lyceum of the philippines universitybatangas college of nursing

8/14/2019 Lyceum of the Philippines UniversityBatangas College of Nursing

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Lyceum of the Philippines University-Batangas

College of Nursing

A Case Study

OnCHOLELITHIASIS

In partial fulfillment on RelatedLearning Experiences

Presented by BSN IIIGroup B/C

Submitted to:Mrs. Esteban, Irene R.N

Clinical Instructor

September 25, 2009

Batang as , R eg io nal Ho sp ital (BR H)

Abanil la, Lovely M.Dimaano, Valerie Gra ceGuerra , Sa rah P.

Macausig, Mary Ros eMateo, Katherin e MaeOrn ales, Mark Alvin

Panganiba n, Mhy liss S.Pangilina n, Meria m

Ramos, Maria RonalynRobles, Grego rioTamet a, Ha izel May

Zamonte, Mark Paul M.


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INTRODUCTION


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INTRODUCTIONCh olel it hiasis is the fif th lea di ng ca use of hos pit aliz ati on amon gadult s. The di sea se may als o be oc cu rri ng in pe rs on s wh o are obes e,wh o have hig h ch oles ter ol, or wh o are on chole ste rol lower in g dru gs .In mos t ca ses , gallbl adde r and bi le duct dis eases oc cu r duri ng middl eage. Be twee n ages 20 and 50, th ey 're six ti mes mor e common inwome n, bu t in cide nce in men and wom en becom es eq ual after age 50.Incide nce ris es with ea ch succ ee din g dec ade . Disea ses of thega llbl adder and bil ia ry tra ct are com mon and pa inful con di ti on s thatmay be lif e thre aten in g and mos tl y req uir e surge ry . They are ge ner ally

assoc ia ted with depos iti on of ca lc uli and in fla mmation .This con dit ion oc cu rs wh en ston es pa ss ou t of th e ga llb la dder andlodg e in the hepa tic and comm on b ile du cts , obs tr uct ing the flow ofbil e in to the du oden um. Chola ngit is , in fect ion of the bil e du ct, iscom mon ly associa ted with ch ol edoc holit hia sis. Predi spos in g factors

may in cl ude ba cte ri al or met abolic alte ra ti on of bil e acid s.Chole cy st iti s, acu te or ch ron ic in fla mm ati on of the ga llbl adder isusuall y assoc ia ted wit h a ga ll ston e impa ct ed in th e cy stic du ct thatmay cause pa in ful dis ten ti on of the ga llb la dder . Postch olec ys tec tom ysyn dr ome common ly res ult s from re sidu al ga ll st on es or stric tu re of thecom mon bi le duct . It ma y be occu rs in 1 % to 5 % of all patien tswh os e ga llbl adde rs have bee n surgi ca lly rem ove d and may produ ceri gh t upper qu adr ant abdom in al pa in, bil ia ry coli c, dy spep sia andin dige sti on .


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Ga lls ton es dev el op in ma ny peopl e wit hou t ca using symptom s.The ch ance of symptom s or compl ic ation s res ulti ng fromch olel it hia sis is abou t 20%. Wit h curren t surgi ca l app roa ches, theou tc om e is exc ell en t wit h no rec urr en ce o f sy mpt oms in ov er 99% ofin div idu als.

We have chosen th is case not on ly bec ause it is on ly the ch oi cebu t someh ow, we obs er ve d and not ice d that du rin g ou r age s, 20-60,we can have th is . An d for furt her kn owled ge to con trol thenumber of the ca se , that will st art on us ev en thou gh we are ju ststu den t nurses .


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OBJECTIVESOf THE STUDY


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GENER AL OB JE CTIV ES:This st udy aim s to de velo p thekno wle dge, ski lls and atti tudes ofstudent nu rses thro ugh effective

ut ili zat ion of nurs ing pro cess inde al ing wit h the cours e treat mentof pa tien t with Chol eli thias is.


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Speci fic Object iv esAt th e end of th e s tu dy, th e stud ent nu rs es will be ab le to:1. State the definition of Cholelithiasis.2. D iscu ss the pat ie nts pr ofi le , pa st hea lt h his to ry ,fami ly hist ory, per so na l hist ory, an d socia lhi st ory as wel l as the prese nt il ln es s of thepa tien t.3. Iden ti fy differ en t la bo ra tory exa min ati ons done thepa tien t and it s s ig nif ican t findi ngs.4. Descr ibe the spe cif ic organ that is af fected by thedisease and its function.5. Di scu ss the pat hoph ysio lo gy o f the di se ase .6. Ut ili ze the nursi ng process as a base lin e guid e forthe de li ve ry of heal th car e to th e p ati en t.7. En umer at e an d discus s the di fferen t dru gs th atwer e admi nis te re d t o the pat ien t.8. Pr ovi de inf ormat io n of the pr ognosi s of thedi se ases of the pat ie nt.


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Patient's Profile


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Patient's Profile

Na me : M rs. M.T .Ag e : 3 8 y ears ol dGender : Fema leAd dr ess : Brg y. Sa nt iag o, Ma lvar , Ba tan ga sDate of B ir th : Dec ember 3, 1 970Rel ii gi on : Roman C at hol icNa tiona li ty : Fil ip inoCi vi l Sta tus : Mar ri edDate of Ad mis si on : Se ptember 13, 2 009 ;9;45amChi ef Compl ai nt : Ri ght u pper Qua dra nt P ainAd mit ti ng D ia gnosi s : choleli thia sisAt tend in g Phys icia n : Dr . Ma cal alad


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Clinical Appraisal


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Clinical Appraisal

Mrs . MT , a 38 yea rs ol d female,was admi tted at Bata nga sRegi ona l Hosp ital fo r th e fi fth tim elast Septe mber 13, 20 09 with thechi ef com pl aint of rig ht5 upperqu adra nt pai n. She is unde r thecare of dr. ma calalad. The fi naldi agnosi s is ch olel ith iasi s.


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Mrs. M.T had childhood illness like measleswhen she was 28 years old even though she has

complete immunization. She does not have any

allergies to drugs, animals, insects, or other

environmental agents. It is her fifth (5) time to behospitalized. The reasons for her hospitalizations

before are appendicitis, she undergone

appendectomy last 1990 and post partum

hemorrhage last 2003, she was given IV fluids andhome medication but she cannot remember the

name of the drugs.

Past Health History


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The patient is married to Mr. X, 48 years

old. They have 4 children the eldest is 20

years old followed by 18 years old, next is 16

years old and the youngest is 12 years old.The patient is 7th among 11 siblings. Both her

parents are still alive. They dont have any

history of disease in the family.


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PERSONAL HISTORY

Mrs. M.T used to eat salty foods beforeshe was hospitalized. She prefers to eat

meat, especially the fatty part of the skin of

the meat, than eating fish and vegetables.

She does not drink any alcoholic beverages,she does not smoke too. She is the one who

cooks and shops for her family, but

sometimes her children helps her. When she

does not feel the pain, she does not have any

difficulties in sleeping and doing basic

activities like eating, grooming dressing,

eliminating and locomotion. doing her dailyhouse hold task is her exercise


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Social HistoryThe patients support system in times of stress

is her family. Her husband and her eldest son

helps her in paying her medical care and hospitalbills, we can say that she is bonded to her children

because her eldest son is on the bed side to

monitor her condition. She also considers going to

albularyos because of financial problem.. Mrs..M.T is a college under graduate and is currently

unemployed. Her husband, who is a laborer, earns

225 /day which is not enough for their daily needs

thats why her eldest son started to work in an

early age . They are currently living in a barangay

where houses are close to each other. It is a quiet

and safe environment and there are available

health centers which is just a walking distance

from their house.


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The major stressor experienced bythe patient is her present condition. But

instead of thinking of her illness, she

focused on her house hold task and herchildren. She is able to verbalize

appropriate emotions. While sitting her

bed, she uses non verbal

communication such as eye movementand use of touch.

Psychological Status


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The condition of Mrs. MT started

more than 3 years ago and she kept it toher self. She was not aware that she was

in a serious condition. Last May 16, 2009

she was diagnosed to have

cholelithiasis. She had undergone

ultrasound and given home meds like

Buscopan for her abdominal pain. Last

September 12, at around 10 in theevening, she felt the symptoms like right

upper quadrant abdominal pain, difficulty

of breathing followed by dizziness.

History of Present illness


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The following day her family

decided to bring her in Batangas

Regional Hospital last September 13,2009 at 9:45 am. She had undergone

some laboratory examinations, X-ray,

ECG, and ulrasound. She was advicedto under go cholecystectomy. She is

still under the care of BRH for further

monitoring of her condition.


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Laboratory examination


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Laboratory examinationX-rayLungs field are clearHeart great and vessels are wi thin norm alOt her chest st ruc ture are not remarkab le.Ultra sonog raphi c ReportThe liver is norm al in size wi th di ffuse increa se in parenc hymal echo geni ci ty. It sborders are sm oo th. The intrahep at ic ducts (4 mm) are und ila ted. The vasc ul arstruc tures are unre mark able.The gal lbladder is dist end ed wi th sm oot h unt hi ck ene d wal ls . Mult iple hi gh int ensi tyecho es wi th post eri or sonic shad owi ng wi th aggrega te diameter of 1.1 cm areseen intral um inal ly .The panc rea s and sp leen are both nor mal in size and echop attern. No focal lesi onsnoted.The ao rt a and paraaor ti c areas are unr em arkab le.The kidneys are nor mal in si zean d echop attern.t he right kidney measures

10.8x4.0 x4 .9 cm wi th cor ti cal thi ck ness of 1. 1 cm. the lef t kid ney meas ures10.8x4.4 x5 .0 cm wi th cort ic al thickness of 1.0 cm. the cent ral echoc omplex esare intact .The ur inary blad der is d ist end ed . It s wal ls are u nt hi ckened .The ut erus mea sur es 7.1 x4.1x4 .8 cm wi th homogeneou s echo patt ern. Theend ome trium is tril amina r me asuri ng 8m m. no ad nex al masse s not ed . No fl ui din the posteri or cut d e sac. Ana lysis :Nor mal s iz e w ith fatt y i nf i ltra t ionCho le lithi asis


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Summary of Laboratory results

Mrs. T was und erg one the fo ll ow ing ex am inat ion; Cl ini cal ch emist ry and theresul t are gluco se and creat inin e is no rm al whi le BUN is dec rea se becausethere is ex cessiv e pro tien breakd own. In cl ini ca l chemis try, most of the resul tsof ex am inat ion is norma l excep t pus cel l because the resul t is 1-2 hpf whi ch isabnormal because it ind icates infec tion and UTI . In X-ray the resul t is norm aland in the Ult rasound , the gal lblad der is dist end ed wit h sm oot h unt hi ckenedwal ls . Mul tiple high int ensi ty echo es wi th post eri or soni c shad owi ng withag greg at e d iam et er of 1.1 cm are s een int ral um inal ly.No rm al si ze wi th fat ty in fi lt rat io n.Cho lel ithi asi sNo rm al Ult ra sound of pa nc reas sp lee n,k idneys, uri nary blad der and u ter us


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PATHOPHYSIOLOGY


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Summary of

pathophysiology


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Summary of pathophysiologyCh ol elith iasis or gallstones is cau sed by pr eci pi tation ofsubstances con tai ned in bil e, ma inly chol esterol an d bili ru bi n.The bil e of which gall stones are form ed usual ly i s

supersa tu rate d with cho les te ro l or bil irub inate. Three factorscontr ib ute to th e formation of gal ls ton es: abnormal iti es in thecomp os ition of bil e, sta sis of b il e, and infl amma tion of thegallbl add er. The formation of chol est erol ston es is as soci atedwith ob esity and occu rs mor e frequ ently in women, especial lywomen who have had mu lti pl e preg nan cies or who are ta kin goral contrace ptives . All of th es e factors cause the li ver toex crete more ch oles te rol into th e bile. Gal lbl add er slud ge(th ick ened gallbl ad der mucop rotei n with ti ny trapp edchol este rol cry stals ) is th oug ht to be a pr ecurs or of gall ston es .Slu dge freq uently develop s dur in g pr egnancy, starv at ion , andrap id weig ht l os s.Infl ammati on of the gallb ladder alters the ab sorp tiv echaract eri sti cs of the mucos al layer, all ow ing ex ce ss iv eabsorp tion of wa ter an d bi le salts. the upper rig ht quad rant ,or ep ig as tri c area, is th e usual loca ti on of th e pa in, often withreferred pa in to the back, ab ove the wa ist, the ri ght shoul ders ,and th e rig ht s capu la or the m id s cap ul ar regi on . A f ew p erson sex peri ence pain on the left sid e. The pain usuall y pers ists for 2to 8 hou rs and is f ol lowe d in the up per rig ht qu adr ant.


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ANATOMY AND

Physiology


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ANATOMY AND PhysiologyGa stroin ste sti nal Tra ctThe ga st roin tes tin al tra ct (G IT) con sis ts of a hollow muscu la r tu besta rt in g from th e or al ca vi ty , wh er e food en te rs the mou th, con tin uingthrou gh th e ph aryn x, es oph agu s, stomach and intes tin es to the rect umand anus, wh ere food is exp ell ed. There are va ri ous acce ssory orga nsthat ass ist th e tra ct by secr et in g en zym es to help break down food intoit s com pon ent nutr ie nts. Thus th e saliv ary gl ands , l iv er, pa ncr ea s andga ll bla dder have impor ta nt funct ion s in the dige sti ve sys tem . Food isprope ll ed a lon g the len gt h of th e GI T by per is talti c move me nts of themuscu la r wa lls . The pri ma ry purpo se of the gastroin te sti nal tra ct is tobre ak do wn food in to nut ri en ts , wh ich ca n be absorb ed into th e bo dyto pr ovi de energy .Focu s: GA LLBLA DDER

The ga llbl add er (or cholecy st, somet im es ga ll bladder ) is a sm all org anwh os e funct ion in th e bo dy is t o harb or bi le and aid in the di ges tiv eproc es s.Anatomy The cys tii c du ct con nec ts the ga ll bla dder to th e com mon hepa tic du ctto for m the com mon bi le duct . The com mon bi le rome ro duct then join s the pancre atic duct , anden te rs th rough the hepa topa ncre atic ampu lla at th e majo r dou den alpa pill a. The fundus of the ga llbl add er is the pa rt farth es t from th e du ct ,loca te d by the lower borde r of the liv er. It is at th e same le ve l as the


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Micros cop ic anatomyThe di fferent layer s of the gallb ladd er are as fol lo ws: The gal lb ladder has a simp le co lum nar ep ith elia l l ini ngch aracte ri zed by rece s se s call ed Asc hof f's re ces ses , which are

pou ches in side the li nin g. Under the epi theli um th ere is a layer of conn ec ti ve ti ssue( lami na pr op ria ). Beneath th e conn ecti ve tis sue is a wall of smoot h mu cle(musc u l a ri s e x te r na ) that con tra cts in res pons e toch olecytok in in, a pep tide h ormon e secrete d by th e duoden um. There is es sent iall y no subm ucos a separati ng th e con nectiv eti ssue from seros a and ad ven titi a.Size and Locati on of th e Gal lb ladderTh e gal lbl add er is a hol low, pear-s haped sac from 7 to 10cm (3-4 inch es) lon g an d 3 cm broa d at i ts w idest poi nt. Itconsist s of a fu nd us, bod y and neck. It can hol d 30 to 50 ml of

bile. It li es on the un dersur fac e of th e livers ri ght lobe and isatta ch ed there by areol ar con necti ve t is sue.Structu re of th e Gallbl add erSe rous, mus cu lar, and mu cous layers comp os e th e wall ofth e gallbl add er. The mu cos al li nin g is arr anged in fol ds cal ledru gae, simil ar i n structu re t o th os e o f th e stomach.


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Th e gal lb ladder st ores bil e th at enters it by wa y of thehepatic an d cys ti c du cts . Durin g th is ti me the gal lb ladderconcent ra tes bil e fivefol d to te nfo ld. Then lat er, when digestionoccur s in the stomach and in tes tin es , the gall blad der con trac ts,eje ctin g the con ce ntrat ed bil e into th e duod enum . Ja und ice ayello w disc olorati on of th e ski n and mu cos a, res ul ts whenob stru ction of bil e flow into the duod enu m occ urs . Bi le isth ereby den ied its normal ex it from th e body in the feces .Inste ad , it is absorb ed in to the blood , and an exc es s of b ilepigmen ts w ith a yellow hu e ente rs the blo od and is depos ited inth e ti ssues.

Th e gallb ladder stores ab out 50 m L (1.7 US flui d oun ce s /1.8 Imp eri al fl uid ounces ) of bil e, which is rel eased when foodcont aini ng fat enters th e di gestiv e tra ct, stim ul ati ng thesecretion of ch olec ystok in in (CCK ). The bil e, prod uce d in theliv er, emul sifi es fats and neu tra lizes aci ds in partly digestedfood .Af ter bei ng stored in th e gall bladd er the bil e become s moreconcent ra ted th an when it left the liver, in cre as ing its pote ncyand in tens ifyi ng its eff ect on fats . Mo st d ig estion occ urs in theduo denu m.


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Nursing care plan


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DRugs


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Cefotaxime Sodium

Claforan

2 grams

IV

PTOR


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Anti - infectives

Third generation cephalosporinthat inhibits cell wall

synthesis, promoting osmoticinstability, usually bacteriacidal


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Treatment of infections

caused by susceptiblemicroorganism, especially seriousand life threatening infections.Brain abscess, gonorrhea ,intensive care, and typhoid fever.


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Contraindicated in patient

hypersensitive to cephalosporins.Possibility of cross sensitivity in patientwho have shown allergy in penicillin.

Intramuscular administration incondition with impaired hemostasis andsevere sepsis.


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GI : Anorexia, diarrhea, nauseaand vomiting, abdominal cramps,and colitis

Hema : transient neutropenia,granulocytopenia, leucopenia,eosonophila,thrombocytopenia

and agranulocytopenia


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Assess patients previous sensitivityreaction to penicillin or other

cephalosporins

Assess patients for signs and symptoms

of infection before and during treatment

Assess for allergic reaction andanaphylaxis


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May increase in alkaline

phosphatase, ALT,AST, bilirubin,GST and LDH levels.May increase eusinophil count

May decreased granulocytes,neutrophil and platelet count

May result positive coombs test

result


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Diclofenac Sodium

Abicfen

75 mg

SIVP

PTOR


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Analgesic, muscle relaxant

Inhibits cyclooxygenase anenzyme needed for the

biosynthesis of prostaglandin

result to the analgesics antipyretic and anti inflammatory

effects


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Use mainly as sodium salt for the relief of

pain and inflammation of variousconditions : musculoskeletal and jointdisorder such as ostroarthritis, andankylosing spondilitis, periarticullardisorder soft tissue disorder and otherpainful condition. Post opretiveinflammation.


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Sensitivity to aspirin or non steroidal anti

inflammatory drug ( NSAID ), soft contact lenses,benzyl alcohol, polyethylene glycolmonomethylether 350, and hyaluronate severe renalimpairment, hypovolemia, or dehydration, inpatient with history of hemorrhagic diathesis,serebrovascular bleeding or asthma and inpatient undergoing surgery or hemorrhage.


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Edema , water retention,hypertention, congestive heart failure.

Headache ,vertigo, drowsiness,dizziness,. Rash, urticaria ,fasciitis,photosensitivity, contact dermatitis,

exfoliation (topical).Diarrhea, vomiting , abdominal pain,dyspepsia, peptic ulcer, gastrointestinalbleeding, acute renal failure, nephritic


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Assess characteristics of pain andinflammation.

Check ROM. Monitor possible adverse reactionAssess for hypersensitivity or

anaphylactic reactionAssess hepatic status and functionbefore and during therapy.

Assess patients for eye pain,

inflammation, redness, and swelling.


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May increase ALT, AST,bilirubin, BUN, andcreatinine levels

May increase or decreaseglucose level.


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Parecoxib

Dynastat

40 mg

IVEvery 4 hours


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Non steroidal anti inflammarory drugs

Inhibits prostaglandin

synthesis by selectivelyinhibiting cyclo-oxygenase 2( cox 2 ). Relieve pain nad

inflammation


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Hypersensitibity to parecoxib.

Patients with active peptic ulcerationor gastrointestinal bleeding. Thierdtrimester of pregnancy and breast

feeding. Patient with severe hepaticdysfunction, inflammatory boweldisease. Patient history of coronary

artery bypass graft stroke, heart


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Hypersensitivity, blood

pressure changes,peripheral edema,

dyspnea, insomia,pruritis and oliguria


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Assess patients range of

motionAssess patients degree of

swelling and pain in affectedjoints before andperiodically throughout the


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Prognosis

Prognosis


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PrognosisThe pati ent Mrs . M. wa s ad mi tted at BRH female surg icalwa rd stati on III las t Septemb er 13, 2009, aroun d FO9: 45a mfor the chi ef comp lain of abdomi nal pa in. She is sti ll inmon ito r for dif fere nt kind s of ex ami nati ons . She wa sund erg one fo r ECG last Au gust 18, 2009 she has a normalfin din gs of Sinu s Rhyth m (electrical imp ul se starts at th ereg ul ar rat e and rh yt hm) , and also she un derg on e forultras on og raph y las t June 26, 2009. The physici ans fin d outth at the gall blad der was dis tend ed with smooth, unth ick enedwa ll, mu lti ple hig h echo es with pos terior son ic shadow ing withagg reg ate di amet er of 1 .1 cm seen in ternal ly .

Th e doctor diag nos ed Mrs . M with ch ol elith ias is. Themed ication th at was bee n giv en prior to op erati on(chol ecyste ctomy ) are the fo llow ing : Ce fota xi me 2mg IV foranti bacte ria and Di clof ema c 75mg IV for anti pyr eti c andanalg es ic.

Sh e was schedu led twice for ch olecy ste ctomy but at th e


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Discharge planning

Discharge planning


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Discharge planning

M

E- Instructed the patient to do exercise as tolerated such as walkingT

H- 1. Encouraged patient to increase fluid intake

2. Encouraged patient to eat foods rich in vitamin and nutrition foods

3. Encourage patient to avoid salty and fatty foods

4. Encouraged patient to have enough rest

Advised the patient to a diet as tolerated but preferably avoiding salty and fattyfoods.

O

D

S- Advised patient to go to church every Sunday with their family.


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BIBLIOGRAPHY

BIBLIOGRAPHY


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BIBLIOGRAPHY

>Laboratory Tests & Diagnostic Procedures by Cynthia C. Chernecky & Barbara J.Berger (5th edition)

>Laboratory Tests & Diagnostic Procedures in Medicine by John H. Dirckx, M.D.

>Nurses pocket Guide, Diagnoses, Prioritized Interventions and Rationales by Marilynn

E. Doenges, Mary Frances Moorhouse, and Alice C. Murr (11th edition)

>Fundamentals of Nursing Concepts, Process, and Practice by Barbara Kozier, Glenora

Erb, Audrey Berman, and Shirlee Synder (7th edition)

>davi's drug guide for nurses by: judith hopfer deglin & april hazard vallerand (9th edition)

>Textbook of Medical-Surgical Nursing 11th edition

>Essentials of Pathophysiology, Carol Mattson Porth, 2nd edition


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PictuRes


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Our clinical instructor


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Our clasmates on duty


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With maam esteban


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Zaimon & Joker


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With rose


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lovely, zaimon & rona


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Robles and our

clasmates


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Rose, zaimon & rona


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Valerie


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With maam esteban

S f th f ll i


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Sorry, for the following

members who are notincluded in thispictures..

Kat-kat mateo

Pangilinan, meriam

lyceum of the philippines universitybatangas college of nursing

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