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Transcript of Cholelithiasis Sample
Holy Angel University Angeles City College of Nursing
A case study on
CHOLELITHIASISSubmitted by Demando, Rovina Ana Dizon, Noeliza Dizon, Shara Joyce Dizon, Stephen Zyrus Gambaloza, Jerisa Gatpolintan, John Arzen Submitted to Mr. Ryan P. Manabat, RNI. I N T R O D U C T I O N
Description of the Disease Cholelithiasis is the presence of one or more calculi (gallstones) in the gallbladder. In developed countries, about 10% of adults and 20% of people > 65 yr have gallstones. Gallstones tend to be asymptomatic. The most common symptom is biliary colic; gallstones do not cause dyspepsia or fatty food intolerance. More serious complications include cholecystitis; biliary tract obstruction (from stones in the bile ducts or choledocholithiasis), sometimes with infection (cholangitis); and gallstone pancreatitis. Diagnosis is usually by ultrasonography. Gallstones are made of cholesterol, calcium bilirubinate, or a mixture of cholesterol and bilirubin pigment. They arise during periods of sluggishness in the gallbladder due to pregnancy, hormonal contraceptives, diabetes mellitus, Chron's disease, cirrhosis of the liver, and pancreatitis, obesity and rapid weight loss. Their development is insidious, and they may remain asymptomatic for decades. Migration of gallstones may lead to occlusion of the biliary and pancreatic ducts, causing pain (biliary colic) and producing acute complications, such as acute cholecystitis, ascending cholangitis, or acute pancreatitis.
Cholelithiasis is a common health problem, affecting about 1 out of every 1,000 people and is the fifth leading cause of hospitalization among adults and accounts for 90% of all gallbladder and duct diseases. The prognosis is usually good with treatment unless infection occurs, in which case the prognosis depends on its severity and response to antibiotics. Prevalence of cholelithiasis is affected by many factors including ethnicity, gender, comorbidities, and genetics. In the United States, about 20 million people (10-20% of adults) have gallstones. Every year 1-3% of people develop gallstones and about 1-3% of people become symptomatic. In an Italian study, 20% of women had stones, and 14% of men had stones. In a Danish study, gallstone prevalence in persons aged 30 years was 1.8% for men and 4.8% for women; gallstone prevalence in persons aged 60 years was 12.9% for men and 22.4% for women. Excision of the gallbladder (cholecystectomy) to cure gallstone disease is among the most frequently performed abdominal surgical procedures.
Objectives The students chose this case study primarily because of interest to gain further understanding regarding the disease condition. This will also help in providing current and accurate information concerning the latest approaches for the treatment of cholelithiasis and its complications. Moreover, it will initiate participation of client and family members in the therapy for the disease. This will also help in ensuring that the client understand treatment options and provide clarification when necessary. The student nurses have the following objectives in this case study: Recognize the disease condition; understand risk factors, pathophysiology, signs and symptoms, and its underlying complications. Gather complete data upon assessment of the patient that will help on the accomplishment of the case study. Formulate nursing diagnosis related to the stress of the illness. Identify the nursing responsibilities for the patient with cholelithiasis. Understand the pharmacology of treating cholelithiasis.
II. N U R S I N G 1. Personal History Demographic Data
This is the case of Mrs. Tweety, 30 years old, female, Filipino. She was born on January 11, 1978 in Quezon City. She is presently residing at 1608 Tamarind St., Clarkview, Brgy. Malabanias, Angeles City. She is the fourth child of Mr. and Mrs Pooh. . She is now married to Mr. Bugs Bunny and is a mother to two children. She was admitted at Angeles Medical Center on August 4, 2008 at 11:48 pm. Socio-Economic and Cultural Factors Ms. Tweety is currently a program supervisor at Sutherland Global Services. Her hospitalization expenses are covered by her insurance company and her needs are adequately compensated as she and her husband are both working. She graduated a four year course in Marketing Management from Angeles University Foundation. She is born a Roman Catholic. She is considered a modern woman; she works and at the same time she is a mother to two children. Mostly for light pains or discomforts she takes pain relievers and consults a clinic if she and/or her other family members experience some health problems. As a working mother and depending on her schedule at work she is barely the one cooking food and if ever she has the time she cooks foods which are easily done for example fried foods. And when at work she eats any food that is available at the place or sometimes passes by fast foods to order.
2. Family-Health Illness History Grand Father Grand Mother Grand Father Grand Mother
A1 A2 A3 tweety
Legend: Blue = male Pink = female = AMI
= DM =HPN
This Diagram shows the family health illness history of the patient. Both grand mother and grand father in her father's side died of old age. On her mother's side her grand father died of old age and her grandmother died due to myocardial Infarction. His father exhibited good health while her mother is hypertensive. Her other siblings also did not manifest any hereditary or existing disease. In the family she was the only person who manifested cholecystolithiasis. The diseases which are present on her mother's side of the family has no relation to her condition, but the Diabetis Mellitus of her grand father may or may not be related to her having Cholecystolithiasis. 2. History of Past Illness She acquired chicken pox and measles when she was young. Mrs. Tweety was hospitalized before for two times already. Those include both her delivery to her two children. But aside from that she was never brought to hospital for conditions which are related to her condition now. 3. History of Present Illness During the past 7 months (starting January) the patients has been experiencing pain on her right upper side part of the abdomen which she ignored. And she verbalized that it was a tolerable pain and when she sleeps the pain is alleviated and due to her work she did not had a check up or medical examinations done. Two months(June 2008) before the hospitalization, she had experienced an intense pain but instead of going to the hospital for check up she just took pain relievers. She had experienced nausea and vomiting. Two days prior to admission the patient again experienced intense pain while at work accompanied by
fever (august 4, 2008) and by 11 pm of August 4(Monday) the patient was admitted at Angeles Medical Center.III. P H Y S I C A L A S S E S S M E N T (I P P A C E P H A L O C A U D A L ) August 4, 2008 (upon admission, based on the patient's chart) Patient Is conscious, coherent but in distress Vital signs: BP- 90/60 T- 38 P-80 R-18 Pale palpebral conjunctiva Normal abdominal Bowel sound, soft (+) epigastric and right upper quadrant tenderness No cyanosis, no edema, (+) jaundice
August 5, 2008(patient's chart) Patient is conscious and coherent with IVF of 1L D5LRS regulated at 30 gtts/min Vital signs: BP-100/70 T-37.1 P-87 R-21 August 6, 2008 (Nurse- Patient Interaction) Patient is awake, conscious and coherent but appears weak
with ongoing IVF of 1 L D5LRS regulated at 30 gtts/min Vital signs: BP-110/80 T-36.7 P-78 R-19
REVIEW OF SYSTEMS HEAD Hair and Scalp: Client has evenly distributed short, thick, coarse, no infestation. Skin and Face: Client has a rounded, smoothly contoured skull. Skull has uniform consistency. No nodules, masses or depression palpated. Facial features are symmetric. Eye and Vision: Clients eyebrow has evenly distributed hair. Eyebrows are symmetrically aligned and with equal movement. Eyelashes are evenly distributed and curled slightly outward. Skin of the eyelids is intact and without discharge. Lids close symmetrically, bilaterally. Sclera appears yellowish. Corneas are transparent, shiny and smooth with details of iris visible. Pupils are black, equal in size, round and have smooth border with round iris. They constrict when illuminated with a penlight. They constrict when looking at near objects and they dilate when looking at far objects. Ears: Auricles are symmetrical, aligned with the outer cantus of the eye and have the same color as the facial skin. They are mobile, firm, not tender, and recoil after being pulled or folded. No cerumen noted. Client can hear voice tones.
Nose and Sinuses: Nose is symmetric and straight. There is no discharge, flaring, lesions and tenderness. Mouth: Lips is pale, soft, moist, smooth and symmetrical in contour. Client is able to purse lips. There is the presence of dental plaque and caries. Tongue is at the center, pink, moist slightly rough with thin whitish coating. It moves freely without tenderness. NECK Neck Muscles: Muscles are equal in size and head centered. Head movements are coordinated and smooth with no discomfort. Lymph Nodes: They are not palpable. UPPER EXTREMITIES Skin and Nails: Skin is yellowish in color and moist in skin folds with no scars of lesions noted. When pinched, skin goes back to previous state. Nail plates are convex, colorless and smooth in texture. No dirt is accumulated under the nails. Muscle Strength and Tone: Muscles are equal in size on both sides of the body without tremors. They are firm with coordinated movements. Bones and Joints: There are no deformities, tenderness or swelling noted. CHEST Heart: Client has regular heartbeat pattern (strong).
ABDOMEN Skin: Skin is yellowish color and the