BULACAN STATE UNIVERSITYCITY OF MALOLOS, BULACAN

COLLEGE OF NURSING

OSPITAL NG GUIGUINTO(MEDICAL WARD)

A CASE STUDY ABOUT

ACUTE CALCULOUS CHOLECYSTITIS

SUDBMITTED BY:

LACAS, JOHN PHILIPREYES, FIONA NOELLE(BSN III-D GROUP 3)

SUBMITTED TO:

MR. ROGIE ABALLOS, R.N(CLINICAL INSTRACTOR)

NURSING ASSESSMENT

A. BIOGRAPHIC DATA

NAME : Wilhelmina Boday

ADDRESS : # 422 Narey Street, Rocka Village, Tabe, Guiguinto, Bulacan

AGE : 48 Years Old

BIRTH DATE : November 02, 1960

GENDER : Female

RELIGION : Roman Catholic

RACE : Asian

STATUS : Married

OCCUPATION : Businesswoman

SOURCE OF HEALTH FINANCING : Herself

DATE OF ADMISSION : September 21, 2009 (12:50pm)

ADMITTING DIAGNOSIS : RUQ Abdominal Pain

FINAL DIAGNOSIS : Acute Calculous Cholecystitis

B. CHIEFT COMPLAINT

The patient complains of RUQ abdominal pain which is happened for almost 2 weeks, according to her.

C. HISTORY OF PRESENT ILLNES

According to her, she often experience RUQ abdominal pain for almost how many years. First, she thought that the pain which she felt is caused by a

hyperacidity attack and try to manage it by taking Aluminum Hydroxide (Kremil S) an antacid drug. As time past by the abdominal pain became

severe and even an antacid drug cannot relieved the symptoms. Then she decided to consult a doctor, which is last January 2009. According to her

the doctor gave her Omeprazole (Prisolec) a Proton Pump Inhibitor which work to stop acid secretion of the stomach. Then it works and it can now

relieve the abdominal pain which she felt. After few months, this September of the same year, the abdominal pain came back and became more sever

with a pain scale of 7/10. Then last Sept. 21, 2009, they decided to bring her in Ospital Ng Guiguinto and seek for some medical explanation. The

doctor said she have gallstone and she will be going to undergo a surgery which is Cholecystectomy.

D. PAST HISTORY OF ILLNESS

According to her, she was complete in different immunization offered at that time. She already has Mumps and Varicella; do not have any known

food or drug allergies: and have not suffered from any minor or major injury when she was a child.

E. FAMILY HISTORY OF ILLNESS

According to her, besides in having Cholecystitis, she also has Hypertension & Diabetes Mellitus Type 1. Her father has Hypertension as well as her

2 siblings: her Mother died with unknown cause; the uncle in her mother side also has Diabetes Mellitus. And there is no family history of

Osteoarthritis, Malignant Neoplasia and Cholecystisis.

48

GENOGRAM

MALE PATIENT ALIVE AND WELL N/A NOT AVAILABLE DIABETES MELLITUS

FEMALE HYPERTENSION DECEASED CHOLECYSTITIS

N/A

69 N/A N/AN/A

N/A72N/A N/A

N/A

N/AN/A

52

50

37

F. DEVELOPMENTAL TASK

 

NAME: WILHELMINA BODAY AGE: 48 YEARS OLD HOSPITAL: OSPITAL NG GUIGUINTO (MEDICAL WARD) DATE: 09-24-09

THEORY ERIK ERIKSON THEORY OF

PSYCHOSOCIAL DEVELOPMENT

SIGMUND FREUD THEORY OF

PSYCHOSEXUAL DEVELOPMENT

JEAN PIAGET THEORY OF COGNITIVE

DEVELOPMENT

LAWRENCE KOHLBERG THEORY

OF MORAL DEVELOPMENT

JAMES FOWLER THEORY OF FAITH

DEVELOPMENT

STAGE MIDDLE ADULTHOOD

PSYCHOLOGICAL CRISIS: GENERATIVITY VS STAGNATION

RELATED ELEMENT IN SOCIETY: PREPARING, EDUCATING & GIVING SOCIAL INVOVEMENT FOR THE NEXT GENERATION.

GENITAL STAGE FORMAL OPERATIONS

POST CONVENTIONAL

UNIVERSALIZING FAITH

DEFINITION

Generativity is the concern of establishing and guiding the next generation. Socially-valued work and

True maturity requires the timing of aggressive and sexual urges, allowing their to released their repress feeling in a more

The person at this stage can think abstractive.

An individual reaches this stage acts out universal principles based upon the equality and worth of all

Unitive view of reality and enlightenment.

disciplines are expressions of generativity. Simply having or wanting children does not in and of itself achieve generativity

social and acceptable manner.

human beings.

 

EXPLANATION

Our pt. has feeling of generativity because she already have established and guided her children by giving a good life and education.

She has a healthy sex life and does not suffering from any sexual problem.

Our pt. accepts opinions from other. She responds correctly and appropriate to situation and questions. The pt. has relevance of thought and good insight in organization of vital event in her life.

She can decide accurately and relevant to situation. And have a good moral insight in her life.

The religion of our pt. is Roman Catholic; there is no problem in terms of faith and devotion to God.

FUNCTIONAL HEALTH PATTERN

PRIOR HOSPITALIZATION DURING HOSPITALIZATION

HEALTH PERCEPTION & HEALTH

MANAGEMENT PATTERN

She believed in herbal medication like Lagundi Leaves extract in treating cough and Guava Leaves extract as an effective anti-microbial agent; she also go to faith healers like Manghihilot as a primary source of health remedies if they experience unserious medical problems.

When I ask her if she can follow what doctor & nurse advices them, she verbalized “ sa abot ng aking makakaya,kailangan kong sundin ang mga gusting ipagawa ng doctor, kasi para rin ito sa kabutihan ko”

The patient also experienced hyperthermia (38.2).

NUTRITIONAL METABOLIC PATTERN

3 DAYS FOOD RECALL

DATE

FOOD FLUID

BREAKFAST LUNCH DINNER BREAKFAST LUNCH DINNER

SEPT. 18, 2009

N/A N/A N/A N/A N/A N/A

SEPT. 19, 2009

N/A N/A N/A N/A N/A N/A

SEPT. 20, 2009

N/A N/A N/A N/A N/A N/A

She’s taking vitamins, specifically Ascorbic Acid continuously, she eats mostly fishes & meat, she is fun of eating food rich in seasoning and drinking cola most of the time, and not experienced weight lost lately. There is no skin problem noted. There are 3 missing molars and there is no problem in wound healing.

3 DAYS FOOD RECALL

DATE

FOOD FLUID

BREAKFAST LUNCH DINNER BREAKFAST LUNCH DINNER

SEPT. 22, 2009

3 Bread Sinigang na Baboy, 1 Cup of Rice, 1 piece of Banana

Chapsuey, 1Cup of Rice

1 Glass of Water

2-3 Glasess of Water

2 Glasess of Water

SEPT. 23, 2009

1 Piece of Egg, 1 Cup of rice

Ginisang Gulay, 1 Cup of Rice

Sinigang na Isada, 1 Cup of Rice

1 Glass of Water

1-2 Glass of Water

1-2 Glass of Water

SEPT.24, 2009

1 Serving of Mami

NPO NPO 1 Glass of Water

NPO NPO

During hospitalization she cannot eat what her want. And there is sudden decreased in appetite.

ELIMINATION PATTERN

FECAL-URINARY ELIMINATION PATTERN

CATEGORY FREQUENCY COLOR/CONSISTENCY DEVIATION

1. URINATON - 5 to 8 as Straw None

FECAL-URINARY ELIMINATION PATTERN

CATEGORY FREQUENCY COLOR/CONSISTENCY DEVIATION

estimated- Depends upon the weather

2. DEFECATION

2 Brown/Formed None

1. URINATON 3 Straw None

2. DEFECATION 1 Brown/Hard Constipation

ACTIVITY-EXERCISE PATTERN

She considered household chores as a form of exercise.

O Feeding O Bathing O Dressing O ToiletingO Shopping O Home Maintenance O Bed Mobility O General Mobility

Level O - IndependentLevel I - With help from othersLevel II - With equipmentLevel III - With help from others & equipmentLevel IV - Dependent

There is no form of exercise upon admittance to hospital.

I Feeding N/A Bathing I Dressing I ToiletingN/A Shopping N/A Home Maintenance I Bed Mobility II General Mobility

Level O - IndependentLevel I - With help from othersLevel II - With equipmentLevel III - With help from others & equipmentLevel IV – Dependent

SLEEP-REST PATTERN Prior hospitalization, she sleep for approximately 7 hours each night from 10pm to 5 am, there is no sleep problem noted, she take naps every afternoon, more often from 2pm to 3pm, all in all the total no. of sleep is 8 hours in every 24 hours, the form of relaxation is thru watching her favorite TV program, chatting with her family or sometimes her friends & reading news clippings.

During hospitalization, she only sleeps for about 5 hours each night in intermittent manner, because of environmental factor (sudden changed in environment) & physiological factor (RUQ Abdominal Pain).

COGNITIVE PERCEPTUAL

PATTERN

No hearing and eye problems. According to her, she often experience tip of the tongue phenomenon together with slight confusion.

Still no change.

SELF PERCEPTION SELF CONCEPT

PATTERN

She is satisfied with her physical appearance; lately she felt easily tired. There is no major problem in her self as a whole, according to hers he easily felt angry to those people whose are liars and do not know how to return dept of gratitude’s.

Still no change.

ROLE RELATIONSHIP PATTERN

She is already married, with 3children. They are 5 in the family. She and Her husband are responsible for most of the health decision in their family. And

Still no change.

these factors made their family as Nuclear in membership and Egalitarian in authority.

There is no major family problem encountered lately, and if there is a problem they handle it by means of having open forums. There is no problem in her community interaction & there is no feeling of isolation from others.

SEXUALLY REPRODUCTIVE

PATTERN

She is sexually active; formerly she’s using Oral contraceptive Pills as a form of family planning method.

Still the same.

COPING STERSS PATTERN

If she has problem, she just kept those problem by herself without saying to others.

Now she is on hospital, she needs the help of other by means of sharing her personal problems to lessen the loads which she kept deep inside.

According to her she is very nervous at the same time fearful about the possible outcome of surgery, if it will be successful or not.

VALUE BELIEF PATTERN

For her religion is very important in her life, although she cannot go to church regularly.

Now she needs more the help of God, she seek for help by means of praying.

PATIENT AND HIS DISEASE

A. SCHEMATIC DIAGRAM

MODIFIABLE FACTOR NON MODIFIABLE FACTOR

- LIFESYLE (SEDENTARY) ` - FEMALE, FAIR, AGE (FORTHY)- DIET (FAT)

HYPERSATURATION OF BILE WITHCHOLESTEROL & CALCIUM

PRESIPITATION OF SOLUTE FROMSOLUTION & BECOME CRYSTAL

CRYSTAL MUST COME TOGETHER

& FUSE TO BECOME CALCULI

GALLSTONE

SHARP PAIN IN THE CHOLELITHIASIS RIGHT HYPOCHONDRIUM

BILIARY COLLIC DISTENTION OF THE GALLBLADDER

VENOUS & LYMPHATIC LOCALIZED CELLULAR DRAINAGE ARE IMPAIRED OR INFILTRATION

PROLIFERATION OF BACTERIA ISCHEMIA

INFLAMMATION OF GALLBLADDER

CHOLECYSTITIS

B. DEFINITION OF DISEASE

Cholecystitis is often caused by cholelithiasis (the presence of choleliths, or gallstones, in the gallbladder), with choleliths most commonly blocking

the cystic duct directly. This leads to inspissation (thickening) of bile, bile stasis, and secondary infection by gut organisms, predominantly E. coli

and Bacteroides species.

The gallbladder's wall becomes inflamed. Extreme cases may result in necrosis and rupture. Inflammation often spreads to its outer covering, thus

irritating surrounding structures such as the diaphragm and bowel.

Stones in the gallbladder may cause obstruction and the accompanying acute attack. The patient might develop a chronic, low-level inflammation

which leads to a chronic cholecystitis, where the gallbladder is fibrotic and calcified.

C. PREDISPOSING & PRECIPITATING FACTORS

Female, Fat (Diet), Frothy(Age), Fertile & Fair

D. SIGN & SYMPTOMS WITH RATIONALE

Cholecystitis usually presents as a pain in the right upper quadrant. This is usually a constant, severe pain. The pain may be felt to 'refer' to the right

flank or right scapular region at first.

RATIONALE: Gallbladder is located in the RUQ of the Abdominal Cavity along the Left Hypochondriac Region. The pain which the patient felt is due to Gallbladder distention & this pain is also known as Biliary Collic.

This is usually accompanied by a fever, vomiting and nausea.

RATIONALE: Fever due to presence of infection; Vomiting is intended to protect a person from harmful ingested substances. However, chronic nausea and vomiting are typically a pathologic response to any of a variety of conditions.

E. REVIEW OF SYSTEM

SYSTEM DEVIATION

1. GASTROINTESTINAL SYSTEM - Although the upper gastrointestinal tract is relatively bacteria-free, bacterial overgrowth could potentially occur in the setting of impaired gallbladder motility.

- Changes in the biliary tract flora, coupled with impairment of the normal barrier function, allow the gallbladder to serve as a reservoir for pathogens that can enter the portal and systemic circulations.

- This condition can cause Peritonitis or Septic Schock.2. INTEGUMENTARY SYSTEM - Accumulation of bile salt under the skin can cause Pruritus or Itching.

- Obstruction of biliary or common bile duct can cause Icterus or Jaundice.

ANATOMY & PHYSIOLOGY

A. ANATOMY OF GASTROINTESTINAL SYSTEM

Upper gastrointestinal tract

The upper GI tract consists of the mouth, pharynx, esophagus, stomach, and duodenum proximal to the ligament of Treitz.

The mouth contains the buccal cavity, which contains the openings of the salivary glands; the tongue; and the teeth.

Behind the mouth lies the pharynx which prevents food from entering the voice box and leads to a hollow muscular tube, the esophagus.

Peristalsis takes place, which is the contraction of muscles to propel the food down the esophagus which extends through the chest and pierces the

diaphragm to reach the stomach.

Lower gastrointestinal tract

The lower GI tract comprises the most of the intestines and anus.

Bowel or intestine

o Small intestine, two of the three parts:

Duodenum

Jejunum

Ileum

o Large intestine, which has three parts:

Cecum (the vermiform appendix is attached to the cecum).

Colon (ascending colon, transverse colon, descending colon and sigmoid flexure)

Rectum

Anus

Accessory organs

Accessory organs to the alimentary canal include the liver, gallbladder, and pancreas. The liver secretes bile into the small intestine via the bile duct, employing the

gallbladder as a reservoir. Apart from storing and concentrating bile, the gallbladder has no other specific function. The pancreas secretes an isosmotic fluid

containing bicarbonate, which helps neutralize the acidic chyme, and several enzymes, including trypsin, chymotrypsin, lipase, and pancreatic amylase, as well as

nucleolytic enzymes (deoxyribonuclease and ribonuclease), into the small intestine. Both of these secretory organs aid in digestion.

B. PHYSIOLOGY OF GASTROINTESTINAL SYSTEM

Specialization of organs

Four organs are subject to specialization in the kingdom Animalia.

The first organ is the tongue which is only present in the phylum Chordata.

The second organ is the esophagus. The crop is an enlargement of the esophagus in birds, insects, and other invertebrates that is used to store food

temporarily.

The third organ is the stomach . In addition to a glandular stomach (proventriculus), birds have a muscular "stomach" called the ventriculus or "gizzard." The

gizzard is used to mechanically grind up food.

The fourth organ is the large intestine. An outpouching of the large intestine called the cecum is present in non-ruminant herbivores such as rabbits. It aids in

digestion of plant material such as cellulose

Transit time

The time taken for food or other ingested objects to transit through the gastrointestinal tract varies depending on many factors, but roughly, it takes 2.5 to 3 hours

after meal for 50% of stomach contents to empty into the intestines. Total emptying of the stomach takes 4 to 5 hours. Subsequently, 50% emptying of the small

intestine takes 2.5 to 3 hours. Finally, transit through the colon takes 30 to 40 hours.

The Gallbladder

The gallbladder is a thin, green, saclike structure located on the inferior portion of the liver that stores and modifies bile not immediately needed for digestion. It is

~8 cm long and 4 cm wide and has three layers: the inner mucosa, muscularis, and serosa. The inner mucosa is folded to allow for expansion. The muscularis

contains smooth muscle that allows for contraction. The serosa is the outer covering. The regions of the gallbladder itself include the fundus, body, and neck. It is

connected to the common bile duct via the cystic duct (Figures 5 & 6). Ingesting large amounts of lipids stimulate cholecystokinin (CCK) release into the

bloodstream causing Bile secretion into the duodenum.

THE PATIENT AND HIS CARE

A. MEDICAL MAGAEMENT

IVF DATE ORDERED GENERAL DESCRIPTION INDICATION CLIENTS RESPONSE

PNSS September 21, 2009 A salt solution (sodium chloride in water) which has the same salt content as the normal body fluid, so that the body will think that it is just a part of the body fluid.

PNSS can be used to replace fluids in dehydration, go with blood transfusions, hyponatremia, and burn victims, it is isotonic,( same osmolarity as our body fluids)

Fluid loss was replaced.

B. DIET

TYPE OF DIET DATE STARTED GENERAL DESCRIPTION

INDICATION SPECIFICT FOD TAKEN

CLIENTS RESPONSE

DIABETES DIET September 21, 2009 - Limiting sweets.- Eating often.- Being careful about when and how many. Carbohydrates you eat.- Eating lots of whole-grain foods, fruits and vegetables.- Eating less fat.- Limiting your use of alcohol.

To maintain nornal blood glucose level.

Whole grains (oatmeal,cereals), vegetables, fishes.

Prevent further complications due to elevated blood glucose level.

NOTHING PER OREM September 4, 2009 - No food should be taken P.O.

- Preparation for abdominal surgery.

- No ingestion of solid or Liquid foods.- All P.O medication should be discontinuing.

- Prevent risk for aspiration during cholecystectomy.

C. EXERCISE & ACTIVITY

CLIENT'S RESPONSE INDICATION GEN. DESCRIPTION DATE EXERCISE

The pt. was cooperative and willing to perform the exercise as he is aware of its importance

An exercise advised to be performed by patients expected and scheduled for surgery

An exercise enhancing the cardiac muscle and organs to function, preparing the patient for surgery and preventing respiratory arrest.

N/A DEEP BREATHING EXERCISE

The pt is actively participative and says that he exercises everyday.

An exercise indicated for patients with musculoskeletal impairment

ACTIVE ROM- this is done by the pt, it increases and maintains muscle tone and joint mobility

PASSIVE ROM- the nurse assists the pt in performing the exercise to enhance joint and muscle function

RESISTIVE ROM- it is the contraction of the muscle against an opposing force or weight, it increases the muscle power

N/A RANGE OF MOTION EXERCISES

SURGIGAL MANAGEMENT

A. CHOLECYSTECTOMY

Is the surgical removal of the gallbladder. Despite the development of non-surgical techniques, it is the most common method for treating symptomatic gallstones,

although there are other indications for the procedure, including carcinoma. Surgery options include the standard procedure, called laparoscopic cholecystectomy,

and an older more invasive procedure, called open cholecystectomy. A cholecystectomy is performed when attempts to treat gallstones with ultrasound to shatter

the stones (lithotripsy) or medications to dissolve them have not proved feasible.

B. NURSING RESPONSIBILITY

PRIOR DURING AFTER

- Secure consent. - Assess & monitor patient general condition. - Reassess vital sign.

- Assess vital sign.

- Maintained NPO.

- Maintain NPO until bowel sound return.

- Diet Progression from clear liquid to full liquid to soft diet.

- Monitor for complications( Bleeding is the priority)

- Administer medication correctly.

- Health teaching regarding present condition.

LABORATORY FINDINGS

A. CHEST X-RAY PA

FINDINGS: HEARTH IS ENLARGED

PULMONARY VASCULARITY IS PROMINENT

DIAPHRAGM IS ELEVATED

IMPRESSION: SLIGHT CARDIOMEGALLY

MINIMAL PULMONARY HYPERVASELARITY

B. ECG

IMPRESSION & FINDINGS: REGULAR SINUS RHYTHM & LEFT AXIS DEVIATION

C. BLOOD CHEMISTRY

DATE: SEPT. 22, 2009

TEST ACTUAL FINDINGS NORMAL FINDINGS

FBS 70-105 mg/dl

BUN 15 mg/dl 8-25 mg/dl

CREATININE 1.0 mg/dl 0.5-1.7 mg/dl

BLOOD URIC ACID 2.5-7.7 mg/dl

CHOLESTEROL <200 mg/dl

TRIGLYCERIDES 44-148 mg/dl

HDL-CHOLE M=26-63 mg/dl

F=33-75 mg/dl

LDL-CHOLE 40-140 mg/dl

VLDL-CHOLE 0-40 mg/dl

Na 142.5 mEq/L 135-155 mEq/L

K 3.9 mEq/L 3.4-5.3 mEq/L

SGPT 5-35 iu/L

SGOT 10-40iu/L

Mg 1.3-2.5 mEq/L

Ca 8.5-10.5 mEq/L

D. HEMATOLOGY

DATE: SEPT.22, 2009

TEST RESULT NORMAL VALUES

HEMOGLOBIN 139 g/L M=140-175

F=123-135

HEMATOCRIT 0.45 g/L M=0.41-0.50

F=0.35-0.44

WBC 8.9*10 g/L 4.5-10

RBC 4.6810 12/L 3.8-5.8

SEGMENTS 78 43-76

LYMPHOCYTES 22 17-48

E. URINALYSIS

PHYSICAL EXAMINATION: CHEMICAL EXAMINATION:

COLOR- YELLOW pH- 5.0 ALBUMIN- =/-CHARACTERISTICS- HAZY SGPT- 1.025 SUGAR- NEGATIVE