Of Bile
About 500mls of bile are secreted by liver daily.
Bile consists of:
-Water
-Mineral salts
-Mucus
-Bile pigments, mainly
bilirubin
-Bile salts, which are derived from the primary
bile acids, cholic acid and chenodeoxycholic
acid.
Cholesterol
Fatty acids
Electrolytes
 DEFINITION
OF
CHOLELITHIASIS
Cholelithiasis is the formation of stone (calculi)
within the gall bladder or biliary duct system.
 
(Lemone.P,Burke.K (2004)Medical-Surgical Nursing,
3rd ed. United States,Pearson Education.P574.)

Cholelithiasis is presence of gall stones in the bladder

or bile ducts.
 
(Weller.B.F(2003)Nurses’ Dictionary,23rd ed. London,
BailliereTindal.P85.)
 
 

 
Calculi, or gall stones, usually form in the gall
bladder from the solid constituents of bile; they
vary greatly in size, shape and composition.
 
(Smeltzer.S.C, Bare.B (2004) Medical-Surgical
Nursing,10th ed. United States, Lippincott Williams
&Wilkins.P1126.)
STATISTIC
 Statistic of Patient With Cholelithiasis in ISH
From January-June 2009

12

10

6 Female
Male
4

0
Jan Feb March April May June
ETIOLOGY
 Etiology
 Cirrhosis
 Hemolysis-(History of Thalassemia)
 Infections of biliary tract
 Ileal resection or disease
 Rapid weight loss
 High Cholesterol
 Risk Factors
1. Family history of Cholelithiasis.

2. Race or ethnicity
- Native American have higher incidence

3. Cystic fibrosis
-A hereditary disorder with accumulation of excessively thick

and tenacious mucus and abnormal secretion of sweat and

saliva.

4. 5F
(i) Female
- estrogen increases the concentration of cholesterol in bile
(ii) Fat
-Obesity also slows down the emptying of the gallbladder

iii) Fertile
-estrogen is increases in the body, it cause concentration of
cholesterol in bile and slowed gallbladder movement.

(iv) Forty
-Especially, women. Because changes of the hormone and
slow down of the digestion process.

(v) Fair
-People who is fair have more chances to get cholelithiasis.
 COMPLICATION
1)Cholecyctitis
-Inflammation of the gall bladder due to cholelithiasis.

2)Pancreatitis
-If gall bladder stone blocking the lower end of
the common bile duct where it enters the
duodenum may obstruct secretion from the
pancrease.

3)Cholangitis
-When the common bile duct is blocked for a
substantial period of time, certain bacteria may find
their way up behind the stone and cause inflammation of the
bile duct.
PATHOPHYSIOLOGY
 PATHOPHYSIOLOGY OF CHOLELITHIASIS

Cholesterol / Fat

Normal constituent of bile

is insoluble in water.

Decrease bile acid synthesis and increase

cholesterol synthesis in the liver.

Resulting bile supersaturated

with cholesterol

Form cholesterol stone

Pain at right upper quadrant of abdomen

CHOLELITHIASIS
 CLINICAL MANIFESTATION
1)Asymptomatic

2)Symptomatic
 Abdominal
-Epigastric discomfort
-chronic, steady spasmodic pain at right upper quadrant
after a meal(especially after a large meals or fatty meals)
 contraction of gall bladder cause friction with gall stone.
-Pain may radiate to the back or below the right shoulder
blade
 the thoracic nerve supply is surrounding the area
 Heart burn sensation
*less bile juice is release from the gall bladder, so
indigest fatty food cause the sensation.

 Sweat and pallor

*Due to excruciating pain cause by the stone.

 Nausea and vomiting

*poor digestion of the food intake

 Jaundice
*excessive bilirubin in the blood
 Itching of skin
*high urea in the body so it will cause itching of the skin

 Stool clay in color

*cystic duct is block, the bile can’t supply to the
duodenum

 Urine dark in color

*cystic duct is block, the bile that contain high bilirubin
that secrete from the liver will direct from the blood
vessels go to kidneys to filter out
Investigation
 INVESTIGATION
Date of Received : 22/04/2009
Date of Report : 23/04/2009
HAEMATOLOGY EXAMINATION
Total RBC : 5.5 M/cmm (M=4.5-6.0,F=4.0-5.5)
Haemoglobin : 16.2 g/dl (M=12.5-17.5,F=11.5-15.5)
PCV : 48 % (M=40-50,F=37-45)
MCV : 87 fl (82-98)
MCH : 29 pg (27-33)
MCHC : 34 % (31-35)
RDW : 13.3 % (11.0-16.0)
Total WBC : 12,600 /cmm (4,000-11,000)
DIFFERENTIAL COUNT ABSOLUTE VALUE
Polymorphs : 61 % (50-70) 7686 /cmm (2000-7500)
Lymphocytes : 35 % (20-40) 4410 /cmm (1000-4000)
Monocytes : 3 % (2-6) 378 /cmm (200-1000)
Eosinophils : 1 % (1-4) 126 /cmm (20-600)
Basophils : 0 % (less than 1%) 0/cmm (<100)
LIPIDS STUDIES
Total Cholesterol : 276 mg/dl
( <200 )
Triglycerides : 122 mg/dl
( <150 )
HDL – Cholesterol : 50 mg/dl
( >40 )
LDL – Cholesterol : 202 mg/dl
( Optimal <100 )
Total Chol./ HDL-Chol. : 5.5
( Risk Indicated if >4.5 )
LIVER FUNCTION TEST
Total Protein : 7.4 gm/dl
( 6.4-8.3 )
Albumin : 4.8 gm/dl
( 3.9-5.0)
Globulin : 2.6 gm/dl
( 2.1-3.6 )
A/G Ratio : 1.8
(1.0-2.2)
Total Bilirubin : 1.0 mg/dl
( up to 1.2 NB : <10.0 )
SGOT/AST : 19 U/L
( 8-37 )
 Cont…
SGPT/ALT : 41 U/L
( 5-44 )
SAP : 102 U/L
( >15yrs : 40-150 <15yrs : <750 )
Gamma GT : 67 U/L
( M 12-64 F 9-36 )
RENAL FUNCTION TEST

Sodium : 140 mmol/L

( 132 – 143 )
Potassium : 4.2 mmol/L
( 3.5 – 5.1 )
Chloride : 106 mmol/L
( 98 – 107 )
Urea : 27 mg/dl
( Adults <50yrs: M 19-44 F 15-40 )
Creatinine : 0.9 mg/dl
( M 0.7-1.3 F 0.6 – 1.1 )
 Cont…

Uric Acid : 3.8 mg/dl

( M 3.5 -7.2 F 2.6-6.0 )
Calcium : 9.4 mg/dl
( 8.4 – 10.2 )
Phosphorus : 3.8 mg/dl
( 2.4 – 4.7 )
HISTOLOGY REPORT

Date : 28/5/2009
 
Clinical history
Gall stones
 
GROSS
Specimen fixed overnight.Consist of a rigid gall bladder measuring
5.5cmx4.5cm in dimension.It contains 3 perforated areas in the
wall which is thick and haemorrhagic.Representative sections
sumitted in two blocks
HISTOLOGY
Sections show a gall bladder with extensive ulcerations of
the mucosa which is replaced by abundantrecent
haemorrhages in the ulcerated areas,accompanied by some
Acute Inflammatory infiltrates as well.The residual epithelial
lining show reactive nuclear changes but no atypia.The wall is
much thickened by oedema,fibrosis and multiple Aschoff-
Rokitansky sinuses.

INTERPRETATION
Gall bladder – Acute haemorrhagic cholecystitis
 
 
 Pre-Op
Management
 Pre Op-Management

1. Explain to the patient regarding the surgery that would be done to the
patient.
R: To give additional knowledge to the patient.
I: I explain the surgery of open cholecystectomy that would be done to the
patient
 
2. Monitor vital signs of the patient and obtained the patient data such as
weight, lab investigations result or radiological result, case notes and the
medication chart.
R: As a baseline data for further interventions and as a references for any
treatment done.
I: I check the patient’s vital signs before going for open cholecystectomy
and provide the case notes.
3. Make sure the consent of the patient is written before the surgery.
 R: To have an agreement and cooperation between patient and medical
staff.
I: I check the consent from the case notes and make sure it is written
before the surgery.
 
4. Do the checklist for the surgical interventions
R: to prepare the patient before the operation.
I: I check the patient for the shaving part, any dentures and also any
history of implant done.
 
5. Keep patient NBM (nil by mouth) at least 8 hours before the surgery.
R: To prevent the complication during surgery such as nausea and
vomiting, aspiration in lung because of the effect of anaesthesia.
I: I explain to the patient that he have to fast before the operation at
least 8 hours. He fasting at 12 midnight.
 
6. Bowel elimination and micturation must be empty before the
surgery.
R: To comfort the patient and to reduce the risk of infection due to
involuntary muscles of the elimination organ.
I: I inform to the patient that he must empty the bowel and his
bladder before he goes for surgery.
 
7. Provide all the information regarding the patient in the case notes,
medication chart and other report for the surgery.
R: For future references and the treatment from the doctor.
I: I send the patient with complete data of the patient inside the case
notes to the operation theater.
 
 
 
Post-Op Management
 Post-Op Management

1. Received the report from OT (Operation theater) staff for the information
regarding the surgery that have been done.
R: For implement the proper treatment after the surgical intervention.
I: I listen the report that been pass over to the staff nurse. The patient has
done Open Cholecystectomy.
 
2. Observe the dressing site for blood stain and present of drainage tube.
R: To obtain baseline data to plan appropriate nursing interventions.
I: I observe the dressing and the drainage of the patient for any leakage,
the amount etc.
 
3. Monitor vital signs of the patient hourly for 6 hours until stable.
R: To detect any abnormalities after surgical interventions.
I: I check the vital signs of the patient hourly until it is stable.
4. Observe any signs and symptoms of bleeding and infection at the wound site
frequently.
R: As prophylactic interventions from any complication such as hypotension.
I: I check the dressing site and the amount of drainage frequently and written
in Intake and output chart.
 
5. Allow sips of water and increase the amount gradually.
R: To prevent dehydration and comfort the patient.
I: I encourage the patient to take sips of water and increase the amount
gradually.

6. Inform the patient to rest in bed at least 6 hours after the surgical
intervention.
R: To reduce the patient pain and excessive bleeding.
I: I explain to the patient that he must rest at least 6 hours after the operation.
 
7. Advice the patient to support the abdomen when coughing.
R: To prevent the pressure exerted at the wound site that cause
bleeding and ruptured.
I: I instruct the patient to support the abdomen when coughing. He
have to put both hand to hold the pressure at the wound site.
 
8. Monitor intake and output of the patient strictly.
R: To detect amount of oral intake, drainage and urine of the patient
I: I check patient’s intake and output of the patient in the I/O chart.
Medication
 Medication

 Tab Dormicum 7.5mg ON

 IV Maxolon 10mg TDS
 IV Augmentin 1.2gm 8h
 Tab Ciprofloxacin 500mg BD
 Tab Panadeine II/II TDS PRN
 Dormicum
Generic Name Midazolam DBL
Group Sedatives
Date On 25/5/2009
Date Off 27/5/2009
Dose order 7.5mg ON
Route Oral
Indication Conscious sedation prior to short surgical,diagnostic,therapeutic
or endoscopic procedures,induction of anaesth,preliminary to
administration of other anaesth agents,sedation in ICU,pre-op
sedation
Adverse Reaction Muscle
stiffness.induration,headache,pain,redness,apnoea,nausea,vomi
ting,coughing,drowsiness,phlebitis,resp depression,variation in
BP and pulse rate.
Contraindication Myasthenia gravis,neuromuscular disorder,shock/coma,acute
alcohol intoxication,acute narrow angle glaucoma.
 IV Maxolon

Generic Name Metoclopramide

Group Antiemetic

Date On 25/5/2009
Date Off 27/5/2009

Dose Order 10mg TDS

Route Intravenous

Indication Dyspepsia,flatulence,digestive disorder associated with hiatus

hernia,peptic ulceration,reflux
oesophagitis,gastritis,duodenitis,cholelithiasis,nause&vomiting

Adverse Reaction Rarely extrapyramidal reactions,tardive dyskinesia,raised serum

prolactin levels,mild sedation

Contraindication -
 IV Augmentin

Generic Name Clavulanate

Group Penicillins
Date On 25/5/2009
Date Off 27/5/2009
Dose Order 1.2gm 8hourly
Route Intravenous
Indication Resp tract,skkin,soft tissue,GUT
infection,septicemia,peritonitis,post-op infection & osteomyelitis
Adverse Reaction Diarrhoe,indigestion,nausea,vomiting,candidiasis,rash,cholestatic
jaundice,crystaluria,haemolytic anemia,CNS disturbances.
Contraindication Hypersensitivity to penicillins,possible cross sensitivity with other
beta-lactams.History of penicillin-associated cholestatic
jaundice/hepatic dysfunction
 Tab Ciprofloxacin
Generic Name Cifran
Groupinfections Antibiotics
Date On 27/5/2009
Date Off 28/5/2009
Dose Order 500mg BD
Route Oral
Indication Resp tract,ocular,abdominal ,skin&soft tissue,bone&joint;otitis
media,sinusitis,UTI&kidney infections:genital infections including
adnexitis,gonorrhea&prostatitis;septicemia.
Adverse reaction GI,CNS&CVS disturbances including dizziness,skin reactions,acute
renal failure secondary to interstitial
nephritis,haematuria,crystalluria,joint swelling,visual disturbance.
Contraindication Hypersensitivity to
quinolones.Children,adolescents,pregnancy,lactation.Drugs that
inhibit peristalsis
 Tab Panadeine

Generic Name Codeine Phospate

Group Analgesics & Antipyretics
Date On 26/5/2009
Date Off 27/5/2009
Dose Order 2Tab TDS PRN
Route Oral
Indication Headache,dysmenorrhea,musculoskeletal
pain,myalgias,neuralgias,after dental work or tooth
extraction.Condition accompanied by discomfort & fever,as in
common cold & viral infection
Adverse Reaction Allergic reactions,GI upsets,constipation,CNS disturbances,dry
mouth
Contraindication -
Nursing Care Plan
Pre-Operation
1. Alteration in comfort; Pain related to inflammation of
the gallbladder
2. Alteration in emotional status; Anxiety related to lack
of understanding regarding to the surgical intervention
(open cholecystectomy)

Post-Operation
3. Alteration in comfort; Pain related to surgical incision
(open cholecystectomy).
4.Potential infection related to surgical incision
5. Knowledge deficit related to home care management

Next Slide
Nursing Care
Plan
1
Date & Time : 25 / 05 / 2009 @ 09.30pm

Nursing Diagnosis:
Alteration in comfort; Pain related to inflammation
of the gallbladder.

Supporting data:
1. Patient verbalized that the pain is at his right upper
quadrant of abdomen.
2. Patient’s facial expression shows that he is in pain.

Goal:
Patient’s pain will be reduced gradually within 1
hour after nursing intervention carried out and during
hospitalization.
Nursing Intervention

1.Assess patient’s general condition, facial expression

and complain.
-The characteristics of pain : mild, moderate,severe,
worst
-Location of pain: right upper quadrant of the abdomen
-Frequency of pain
R) - As a baseline data and to plan further nursing
intervention.
(I) I assessed Mr.A’s level of pain by using the pain
scale. Patient said that the pain scale is 6 and the
location is right upper quadrant of the abdomen.
2) Monitor Mr.A’s vital sign.
R) Increase reading in vital sign may indicate pain
experience.
I ) I did check Mr.A’s vital sign and the reading is
140/90mmHg.

3) Administer medication as ordered by Dr. K,sedatives

– Tab Dormicum 7.5mg.
R) To reduce pain in patient.
(I) I administer the medication on the night duty under
SRN supervission.
4) Advice patient to rest in bed.
R) To reduce or minimize mobility which might indicate
pain.
(I) I encourage Mr.A to rest in bed and advice him not
to move too much because it will indicate pain.

5) Provide divertional therapy for the patient such as

turn on the television.
R) To divert patient’s mind from thinking of their pain.
I ) I encouraged Mr.A to watch television so that he will
not think about his pain. I help Mr.A to turn on the
television.
6) Provide condusive environment to the patient.
R) To give patient calmness and not to think of the pain.
(I) I advice the wife not to allow too many visitor in so that it
can maintain not to be too crowded or too noisy.

Date & Time: 25/ 05 / 2009 @ 10.30pm

Evaluation :
Patient pain had reduced after the nursing intervention
carried out and during hospitalization.

Supporting Data:
- Patient verbalized less pain at the right upper quadrant
of the abdomen.
- Patient appear more comfortable.
Back
Nursing
Care Plan
2
Date & Time: 26 / 05 / 2009 @ 8.00am

Nursing Diagnosis:
Alteration in emotional status; Anxiety related to lack of
understanding regarding to the surgical intervention
(open cholecystectomy).

Supporting data:
1. Patient’s facial expression showed that he was very anxious
and keep asking about the surgery.
2. Mr.A also verbalized that he felt very anxious because this is
the first time he is going for an operation.

Goal:
Mr.A will feel less anxious, more calm and give co-
operation within 1 to 2 hours after nursing intervention
carried out and during hospitalization.
Nursing Intervention:
1. Assess the patient level of knowledge by asking the question
regarding the surgical interventions (Cholecystectomy) that
would be done.
R)To obtain baseline data to plan appropriate nursing
interventions.
(I)I assess the patient level of knowledge by asking the patient
how far he knows about the procedure that would be done to
him.
 
2) Reinforce doctor’s explaination about his disease and surgery.
R) To provide patient’s further understanding and reduce anxiety.
(I) I explained to Mr.A again about the explaination given by the
doctor. I explained to patient about the purpose of the
operation.
3) Encourage patient to express doubt and worries
regarding his disease and procedure(open
cholecystectomy)
R) To provide confident in patient.
(I) I asked Mr.A to express about anything that he don’t
understand and encourage him to ask more questions.

4) Answer patient’s question by using simple words.

R) For patient better understanding.
(I) I answered Mr.A question by using simple word and
avoid using medical terms.
5) Explain to patient the purpose of every procedure
performed such as skin preparation (shaving at umbilical
area).
R) To relay patient’s anxiety for better co-operation .
(I) I explained Mr.A about the purpose of skin preparation
is to prevent from infection during operation.

6) Provide divertional therapy such as watching television

and reading newspaper.
R) To divert patient mind from thinking about the disease.
(I) I switch on the television for my patient and tuned to
the channel that he request.
7) Encourage family member to accompany patient.
R) To provide family emotional support and reduce
anxious.
(I) I encouraged his wife to stay with him, this will make
him more supportive and confidence.
Date & Time: 26 / 05 / 2008 @ 9.00am

Evaluation :
Mr.A appear less anxious and more calm.

Supporting data:
1) Mr.A facial expression looked more calm.

Back
Nursing Care Plan
3
Date & Time: 26 / 05 / 2009 @ 2.00pm

Nursing Diagnosis:
Alteration in comfort; Pain related to surgical incision
(open cholecystectomy).

Supporting data:
1. Mr.A complain of pain at the surgical site.
2. Patient’s facial expression show that he is in pain.

Goal:
Patient will verbalize pain tolerated within 1 hour
after nursing intervention carried out and during
hospitalization.
Nursing Intervention:

1) Assess patient’s general condition and the severity of pain

mild, moderate, or severe through facial expression and
verbalization.
R) To plan appropriate nursing intervention.
(I) I assess Mr.A severity of pain by his verbalization and facial
expression. Mr.A told me that his pain is moderate at
incision site.

2) Check patient’s vital sign every hourly for 6 hours.

R) Increase in blood pressure and tachycardia may indicate
pain.
(I) I checked Mr.A’s vital sign, it is slightly high, blood pressure
140/90 mmHg and pulse is 90 bpm.
3) Administer analgesic as prescribed by the doctor.
R) To reduce pain.
(I) Patient was in PCA(patient controlled
analgesia)-pethidine 25mg for 2days post op.

4) Position patient in position that patient desire.

R) To reduce pain and tightness at the surgery site.
(I) I encouraged Mr.A to lie in his desires position
because it make him feel more comfortable and
Mr.A had told me that he prefer to lie in
recumbent position.
5) Encourage patient to do deep breathing
exercise.
R) To reduce the pain by relaxing the sphincter
muscle.
(I) I teached Mr.A the way to do deep breathing
exercise and I encourage him to do it when he
felt the pain.

6) Encourage patient to rest in bed.

R) Excessive movement will increase pain.
(I) I advised Mr.A to rest in bed and I put his all his
belonging near to his reach.
7) Provide divertional therapy to the patient.
R) To divert patient’s mind from thinking of the
pain.
(I) I help Mr.A to switch on the television and tuned
to the channel that he wants to watch.

8) Inform doctor if the pain still persists.

R) For further treatment and management.
(I) Staff nurse did not inform doctor because patient
pain had reduced.
Date & Time: 26 / 05 / 2009 @ 3.00pm

Evaluation :
Mr.A verbalized pain had reduced after the
medication was given and he is resting without
any complication.

Supporting Data:
1) Patient looks comfortable and no complain.
2) Patient’s vital sign back to normal range, blood
pressure 120/80 mmHg and pulse 84 bpm.

Back
Nursing
Care Plan
4
Date: 26/5/2009
Time: 3pm

Nursing Diagnosis: Potential infection related to surgical

incision.

Supporting data :
1.Mr A had done open cholecystectomy
2.Patient had incision wound at the abdomen

Goal :
Mr A will be not experiences from any sign and symptom
of infection after nursing intervention given and during
hospitalization.
Nursing Intervention :

1) Assess Mr A’s incision site such as sign and symptom of

infection, skin condition,redness, swelling, warm, pain,
discharge, high body temperature.
R) As a baseline data and to plan appropriate nursing
intervention.
I) I assess my patient’s incison site and vital sign. He has
not show sign and symptom of infection.
2) Monitor and record Mr A’s vital sign especially temperature
every hourly for 6hour followed by 4hourly or as ordered by
doctor.
R) Raised of temperature indicates that body response to
infection.
I) I monitored and recorded Mr A’s vital sign every hourly
post operation for 6hours and then 4hourly.

3) Observe patient’s dressing site during observation and

when change shift.
R) To detect any discharge,oozing,smell or odour from the
dressing site and to prevent bacterial growth.
I) I check patient’s dressing site during observation and inform
staffnurse to record in the nurses report.
4) Maintain aseptic technique when handling patient’s
wound.
R) To prevent from introducing microorganism to
patients wound.
I) I perform hand washing before checking the
dressing site.

5) Advise patient do not touch at incision site.

R) To prevent cross infection.
I ) I advise my patient do not touch at incision site.
6)Ensure dressing is dry intact and change dressing if there
is any discharge
R)To prevent infection.
I) I check the patient dressing site and changed the
dressing if wet or oozing.

7) Inform doctor if any sign and symptoms infection

detected.
R) For further management.
I) I did not inform doctor because my patient free from
infection
Date & Time: 28 / 05 / 2009 @ 9.45am

Evaluation :
Patient signs of infection is not detected with evidence
of patient verbalization. His temperature is in normal
range, 36.4⁰C.

Supporting data :
1. Patient’s body temperature is within normal
range(36.4⁰C).
2. Patient did not have any sign and symptom of
infection

Back
 Nursing
Care Plan
5
Date: 29/5/2009
Time: 9am

Nursing Diagnosis: Knowledge deficit related to home care

management .

Supporting data :

1. Patient ask a lot of questions about home care management.

2.Patient’s facial expression shows confused and worried.

Goal :
Patient’s knowledge will increase especially related to home care
management after nursing intervention given and during
hospitalization.
Nursing Intervention:

1)Assess patient’s level of understanding and knowledge

regarding home care.
R) To ensure patient’s level of understanding about his own
disease more details.
(I) I asked Mr.A whether he knows about care of wound, diet
and ask him to verbalize.

2) Instruct patient regarding way to reduce the risk for recurrent

gallbladder attack such as consume low to moderate fat diet.
R) For more understanding about healthy diet.
(I) I asked Mr.A to avoid consuming foods or fluids that is high
in fat such as butter, cake, ice cream and fried foods.
3) Provide health education to the patient regarding the prevention and
the self care management.
R)To ensure continuous care at home.
(I)I provide some health education to the patient regarding
his self care management before he discharged. The health
education I give was related to the wound care, diet, activity and
the continuous treatment with the doctor.

4) Explained to patient regarding the name, dose, and

time to consume the medication that prescribed by
the doctor.
R) For patient’s better understanding and prevent from
wrongly consuming medication.
(I)I explained to Mr.A that tablet Ciprofloxacin to be taken one
tablet per day and tablet Panaedine to be taken when necessary.
5)Advice Mr.A to inform or seek for medical treatment if
there are any sign and symptom of infection is present.
E.g. fever,lose stool, recurrent episode pain, nausea and
vomiting.
R) To prevent from any infection and inflammation.
(I)I advice Mr.A that if any sign and symptom of abnormal present,
quickly go to the hospital. E.g. fever, lose stool, nausea and
vomiting and abdominal pain.
6) Explain the importance of follow up with the doctor.
R) To maintain healthy life style and also for early
detection of any abnormalities.
(I) I advice and reminded Mr.A about the importance of
follow up to check the incision site with his doctor.

7) Advice patient to take small amount of food but

frequently.
R) For easy and better food digestion and to prevent
from bowel upset.
(I) I had advice and encourage Mr.A to take small
amount of food but frequently.
8)Advice patient not to apply any ointment or traditional
medication to the incision site.
R) To prevent from any infection.
(I) I had advice Mr.A not to apply any ointment or
traditional medication to the incision site and also had
explain to him why not to do so.
Date & Time: 29 / 05 / 2009 @ 9.45am

Evaluation :
Mr.A verbalized that he understand and had gain
knowledge about home care management after explaination
given before discharge.

Supporting data :
1. Mr.A able to explain back health education that had been
given.

Back
Health Education
Diet
 Medications
Right dose
Right time
Right route
Right drug
 Activity
I remind Mr.A stay at
home and rest during
the medical leave.
I advice Mr.A to avoid
strenuous activity and
heavy lifting to prevent
increase intra-
abdominal pressure. No
gardening, digging or
other any force that can
cause increase intra-
abdominal pressure.
 Wound Care

I adviced Mr.A always

change his clothes when
it is wet or dirty to
prevent create a source of
infection.
I remind Mr.A don’t
apply any ointment,
powder or traditional
medicine to the wound
site to prevent infection.
 Follow Up
I reminded Mr.A to
come for follow up
on date to assess his
recovery status.
I advice him that he
can come to hospital
anytime if he have
any complication on
his condition or sign
and symptom of
infection occur.
Discharge
 Discharge
Date : 29th May 2009
Time : 1pm

Mr A was discharge on 29th May 2009 after

seen by Dr K. I have reinforced again the
health education that I have gave before regarding
his disease and home care management of post
operation which includes diet, medication, wound
care, activity and follow up on 4th June 2009.Patient
was ambulating well.
MEDICATIONS

- Panadeine II/II PRN

- Ciprofloxacin 500mg Daily

Mr A discharge with accompanied by his wife.

He thanked all the staff and student nurses.
Follow
up
The doctor had given follow up as below:

• Date : 4th June 2009

• Day : Monday
• Place : Dr. K clinic
• Time : 11.00 am
 On Follow Up day
Before the follow up day I have called my
patient and reminded him to come for his
appointment with Doctor K at clinic.
But he unable to come because he got
something to be settle up and his appointmet
was postpone to 8th June 2009,11am at Doctor
K’s clinic.
On 8th June 2009,Mr A came alone and he
looked comfortable and well being.
 Doctor K was examine him and told him that the
wound healing is very good.
 Doctor K advice him to take low fat, small amount
but frequent meal as I mention to him before. He
also understand and follow the advice.
 Lastly,Doctor K didn’t prescribe any medication for
Mr A.
Summary
My patient, Mr.A, 40years old,male,admitted
in Ipoh Specialist Hospital (ISH) on 25 / 05 /
2009 at 8.25pm.
He admitted into the hospital with the
complaint of pain on and off at right upper
quadrant of abdomen.
He was admitted under Dr.K (general surgeon).
Mr A was admitted into ward 7B.
On the 26 / 05 / 2009 at 9.00am he went to
operation theater for open cholecystectomy
procedure under General Anaesthesia(GA).
During hospitalization, Dr.K prescribed some medication for
Mr.A, such as;
1) Tab Dormicum 7.5mg ON
2) IV Maxolon 10mg TDS
3) IV Augmentin 1.2gm 8h
4) Tab Ciprofloxacin 500mg BD
5) Tab Panadeine II/II TDS PRN

After 2 days of operation,on 29 / 05 / 2009 at 1.00pm, patient

were discharged by Dr.K and were given with the follow up
appointment card which is on 4 / 06 / 2009.
There are also some medication that prescribed by Dr.K for Mr.A
to take home, such as;

1) Panadeine II/II PRN

2)Ciprofloxacin 500mg Daily
Mr.A was punctual on his follow up
appointment on the 8 / 06 / 2009 in the
morning at 11 am.
After Dr.K had check on it, doctor said the
incision site all is healing very well and there is
no sign and symptom of infection.
Doctor K did’nt prescribed any medication
during his follow up.
Conclusion
 Conclusion

As a student nurse, I am happy to do this case

study.
I learnt a lot about Cholelithiasis and enhance a lot of
knowledge about the sign and symptoms and
treatment for patient with cholelithiasis. I was also able
to achieve all the learning objectives. While I was
studying on this case I became closer with my patient
because I had to have a good relationship with my
patient in order to understand him better.
 Not only with the patient I had a good bond with
the doctors, staff, sisters, pharmacist in the hospital
because I always referred to them when I had any
doubts and problem in completing my case study. They
all gave me support and courage to complete my case
and be with my patient till he was discharged.

I am very glad I have finally completed this case

study and now the knowledge I have about Cholelithiasis
are a lot and I will never forget till the end of my life.I
have learnt a lot from this case study and hope to
remember till the end life.
References
 References

 Lemone.P,Burke.K (2004)Medical-Surgical Nursing, 3rd ed. United

States,Pearson Education.P574
 Weller.B.F(2003)Nurses’ Dictionary,23rd ed. London, Bailliere Tindal.P85
 Smeltzer.S.C, Bare.B (2004) Medical-Surgical Nursing,10th ed. United States,
Lippincott Williams &Wilkins.P1126
 http://www.merck.com/mmpe/sec03/ch030/ch030b.html
 MIMS Annual Malaysia, Dims, P.J, (Full Prescribing Information) 16th Edition
(2004) Sdn.Bhd

 
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