cholelithiasis GRAND CASE PRES

CHOLECYSTITIS

( Inflammation of the Gall Bladder)

IN TRODUCTION

CHOLECYSTITIS

• Very rarely, even in the absence of cholelithiasis, gall bladder can become inflamed and infected. This is known as acute acalculous cholecystitis, where the pain lasts longer and is severe

• Typically, people have abdominal pain that lasts more than 6 hours, fever, and nausea.

• Ultrasonography can usually detect signs of gallbladder inflammation.

OBJECTIVES

• To determine the content on the nursing assessment, diagnosis, planning, Implementation and evaluation for this specific disease condition

• To know the underlying causes and health history on the clients medical diagnosis upon admission

• To search the medical management as being

ordered based upon the clients diagnostic and laboratory results

• To compare and contrast the ideal and actual nursing care management for this specific disease condition

• Utilize the nursing process as a framework for care of patients with cholecystitis

• To evaluate the effectiveness of the interventions and detect any progress of the clients condition.

PATIENT PROFILE

PRESENT MEDICAL HISTORY

• THREE DAYS PTA: The patient has epigastric pain with a pain scale of 5/10 accompanied with 2 bouts of vomiting of previously ingested food.

• ( - fever )• No medication taken; no consultation.• ONE DAY PTA: still with above condition. Patient given Tromadol

offered no relief.• FEW HOURS PTA: persistence of above condition. Consult advised

admission.• VITAL SIGNS (taken May 15,2010)• Temperature: 37.1C• Pulse rate: 120• Respiratory rate: 19• Blood Pressure: 140/90

Past medical history• ( + ) Hypertension highest BP 170/100 (1999)

usual BP 130/80• (amlodipine 10mg OD)• • ( + ) CVA infarct in the left hemisphere (april

23,2010)• (Citicoline 1g BID)• (ASA 325mg OD)• (Simvastatin 20mOD)• (Combizar 1tab OD)• (Lexapin 10mg OD ½ cap)• (Iron OD)

THEORETICAL FRAMEWORK

Self – Care Deficit Theory of Nursing

Self Care

Agency

Self care

Therapeutic Self care

demands

Nursing Agency

Deficit

R R

R

R R

GORDON’S FUNCTIONAL

HEALTH PATTERN

Before Hospitalization During Hospitalization

Health Perception and Health Management Pattern

- Knows the importance of being healthy; observes proper hygiene; consults doctor

- Knowledgeable about her condition

Nutritional and Metabolic Pattern

- Eats vegetables; loves sour foods; loves to drink softdrinks;

-Loss of appetite

Elimination Pattern - Defacates twice a day; micturates 8-9 times a day

- Uses commode

Activity-Exercise Pattern - Walking and cleaning the house; watching tv is her past time

- Stays in bed

Gordon’s Functional Health Pattern

Before Hospitalization During Hospitalization

Sleep-Rest Pattern - 6 hours of sleep and 2 hours of nap in the afternoon

- Sleeps more often than the usual sleep pattern

Cognitive-Perceptual Pattern - Hearing is clear; has difficulty in writing

- Hearing is clear; has difficulty in writing

Self Perception and Self Concept Pattern

- Visualizes herself as a strong person; focuses on her family

- Tries to be more stronger for her family and herself

Religion - Roman Catholic; goes to church and prays the rosary

- Never forgets to pray the rosary

Vices - Doesn’t have any vices - Doesn’t have any vices

Sexual Pattern - Believed in family planning Decreased interest in sexual activity

PHYSICAL ASSESSMENT

PHYSICAL ASSESSMENTPhysical assessment done:

May 19, 2010

GENERAL

HEENT Unremarkable

RESPIRATORY Unremarkable

CARDIOVASCULAR Unremarkable

GASTRO-INTESTINAL Remarkable

GENITO-URINARY Unremarkable

ENDOCRINE Unremarkable

MUSCULO-SKELETAL Unremarkable

PSYCHIATRIC Remarkable

ANATOMY AND PHYSIOLOGY

PATHOPHYSIOLOGYCHOLECYSTITIS WITH

CHOLELITHIASIS

Cause: UNKNOWN PREDISPOSING FACTORS:

(5 F’s)

Forty

Fertile: (multigravida; use

of OCP)

Fat (obese)

Decrease bile acid synthesis in the liver

Fair (Caucasian)Increase cholesterol synthesis in the liver

Bile supersaturated with cholesterol

Bile stone

CHOLELITHIASIS

Female

Hemolysis

Hemoglobin

Bilirubin

CA bilirubinate/ Calcified bilirubin

Gallstones

Irritation of the gall bladder (inflammation) CHOLECYSTITIS

> Biliary colic> N&V> Murphy’s sign> Jaundice

>RUQ pain that may radiate to midsternal/ right shoulder>N&V>Fever>Leukocytosis

LEGEND:Predisposing factors

Pigmented gallstonesCholesterol gallstones

S/S of CholelithiasisS/S of Cholecystitis

Bile flow obstrnBILE STASIS

Cause: UNKNOWN PREDISPOSING FACTORS:

(5 F’s)

Forty

Fertile: (multigravida; use

of OCP)

47

2 children

CHOLELITHIASIS

Female

Hemolysis

Hemoglobin

Bilirubin

CA bilirubinate/ Calcified bilirubin

Gallstones

Irritation of the gall bladder (inflammation)

CHOLECYSTITIS

> Biliary colic> N&V

>RUQ pain that may radiate to midsternal/ right shoulder>N&V>Leukocytosis - 39

LEGEND:Predisposing factors

Pigmented gallstonesCholesterol gallstones

S/S of CholelithiasisS/S of Cholecystitis

Bile obstruction BILE STASIS

RBC:3.29 (4.2-5.4 X10 /L)Slightly anisocytosis and slightly poikilocytosis

Hgb: 97 (117-157 g/L)

Direct Bilirubin: 9.48umol/LIndirect BIlirubin:18.51umol/L

SGPT: 168 (5-40 U/L)SGOT: 233 (0-35 U/L)

LABORATORY AND

DIAGNOSIS

Date Lab/Dx Diagnostic Use Px Result Normal Values Signifi-cance05-15-2010 FBS 8.60 3.9-6.05 mmol/L Transient hypergly-

cemiaCholes-terol CVA

Cholesterol bile stone2.62 3.64-6.50 Hypocholes-

terolemia (CVA)SGPT Liver Fxn 168 5-40 U/L Biliary stasisSGOT Liver Fxn 233 0-35 U/L Biliary stasisDirect Bilirubin Measure bilirubin from hgb

breakdown9.48 0-8.55 umol/L Biliary stasis

Indirect Bilirubin Measures bilirubin that has been processed by the liver

18.51 8.55-17.1 umol/L Biliary stasis

Amylase R/O acute inflammation of the pancreas

31 30-110 U/L

Na Check for electrolyte imbalance

120 135-148 mmol/L Hyponatre-mia

K Check for electrolyte imbalance

2.4 3.5-5.3 mmol/L Hypokale-mia

F/A R/O other abdominal diseases that causes abdominal pain like rotavirus, amoebiasis etc.

Color: Greenish brownMicroscopic reading: NOPS

Brown (diet dependent)

Bile leakage into the feces

U/A To screen for metabolic and kidney disorders and for urinary tract infections

Color: d. yellowCHON: tracePus: 3-5RBC: 1-2Hyaline cast:5-7/lpfFine granular cast:1-2/lpf

Straw/amberNegative0-1/hpf0-1/hpf0/lpf0/lpf

Stressed kidney

http://www.labtestsonline.org/understanding/conditions/kidney.html

http://www.labtestsonline.org/understanding/conditions/uti.html

Date Lab/Dx Diagnostic Use Px Result Normal Values Signifi-cance

5-15-2010 CBC Act as baseline diagnosis; broad screening test to check for disorders such as anemia, infection and other disorders

Hgb: 97Hct: .27RBC: 3.29Remarks: Slghlty anisocytosis, slighltly poikilocytosisWBC: 39Neu: 0.95Platelet: 440

117-157 g/L.37-.47 %3.80-5.20x10/L4.5-11 x 10/L.40-.70 %150-400x 10/L

ANEMIAINFECTIONBacteria

5-16-2010 CBC Hgb:90Hct:.26RBC: 3.27WBC:25Neu:0.93

5-17-2010 CBC Hgb: 91Hct:.28RBC:3.31WBC: 22Neu: 0.93

1hr post BT 1u PRBC250 cc10-04-1600

5-18-2010 CBC Hgb: 93Hct:.27RBC:3.39WBC: 22.4Neu: .87

1hr post BT 1u PRBC250 cc09-25-1962

5-19-2010 CBC Hgb: 113Hct:..33RBC:4.06WBC: 21.3Neu: .88

Date Lab/Dx Diagnostic Use Impression Significance5-15-2010 Portable CXR (AP

view)CP clearnce Probable Cardiomegaly CVA

Abdominal UTZ Check for bowel obstruction

Mild pelvocaliec-tasis/ R kidney Suspected stones

Gall bladder and liver UTZ

Measure the size of the organ and suggestive diagnosis

Minimal fluid collection right sub-hepatic area

Cholecystitis with cholelithiasis and bile sludge formation

Pericholecystic collection Borderline common bile duct size Suggestive of diffuse

parenchymal liver diease

Inflammation of the gall bladder with stone formation

Gynecology and fertility UTZ

Check for reproductive system abnormality

Anteverted sized uteru with homogenous myometrium

Secretory phase-like endometrium N ovaries Encysted fluid (+) fluid in the cul-de-sac Remarks: anterior to uterus is an

irregular fluid collection with thin septations measuring 37x26x34 mm.

Suggestive of encysted fluid

Date Lab/Dx Diagnostic Use Px Result Normal Values Signifi-cance

5-15-2010 Potassium Electrolyes Imbalnce; CVA

2.4 3.5-5.3 mmol/L Hypokalemia- vomiting

5-16-2010 K 2.8 1 hr after K correctionPNSS 85cc + 30 meqs KCl 3hrs x 1 cycle

5-17-2010 K 3.1



5-20-2010 K 3.9

PRE AND POST OPERATIVE

PLAN

• On admission to the hospital, an informed consent form acknowledging that the patient understands the procedure, the risks, and that they will be receiving anesthesia and possibly other medications must be signed.

• IV fluid to replace fluid electrolyte losses due to vomiting.

• DBCT exercises to prevent respiratory complications.

Pre – Operative Care

Post – Operative Care

• Position low /semi – fowler’s position to promote lung expansion.

• NGT to prevent gastric distention.• DBCT exercises to avoid atelectasis.• Low fat diet for 2 – 3 months.• Ambulation after 24 hours post –

operatively.

Surgical Procedure

Laparoscopic Cholecystectomy

Laparoscopic cholecystectomy is performed through a small incision or puncture made through the abdominal wall at the umbilicus. The fiberoptic scope is inserted through the small umbilical incision. Several additional punctures or incisions are made in the abdominal wall to introduce other surgical instruments into the operative field. The surgeon visualizes the biliary system through a laparoscope, the gallbladder is then removed from the abdominal cavity after bile and small stones are aspirated.

DRUG STUDY

DRUG INDICATION MECHANISM OF ACTION

CONTRAINDICATION ADVERSE EFFECT NURSING RESPONSIBILITIES

Generic: clonidine hydrochlorideBrand: CatapresClassification:antihypertensiveDosage:75 pcg/ tabRoute: SLFrequency: PRN for BP 160/90 mmHg

Management of mild to moderate

hypertension.

Stimulates alpha-adrenergic receptor in the CNS; w/c results in decreased sympathetic

outflow inhibiting cardioacceleration and

vasoconstriction centers. Decreased

blood pressure.

Contraindicated w/ hypersensitivity to clonidine or any adhensive layer

components of the transdermal system.

bradycardia, hypotension,

palpitation, drowsiness, dry mouth

Monitor blood pressure and pulse frequently during initial dosage adjustment and periodically throughout therapy.Instruct patient to take clonidine @ the same time each day, even if feeling well.Inform patient that clonidine may cause drowsiness; w/c usually diminishes w/ continued use. If dry mouth occurs, advise patient to rinse mouth frequently.Instruct patient and family on proper teaching for blood pressure monitoring at least weekly.

5-15-2010


CONTRAINDICATION ADVERSE EFFECT

NURSING RESPONSIBILITIES

Generic: metronidazoleBrand: FlagylClassification: antibacterialantiprotozoalantibioticDosage: 5 mg/ml infused over 30-60 mins.Route: IVFrequency: q8

Acute infection w/ susceptible anaerobic bacteria.Acute intestinal amebiasis.Perioperative, intraoperative, postoperative prophylaxis for patients undergoing colorectal surgery.

Inhibits DNA synthesis in specific anaerobes causing cell death.amebicidal action.

Contraindicated with hypersensitivity to

metronidazole.

seizures, dizziness, headache,

abdominal pain, darkening of the urine, nausea, vomiting and metallic taste

Monitor neurologic status during and after IV infusion. Inform physician if seizure, dizziness or headache occur.Inform the patient that his urine will be darker than usual.Take full course of drug therapy; take the drug with food or milk if GI upset occurs.Instruct the patient to take medication exactly as directed evenly spaced times between dose, even if feeling better. Do not skip doses or doble up missed doses. If a dose is missed, take as soon as remembered if not almost time for next dose.Inform patient that medication may cause an unpleasant metallic taste.

5-16-2010




Generic: ciprofloxacinBrand: CiproClassification: anti infectivesDosage: 40 mg.Route: IVFrequency: qid

Treatment of the following bacterial infections: Urinary tract infections including cystitis,gynecologic infections, respiratory tract infections.

Inhibit bacterial DNA synthesis by inhibiting DNA gyrase.Therapeutic effects: Death of susceptible bacteria.

Hypersensitivity. Cross-sensitivity among agents within class may occur .Use cautiously in: Known or suspected CNS disorder; Renal Impairment.

dizziness, headache,

drowsiness, diarrhea, nausea, vomiting,

abdominal pain

May cause dizziness & drowsiness. Caution patient to avoid driving or other activities requiring other activities requiring alertness until response to medication is known.Assess for infection prior to & during theraphy.Instruct patient to notify health care profesiional if fever & diarrhea develop, especially if stool contains blood, pus, or mucus. Advise patient not to treat diarrhea without consulting health care professional.If gastric irritation occurs, ciprofloxacin may be administered with meals.

5-16-2010


CONTRAINDICATION ADVERSE REACTION NURSING RESPONSIBILITY

Generic: diphenhydramineBrand: Hizon diphenhydramine injectionClassification: antihistamine/ sedative hypnoticDose: 25 mgRoute: IMFrequency: 1 dose

Relief of allergic symptoms caused by histamine releaseMild sedation

Competitively blocks the effects of

histamine at H1-receptor sites; antipruritic and sedative effect.

HypersensitivityAcute attacks of asthmalactation

drowsiness, dizziness, blurred vision and dry

mouth

Monitor patient response; and arrange for adjustment of dosage to lowest possible effective dose.Inform the patient before administering that the medication may cause drowsiness, dizziness and blurred vision.Report DOB, hallucination, unusual bleeding and irregular heartbeat.

5-20-2010

DRUGS:Indication

Action: Contra-Indication Adverse Reactions

Nursing responsibilities

Generic: Nalbuphine Dose: 5mgFrequency:q6Brand:NubainRoute: IVClassification: Opioid Analgesic

Moderate to severe pain. Also provide: sedetion before surgery, supplement to balance anesthesia.

Binds to opiaite receptor in the CNS. Alter the perception of or/ and response to painful stimuli while producing generalized CNS depression.

HypersensitivityPatient who are physically on opioids and have not been detoxified.

Dizziness, headache , dry mouth, N/V, clammy feeling.

Assess bp, pr, rr bef. And periodically during administration.

(<10min assess for level of sedation) Instruct pt. on how and when to ask for pain

medication. May cause dizziness. Advice pt. to call for

assistance when ambulating until response to the med is known.

Advice pt. that freq. mouth rinses, good oral hygiene, can decrease dry mouth.

DATE: MAY 20, 2010




Generic: omeprazoleBrand: omepronClassification: anti ulcer agentDosage: 40 mgRoute: POFrequency: OD

GERD/ maintenance of healing in erosive esophagitis.Short term treatment of active benign gastric ulcers.

Binds to an enzyme on gastric parietal cells in the presence of acidic gastric pH, in preventing the lumen.

Contraindicated with hypersensitivity to

omeprazole.

drowsiness, headache,

abdominal pain,diarrhea,

PO: Administer doses before meals, preferable in the morningMay cause occasional drowsiness. Caution patient to avoid driving or other activities requiring alertness until response to medication is known.Assess patient routinely for epigastric/ abdominal pain & frank or occult blood in the stool,emesis.Advise patient to avoid alcohol, products containg aspirin/ NSAIDS & foods that may cause an increase in GI irritation.Advise patient to report onset of black, tarry stools, diarrhea; abdominal pain or persistent headache to health care professional promptly.

5-20-2010


CONTRAINDICATION ADVERSE REACTION

NURSING RESPONSIBILITY

Generic: parecoxibBrand: DynastatClassification: NSAIDDose: 40 mgRoute: IVFrequency: 1 dose

Short term treatment of acute pain and

post-op pain

Inhibits prostaglandin synthesis by selecting

inhibiting cyclo-oxygenase-2.

Relieves pain and inflammatory

Contraindicated w/ allergies to celecoxib, NSAIDs and aspirinSignificant renal impairment

headache, dizziness, fatigue, flatulence,

abdominal pain

Asses BP, RR, PR before and periodically during administration.Inform the patient that he will experience adverse effect such as dizziness and drowsiness.Advise patient that frequent mouth rinse, good oral hygiene and candy can decrease dry mouth.

5-21-2010

NURSING CARE PLAN

LEGEND:ProfileSubjectiveObjectiveDiagnosisInterventionRationaleEvaluation

Patient A41 F

Dr. Romcilla

“ Ang sakit ng tiyan ko” as verbalized by the patient

After 8 hours of nursing intervention the client will be able to demonstrate use of relaxation skills and diversional activities as indicated, for individual situation

Guarding Behavior protective gestures and positioning to avoid pain

Facial Grimace

RUQ PainPain Scale: 5/10BP: 140/90PR:90

Accepted client’s description of pain.

Encouraged use of relaxation techniques. (eg. Music)

Administer analgesics as indicated, to maximum dosage, as needed

After 8 hours of nursing intervention the client will be able to demonstrate use of relaxation skills and diversional activities as indicated, for individual situation

Provide comfort measures touch, repositioning, use of hot and cold packs, quiet environment

To distract attention and reduce tension.

Promotes non – pharmacological pain mngt.

LEGEND:

ProfileSubjectiveObjectiveDiagnosisInterventionRationaleEvaluation

Pre - Operative Acute pain related to inflammation of the gallbladder

DISCHARGE PLANNING

• M – Medication (geltasine, omeprazole, ciprofloxacin, catapres, metronidazole)

• E – Exercise

• T – Treatment

• H – Health Teaching

• O – Outpatient

• D – Diet (what and what not to eat)

• S – Spiritual

cholelithiasis GRAND CASE PRES

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