Case Study Calculous Cholecystitis

Bulacan State University COLLEGE OF NURSING City of Malolos, Bulacan

A Case Study of

A 22 YEAR OLD MALE, DIAGNOSED WITH CALCULOUS CHOLECYSTITIS In Partial Fulfillment of the Requirements in RLE (103-A) at the

Bulacan Medical Center (Medical Ward) BSN 3-E (GROUP 2) Castro, Mary Joyce De Guzman, Liberty C. Fabian, Shiela Marie Ilag, Caress S. Miranda, Marife Roque, Lyra Cariza

Dela Cruz, Carllae Lucille Delloro, Ephraim GABRIEL , ANER M. (Leader) Macaranas, Carmona Jane Pangan, Mary Grace S. Vidon, Jill Irish Kae

September 24, 2010 1

TABLE OF CONTENTS

I.

INTORDUCTION a. Reason why ……………………………………………………………………………………. b. Objectives ……………………………………………………………………………………..

1 3

NURSING HEALTH HISTORY a. Demographic Data ……………………………………………………………………………. b. History of illness (present, fast and family illness ) ………………………………………… c. Genogram ……………………………………………………………………………………... d. Functional Health Pattern (Prior and during hospitalization) ……………………………. e. Growth and Development …………………………………………………………………….

5 6 7 8-14 15-16

III.

ANATOMY AND PHYSIOLOGY ……………………………………………………………………..

17-21

IV.

PATHOPHYSIOLOGY a. Schematic Diagram …………………………………………………………………………… b. Definition of the disease ………………………………………………………………………. c. Signs and symptoms ………………………………………………………………………….. d. Precipitating factors ………………………………………………………………………….. e. Predisposing factors ………………………………………………………………………….. f. Review of system ………………………………………………………………………………

22-24 25 26 27-28 29 30

II.

2

V. VI.

PHYSICAL ASSESSMENT ……………………………………………………………………………. LABORATORY AND DIAGNOSTIC PROCEDURES ………………………………………………

VII. PATIENT AND HIS CARE a. Medical Management …………………………………………………………………………. b. Drugs ………………………………………………………………………………………….. c. Diet ……………………………………………………………………………………………… d. Exercise ………………………………………………………………………………………….

31-43 44-49

50-51 52-57 58-59 60

VIII. SURGICAL MANAGEMENT a. Nursing Responsibilities (postoperative) and Client’s Response…………………………………………………………………………………………… 61 IX.

NURSING CARE PLAN………………………………………………………………………………….

62-69

X.

HEALTH TEACHING …………………………………………………………………………………...

70

XI.

DISCHARGE PLANNING ………………………………………………………………………………

71-72

XII. CONCLUSION ……………………………………………………………………………………………

73

XIII. BIBLIOGRAPHY …………………………………………………………………………………………

74-75

3

I.

INTRODUCTION

This is a case study of a 22 year old male nursing graduate of Our Lady of Fatima University who was rushed at Bulacan Medical Center complaining of severe pain on the right upper quadrant of the abdomen. He was admitted last August 01, 2010 at 6:45 a.m. The patient was initially diagnosed with abdominal mass to confirm calculous cholecystitis after performing laboratory and diagnostic tests, because the results shows that the patient is suffering from an inflamed gallbladder due to calculi or stones. The physician then decided to perform an emergency procedure an open cholecystectomy at 11:15 am. Calculous cholecystitis is caused by obstruction of stone in the bile duct leading to inflammation of the gallbladder. The gallbladder is an organ which aids in the digestive process. Its function is to store and concentrate bile. The bile in turn emulsifies fats and neutralizes acids in partly digested food. Despite its importance in the digestion of fat, many people are unaware of their gallbladder. Fortunately enough, the gallbladder is an organ that people can live without. Perhaps, this fact contributes to the laxity of the majority. The gallbladder tends to be taken for granted or ignored of the proper care and conditioning. Lifestyle together with heredity, sex, race and age are just some factors that leave a room for gallbladder complications to occur . The most common cause of cholecystitis is gallstones. The bile becomes concentrated in the gallbladder. This later causes irritation and is probably the leading cause of inflammation. Cholecystitis affects women more often than men and is more likely to occur after age 60. People who have a history of gallstones are at increased risk for cholecystitis. In the international level, cholecystitis has an increased prevalence among people of Scandinavian descent, Pima Indians, and Hispanic populations, whereas cholelithiasis is less common among individuals from sub-Saharan Africa and Asia. It affects 20.5 million people (1988-1994) with a mortality record of 1,077 deaths in 2002. Hospitalizations total up to 636,000 in the same year and over 500,000 have undergone cholecystectomies. In the Philippines alone, 24,913 people are affected by the disease and 139 number of reported deaths last 2007. (http://digestive.niddk.nih.gov/statistics) Calculous cholecystitis is the cause of more than 90% of cases of acute cholecystitis. In calculous cholecystitis, a gallbladder stone obstructs bile outflow. Bile remaining in the gallbladder initiates a chemical reaction; autolysis and edema occur, and the blood vessels in the gallbladder are compressed, compromising its

4

vascular supply. Gangrene of the gallbladder with perforation may result. Bacteria play a minor role in acute cholecystitis; however, secondary infection of bile with Escherichia coli, klebsiella species, or streptococcus is identified with cultures obtained during surgery in a small percentage of surgical treated patients. SIGNIFICANCE OF THE STUDY We, the student nurses have chosen this case as we see it fit for the peri-operative concept as the patient, who is a nursing graduate had to undergone open cholecystectomy. Moreover, despite the cholecystitis’ low incidence, we would like to give credit and to know more of the nature and function of the gallbladder. Much often this small organ is not given importance. Thus we are in a pursuit for knowledge to be able to impart it to others. Furthermore, this case is quite interesting since it does not always affect only females and elderly. It can affect everyone. It can be alarming since many people are confused and unaware of the symptoms presented. As teen-agers living in a fast-phased world and governed by schedules, just like NJE a nursing graduate, we too are predisposed to lifestyle modification – especially diet and food preferences which can contribute to the disease. With this study, we hope to apply our learning in taking care not only of our patients but also of ourselves. As nursing students and future nurses, we would want to understand and appreciate more on what is happening to a patient with calculous cholecystitis. Consequently, we are interested on what will be the necessary management that will be given. Through this, we are hoping that we will be able to find the right plan of care and sound interventions, not forgetting the patient’s rights as a person. All in all, these will help us to become efficient nurses and better persons later on.

5

OBJECTIVES General Objective: Our first main goal is to gain knowledge through the completion of the case study and to impart this learning to those directly and indirectly involve with the completion of this case. In psychomotor aspect, our goal is to apply all what we have learned during the process of completing this case study to improve nursing care that will meet NJE’s need for the improvement of his general welfare. With the knowledge gained and through the application of this knowledge, another goal is that we will be able to empathize with the current situation of the patient and to gain some values like the value of patience and calmness which is important for us to have in order to become better nurses in the future.

Specific Objectives: 

To determine functional health status of client with cholecystitis.



Integrate knowledge of nursing care in post cholecystectomy client to formulate a quality nursing care plan.



Implement appropriate nursing intervention to satisfy the patient’s needs.



Prepare clients for understanding the purpose and significance of cholecystectomy.

6

Client-centered: 

Conduct a thorough physical assessment and to interpret the assessment in order to give the care the patient need.



To identify intervention that appropriate for patient’s needs.



Integrate psychosocial and spiritual consideration into plan of care for client with gallbladder disorder.



Research and understand the disease process of the patient’s illness and also the possible causes and the symptoms the patient experience that may suggest the current condition of the patient.

Student-centered: 

To use knowledge in assessing and understanding the manifestation of gallbladder disease.



To determine the priority nursing intervention and diagnosis that we can contribute by using our knowledge that we have learned in clinical setting.



To implement quality nursing care that suited for client undergone cholecystectomy



Use critical thinking to evaluate the effectiveness of the nursing intervention given in meeting the needs of the patient.

7

II. Nursing Health History PATIENT’S PROFILE Biographic Data Name: NJE Address: 916 Ibayo, Sto Rosario, Paombong, Bulacan Birthday: December 04, 1987 Birthplace: Paombong, Bulacan Age: 22 years old Sex: Male Status: Single Occupation: None Nationality: Filipino Educational attainment: College Graduate (BS Nursing-OLFU) Religious Orientation: Roman Catholic Health Care Financing and usual source of Medical Care: Philhealth (beneficiary) Date of Admission: August 01, 2010 at 6:45 a.m. Date of operation: August 01, 2010 11:15 am. Date discharge: August 05, 2010 Chief Complaint: Abdominal pain on the right upper quadrant Initial Diagnosis: Cholelithiasis Final Diagnosis: Calculous Cholecystitis 8

History of Present Illness Three months prior to admission, (May 03, 2010), NJE experienced sudden onset of pain in the right upper quadrant of the abdomen. The pain become mild to moderate and sometimes does not relieve by position. The patient noticed loss of weight, pallor, weak and easy fatigability. The patient was worried about his condition so he seeks medical attention to a private physician. The patient undergone abdominal ultrasound and the results revealed presence of gallstones. A day prior to admission (July 31, 2010 10:40 pm), patient experienced severe epigastric pain radiating to the right upper quadrant of the abdomen (pain scale of 7/10), and associated bloatedness with nausea and vomiting. There is presence of facial grimace and guarding behavior. A decrease in appetite was also experienced on that day. According to the patient, he noticed a yellowish discoloration of his skin and a clay-colored stool. By August 01, he was rushed at Bulacan Medical Center due to intolerable pain (pain scale of 9/10) accompanied by fever. Diagnostic exams were done such as Abdominal Ultrasound, Complete Blood Count, Platelet Count, Prothrombin Time and Partial Thromboplastin Time. He received IVF of D5LRS 1L regulated @ 30 gtts/min. Ultrasound revealed Calculous Cholecystitis, so the patient was advised for admission and operation. Past history of illness: NJE experienced common illness such as colds, cough, chicken fox and fever during his childhood. However, he could not recall at what age he got the disease. Her mother used “cilantro” for the management of his chicken pox. He had no food and drug allergy and he does not experience any injuries and accidents in the past. He received oral polio vaccine (OPV), diphtheria, pertusis and tetanus (DPT) for his immunizations. Family history of illness: The grandparents of our patient are both deceased and he can’t recall the cause and the age of death. His father died on 1998 due to kidney disease and his mother was 41 yrs old and still alive. He has three siblings, he was the eldest, second to him is 19 years old, the third was 15 years old and the youngest is a 12 yr. old male. No one in his family has the same condition with him.

9

FATHER’S SIDE

GENOGRAM:

55 y/o TME

22 y/o NJE

45 y/o RME

16 y/o KJE

44 y/o PME

MOTHER’S DAY

41 y/o YMJ

13 y/o CJE

59 y/o PMJ

55 y/o CMJ

55 y/o SMJ

19 y/o HJE

LEGEND: MALE

CALCULOUS CHOLECYSTITIS

FEMALE

DECEASED

UNKNOWN CAUSE OF DEATH

PATIENT

KIDNEY DSE

UNKOWN AGE

10

Functional Health Pattern

Prior Hospitalization

During Hospitalization

Health perception

He told us that the most important factors for a healthy life is just eating According to him, during his hospitalization, he feels weak but he is

and Health

nutritious foods, having a balance diet and having enough hours of sleep. eager to get well so, he tries to follow the doctor’s order for fast

management

He does not smoke but drinks alcohol frequently (2 bottles. of BAR every recovery. He takes his medicine on time. The following medicines Saturday. He does not believe in faith healer. When he is in pain he will are administered to the client as part of his regimen. take OTC drugs, when we asked him what drugs is that he told us it was mefenamic acid 500mg.

   

Metronidazole- 500 mg TIV q8 Ranitidine – 50 mg TIV q8 Celecoxib – 200 mg OD Cefuroxime -750 mg TIV q8 IV Fluids



D5LRS 1,000 mL regulated @ 30-31 gtts/min.

Nutritional and

He likes to eat fried foods and he doesn’t have any eating difficulty. During his first day of hospitalization (August 01, 2010) he was

metabolic pattern

Whenever the patient is suffering abdominal pain, his appetite decreases. ordered NPO in preparation for operation and change it to General He doesn’t take any vitamin supplements. According to him when he has liquid diet on August 02, 2010 post operation and on August 03, wound it heals well. He doesn’t have any dentures.

2010 at 12:15pm he was instructed on a DAT diet with fat restriction to provide nutrition after the operation..

11

Date

July 29, 2010

Breakfast

Lunch

Dinner Date

Breakfast

Lunch

Dinner

1/2 cup of rice

1 cup of rice

1/2 cup of rice

1 fried egg

1 piece fried

2 pcs of fried

220 ml of

pork chop

chicken

water(1 glass)

440 ml of

220 ml of

August 01,

Nothing

water

coffee with

2010

Orem

Orem

Orem

AM SNACK:

AFTERNOON SNACK:

EVENING SNACK:

None

None

milk(1 cup) AFTERNOON

AM SNACK: 1 order of Jollihotdog with 300 mL of coke.

Per Nothing

Per Nothing

SNACK:

240 ml of soft EVENING drink(RC cola) SNACK: 21

grams

of

Adobo Kita Cheese biscuit (2 Peanut (Sugo) Garlic

packs)

Per

None

August 02,

30 ml of

30 ml of

30 ml of

2010

water

water

water

AM SNACK:

AFTERNOON

EVENING

SNACK:

None None

SNACK: None

12

July 30, 2010

1 cup of rice 3 pieces of fried hotdog 340 ml of water (1 ½ glasses)

1 cup of rice 2 pcs fried chicken 220 ml of water (1 glass) AFTERNOON

AM SNACK: SNACK: 350 ml Coke 1 pc hamburger 1 cup coffee w/ cheese 1 sliced of chicken sandwich

1 cup of rice 2 pieces of 2x4 inches of fried beef tapa 440 ml of water (2 glasses) EVENING SNACK: 1 pack (3 pcs) of Sky flakes 150 ml of water

August 03,

Soft diet with

3 tbsp of

2010

SAP

Lugaw

3 tbsp of

3o ml of

Lugaw

water

3o ml of

AFTERNOON

water AM SNACK:

July 31, 2010

1 cup of rice 1 slice pritong bangus 220 ml of water(1glass) AM SNACK: 1 cup coffee w/

1 ½ cups of rice 1 pc fired pork chop

EVENING

SNACK:

1 piece Boiled egg 30 ml of water EVENING SNACK:

None None

None

SNACK: NONE

440 ml of water(2 glasses) AFTERNOON SNACK:

milk 1 pc hamburger w/cheese

13

Elimination Pattern He doesn’t have excessive perspiration or body odor.

He doesn’t have excessive perspiration or body odor. August 01-03, 2010

Color

Frequency

Consistency

Odor

Once a day

Formed

Foul

6X a day

Clear

Aromatic

Difficulty

Color

Frequency Consistency

Odor

Difficulty

Aromatic

None

ClayJuly 28- 31, 2010

Stool

colored/ gray

None

Stool

None

Amber/s Urine

traw

None

Urine

Amber 4x a day / straw

(August 02-

vomit

Whitish

Once(July

(+) food

“sour

With

31, 2010)

fragments

smell”

difficulty

clear

03,2010)

vomit

None

14

Activity-Exercise

He has sufficient energy to finish his daily activities. Walking for 15 During his hospitalization he is often lying on his bed. He just listen

Pattern

minutes in the morning every day, except rainy days, is his form of to radio or chats with his relatives and some of the patient in the exercise, and he doesn’t easily get tired. When he has free time he chats ward. As of august 03, 2010. with his friends or watch television

Activity

Activity

Level

Feeding

0

Bathing

2

Bed mobility

0

Dressing

2

Grooming

0

Toileting

2

Level

Feeding

0

Bathing

0

Bed mobility

0

Dressing

0

Grooming

0

Toileting

0

Level 0 – full self care Level I-requires use of equipment Level II-requires assistance or supervision from another person Level III- requires assistance or supervision from another person or device Level IV- dependent or does not participate.

Level 0 – full self care Level I-requires use of equipment Level II-requires assistance or supervision from another person Level III- requires assistance or supervision from another person or device Level IV- dependent or does not participate

15

Sleep and rest pattern

The patient sleeps for about 7 hours and 30 minutes continuously from 11 The patient sleeps for about 4 to 5 hours at night. His sleep is p.m. – 6:30 a.m. and he does not have any difficulty falling asleep and does disrupted due to pain felt on his incision site. He takes nap 1 hour in not take any sleeping medications. He takes nap for 2 hours in the the afternoon. afternoon.

Cognitive and

He does not have problems in vision and hearing. According to NJE, he He does not have problems in vision and hearing as well as any

Perceptual Pattern

had a sharp memory. He does not have any learning difficulty.

Self perception and

According to NJE he sees himself as a friendly person. The things that can The patient sees himself as a friendly person. When we asked him

self concept

make him frustrated are when things got out of his control. Sometimes what he feels about being hospitalized he told us that he feels fine

Role and Relationship pattern

learning difficulties.

chats with his friend to lessen his frustration.

and he added that he wants to go home already.

The patient has a nuclear family according to members, matriarchal

His mother is the one who decides about financial matters in their

according to authority and neolocal according to location. He is living with family and according to him their budget is enough for his his parents. When problem arises he and the rest of the family talk to each hospitalization. other to solve it. He does not belong in any social group but he has a lot of friends in their neighborhood.

16

Sexualreproductive

According to the patient his sex life is complicated and admitted that he is

The patient sexual life is inactive.

a gay.

pattern

Coping Stress tolerance

When the patient feels tense he chats with his friends and when he has The big change in his life is when he found out that he has gallstones. problem he usually share it with his friends to ask for their opinion to solve When he has problem he usually share it with his friends and the problem and according to him it lessen his burdens.

Values belief pattern

according to him it is effective.

According to him he doesn’t get easily the things he wanted, he works hard He prays at night before sleeping to ask God for good health. for it. Religion is important to him and his family. They also go to church every Sunday and ask God for guidance and good health.

17

III.

GROWTH AND DEVELOPMENT

Theories

Stages

Justification

Resolution

Genital stage: post puberty Freud’s Stage of Psychosexual Development

During the final stage of psychosexual development, the individual develops a strong sexual interest in the opposite sex. Where in earlier stages the focus was solely on individual needs, interest in the welfare of others grows during this stage. If the other stages have been completed successfully, the individual should now be well-balanced, warm and caring. The goal of this stage is to establish a balance between the various life areas. The formal operational stage (20 to Adulthood)

The patient is in the genital stage but he does not developed sexual interest with the opposite sex rather than same sex. According to him he is not attracted with girls but he enjoys hanging out with them as friends.

The patient does not developed sexual interest with opposite sex.

Jean Piaget’s Stage of Cognitive Development

During this time, people develop the ability to think about abstract concepts. Skills such as logical thought, deductive reasoning, and systematic planning also emerge during this stage.

The client thinks rationally and logically. He is able to solve the problem with his family by communicating to them and vice versa.

Positive The patient thinks logically and rationally.

Positive

Young Adulthood (19 to 40 years) Erickson’s Stage of Psychosocial Development

Intimacy vs. Isolation Young adults need to form intimate, loving relationships with other people. Success leads to strong relationships, while failure results in loneliness and isolation.

The patient share more intimately with others. He has a strong bond with his friends and family.

The patient developed intimacy.

18

Kohlberg’s Stage of Moral Development

Fowler’s Faith development pattern

Level 3. Post conventional Morality Stage 5 - Social Contract and Individual Rights At this stage, people begin to account for the differing values, opinions and beliefs of other people. Rules of law are important for maintaining a society, but members of the society should agree upon these standards.

Individuative-Reflective Faith: (early 20 to adulthood) One begins to move beyond the group identity and adopt individual views; a "de-mythologizing" stage of faith; translates the symbols and images of one's tradition into personal concepts and ideas; beginning of post-conventional morality.

The patient understands the different roles of the society, and can distinguish what is right or wrong based on internalized rules on conscience rather than social law. He follows rules according to his willingness. According to him, he will follow all the orders of the doctor that will help to make his condition better. He also said that he does things if he knows that it is good for him and according to his willingness.

Positive The patient follows rules according to his knowledge and willingness.

The patient has a religious side of him. He Positive believed in God and go to church every Sunday. To his present illness, he believed in God and to The patient develops matured sense of faith the health care provider that he can overcome his illness.

19

IV.

ANATOMY AND PHYSIOLOGY

20

LIVER 

Largest organ in the body



Lies under the diaphragm; occupies most of the right hypochondrium and part of the epigastrium.



Weighing 1.5 kgs.

LIVER LOBES AND LOBULES 

The liver has two lobes, separated by the falciform ligament



Left lobe- about one sixth of the liver



Right lobe- about five sixth of the liver.

BILE DUCTS 

Right hepatic duct- drains bile from the right functional lobe of the liver



Left hepatic duct- drains bile from the left functional lobe of the liver



Common hepatic duct-is the duct formed by the convergence of the right hepatic duct and the left hepatic duct ; Length: Usually 6–8 cm. Approximate width: 6 mm in adults; merges with cystic duct to form common bile duct, which opens into the duodenum.



Cystic duct- is the short duct that joins the gall bladder to the common bile duct.



Common bile duct- formed by the union of the common hepatic duct and the cystic duct (from the gall bladder).

21

FUNCTIONS OF THE LIVER 

The liver stores a multitude of substances, including glucose (in the form of glycogen), vitamin A (1–2 years' supply), vitamin D (1–4 months' supply), vitamin B12, iron, and copper.



Glucose metabolism- after meal, glucose is taken up from the portal venous blood by the liver and converted into glycogen (glycogenesis), which is stored in the hepatocytes. Glycogen is converted back to glucose (glycogenolysis) and release as needed into the blood stream to maintain normal level of the blood glucose



Ammonia conversion- use of amino acid from protein for glycogenesis results in the formation of ammonia as a byproduct. Liver converts ammonia to urea.



Protein metabolism- liver synthesizes almost all of the plasmas protein including albumin, alpha and betaglobulins, blood clotting factor plasma lipoproteins.



Fat metabolism- fatty acid can be broken down for production of energy and production of ketone bodies.



Bile formation- bile is formed by the hepatocytes -

Composed of water, electrolytes such as sodium, potassium, calcium, bicarbonate, lecithin, fatty acids, cholesterol, bile salts

-

Collected and stored in the gallbladder and emptied in the intestine when needed for digestion.

BILE Bile is the greenish-yellow fluid (consisting of waste products, cholesterol, and bile salts) that is secreted by the liver cells to perform two primary functions, including the following: 

to carry away waste



to break down fats during digestion

Bile salt is the actual component which helps break down and absorb fats. Bile, which is excreted from the body in the form of feces, bile gives feces its dark brown color. 22

TRANSPORT OF BILE 1. When the liver cells secrete bile, it is collected by a system of ducts that flow from the liver through the right and left hepatic ducts. 2. These ducts ultimately drain into the common hepatic duct. 3. The common hepatic duct then joins with the cystic duct from the gallbladder to form the common bile duct, which runs from the liver to the duodenum (the first section of the small intestine). 4. However, not all bile runs directly into the duodenum. About 50 percent of the bile produced by the liver is first stored in the gallbladder, a pear-shaped organ located directly below the liver. 5. Then, when food is eaten, the gallbladder contracts and releases stored bile into the duodenum to help break down the fats.

GALLBLADDER 

The gallbladder is a small organ whose function in the body is to store bile and aid in the digestive process.



A hallow pear- shaped sac from 7- 10 cm (3-4 inches) long and 3 cm broad. It consists of a fundus, body and a neck.



Fundus - the lower free and the expanded end of the Gall bladder.



Body - the body of the gall bladder is the portion that is lying between that of the fundus and also the neck. The direction of the body is upwards, backwards, and to the left.



Neck-it is the “S” shaped curve present above the body, and extends up to the cystic duct. Direction is upwards, forwards and then takes a turn and becomes downwards and backwards. 23



It can hold 30 to 50 ml of bile.



It lies on the undersurface of the liver’s right lobe and attached there by areolar connective tissue.



The cystic duct connects the gallbladder to the common hepatic duct to form common bile duct.

FUNCTION OF THE GALLBLADDER Stores bile enters to the gallbladder by way of the hepatic and cystic duct. During this time the gallbladder concentrates bile five folds to ten folds. Then later when digestion occurs in the stomach and in the intestines, the gallbladder contracts, ejecting the concentrated bile into the duodenum. Jaundice, a yellow discoloration of the skin and the mucosa, results when obstruction of bile flow into the duodenum occurs. Bile is thereby denied its normal exit from the body in the feces. Instead, it absorbed in the blood, and an excess of bile pigments with a yellow hue enters the blood and is deposited in the tissues. The gallbladder stores bile, which is released when food containing fat enters the digestive tract, stimulating the secretion of cholecystokinin (CCK). The bile, which is produced in the liver, emulsifies fats and neutralizes acids in partly digested foods.

24

V. PATHOPHYSIOLOGY

Liver excrete relatively high proportion of cholesterol in the bile

Bile is supersaturated with cholesterol

Formation of solid Crystals

Non Modifiable Factor:

Modifiable and Precipitating Factor:

Heredity

Food preference (high cholesterol/fat)

Liver excrete conjugated bilirubin into bile

The bacteria hydrolyze conjugated bilirubin

Increase in unconjugated bilirubin

Invasion of bacteria in the gallbladder

Attraction of Leukocytes

Leukocytes hydrolyze bilirubin conjugates and fatty acids

Liver excrete some unconjugated bilirubin into bile Calcium enters bile passively along with other electrolytes

Unconjugated Bilirubin tends to form insoluble precipitates with calcium 25

Crystals must come together and fuse to form stones

Formation of Calcium Bilirubinate

Formation of stones

Gallstones in the bile ducts/gallbladder (Cholesterol, brown/black pigment)

Mild to moderate pain/biliary colic in the right part of the abdomen – due to functional spasm of the cystic duct; irritation of the viscera (July 30, 2010)

Obstruction of the bile ducts

26

Continues irritation of the gallbladder

Inflammation of the gallbladder

s/s

Jaundice – due to obstruction of bile flow (July 30, 2010)

Clay-colored stool – may result from problems in the biliary system; due to absence of bile in the duodenum; warning signal that’s something wrong with digestion

CALCULOUS CHOLECYSTITIS

s/s Nausea and vomiting – may accompany a gallbladder attack

Severe Pain/biliary colic – due to inflammatory process

(July 31, 2010)

(August 01, 2010)

Fever – due to elevated WBC because of bacteria invasion in the injured gallbladder (August 01, 2010)

(July 31, 2010)

Facial grimace

Guarding behavior

(August 01, 2010)

(August 01, 2010) 27

IF TREATED  PHARMACOLOGIC TREATMENT o Antimicrobials o Narcotic Analgesics o Anticholinergics o Antiemetic o Gallstone solubilizer  SURGICAL TREATMENT: o Open/Laparoscopic Cholecystectomy o Lithotripsy o Endoscopic papillotomy

IF NOT TREATED POSSIBLE COMPLICATIONS:      

Ischemia Necrosis Rupture of gallbladder Gangrene Peritonitis Liver diseases such as Liver cirrhosis, Liver Cancer

28

CALCUOUS CHOLECYSTITIS - is the inflammation of the gall bladder resulting from an obstruction of bile outflow due to gallstones Signs and Symptoms Rationale Biliary Colic

The most common symptom is pain in the right upper part of the abdomen or epigastrium. This can cause an attack of abdominal pain, called biliary colic, which: develops quickly, is severe, lasts about one to three hours before fading gradually, isn't helped by over-the-counter drugs and isn't helped by passing wind. The pain may radiate to the back, right scapula or shoulder. The pain often begins suddenly following a meal. The pain of biliary colic is caused by the functional spasm of the cystic duct when obstructed by stones, whereas pain in acute cholecystitis is caused by inflammation of the gallbladder wall.

Nausea and Vomiting

These signs and symptoms may accompany a gallbladder attack. Pain is usually accompanied by nausea and vomiting.

Fever and chills

Gallstones sometimes get trapped in the neck of the gallbladder and can cause persistent pain that lasts more than several hours and is accompanied by fever, also due to the irritation and inflammation of the gallbladder wall. Fever occurs in about one third of people with acute cholecystitis. The fever tends to rise gradually to above 100.4° F (38° C) and may be accompanied by chills

Loss of appetite and Anorexia

The pain often begins suddenly following a large or rich meal. People tend not to eat, especially fatty or oily foods, in order not to experience that pain. Fat absorption is also impaired for the lack of bile salts; As a result, rapid loss of weight and anorexia can occur.

Jaundice

Due to obstruction of the bile flow.

Clay-colored stool

may result from problems in the biliary system; due to absence of bile in the duodenum; warning signal that’s something wrong with digestion

Nausea and vomiting

may accompany a gallbladder attack

Facial grimace and Guarding behavior

Accompanied by pain

29

Precipitating Factors: Factors

Rationale Increased intake of cholesterol and saturated fats has all been postulated to cause cholesterol gallstones.

Diet (high cholesterol, high fats)

If there is an increased production of cholesterol, bile is being supersaturated with cholesterol, that leads in formation of crystals/stones. Hypolipidemic agents (clofibrate, gemfibrozil) that lower serum cholesterol by increasing biliary cholesterol secretion increase the risk of cholesterol

Medications

gallstones by two fold to three fold. Estrogen therapy is associated with an increased risk of developing cholesterol gallstone; estrogen increases biliary cholesterol secretion. Oral contraceptive steroids increase biliary cholesterol secretion and saturation but do not affect gallbladder motility. TPN is a powerful risk factor for gallstone formation. Gallstones form during TPN because of decreased gallbladder motility from lack of meal-stimulated

Total Parenteral Nutrition

cholecystokinin (CKK) release, resulting in increased fasting and residual volumes. Patients with spinal cord injury have 10% incidence of forming gallstones within the first year after injury. This high risk, which is 20 times normal, is

Spinal Cord Injury

believed to be secondary to abnormal gallbladder motility and probably biliary hypersecretion of cholesterol from the progressive reduction in body mass. Patients with primary biliary cirrhosis have an increased prevalence of gallstones. Stone analysis has not been performed, but the elevated cholesterol

Primary Biliary Cirrhosis

saturation of bile in these patients suggests that they form cholesterol stones. Despite obesity and increased total body cholesterol synthesis and decreased gallbladder motility seen in patients with diabetes, diabetes mellitus itself

Diabetes Mellitus

does not appear to be an independent risk factor for cholesterol gallstone disease. Inherited hemolytic anemia, sickle cell disease, sphericytosis, thalassemia, chronic hemolysis associated with artificial heart valves, and malaria

Hemolytic Syndromes

dramatically increase the risk of pigment stone formation because of increased biliary secretion of total bilirubin conjugates, especially bilirubin monoglucoronide, at the expense of the bilirubin diglucuronide, the predominant conjugate in healthy individuals.

30

Ileal Disease, Resection, and Bypass

Patients with ileal dysfunction have a strikingly increased risk for developing gallstones. Gallstones develop in 30-50% of patients with ileal Chron’s disease; the risk correlates positively with the extent and duration of ileal dysfunction, Although ilieal disease or resection leads to cholesterol supersaturation and cholesterol stone formation in some Patients, careful studies now show that most patients with ileal dysfuncyion form black pigment, not cholesterol stones. Brown pigment stones are frequently found in the intrahepatic bile ducts and are always associated with infection by colonic organisms usually

Biliary Infection (bacterial)

E.coli or parasitic infestation (Ascaris lumbricoides, or other helminthes). Intraductal stones developing after cholecystectomy are invariable associated with bile stasis, biliary tree infection, and/or retained suture material. Obesity is strongly associated with increased gallstone prevalence. The risk is proportional to the increase in total body fat. Obese people synthesize more

Obesity

cholesterol in both hepatic and nonhepatic tissues, transport it to the liver, and secrete more of it into the bile, leading to bile that is often greatly supersaturated with cholesterol. Obese patients undergoing rapid weight loss (1-2% of body weight or approximately 1-2 kg/week), either by very low caloric dieting or gastric stapling, have

Rapid Weight Loss/ Fasting diets

a 25-40% chance of developing gallstones within 4 months. During rapid weight loss, biliary cholesterol saturation increases acutely as cholesterol is mobilized from adipose tissue and skin and secreted into bile.

31

Predisposing Factors: Factors

Rationale Women have twice the risk as men of developing cholesterol gallstones because estrogen increases biliary cholesterol secretion. Before puberty this risk is

Gender

negligible, and beyond menopause the increased risk disappears. The incidence increases with age. Less than 5-6% of the population under age 60 has stones, in contrast to 25-30% of those over 80. It usually affects

Advancing Age

people with age of over 60 but it is more prevalent after 80 years of age. Prevalence highest in North American Indians, Chilean Indians, and Chilean Hispanics, greater in Northern Europe and North America than in Asia, lowest

Race

in Japan; familial disposition; hereditary aspects Family history alone imparts increased risk, as do a variety of inborn errors of metabolism that lead to impaired bile salt synthesis and secretion

Heredity

or generate increased serum and biliary levels of cholesterol, such as defects in lipoprotein receptors (hyperlipidemia syndromes), which engender marked increases in cholesterol biosynthesis. Pregnancy is an independent risk factor for cholesterol gallstones. The risk increases with increasing parity, especially with more than two children. During

Parity/ Pregnancy

pregnancy, elevated estrogen and progesterone levels increase biliary cholesterol secretion. Elevated progesterone also inhibits gallbladder contractility. 40% of women develop biliary sludge in their gallbladder and 12% of women form their first stones during pregnancy.

32

REVIEW OF SYSTEMS LYMPHATIC 

Increase WBC o There is an attraction of leukocytes due to invasion of bacteria.

GASTROINTESTINAL 

Inflammation of the gallbladder o Due to obstruction of cystic duct and decrease blood flow that can cause invasion of bacteria, bacteria attracts leukocytes, phagocytosis occur that results in inflammation of gallbladder



Improper emulsification of fat (problem with GIT) o Due to obstruction of bile out flow, there is an insufficient amount of bile that comes in the duodenum

INTEGUMENTARY



Jaundice o

Due to obstruction bile outflow into the duodenum

RESPIRATORY 

Short shallow breathing o Due to pain

33

PHYSICAL ASSESSMENT Name: NJE

T – 37.2 ºC

Age: 22y/o

P – 91 bpm

Date of assessment - August 02, 2010

R – 31 cpm BP – 110/80mmHg

GENERAL APPEARANCE Method

Normal Findings

Inspection and observation

Proportionate, normal BMI in

Actual Findings

Remarks

1. Body Built Ht. Wt.

relation to age

BMI

Proportionate Ht:5’6’’

Normal

Wt:54kg BMI:19.1

2. Posture and Gait

Inspection and observation

Relaxed, erect posture, coordinated movement

Slouched, uncoordinated movement

3. Over-all Hygiene and Grooming

Inspection and Observation

Clean and neat

Clean and neat ; no body and breath odor

Deviation from normal due to the pain @ the incision on the right upper quadrant of the abdomen

Normal 34

4. Signs of Distress

Inspection and observation

No signs of distress

Present signs of distress such as facial grimace with guarding behavior

5. Obvious signs of health or illness

Inspection and observation

No signs of illness or disease

Appears weak with facial grimace and guarding behavior

Deviation from normal due to pain at the site of incision at right upper quadrant of the abdomen

Deviation from normal due to present condition; Post cholecystectomy

MENTAL STATUS

1. Level of Consciousness/

Inspection

Conscious and coherent; Oriented to time, place and situation

Oriented to date, place and time situation

Normal

Orientation

2 Emotional Status

Inspection

No facial grimace

(+) facial grimace

Deviation from normal due to pain at the site of incision at right upper quadrant of the abdomen

3. Attitude

Inspection

Cooperative

Cooperative during assessment

Normal

4. Affect/mood, appropriateness of responses

Inspection

Appropriate to the situation

Responses are appropriate to the situation; irritated

Deviation from normal due to pain at the site of incision at right upper quadrant of the abdomen.

35

SKIN

1. Color

2. Presence of Edema

Inspection

Inspection and

Yellowish discoloration

Deviation from normal due to the effect of bilirubin that is still present at the blood streams.

Absence of Edema

(+) peripheral edema

Deviation from normal due to water retention caused by fluid shifting from intracellular to intravascular.

Uniform in color

Palpation

3. Presence of Lesions

Inspection

No Lesions

With incision at the right upper quadrant of abdomen

Deviation from normal due to status post cholecystectomy

4. Moisture of the skin

Palpation

Moist in Axilla and skin folds

Moist in Axilla and skinfolds

Normal

5. Temperature

Palpation

Uniform temperature

Uniform temperature

Normal

6. Skin Turgor

Palpation

When pinched, it springs back within 3 seconds

It springs back to previous state > Explain the > Patient can >> explain the purpose and the expect to procedure of the following: resume test. her/his normal activities Impression: >patient will be immediately. ask to lie on the examination > Instruct him couch next to not to eat solid ultrasound food for 12 >inform IMPRESSION machine hours prior to patient exam to allow regarding the > Solitary Cholecystitis with increase greatest dilation result of the in size gallbladder

>the area to be >Inform patient scanned will be that ultrasound exposed and a is a noninvasive clear waterprocedure. soluble gel will be applied to the skin for the transmission of sound waves into the patient’s body

51

>a scan probe will then be placed in contact with patient’s body and move over the skin to examine the tissues below. >the parient will experience no pain during the procedure >Ultrasound scans take approximately 30 min. to complete.

52

VII.

Patient and His Care A. Medical Management

MEDICAL MANAGEMENT TREATMENT

1.) IVF (D5LRS)

DATE ORDERED/ DATE PERFORMED/ DATE CHANGE OR DC

Date ordered/performed

>Regulated @ 3031 gtts/min

August 01, 2010 Date discontinued: August 03,2010

GENERAL DESCRIPTION

5% Dextrose in Lactated Ringers Solution

INDICATIONS/ PURPOSE

For rehydration

CLIENTS RESPONSE TO THE PROCEDURE No signs of dehydration.

NURSING RESPONSIBILITIES

PRIOR:  Determined the type of solution to be infused.  The rate of flow or the time over which the infusion is to be completed.  Assess the vital signs, skin turgor. DURING:  Prepare the infusion set.  Spike the solution container.  Prime the tubing.  Perform aseptic technique.  Initiate the infusion.  Regulate the infusion. AFTER:  Document relevant data.  Monitor client’s response.  Evaluate if IV flow is consistent with what ordered.  Assess the infusion site.

53

MEDICAL MANAGEMENT TREATMENT

DATE ORDERED/ DATE PERFORMED/ DATE CHANGE OR DC

GENERAL DESCRIPTION

INDICATIONS/ PURPOSE

CLIENTS RESPONSE TO THE PROCEDURE

-facilitate breathing

-the patient relieved difficulty of breathing.

NURSING RESPONSIBILITIES

Date Oxygen therapy (3LPM via face mask)

ordered/performed: August 01, 2010 Date discontinued: August 02,2010

- Oxygen therapy is the administration of oxygen as medical intervention. Oxygen is essential for cell metabolism, and in turn, for tissue oxygenation.

-to increase oxygen saturation in tissues



Check and how to administer for the oxygen tank, humidifier, and flow rate meter if they are working.



Place “no smoking” sign at the head or foot of the bed.

-the patient demonstrate adequate

-it is an administration of oxygen at concentration greater than that in room air to prevent hypoxemia and hypoxia.

PRIOR:  Check for the doctor’s order including the flow rate of O2

oxygenation

DURING:

   

Assess for kinks and obstruction Secure the tubing, comfortably. Observe for moisture in the mask to prevent aspiration. Observe the pressure necrosis.

AFTER:  Check for client’s response to the therapy.  Check for the skin irritation.  Perform after care.

54

B.Drugs

Name of drug

Date ordered, taken/given Date changed/ D/C

Route of administration, dosage, frequency

General action, Classification, Mechanism of Action

Indications/Purpose

Client response to the medication, actual side effects

Classification:

Nursing Responsibilities

PRIOR

H2 RECEPTOR

Generic Name: RANITIDINE

Brand Name: ZANTAC

Date ordered: August 01, 2010

50 mg TIV Q8

Stock Dose: 25 mg/mL

INDICATION

Clients response

GENERAL ACTION

>Short-term treatment

>decreased

>anti-ulcer

of active duodenal ulcer abdominal pain

MECHANISM OF

> Maintenance therapy

ACTION

for duodenal ulcer at

BLOCKER

>Competitively inhibits the

reduced dosage

action of histamine at the

>Short-term treatment

H2 receptors of the parietal

of active, benign gastric

cells of the stomach, inhibiting basal gastric acid secretion and gastric acid secretion that is stimulated by food, insulin, histamine, cholinergic agonist,

ulcer

1. Assess patient for contraindication. 2. Assess for baseline data. 3. Tell patient that he may experience side effects brought about by the drug.

Side effects >abdominal pain, constipation,

DURING 1. Administer the drug slowly. AFTER 1. Instruct him to report intolerable side effects so as prompt intervention could be done. 2. Instruct him to report adverse effects that he may experience.

gastrin, and pentagastrin. 55

.Name of drug

Date ordered,

Route of

taken/given

administration,

General action, Classification,

dosage,

Mechanism of Action

Date changed/ D/C

Client response Indications/Purpose

frequency

to the medication,

Nursing Responsibilities

actual side effects PRIOR

Generic Name: VITAMIN K Brand Name: Aquamephyton

Date ordered: August 01, 2010

10 mg TIV Q8

Classification:

Indication:

Fat soluble vitamin

>Prevention of

GENERAL ACTION

bleeding,

Clients response

2. Assess for baseline data. >N/A

>hypoprothrombinemia Side effects:

3. Teach patient not to take other supplements, unless directed by prescriber, to take this medication as

>anti-coagulant >N/A MECHANISM OF ACTION

1. Assess for contraindication.

directed. 4. Tell patient that he may experience

>Vitamin K is essential for the

side effects brought about by the

hepatic synthesis of factors II,

drug and to report symptoms of

VII, IX, and X, all of which are

bleeding: bruising, nosebleeds,

essential for blood clotting.

bleack tarry stools, hematuria.

Vitamin K deficiency causes an

DURING

increase in bleeding tendency,

1.Slowly administer the medication

demonstrated by ecchymoses, epistaxis, hematuria, GI bleeding.

AFTER 1.Instruct patient to report adverse effect that he may experience 56

Name of drug

Date ordered,

Route of

taken/given

administration, dosage,

Date changed/ D/C

frequency

General action,

Client response to the

Classification,

Indications/Purpose

medication, actual

Mechanism of Action

Nursing Responsibilities

side effects

PRIOR Generic Name: CEFUROXIMESODIUM

Date ordered: August 01, 2010

750 mg

Classification:

Indication:

TIV

ANTIBIOTIC;CEPHAL

>Maintenance Surgical

Q8

OSPORIN

(2ND prophylaxis

GENERATION)

Clients response >pain is felt upon administering IV push

1. Assess patient for contraindication. 2. Assess for baseline data. 3. Have vitamin K readily available in case of hypoprothrombinemia occurs.

Brand Name: CEFUROXIME

Stock dose: 750 mg/50 mL

DURING

GENERAL ACTION: Side effects

>Bactericidal MECHANISM

OF

ACTION >inhibits bacterial

synthesis cell

causing cell death.

of wall,

>no side effects

1.Reconsitute 1gram with 10 or more ml of sterile water AFTER 1. Instruct patient to avoid alcohol for 3days

after

drug

administration

because serious reactions often occur. 2. Tell patient that he may experience some side effects brought upon by the drug.

57

Name of drug

Date ordered,

\Route of

taken/given

administration, dosage,

Date changed/ D/C

Generic name:

Date ordered:

METRONIDAZOLE

August 02, 2010

General action, Classification, Mechanism

TIV

Classification: >Nitroimidazole derivative

Q8 GENERAL ACTIONS:-

Brand name: FLAGYL IV

500 mg/100 mL

Client response to the medication,

INDICATION

Clients response

PRIOR

>for

>N/A

1. Check for doctor’s order

>dark urine >Anti-protozoal MECHANISM OF

3. Inform the patient about the possible side effect of the drug

1. Inject IV port slowly, over not less than 2

>Disturbs DNA synthesis in

organism.

hypersensitive to drugs

DURING

ACTION

susceptible

2. Not to be given in patients

prophylaxis Side effects

>Anti-infective

Nursing Responsibilities

actual side effects

preoperative

HYDROCHLORIDE

Stock dose:

ose

of Action

frequency

500 mg

Indications/Purp

bacterial

min.

AFTER 1. Advise patient to report abdominal pain.

58

Name of drug

Date ordered,

Route of

General action,

Indications/Purp

Client response to

taken/given

administration,

Classification, Mechanism

ose

the medication,

dosage,

of Action

Date changed/ D/C

actual side effects

frequency Classification

Generic name:

Date ordered:

PARACETAMOL

August 02, 2010

Nursing Responsibilities

300mg, TIV now, q4, PRN for ≥ 38°C

PRIOR

Nonopoid analgesics and antipyretic

INDICATION

Clients response

1. Check for doctor’s order

GENERAL ACTIONS

>reduce body temperature

>fever decreases

2. Not to be given in patients

from 38°C- 37°C

hypersensitive to drugs

Brand name: > decreases body ACETAMINOPHEN

temperature

3. Inform the patient about the possible side effect of the drug

MECHANISM OF ACTION > Reduces fever by acting directly on the

DURING 1. Inject directly slowly AFTER

hypothalamic heatregulating center to cause vasodilation and sweating, which helps dissipate heat.

1. Tell patient that he may experience some side effects brought upon by the drug

59

Date ordered, taken/given Name of drug Date changed/ D/C

Route of administration, dosage, frequency

General action, Classification, Mechanism of Action

Indications/Purpose

Client response to the medication, actual side effects

Nursing Responsibilities

PRIOR

Generic Name: CELECOXIB Brand Name: CELEBREX

Date ordered: August 02, 2010

200 mg PO FOR PAIN Stock dose: 100 mg and 200 mg

Classification: NONSTEROIDAL ANTIINFLAMMATORY DRUG

. Indication: >Management of acute pain.

Clients response >verbalized decreased pain felt

1. Take drug with food if GI upset occurs

2. Determine any GI bleed/ulcer history, sulfonamide allergy, aspirin and other NSAID-

GENERAL ACTION

 Contraindications: >Contraindicated with allergies

>Pain reliever

to sulfonamides, NSAID, or aspirin

allergic type reaction

celecoxib,

induced asthma, urticaria,

3. Monitor sign and symptoms MECHANISM OF ACTION

4. Assess for liver or renal dysfunction; reduce dose

>Inhibits prostaglandin synthesis, primarily by inhibiting cyclooxygenase-2 thus decreasing inflammation.

DURING

1. Take with foods; decreases stomach upset AFTER 1. Tell patients that he may

experience some side effects brought about by the drug

60

C. Diet

Type of diet

NPO(Nothing Per Orem)

General Liquid Diet

Date Started 08/01/10

08/02/10

Date Change

08/02/10

08/03/10

General Description

Indication/ Purposes

An instruction meaning to withhold oral foods and fluids, but for patients who will undergo surgery, the physician will allow small amount of fluid intake for oral medication

This diet is usually ordered for preparation prior to surgery specially who will undergo general anesthesia to prevent aspiration and pneumonia

Diet that allows intake of fluid or liquid forms of food only

Before DAT diet is instructed the physician first ordered is general liquid diet to train the normal digestion and to bring back the normal digestion process

Specific foods/fluids taken None

Client Response

Nursing Responsibilities Prior

Feels hunger -asses the level of and thirst, understanding of appears weak the patient -Explain the importance of following strictly NPO in terms that the client can understand and then evaluate

90 ml of water

Feels hunger, -Asses the level of appears weak understanding of the patient -Explain the importance of following strictly General Fluid diet in terms that the client can understand and then evaluate

During

Post

-Strictly monitor clients behavior in following NPO.

-Instruct the client to continue NPO as prescribed by the physician.

-Strictly monitor clients behavior in following General Liquid diet

- General Liquid diet was instructed and maintained to train the normal digestion process.

61

-Emphasize what kind of foods the client can eat during this diet. DAT( diet as tolerated)

08/03/10

(until discharge)

It is a diet that allows the patient to eat all types/kinds of foods as long as the client can tolerate it.

Instructed following a general liquid diet for better source of good nutrition.

Lugaw, egg and rice Pinakbet and rice Monggo and rice Sinigang na bangus and rice

Relieved hunger

-Asses the level of understanding of the patient -Explain that immediate shifting of foods from NPO to General Fluids to DAT without undergoing soft diet can result to constipation, that’s why we need to emphasize eating first soft foods before eating any solid foods

-Strictly monitor clients behavior in following DAT diet

-Advised the client to take soft foods and avoid food rich in fats.

62

D. Exercise

Type of exercise

Date started

General description

Indications/purpose

Client response NURSING RESPONSIBILITY

Ambulation exercise

08/02/10

A type of exercise that requires the patient to move by feet

 aids in good circulation

>Walking

 stimulate peristalsis

 facilitate voiding

 prevent thromboembolism

The patient tolerated the exercise but he felt little bit tired

BEFORE: Ensure that the patient understand the reason for doing the exercise Assist to stand to prepare for ambulation. DURING: Assist patient while doing the exercise if necessary. Check if there is difficulty in breathing Check if he feels any pain while doing the exercise AFTER: Recheck if he feels any pain after the exercise Monitor the V/S of the patient to check if there are changes Document relevant data’s.

63

VIII.

SURGICAL MANAGEMENT 

The circulator accompanies the anesthesia provider and the patient to the PACU; he/she gives the PACU perioperative practioner a detailed intraoperative patient report regarding the course of events as they apply to the individual.



Assess the patient: appraise air exchanges status & note skin color; verify & identify operative status & surgeon performed; assess neurological status (LOC)



Postoperative

PACU nurse observes the patient’s breathing, monitors blood pressure and vital signs, and documents all pertinent information.



PACU nurse assumes the role as the patient’s advocate..



Report for abnormalities especially for signs and symptoms of shock



Perform safety checks – good body alignment, side rails and maintain patent airway and cardiovascular stability

Relieve pain and anxiety Post operative:

Client Response



Patient finds it hard to sleep because of pain felt on the incision site



Client appears weak

Skin color improvement (August 03, 2010)

64

IX. NURSING CARE PLAN

Assessment

Nursing Diagnosis

S: “masakit yung

Acute Pain related

tahi ko,” As

to inflammation

verbalized by the

and distortion of

patient.

tissues r/t injuring

O:Facial Grimace

agent

Background Knowledge

Cholecystectomy

Planning

Nursing Interventions

Short Term:

Independent

After 2 hours of

1. Observe and document

Rationale

Goal met. 1. Assists in

After 2 hours of

nursing intervention location, severity and

differentiating cause

nursing intervention

the patient pain

of pain and provides

the patient pain scale

information about

was decreased from

disease progression/

6/10 -3/10.

character of pain.

Surgical incision on scale will decrease the right lower from 6/10 – 3/10 quadrant of the abdomen

resolution,

>With guarding

development of

behavior

complications and

>Rigidity of the abdomen

Disruption of skin tissue and muscle integrity at RUQ

>Pain scale of 6/10 >RR= 24 cpm >With short and

effectiveness of

Long Term:

interventions. After 8 hours of Nursing intervention the

Stimulation of sensory nerve endings

2. Note location of

2.This can influence

surgical procedure

the amount of post-

After 8 hours of nursing intervention the

patient

was

reportedly relief of pain.

operative pain

patient will report

experienced

relieved of pain.

shallow breathing 3.Instruct/encourage use PAIN

Evaluation

of relaxation techniques such as breathing

3. To divert attention and reduce tension and to relieved the patient from pain. 65

exercise 4. To divert attention Source:

4. Encouraged divisional

Porth CM. (2002).

activities.

patient from pain. 5.To prevent fatigue

Pathophysiology: Concepts of Altered

5. Encourage adequate

Health

rest periods.

States.

and to relieved the

Philippines: Lippincott Williams

6. Make time to listen to

& Wilkins.

complaints and maintain frequent contact with the patient.

6. Helpful in alleviating anxiety and refocusing attention which can relieve pain.

7. To impart 7.Discuss with significant others ways where in they can assist client and reduce precipitating factors that may cause pain

knowledge to the SO regarding ways on how they can participate in alleviating the pain of the patient.

66

Dependent

To relieve pain.

Administer medication as prescribed.

SOURCE: Nurses pocket guide Diagnoses, prioritize interventions, and rationale, 11th edition

\

67

Assessment

Nursing

Background

Diagnosis

Knowledge

Planning

SHORT TERM : surgical incision on the right upper quadrant of the abdomen,

S: “kumikirot ang

Impaired tissue

sugat ko sa

integrity related

tagiliran” as

to surgical

the patient verbalize

verbalized by the

incision

understanding of

patient

(surgery)

trauma to the skin

nursing intervention

condition and causative factor.

O: >Incision at right upper right quadrant of the abdomen with intact and dry dressing

Within 2hrs of

thus impairing the integrity of the skin LONG TERM: Source:

Nursing Interventions 1. Place the pt in a

operation cholecystectomy.

1. To prevent backaches or

comfortable position. muscle aches. 2. Monitor and record vital signs.

2. To note any significant

Assess general

changes that may be brought

condition of skin.

about by the disease.

Evaluation

Goal met: After 2hrs of nursing intervention the patient verbalized understanding of condition and causative factor.

3.Practiced aseptic technique for

3. Healthy skin varies from

cleaning /dressing/

individual to individual, but

medicating wound

should have good turgor, feel

LONG TERM:

After 2-3 days of

warm and dry to the touch, be

After 2-3 days of

nursing intervention

free of impairment, and have

nursing intervention

quick capillary refill.

the patient displayed

http://www.nlm.nih.gov/ the patient displays >Status: post

Rationale

medlineplus/ency/articl

progressive

4. Emphasize

e/002930.htm

improvement in

importance of proper

wound healing.

nutrition and fluid

progressive 4.Reduced risk for infection

improvement in wound healing.

intake.

68

5. Encourage adequate period of

5. To maintain general good

rest and sleep.

health and skin turgor.

6.

Promote

ambulation.

early 6.

a.)

To

limit

metabolic

demands, remain energy available for healing and meet comfort needs.

b).Promote

circulation

and

prevent excessive tissue pressure.

Sources: Nurses pocket guide Diagnoses, prioritize interventions, and rationale, 11th edition

69

Assessment

Nursing Diagnosis

S: “ Namumula

Risk for infection

ang sugat ko sa

related to increase

tagiliran” as

environmental

verbalized by the

exposure to

patient.

pathogen

O: >Surgical incision

Background knowledge surgical incision

abdomen >With intact, dry

traumatized tissue on the injured site

Operation Cholecystectomy

nursing intervention the patient will identify

increasing risk of infection

Nursing Interventions

1. Monitor vital signs.

Rationale

1. Suggestive of presence

Note onset of fever,

of infection/ developing

chills, and

sepsis.

2.Practice good hand

2 .Reduce risk of spread of

intervention to

washing and aseptic

bacteria/ prevent cross

prevent/ reduced

wound care.

contamination.

3. Inspect incision and dressings. Long term goal:

3. Provides early detection of developing infectious process.

After 1-4 days of Source: Mattson Porth,

Goal met. Short term goal:

intervention the patient will identify intervention to prevent/ reduced the risk of infection. Long term goal:

infection. may result to further complication if not prevented

Evaluation

After 5 hours of nursing

diaphoresis.

the risk of

dressing >Status : Post

Short term goal: After 5 hours of

at the right upper quadrant of the

Planning

After 1-4 days of nursing intervention the patient showed progress of wound healing.

nursing intervention 5. Cleanse incision site

5. Disinfects site and

the patient will

prevents multiplication of

with povidone iodine.

Essentials of

show progress of

microorganisms which may

Pathophysiology

wound healing

cause infection.

Concepts of Altered 70

Health Status, Lippincott Williams

6. Instruct client not to

6.Microorganisms thrive at

wet incision site.

damp areas and makes it conducive for replication

and Wilkins, 2007

7. Provide a cool

7. Hot room temperature

environment.

induces sweating which may inhibit the healing of wound and eventually cause moisture at the area delaying the healing process.

8. Assess patient’s ability to move.

8. Immobility is the greatest risk factor in skin breakdown.

9. encourage change

9. to prevent pressure to

of

certain parts of the body

position in a

regular basis

10. emphasize importance of

10.to maintain general good health and skin turgor

adequate nutritional/ fluid Intake 71

11. encourage

11.to enhance good

ambulation as tolerated

circulation

Dependent: >Administer

> Prevents invasion of

medications as

bacteria or microorganisms

prescribed (antibiotics)

at site and eventually prevents possible infection.

Sources: Nurses pocket guide Diagnoses, prioritize interventions, and rationale, 11th edition

72

X. HEALTH TEACHINGS Health Teaching

Encourage to avoid intake of foods high in fat/cholesterol.

Rationale

After cholecystectomy, the liver still produce bile but in a slow trickle process, therefore if the diet is high in fat, the malabsorption of fat occurs because the minimal production of bile cannot handle the normal absorption process

Explain the importance of ambulation.

To promote good circulation

Explain to the patient the importance of deep breathing exercises/ divertional activities.

Deep breathing exercises/divertional activities help to reduce pain.

Explain to the patient the importance of splinting.

Splinting reduces the pressure in the abdomen thus reducing the pain.

Explain to the patient not to touch the incision site with bare hands.

To prevent infection.

Explain to the patient the importance of eating small frequent meals (preferably 4-6

Since cholecystectomy is done, the liver will compensate by excreting slow and low

meals) rather than to eat 3 times a day.

level of bile that can cause the malabsorption of fat.

Explain the importance of proper hygiene.

Prevent the spread of microorganism/cross contamination.

Explain to the patient the importance of maintaining a clean and well ventilated environment.

To reduce the risk of infection and to promote patient’s comfort.

73

XI. DISCHARGE PLANNING Medicines:  Teach the ff: to the client with regards to proper administration of the prescribed medication -

Cefuroxime 500 mg 3X/day (TID)

-

Celecoxib 200 mg PRN when feeling pain.

Environment and Exercise  encourage to establish a clean and well ventilated environment  avoid strenuous exercise that cause tension on the affected area and further deprivation  Daily activities should be spaced to provide rest periods between times of exercise

Treatment  Advise to continue to take the prescribed home medication until end of the regimen or unless specified by the physician.  Give relevant information about the drugs, their side effects & their adverse effects.

Health Teaching:  Explain to patient what to expect afterwards. As the anesthetic wears off, there is likely to be some pain. The anesthetist will prescribe painkillers. Suffering from pain can slow down recovery, so it’s important to discuss any pain with the doctors or nurses.  Instruct caring for the stitches, hygiene & bathing, and will arrange an outpatient appointment for the stitches to be removed.  Instruct patient to comply with the home medications that would be given by his physician.  Encourage the patient to do the recommended light exercises such as walking. Avoid doing strenuous activities which could slow down his recovery. 74

 Encourage him to comply with the dietary modifications; limit the intake of saturated fat to prevent the occurrence of serious post-cholecystectomy side-effects.  Explain to patient to refer for unusualities immediately.

Out Patient Care:  Instruct to visit the physician for follow-up check up after 1 week  If any of the following symptoms are noted he should contact his doctor: 

If the wound become more painful, red, inflamed or swollen.



If the abdomen swells



If the pain is not relieved by the prescribed painkillers.



If a fever develops these could be a sign of an infection that may need to be treated with antibiotics.

Diet:  Instruct client to limit the intake of foods high in fat  Advise the patient to eat smaller amount of foods during a single meal. Advised to eat around 5 or 6 smaller meals a day instead of 2 or 3 usual meals.

Spiritual/Safety:  Encourage going to church and asking for guidance, encourage praying.  Avoid strenuous activity.

75

XII.

CONCLUSION

Generally, we, the student nurses six days exposure and duty at Bulacan Medical Center have been a memorable experience to us. The exposure had been an avenue for further development and enhancement of our skills and capabilities in rendering care and promoting holistic wellness to our clients. It reminded us again that nursing profession entails a deep sense of responsibility and challenging tasks. After a six (6) days of exposure at BMC Surgery Ward, we the student nurse has identified and understood the causative factors of cholecystitis, its signs and symptoms, clinical manifestations, diagnostic studies, medical, pharmacological and nursing interventions through obtaining cues and health history in conjunction to the disease process. We underwent extensive research in order to comprehensively understand our patient’s condition. Upon learning his case, it challenged and motivated us to work hard to provide the appropriate and effective nursing intervention and care. Moreover, cholecystitis is the most common problem resulting from gallbladder stones. It occurs when a stone blocks the cystic duct, which carries bile from the gallbladder. Predisposing factors can include heredity, age, sex and race. With t he presented factors that cannot already be modified, one has to take action towards preventing the disease to happen. The only one who can help yourself is you alone. With the proper knowledge about the nature of the disease as well as its preventive measures along with responsibility and sense of will, one can surely direct himself away from the complications.

- GROUP 2

76

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http://www.nottingham.ac.uk/nursing/sonet/rlos/bioproc/resources.html



http://www.le.ac.uk/pa/teach/va/anatomy/case2/frmst2.html



http://www.le.ac.uk/pa/teach/va/anatomy/case5/frmst5.html

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http://digestive.niddk.nih.gov/statistics

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Barbara Howard, Clinical and Pathologic Microbiology, 2nd Edition

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Carol Porth, Pahtophysiology Concepts of Altered Health Sciences, 7 th Edition

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Pathology 3rd Edition by Stanley L. Robbins, M.D.

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Clinical Applications of Nursing Diagnoses. F.A. Davis Company, Philadelphia. o 4th edition.

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Nutritional Therapy and Pathophysiology. Nelms, Sucher, Long. 2007. Thomson o Brooks/Cole, The Thomson Corporation. 10 Davis Drive Belmont, CA, USA. 77

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Doenges, Marilynn E., Moorhouse, Mary Frances, Murr, Alice C. Nursing Care o Plans 7th ed. F.A. Davis Company, Philadelphia, Pennsylvania,2006.

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