INTRODUCTION Cholelithiasis is the presence of one or more calculi (gallstones) in the gallbladder and is the fifth leading cause of hospitalization among adults. The disease may also be occurring in persons who are obese and who have high cholesterol. In most cases, gallbladder and bile duct diseases occur during middle age. Between ages 20 and 50, they're six times more common in women, but incidence in men and women becomes equal after age 50. Incidence rises with each succeeding decade. More serious complications include cholecystitis; biliary tract obstruction (from stones in the bile ducts or choledocholithiasis), sometimes with infection (cholangitis); and gallstone pancreatitis. Diagnosis is usually by ultrasonography. If cholelithiasis causes symptoms or complications, cholecystectomy is necessary. Cholecystitis, acute or chronic inflammation of the gallbladder is usually associated with a gallstone impacted in the cystic duct that may cause painful distention of the gallbladder. Postcholecystectomy syndrome commonly results from residual gallstones or stricture of the common bile duct. It may be occurs in 1 % to 5 % of all patients whose gallbladders have been surgically removed and may produce right upper quadrant abdominal pain, biliary colic, dyspepsia and indigestion. Gallstones develop in many people without causing symptoms. The chance of symptoms or complications resulting from cholelithiasis is about 20%. With current surgical approaches, the outcome is excellent with no recurrence of symptoms in over 99% of individuals.
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INTRODUCTION
Cholelithiasis is the presence of one or more calculi (gallstones) in the gallbladder and is the fifth
leading cause of hospitalization among adults. The disease may also be occurring in persons who are
obese and who have high cholesterol. In most cases, gallbladder and bile duct diseases occur during
middle age. Between ages 20 and 50, they're six times more common in women, but incidence in men
and women becomes equal after age 50. Incidence rises with each succeeding decade. More serious
complications include cholecystitis; biliary tract obstruction (from stones in the bile ducts or
choledocholithiasis), sometimes with infection (cholangitis); and gallstone pancreatitis. Diagnosis is
usually by ultrasonography. If cholelithiasis causes symptoms or complications, cholecystectomy is
necessary.
Cholecystitis, acute or chronic inflammation of the gallbladder is usually associated with a
gallstone impacted in the cystic duct that may cause painful distention of the gallbladder.
Postcholecystectomy syndrome commonly results from residual gallstones or stricture of the common
bile duct. It may be occurs in 1 % to 5 % of all patients whose gallbladders have been surgically removed
and may produce right upper quadrant abdominal pain, biliary colic, dyspepsia and indigestion.
Gallstones develop in many people without causing symptoms. The chance of symptoms or
complications resulting from cholelithiasis is about 20%. With current surgical approaches, the outcome
is excellent with no recurrence of symptoms in over 99% of individuals.
gallbladder contracts as it tries to release bile and expel
the stone
Biliary Colic characterized as right upper quadrant pain that may radiate to sternum, right shoulder and right scapula
nausea and vomiting
decrease production of bile in the GI tract
disruption in normal digestion process
indigestion flatulence pain after eating
fatty meal
infection
decreased emulsification
of fats
Increased concentrationof fats in blood
↑ Total Cholesterol
↑Triglycerides
gallstones in the gallbladder
LABORATORY DATA
Laboratory Procedure Date Ordered Results Normal Values
Analysis and Interpretation of
Results
HEMATOLOGY REPORT
Hemoglobin
Hematocrit
WBC Count
Differential Count:
Neutrophils
Lymphocytes
January 7, 2011
15.7
0.47
13.4 x 10 g/L
0.82
0.20
12.5-17.5 g/dL
.40-52
5-10 x 10 g/L
.45-.65
.20-.35
> Normal
> Normal
> Elevated. It indicates inflammation and possible infection.
> Elevated. It indicates an acute infection.
> Normal
Laboratory Procedure Date Ordered Results Normal Values
Analysis and Interpretation of
ResultsBlood Chemistry
Glucose (FBS)
Blood Urea Nitrogen
Creatinine
Cholesterol
Triglycerides
HDL
LDL
SGOT
SGPT
January 3, 2011
120.2
14.4
0.6
210
205.7
22.0
135.0
30.1
88.1
70-105 mg/dL
7-18 mg/dL
0.40-1.40 mg/dL
150-200 mg/dL
44-148 mg/dL
30-75 mg/dL
66-178 mg/dL
5-34 U/L
4-36 U/L
> Elevated. It indicates hyperglycemia
> Normal
> Normal
> Elevated. There is decreased production of bile in the GIT due to obstruction causing decreased emulsification of fats.
> Elevated. There is decreased production of bile in the GIT due to obstruction causing decreased emulsification of fats.
> Decreased. “Good cholesterol” is decreased in amount.
> Normal
> Normal
> Elevated. Suggest possible liver disease
Diagnostic Test Date Ordered Result
Abdominal Ultrasound January 5, 2011Abdominal sonography reveals a liver, within normal in size with no solid mass or cyst noted.There are focal fatty infiltration seen in the liver.The intrahepatic and common ducts are not dilated with common duct measuring 0.5 cm in diameter.There are multiple calculi in the gall bladder one measuring 0.9 cm. The gall bladder wall is thickened measuring 0.4 cm with tenderness elicited on pressure of the gall bladder.The pancreas is normal in size and echogenicity with the head and the body seen with no mass or cyst demonstrated.The proximal abdominal aorta is seen and not dilated.The spleen is homogeneous and not enlarged with no mass or cyst outlined.The kidneys are within normal in sizes and echogenicity with no solid mass, cyst, calculus or hydronephrosis demonstrated.There is minimal ascites in the Morrison’s pouch.There is pleural effusion seen bilaterally.
DRUG STUDY
Drug Name Action Dosage Indication Contraindication Side Effects Nursing ResponsibilitiesGeneric Name:Cefuroxime
Classification:Cephalosporin
Therapeutic Classification:Antibacterial
Cefuroxime binds to one or more of the penicillin-binding proteins (PBPs) which inhibits the final transpeptidation step of peptidoglycan synthesis in bacterial cell wall, thus inhibiting biosynthesis and arresting cell wall assembly resulting in bacterial cell death.
> Explain to the client the purpose and action of the drug.> Administer slowly> Monitor for kidney and liver function test> Advise patient to immediately report rash or bleeding tendency.
Drug Name Action Dosage Indication Contraindication Side Effects Nursing Responsibilities
Generic Name:Ranitidine
Therapeutic classification:Antiulcer drug
Ranitidine blocks histamine H2-receptors in the stomach and prevents histamine-mediated gastric acid secretion. It does not affect pepsin secretion, pentagastrin-stimulated factor secretion or serum gastrin.
> Explain to the client the purpose and action of the drug.> Administer slowly> Monitor CBC and liver function tests.
Drug Name Action Dosage Indication Contraindication Side Effects Nursing
ResponsibilitiesGeneric Name:Ketorolac
Classification:NSAIDS
Therapeutic classification:Analgesic, Anti inflammatory
Ketorolac inhibits prostaglandin synthesis by decreasing the activity of the cyclooxygenase enzyme.
30 mg IVP q 8
Moderate to severe pain
>Hypersensitivity to aspirin>hypovolemia or dehydration> history of peptic ulcer or coagulation disorders> moderate to severerenal impairment> GI bleeding> Cerebrovascular bleeding
GI: dry mouth, GI ulcer, nausea, bleeding and perforation
CNS: drowsiness, hypotension, headache
Cardio: bradycardia, chest pain
Skin: fever, sweating , rash, pallor, edema
Others: liver function changes
> Explain to the client the purpose and action of the drug.> Administer slowly> Instruct patient to avoid aspirin products and herbs during therapy.> Monitor patient for CNS changes> Provide safety
Drug Name Action Dosage Indication Contraindication Side Effects Nursing
ResponsibilitiesGeneric Name:Hyoscine N butyl bromide
Therapeutic classification:Antispasmodic
Hyoscine competitively blocks muscarinic receptors and has central and peripheral actions. It relaxes smooth muscle and reduces gastric and intestinal motility.
1 ampule IVP now
Gastrointestinal tract spasm
Narrow-angle glaucoma, acute haemorrhage, paralytic ileus, tachycardia due to cardiac insufficiency, myasthenia gravis
CNS: postural hypotension, drowsiness, dizziness, headache, memory loss
Skin: flushing, dry skin, erythema, increased sensitivity to light, rash
> Explain to the client the purpose and action of the drug.> Administer slowly> Check for mental status changes> Provide safety> Evaluate fluid intake and output.
S – “Masakit ang tiyan ko”, as claimed With pain scale of 7/10
O > grimace noted > muscle guarding behavior on the right upper quadrant > pain is aggravated by abrupt movements > pain is referred to the right shoulder and right scapula > use of abdominal muscles in breathing > diaphoretic > slightly exaggerated depth of respiration > tachypneic (25 cpm) > irritable at times
Acute pain r/t inflammation of the gall bladder
Scientific Explanation:As the gallbladder is inflamed and tries to contract to release bile and expel the obstructed stone it produces spasm.
Within 1 hour of proper nursing intervention the patients’ pain scale of 7/10 will decrease to 5/10.
> Assist and place on the preferred position > Assist when changing position > Encourage deep breathing exercise > Provide comfort measure such as back rub > Encourage verbalization of feelings > Eliminate additional stressors or sources of discomfort whenever possible > Administer analgesics and antispasmodic for as ordered
> promote comfort
> to conserve energy > to relieve muscle tension > to promote comfort
> decreases anxiety
> to divert the attention of the patient and to relieve muscle tension
> Decreases spasm and relieve the patient from pain
After one hour of proper nursing intervention the patients’ pain scale of 7/10 will be decreased to 5/10 as manifested by:
a. lessen grimaceb. lessen muscle
guarding behavior
c. lesser use of accessory muscles in breathing
d. RR will decrease within the normal range of 12-20 cpm
O > weak in appearance> flushed skin> irritable > febrile: body temperature of 38.1 degree Celsius > tachycardic: 103 > tachypneic: 24 cpm
Altered thermoregulation related to inflammation and presence of infection of the gallbladder
Scientific Explanation:The presence of inflammation and infection can activate immune response resulting to increased body temperature.
Within 30 minutes of proper nursing intervention the patients’ pain scale of 38.1 will decrease to 37.5 degree Celsius
> Remove excessive clothing
> Provide tepid sponge bath
> Maintain patient in bed rest
> Increase fluid intake.
> Encourage patient to eat fruits rich in Vitamin C
> Encourage patient to eat foods rich in carbohydrates and protein
> Administer medication as ordered
> promote cooling effect
> To help lowered body temperature and promote cooling effect. > To decrease metabolic demands > To replace loss fluids.
> To boost immune system
> To meet metabolic needs of the body.
> Antipyretic drugs help in lowering body temperature.
After 30 minutes of proper nursing intervention the patients’ pain scale of 38.1 will be decreased to 37.5 degree Celsius as evidenced by:
a. moist skin b. afebrile
EVALUATION
The patient undergoes cholecystectomy last January 8, 2011. The patient was given take home medications for management of pain and antibiotics as prophylaxis from surgical infection. Daily wound care was taught to the patient. Avoidance of strenuous activities was also advised. The patient was also encouraged to eat foods rich in protein and Vitamin C for wound healing and collagen formation. The prescribed diet is low fat and law salt since the gallbladder is removed. The client was also advised to comply with the follow up check-up for the removal of sutures.
After the surgical treatment done and postoperative management, patient condition is now stable.