CHOLELITHIASIS [Autosaved]

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(GALL STONES)

CHOLELITHIASIS


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INTRODUCTION


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Cholelithiasis (Gallstones)

It is the presence of stone in the gallbladder.

Gallstones are crystalline structures formed by concretion oraccretion of normal or abnormal bile constituents.

Ultrasonography and Xray detect gallstones.

Cholecystolithiasis It is the presence of one or more gallstones in the

gallbladder. Diagnostic Sonography (Ultrasonography) and Percutaneous

Transhepatic Cholangiography technique used to visualizethe biliary tract.


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PATIENTS PROFILE

Name: Mrs. ACAge: 61 y/oDate of Birth: September 01, 1949Status: MarriedNationality: FilipinoReligion: Catholic

Home address: 7A, Don Julio Gregorio, Bagbag, Novaliches, Q.C.Occupation: NONEChief Complaint: Right Upper Quadrant PainAdmitting diagnosis: CholecystolithiasisAdmitted by at: 7:00 pm

On: May 06, 2011Operated: May 17, 2011


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THEORETICAL FRAMEWORK

We chose Orems theory which includes three related concepts: self-care, self-care deficit, and nursing systems. Self-care theory has self-care, self-care requisites, and therapeutic self-care demand. Self-care refers to activitiesan individual performs independently throughout life to promote andmaintain personal well-being. Self-care requisites, also called self-care needs,are measures or actions taken to provide self-care. There are three categories

of self-care requisites:Universal requisites, include maintaining intake and elimination of

air, water, and food.

Developmental requisites are associated with conditions or events,such as adjusting to a change in body image.

Health Deviation requisites result from illness, injury, or disease or itstreatment. They include actions such as carrying out prescribed therapies, andlearning to live with the effects of illness or treatment.


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PERSONAL

DATA


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Patients Name: ACAge: 61 years oldGender: Female

History of Present Illness:1 year PTC - patient had pain onRUQ area. No other symptomsnoted. Consult due Ultrasound:

Fatty liver, gallbladder not dilatedwith multiple gallbladder stones,length 1.3 cm.

1month PTC- Patients UltrasoundResult: (+) Fatty liver still withmultiple gallbladder stones, length1.2 cm.

Family Medical History:

(+) HPN & DMmother

(-) Cancer(-) Asthma

P/S History:

(-) smoker(-) alcoholic beverage drink

Vital Signs:Temperature- 36.9Pulse Rate- 74 bpmRespiration Rate- 19cpmBlood pressure- 130/90 mm/Hg


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GORDONSFUNTIONAL HEALTHPATTERN


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Gordons functional

health patterns

Before During Interpretation Analysis

HEALTH PERCEPTION The patient

sees health as a

very important

aspect in life.

She gives

importance to it.

Coordinates

in the post-

operative

nursing care.

The patient

responds

very well in

the

treatment

given to her.

Cooperation helps

the patient in

recovering to

achieve optimum

healing.

NUTRITIONAL-

METABOLIC

Eats 3x a day,

fond eating

chicharon.

Eats anything

prepared

especially

bagoong,

alamang, seedy

and fatty foods.

Drinks 2-3L/day

On DAT diet

Taste foods

as tasteless

Adviced to

eat low salt-

low fat diet.

Drinks 1-

2L/day

Food Restriction

insufficient fluid

intake

She is restricted to

foods that can

worsen her

condition. She is

given a diet to

promote early

recovery.


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Elimination Moves bowel

once a day.

In the morning,

usually soft

brown color, had

clay colored stool

1 week before the

admission.

Voids 5-6 times a

day, dark yellow

in color

Hx of UTI.

Moved bowel once,

soft light yellow

stool.

Voids 3-4 times a

day light yellow in

color.

Color of Stool

changed from

clay to light

yellow.

Urine changed

from dark yellow

to light yellow.

Clay-colored stool

and dark yellow

colored urine is a

result from

obstruction of bile.

ACTIVITY-

EXERCISE

Does household

chores, takes careof grandchild and

jogs atleast 1 hour

in the morning

Not doing household

chores. Needs assistance

during ambulatory

Walks as exercise

Normal Normal


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SLEEP-REST Sleeps 9-10 hours

a day

Experiences

waking up at

midnight, voidsthen return sleep

again.

Sleeps usually 7pm

until 4am.

Does not taking a

nap.

Sleeps longer

Can sleep

anytime

Have naps

duringafternoon

But

experienced

difficulty in

falling asleep

because of

noisy and hot

environment.

Longer rest

period during

admission for

maximum rest

and fasterhealing.

COGNITIVE-

PERCEPTUAL

Experiencing pain on

the Right upper

abdominal quadrant

radiating to the right

scapular area with a

pain scale of 6/10

Experienced

post operative

pain on the

same quadrant

with a pain

scale of 8/10.

Normal Normal


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SELF-

PERCEPTION

She is now a well

contented mother

having 6 children,

all have their

college degrees,having own

families except

the last child.

Does not

consider herself

as a burden to

her husband and

children.

Patient sees herself

positively.

Normal

ROLE

RELATIONSHIP

Lives with

husband, daughter

and grandchild.

Defines herself as

a very good

mother.

Have a well-

established family

relationship.

She stated that

this confinement

cannot affect her

role as a mother.

Normal Normal


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SEXUALITY Before she turned

menopause, she

and her husband

were so active in

sex.

Does self-breast

examination

Menopauses 11 yrs

ago.

Still does self

breast examination.

normal

COPING

STRESS

Asks for massage

from her children

when felt stress.

Expresses problems

to family and friends. praying everyday

Praying

everyday

Having some

conversations

with copatients.

Normal

VALUE BELIEF she is a Roman

Catholic

Believes that every

person should have a

strong faith with the

Lord.

Believes in the loving

care of Mother Mary,

Sto. Nino.

Usually goes to

church every

Sundays

Prays Holy Rosary

Felt stronger

faith to God and

became closer

to him.

Wears rosary on

her neck.

Normal


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PHYSICAL

ASSESMENT


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Body part Method ofassessment

Actual findings interpretation

Skin Inspection Dry skin Skin may be drybecause of

insufficient fluid

intake

Lips Inspection Dry lips lips may be drybecause of

insufficient fluid

intake

Neck Inspection Presence of scar on

right jaw

Scar from infected

boilAbdomen Inspection

palpation

With right upperdressing

(+) tenderness onincision area

Gallbladder isremoved through anabdominal incision(usually at the right

subcostal)


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ANATOMY &

PHYSIOLOGY


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PATHOPHYSIOLOGY


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Predisposing

-female

-61 y/o

Precipitating

factors

-obesity

-high fatty and salty

diet

Fat / Cholesterol

Resulting bile

supersaturated with

cholesterol.

Form cholesterol stone.

-fever

-RUQ pain

-Murphys sing

-Biliary colic

-N & VCholelithiasis


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Obstruction of the cystic

duct

Duodenum secretes

cholecystokinin.

Cholecystolithiasis

Gallbladder becomes

distended and

inflamed

-RUQ pain that may

radiate.

-Fever

-N & V

Bile Obstruction, Bile

Stasis

Gallstones obstruct

cystic duct

-Biliary colic


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LABORATORY

RESULTS


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ULTRASOUND REPORTThe gallbladder measures 5.8 X 2.6 cm which is within normal.

There are multiple intraluminal hyperechic foci, largest measuring 1.3 cmwith posterior acoustic shadowing. The wall is smooth and not thickened.

IMPRESSION:CHOLECYSTOLITHIASIS


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TEST RESULT INTERPRETATION HBA1C 6.0 % Within normal range

BUN 6.24 mmol/L Within normal range

CREATININE 87.2 umol/L Within normal range

SADIUM (Na) 142.5 mmol/L Within normal range

POTASSIUM (K) 3.36 mmol/l HYPOKALEMIA

BLOOD CHEMISTRY


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NCP


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ASSESMENT

DIAGNOSIS PLANNING NURSINGINTERVENTIONS

RATIONALE EVALUATION

Subjective:

masakit pa

din yung tahiko, as

verbalizedby

the patient.

Pain scale:

8/10

Objective:

Protectivebehavior

Facial

grimace

irritability

Acute pain

related to

interruption inskin and

tissue layers

with

mechanical

closure.

After 30

minutes of

nursingintervention

the patient

will report

pain is

lessened.

Monitored vital

signs.

Assisted in

different position

like sitting and

side lying

position.

Encouraged

patient to use

relaxation

exercise.

-deep breathing

exercise

Encouragedadequate periods

of rest.

It serves as a

baseline data

to check ifthere are any

deviations from

her vital signs.

It reduces

muscle tension

and fatigue.

Deep breathing

exercise contribute to

relief of pain.

To prevent fatigue.

After 30 minutes of nursing

interventions the patient

reported that the pain waslessened and the pain scale

became 5/10.


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ASSESMENT DIAGNOSIS PLANNING NURSINGINTERVENTIONS


Subjective:

Minsan

kumakati yung

paligid ng tahiko, as

verbalized

by the patient.

Objective:

Surgical wound

on the right

upper quadrant.With RUQ

abdominal

dressing

Impaired skin /

tissue integrity

related to

surgery.

After 3 days of

nursing

interventions

the patient willdisplay timely

healing of

wounds without

complications.

inspected skin on

a daily basis,

describing lesions

and changesobserved.

Kept the area

clean and dry,

carefully dress

wound.

Used appropriatebarrier dressings

and wound

coverings.

Instructed in

aseptic/ clean

techniques for

dressing changes

and proper disposalof soiled dressings.

To monitor

progress of

wound healing.

Assist bodys

natural process

of repair.

To protect thewound.

To prevent the

spread of

infectious

agents.

After 3 days of

nursing

interventions the

patient displayedhealing of

wounds without

any

complications.


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Provided

optimum

nutrition and

encourage to

increase protein

intake.

Encouraged

early

ambulation.

To provide a

positive nitrogen

balance to aid in

healing and to

maintain general

good health.

Promotes

circulation and

reduces risk

associated with

immobility.


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ASSESMENT DIAGNOSIS PLANNING NURSINGINTERVENTION

S


Subjective:

Ang sakit ng ulo

ko at ang sama

ng pakiramdam

ko, as

verbalized by the

patient.

Objectives:

T- 38.1C

P- 124

R- 28

Warm to touch

Flushed skin

Hyperthermia

related to

dehydration.

After 30 minutes

of nursing

intervention thepatients

temperature will

decreased and

be able to reach

the normal

range.

Monitored vital

signs.

Performed

tepid sponge

bath.

Promotedventilation of skin

by wearing loose

clothes.

Maintained bed

rest.

Administered

replacement

fluids and

electrolytes as

ordered.

To monitor if

theres

progress.

To promote

cooling of the

body surface.

To facilitate

heat lost.

To reduce

metabolic

demands/

oxygen

consumption.

To support

circulating

volume and

tissue perfusion.

After 30 minutes

of nursing

interventions thetemperature

decreased from

38.1C to 37.6C.


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DRUGS STUDY


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Drug Name Classification Action Indication Contraindicati

on

Side effects Nursing

Considerations

Generic Name:

Potassium

Chloride

Brand Name:

Kalium Durule

Electrolytic and

water balance

agent;

replacement

solution.

Essential for

maintenance of

intracellular

isotonicity,

transmission of

nerve impulses.

Plays prominent

role in both

formation andcorrection of

imbalances in

acid- base

metabolism.

To prevent and

treat potassium

deficit

secondary to

diuretic or

corticosteroid

therapy. Also

indicate when

potassium isdepleted by

severe vomiting,

diarrhea;

intestinal

drainage,

fistulas or

malarbsorption;

prolonged

dieresis,

diabetic

acidosis.

Severe renal

impairment;

severe

hemolytic

reaction;

untreated

Adisons

disease; crush

syndrome; earlypost operative

oliguria.

GI: nausea,

vomiting,

diarrhea,

abdominal

distension.

Body as a

whole:

Pain, mental

confusion.Urogenital:

oliguria, anuria.

CV:

hypotension,

bradycardia.

Monitor I & O

ratio and pattern

in patients

receiving the

parenteral drug.

Lab test:

frequent serum

electrolytes are

warranted.Monitor for and

report signs of

GI ulceration (

esophageal of

epigastric pain

or

hematemesis.


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Drug Name Classification Action Indication Contraindicati

on


Consideration

s

Generic

Name:

Celecoxib

Brand Name:

CELEBREX

Therapeutic:

Anti-

rheumatics,

NSAIDS.

PhysiologicMechanism

Decreasedpain and

inflammationcaused byarthritis

PharmacologicMechanism

Prevention

of Inhibits the

enzyme COX-2.

This enzyme is

required for the

synthesis ofprostaglandins.

Has analgesic,

anti-

inflammatory,

and antipyreticproperties.

Relief of signs

and symptoms

of osteoarthritis. Relief of signs

and symptomsof rheumatoid

arthritis inadults.

Hypersensitivit

y to

cephalosporin

s. Serious

hypersensitivity

to penicillin.

CNS:

Seizures (high

doses) GI:

Pseudomembranous

colitis, diarrhea,

nausea,

vomiting,cramps

GU:

Interstitialnephritis

DERM:

Rashes, urticaria

HEMAT:

Blood

dyscrasias,

hemolyticanemia

Assess

patients range

of motion,degree of

swelling, andpain in affected

joints before and

periodically

throughout

therapy. May be

administered

without regard to

meals. Instruct

patient to take

celecoxib

exactly as

directed. Do not

take more than

prescribed

dose.Increasing

doses does not

appear toincreaseeffectiveness.


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Drug Name Classification Action Indication Contraindication Side effects Nursing

Consideration

s

Generic

Name:

Metformin

Hydrochloride

Brand Name:

Fortamet,

Apo-Metformin

(CAN)

Antidiabetic Exact

mechanism is

not understood;possibly

increases

peripheral

utilization of

glucose,

decreases

hepatic glucose

production, and

alters intestinal

absorption of

glucose.

Adjunct to

diet to lower

bloodglucose with

type 2

diabetes

mellitus with

patients 10 yr

and older.

Contraindicated to

allergy with

metformin; heartfailure; diabetes

complicated with

fever; sever

trauma; severe

infections

Use cautiously with

elderly

Endocrine:

hypoglycaemia

GI: anorexia,nausea and

vomiting,

heartburn,

diarrhea,

flatulence

Do not

discontinue

meds withoutconsulting

health care

provider

Monitor blood

for blood

glucose as

prescribed

Swallow

extended

tablets do not

crush or chew

Avoid usingalcohol while

taking this drug

Report

hypoglycaemic

and

hypoglycaemic

reactions


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Drug Name Classification Action Indication Contraindicat

ion


Consideratio

ns

Generic

Name:

Omeprazole

Brand Name:

Prilosec

Proton Pump

Inhibitor

Antisecretory

Drug

Gastric acid

pump inhibitor.

Suppresses

gastric acid

secretion by

specific

inhibition of

the hydrogen-

potassium

ATPase

enzyme

system at the

secretory

surface of the

gastric parietal

cells; blocks

the final stepof acid

production.

Short term

treatment of

active

duodenal

ulcer.

Treatment of

hearturn or

symptoms of

GERD.

Short term

treatment of

active benign

gastric ulcer.

Use cautiously

with

pregnancy,

lactation.

Contraindicate

d with

hypersensitivit

y to

omeprazole or

its

components.

GI: diarrhea,

abdominal

pain, nausea

and vomiting,

constipation,dr

y mouth

Respiratory:

URI

symptoms,

cough,

epistaxis

Other:

Back pain

fever

Administer

befor meals.

Do not crush

or chew

capsules

(swallow

capsule whole)

Have regular

follow up

check ups

Report severe

headaches,

chills and

severediarrhea.


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Medications Omeprazole Metformin

Celebrex

Kalium Durule

Exercise Begin light exercise such as walking.

Deep breathing and coughing exercises.

Treatment Take medications as ordered. Finish medication course.

Health Teaching

Taught proper wound care. If experiencing pain and to ease discomfort sit in an upright position, walking and use of a

heating pad can ease the pain and discomfort. Take analgesics as prescribed. Do not self-medicate.

Out Patient Follow up Attend follow up checkups after one week.

Call your surgeon if you experience any signs and symptoms of infection.

Diet Low Salt Low Fat Diet.

Eat foods that are rich in vitamins and minerals.

Avoid fatty and salty foods.

Spiritual counselling Tell client to verbalize her feelings.

Talk to the relati es to be s pporti e in the clients acti ities for better and faster reco er

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