Our Lady of Fatima University

College of Nursing

Valenzuela Campus

Acute Cholangitis

A Case Study

Presented to:

Sir Francis Culala

Presented by:

Salvador, Diana T.

February 2-4 and 9-11, 2015

TABLE OF CONTENTS

I. Introduction

II. Objectives

III. Patient’s Profile

IV. Anatomy and Physiology

V. Pathophysiology

VI. Laboratory Examination Results

VII. Gordon’s Assessment

VIII. Nursing Care Plans

IX. Drug Study

I. INTRODUCTION

Acute obstructive cholangitis was defined by Reynolds and Dargan in

1959 as a syndrome consisting of lethargy or mental confusion and shock, as

well as fever, jaundice, and abdominal pain caused by biliary obstruction. These

five symptoms were then called Reynolds' pentad.

Acute cholecystitis is an acute inflammatory disease of the gallbladder,

often caused by gallstones; however, many factors (eg, ischaemia, motility

disorders, chemical injury, infections by micro-organism, protozoon and

parasites, collagen disease, and allergic reactions) are also involved.

The term hepatic fever was used for the first time by Charcot in his report

published in 1887. Intermittent fever accompanied by chills, right upper quadrant

abdominal pain, and jaundice have been established as Charcot’s triad.

Bile is normally sterile; however, if the common bile duct (CBD) is

obstructed the flow of bile is reduced (biliary stasis) and infection can occur.

Infection can also flow in a retrograde direction up the CBD as a result of acute

cholecystitis or instrumentation such as endoscopic retrograde

cholangiopancreatography (ERCP).

The most common in the UK are Klebsiella spp., Escherichia coli,

Enterobacter spp., enterococci and streptococci. More than one organism may

be involved. Outside the UK, cholangitis can be caused by roundworm and liver

fluke.

HISTORY OF PRESENT ILLNESS

Mrs. F. is known hypertensive, 18 hours post ictus with right sided

weakness, accompanied with a sleeping time.

PHYSICAL ASSESSMENT

GCS 9 (E2M5V2)

GENERAL SURVEY

Mrs. F. Assessed/received patient lying on bed, awake, conscious,

incomprehensive sounds. With the following vital signs:

Temperature: 36.8 °C

Heart rate: 95 bpm

Respiratory rate: 21 bpm

Blood Pressure: 150/100 mmHg

NUTRITIONAL STATUS

Upon admission, Mrs. F was placed on a low salt low fat diet

.

HAIR

> Hair is black and is evenly distributed.

> Silky and smooth hair.

> No areas of hair loss noted.

> Thick hair strands.

NAILS

> Trimmed clean nails.

> Concave shaped; with a nail plate angle of about 160 degrees.

> Smooth in texture.

> Intact epidermal lining around the nails.

> Capillary Refill Test less than 3 seconds.

SKULL AND FACE

> Rounded (normocephalic and symmetrical with frontal, parietal and occipital

prominences).

> Head size is appropriate to body size.

> No nodules or masses upon palpation.

EYES AND VISION

> Eyebrows and eyelashes are evenly distributed.

> Eyelids are intact.

> Sclera appears white.

> No discharges and discoloration noted.

> Blink reflex intact.

EARS AND HEARING

> Ears are symmetrical in size and in line with the outer canthus of the eyes.

> Color of ears is the same with the facial skin.

> No discharges and foul odor noted upon inspection.

> Pinna and ear canal are clean.

> Auricles are firm and recoil to previous state when folded.

> No nodules or masses noted upon palpation.

NOSE AND SINUSES

> Symmetric and straight.

> No watery discharges.

> Has a slow uneven breathing pattern.

> No tenderness masses and pain noted upon palpation.

> Oxygen inhalation attached.

NECK

> Jugular vein is not visible.

> Muscles are equal in size with the head centered.

> Slow muscle movement.

> Lymph nodes are not palpable.

CARDIOVASCULAR AND PERIPHERAL SYSTEM

> Skin color of palm of the hand and feet is pink.

> Pink nail beds upon inspection.

> Symmetric pulse volumes, full pulsations of peripheral pulses.

> Heart rate is 95 beats per minute.

> Blood Pressure is 150/100 mmHg.

> (Vital signs taken during the time of assessment on February 18, 2015 at

7:00 am).

Respiratory System

> Chest is symmetric.

> Skin and chest wall are intact and has uniform temperature.

> No tenderness and masses noted upon palpation.

> Regular breathing pattern

> Presence wheezing and crackles sound upon auscultation.

> Full and symmetric chest wall expansion.

BREAST AND AXILLAE

> Breasts are symmetrical in size; color is the same as with the abdomen.

> Both nipples are symmetrical in size.

> No discharges noted.

> No tenderness, masses, and nodules noted upon palpation.

ABDOMEN

> Abdominal skin is intact.

> Distended abdomen noted.

> Audible bowel sound upon auscultation.

> Abdominal dullness upon percussion.

NEUROLOGIC

> Patient has times of looking in the distance and is slow in response when a

question asked.

URINARY SYSTEM

> Patient usually urinates 5 times a day.

REVIEW OF SYSTEM

Integumentary System

The patient has no history of bruises in both upper and lower extremities.

Ears and Hearing

Patient had no history of smelly discharges on both ears, and no complaints

of hearing impairment.

Breast and Axillae

The patient had no history of breast nodules, no enlargement, no tenderness,

no pain and unusual discharges.

Respiratory System

The patient experienced slow irregular breathing patterns.

Cardiovascular System

The patient has a history of hypertension.

Genitourinary System

The patient had no history of any genital problems. Usually urinates 5 times a

day.

Gastrointestinal System

The patient had no history of difficulty in defecation.

Musculoskeletal System

Patient has no history of joint pain.

Neurologic System

Patient had no history of any major mental problems but had episodes of

mental absences.

IV.ANATOMY AND PHYSIOLOGY

V. PATHOPHYSIOLOGY OF RIGHT BASAL GANGLIA HEMORRHAGE

(INTRACEREBRAL HEMORRHAGE)

Precipitating Factors: - Hypertension - Hypercholesterolemia - High Blood Glucose - High T CHON

Predisposing Factors: - Sedentary lifestyle - Age - Diet - Hereditary - Self-medication

VASOCONSTRICTION

Blockage of the blood vessel

Lack of oxygen and nutrient supply

Altered Cerebral Perfusion

Decreased Cerebral Perfusion

Intracerebral hemorrhage (bleeding)

Blood irritates the nerves and tissues

Pain and Vomiting; parts of the brain will shut down; decreased

LOC

Blood clot formation

Pressure and brain compression

Signs and Symptoms: - Changes in movement (Ataxia) - Muscles Weakness (difficulty in swallowing, smiling and talking) - Decreased cognitive function - Headache,nausea and vomiting - Personality changes: change in judgment, confused, difficulty in understanding what is happening around. Inappropriate emotional responses

VI. DIAGNOSTIC AND LABORATORY PROCEDURES

DIAGNOSTIC/

LABORATORY

PROCEDURES

DATE

ORDERED,

DATE

RESULTS IN

INDICATIONS RESULTSNORMAL

VALUES

ANALYSIS AND

INTERPRETATION

BLOOD CHEMISTRY

CREATININE

DO: 02/24/15

DR: 02/24/15

This is to reveal if

there is alteration

with the

excretory

function of the

patient’s kidney

and it suggests

its chronicity

since it tends to

rise in the later

part of the

disease

condition.

77.04 45-104 umol/L Creatinine is within

normal range which

indicates urination is

normal.

DIAGNOSTIC/

LABORATORY

PROCEDURES

DATE

ORDERED,

DATE

RESULTS IN

INDICATIONS RESULTSNORMAL

VALUES

ANALYSIS AND

INTERPRETATION

BLOOD CHEMISTRY

SODIUM DO: 02/24/15

DR: 02/24/15

This is to reveal if

there is alteration

with the

excretory

function of the

patient’s kidney

and it suggests

its chronicity

since it tends to

rise in the later

part of the

disease

condition.

135.50 135-143

umol/L

Sodium is within

normal range. Which

indicates that there is

a balance between

sodium and water in

the urine.

DIAGNOSTIC/

LABORATORY

PROCEDURES

DATE

ORDERED,

DATE

RESULTS IN

INDICATIONS RESULTSNORMAL

VALUES

ANALYSIS AND

INTERPRETATION

BLOOD CHEMISTRY

POTASSIUM

DO: 02/24/15

DR: 02/24/15 This is to reveal if

there is alteration

with the

excretory

function of the

patient’s kidney

and it suggests

its chronicity

since it tends to

rise in the later

part of the

disease

condition.

3.29 3.4-4.82

umol/L

Potassium is within

normal range which

indicates

NURSING RESPONSIBILITIES

Before :

Explain to the patient what you are going to do, why it is necessary and how she

can cooperate.

Tell the patient that a blood sample will be taken. Explain who will perform the

venipuncture and when.

Explain to the patient that he may feel slight discomfort from the needle puncture

and the tourniquet.

Assemble the equipment and supplies needed in the procedure.

During:

Observe appropriate infection control procedures.

Select and prepare the vascular puncture site. Clean the site with the antiseptic

swab allows it to dry completely before obtaining the blood specimen.

Ensure that the subdermal bleeding has stopped before removing pressure.

After:

Send the sample to the laboratory promptly.

Report abnormal laboratory findings to the health care provider in a timely

manner consistent with the severity of the abnormal results

Diagnostic /

Laboratory

Procedures

Date

Ordered

Date

Results in

Indications or

PurposesResults Normal Values

Analysis and Interpretation

of results

1.

Hematology

test

Date

ordered:

Febuary 2,

2015

Date of

Results:

February 2,

2015

to see the

hemoglobin

content in the

red blood cells Hemoglobin: 14.9

gms/L

Hematocrit: 42.5

gms/L

12.2-16.2

37.7-47.9g/L

The result indicated that the

hemoglobin (the iron-containing

part of blood that carries

oxygen to cells) level of the

patient is within normal level,

which indicates that the RBC is

receiving adequate amount of

oxygen

The level of white blood cell

WBC count:

17.99 x 10^3/L

Lymphocytes:

4.4

Monocytes: 4.1

Eosinophils; 0.00

Basophils 0.1

MCV: 83.7 fL

MCH: 29.3 pg

4.8-10.2 x 10^3 /L

10.0-50.0

0.0-14.0

0.00 – 7.0

0.00 – 1.15

80.0 – 97.0 fL

27 – 31.2 pg

count is very high since there

are invading pathogens due to

her condition.

The number of Lymphocytesis

very low than the normal level.

The number of monocytes is

within the normal range.

The eosinophils count is within

the normal range.

The basophils count is on the

normal range

MCHC: 35.1

RDW: 38.7

31.8 – 35.4 g/dL

.

NURSING RESPONSIBILITIES

Before:

Confirm the patient’s identity using two patient identifiers according

to facility policy.

Explain that this analysis helps to diagnose renal or urinary track

disease and to evaluate overall body function.

Inform the patient that there are no dietary restrictions required.

Notify the laboratory and practitioner of drugs the patient is taking

that may affect the results.

During:

Collect a random urine specimen of at least 15 ml. Obtain a first

voided morning specimen if possible

Keep the specimen container clean. Make sure that the container

won’t come in contact with any article, this may contaminate the

specimen.

After:

Inform the patient that he may resume his usual diet and

medications.

Notify the physician for abnormal findings.

VII. GORDON’S ASSESSMENT

A. Health Perception and Management

Patient can recall being completely immunized

Visits a doctor for consultation

Takes OTC drugs and herbal medications

B. Nutrition/Metabolism

Eats more of fruits and vegetables

Eats dried /preserved fish

Eats her meals three times a day

No allergies on foods

C. Elimination

Voids usually five times a day

Urine color is dark yellow

Defecates usually once a day during morning

D. Activity/Exercise

Patient does household chores

Able to bathe herself

She does simple exercises such as arm exercises by means of shaking and stretching

E. Sexuality/Reproductive

Married

A mother of 3 children

No history of STDs

F. Cognitive/Perceptual

Oriented to people, time and place

Responds to stimuli verbally and physically

Able to read and write

College graduate

In normal thought process

G. Roles/Relationship

Married

With 3 children

Well-supported by the family

Loves her family so much

H. Self –Perception/Self-Concept

Hopeful to be relieve and treated

Manages to practice healthy lifestyle

I. Value/Belief

A Baptist

Has a strong faith in God

Attends Sunday mass

J. Coping/Stress

No traumatic events experienced before

Copes up with problems by talking about it with the family and finds ways to resolve it together

K. Sleep/Rest

No difficulties in sleeping

Have enough rest intervals

L. Medication History

Herbal medications before admission