Case Study Cholecystitis

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Transcript of Case Study Cholecystitis

I.

INTRODUCTION

Cholecystitis is an inflammation of the gallbladder wall and nearby abdominal lining. Cholecystitis is usually caused by a gallstone in the cystic duct, the duct that connects the gallbladder to the hepatic duct. The presence of gallstones in the gallbladder is called cholelithiasis. Cholelithiasis is the pathologic state of stones or calculi within the gallbladder lumen. A common digestive disorder worldwide, the annual overall cost of cholelithiasis is approximately $5 billion in the United States, where 75-80% of gallstones are of the cholesterol type, and approximately 10-25% of gallstones are bilirubinate of either black or brown pigment. In Asia, pigmented stones predominate, although recent studies have shown an increase in cholesterol stones in the Far East. Gallstones are crystalline structures formed by concretion (hardening) or accretion (adherence of particles, accumulation) of normal or abnormal bile constituents. According to various theories, there are four possible explanations for stone formation. First, bile may undergo a change in composition. Second, gallbladder stasis may lead to bile stasis. Third, infection may predispose a person to stone formation. Fourth, genetics and demography can affect stone formation. Risk factors associated with development of gallstones include heredity, Obesity, rapid weight loss, through diet or surgery, age over 60, Native American or Mexican American racial makeup, female gender-gallbladder disease is more common in women than in men. Women with high estrogen levels, as a result of pregnancy, hormone replacement therapy, or the use of birth control pills, are at particularly high risk for gallstone formation, Diet-Very low calorie diets, prolonged fasting, and low-fiber/highcholesterol/high-starch diets all may contribute to gallstone formation. Sometimes, persons with gallbladder disease have few or no symptoms. Others, however, will eventually develop one or more of the following symptoms; (1) Frequent bouts of indigestion, especially after eating fatty or greasy foods, or certain vegetables such as cabbage, radishes, or pickles, (2) Nausea and bloating (3) Attacks of sharp pains in the upper right part of the abdomen. This pain occurs when a gallstone causes a

blockage that prevents the gallbladder from emptying (usually by obstructing the cystic duct). (4) Jaundice (yellowing of the skin) may occur if a gallstone becomes stuck in the common bile duct, which leads into the intestine blocking the flow of bile from both the gallbladder and the liver. This is a serious complication and usually requires immediate treatment. The only treatment that cures gallbladder disease is surgical removal of the gallbladder, called cholecystectomy. Generally, when stones are present and causing symptoms, or when the gallbladder is infected and inflamed, removal of the organ is usually necessary. When the gallbladder is removed, the surgeon may examine the bile ducts, sometimes with X rays, and remove any stones that may be lodged there. The ducts are not removed so that the liver can continue to secrete bile into the intestine. Most patients experience no further symptoms after cholecystectomy. However, mild residual symptoms can occur, which can usually be controlled with a special diet and medication.

II.

NURSING ASSESSMENT A. Personal History

Mr. Aproniano Castro is a 56 year old male, a Filipino citizen who resides at Pulong Santol, Porac Pampanga. He was born on January 22, 1950 at Pulong Santol, his religious affiliation is Roman Catholic and he is married to Mrs. Brigida M. Castro. He is a jeepney driver bound in Porac-Angeles route. He is also the president of their jeepneys association. Mr. Castro usually works for 10 to 12 hours a day usually around 7am to 7 pm. He always sleeps around 9 in the evening and wakes up at 6 in the morning. His wife was the one who prepares him the breakfast and the snack. He has day-offs but uses this day in working as the president of the jeepney association. He usually eats instant food and love eating foods which has condiment like patis, vinegar and soy sauce. He also love eating vegetable salads and fatty salty food. He is not also choosy on the food he eats because he really eat a lots. He seldom drinks alcohol and smoke. Regarding the finances about health he is using his wifes PHILHEALTH card to compensate the finances needed. Family Health and Illness History B. Family Health and Illness History According to Mr. Castro that the familial disease he knows that they have in their family was the hypertension that is on his fathers side. His father died because of heart attack and her mother died of natural cause. He also added that cholecystitis is prone to their family, because of one of his siblings also had acquired this disease. C. History of Past and Present Illness This is the second time Mr. Castro been admitted into this hospital (Porac District Hospital). On his first admission into this hospital he had undergone throidectomy operation, which is almost 3 years ago. He had not experience any accident and injuries, even though his job is prone to accident particularly vehicular accident. He also added that he had an ashtma when he was 7 years old that lasts when he is 21 years old, his ashtma just stopped when he start drinking alcohol beverages as he said.

As for his present illness, he was admitted into this hospital because of cholecystitis, he was admitted last February 13, 2006. He was been diagnosed with cholecystitis with multiple cholelithiasis a month prior to admission due to severe epigastric pain and weight loss and was advised to remove his gallbladder. He just did not have his cholecystectomy done immediately due to financial problem. When the money needed for his operation was enough he then goes to Porac District Hospital last February 13, 2005 for his operation. He was diagnosed and surgically operated by Dr. Serrano.According to Mr. Castro. Upon admission he had undergone some laboratory examination such as UTZ, Chest X-ray, U/A, CBC, FBS, BUN,Creatinine and ECG. His initial medication were H2bloc and Cefuroxime. D. Physical Examination Physical Assessment done by the attending physician reveals that patient is; afebrile with pink palpebral conjunctiva (-) cyanosis (+) NABS non tender abdomen Vital Signs upon admission (February 13, 2006) BP- 130/90 RR-19 PR-84 Temp-36.5 oC Physical Assessment done by the student reveals that patient is; afebrile with pink palpebral conjunctiva (+) dry lips (+) paleness (+) dryskin decreased skin turgor (-) bowel movement (-) weakness Vital Signs taken and recorded as of February 15, 2006 are as follows; BP- 140/90 PR- 85 RR- 21

Temp- 36.4 oC

III.

ANATOMY AND PHYSIOLOGY

Gallbladder, muscular organ that serves as a reservoir for bile, present in most

vertebrates. In humans, it is a pear-shaped membranous sac on the undersurface of the right lobe of the liver just below the lower ribs. It is generally about 7.5 cm (about 3 in) long and 2.5 cm (1 in) in diameter at its thickest part; it has a capacity varying from 1 to 1.5 fluid ounces. The body (corpus) and neck (collum) of the gallbladder extend backward, upward, and to the left. The wide end (fundus) points downward and forward, sometimes extending slightly beyond the edge of the liver. Structurally, the gallbladder consists of an outer peritoneal coat (tunica serosa); a middle coat of fibrous tissue and unstriped muscle (tunica muscularis); and an inner mucous membrane coat (tunica mucosa). The function of the gallbladder is to store bile, secreted by the liver and transmitted from that organ via the cystic and hepatic ducts, until it is needed in the digestive process. The gallbladder, when functioning normally, empties through the biliary ducts into the duodenum to aid digestion by promoting peristalsis and absorption, preventing putrefaction, and emulsifying fat. Digestion of fat occurs mainly in the small intestine, by pancreatic enzymes called lipases. The purpose of bile is to; help the Lipases to Work, by emulsifying fat into smaller droplets to increase access for the enzymes, Enable intake of fat, including fat-soluble vitamins: Vitamin A, D, E, and K, rid the body of surpluses and metabolic wastes Cholesterol and Bilirubin.

IV. PATHOPHYSIOLOGY Risk factorHeredity Obesity Rapid Weight Loss, through diet or surgery Age Over 60

Bile must become supersaturated with cholesterol and calcium

The solute precipitate from solution as solid crystals

Crystals must come together and fuse to form stones

Gallstones

Obstruction of the cystic duct and common bile duct Sharp pain in the right part of abdomen

Jaundice

Distention of the gall bladder

Venous and lymphatic drainage is impaired

Proliferation of bacteria

Localized cellular irritation or infiltration or both take place

Areas of ischemia may occur

Inflammation of gall bladder

CHOLECYSTITIS

V.

DIAGNOSTIC AND LABORATORY PROCEDURE 1. Complete Blood Count (CBC) This is to determine blood components and the response to

inflammatory process and streptococcal infection. Date Ordered: February 13, 2006 Date Result In: February 13, 2006 Results: WBC RBC Lymphocyte Conclusion: WBC is slightly elevated based on the normal value of 4.3-10 g/l which confirms the presence of infection. 2. Fasting Blood Sugar This is to measure the blood glucose levels. Date Ordered: February 13, 2006 Date Result In: February 13, 2006 Results: 94.8 mg/dl Conclusion: The result is within normal range based on the normal value of < 126 mg/dl. 10.9 g/l 5.5 g/l 27

3. Creatinine This is the indicator of the renal function Date Ordered: February 13, 2006 Date Result In: February 13, 2006 Results: 1.0 mg/dl Conclusions: The result is w