CHOLELITHIASIS

PRESENTED BY: 07DIN0232

GROUP 33 ( 2/2007 )

LEARNING OBJECTIVE

At the end of my case study I will be able to :

1.Explain the Anatomy & Physiology of gall bladder.

2.State the definition of cholelithiasis.

3.Describe Statistic of cholelithiasis.

4.State the Etiology of cholelithiasis .

5.Explain the Risk Factors of cholelithiasis.

6.Explain the Pathophysiology of cholelithiasis.

7. Explain the Clinical Manifestation of cholelithiasis.

8. State the Complication of cholelithiasis.

9. State the Investigation of cholelithiasis.

10. Explain the Treatment of cholelithiasis.

11. Described the care of cholelithiasis patient by using

the nursing process.

12. Explain the health education to the patient with open

cholecystectomy

INTRODUCTION

ON ADMISSION

My patient is Mr.A from Pulau Pangkor was

admitted to Ipoh Specialist Hospital on 25 May

2009 @ 8.25 pm under Dr.K (general surgeon). He

is a 40 years old malay man. He is a contractor. He

is married and he is very friendly, cheerful person.

Mr.A had admitted because complaint of pain on & off at

right upper quadrant of abdomen since 1day. This problem

had disturb his activity daily living for sometimes and at

last he decided to do operation as suggested by Dr.K

where he was suspected with cholelithiasis.

NURSING ASSESSMENT

PATIENT’S PERSONAL DATAName : Mr AMRN : 23456Bed No : 7xxAge : 40yearI/C No : 69xxxx-08-xxxxRace : MalayReligion : IslamOccupation : ContractorLanguage Spoken : B.MalaysiaTel No : 012-5yyxxxxNext of Kin : Mrs SRelationship : Wife

Cont..Consultant : Dr KDate/Time of Admission : 25/5/09 @ 8.25pmReason For Admission :c/o pain at right upper quadrant of abdomen on and off x1/7Diagnosis : CholelithiasisMedical History : Diabetic Mellitus <1yearsSurgical History : NilFamily Medical History : Mother-HypertensionCurrent Medication : Gliclazide 80mg dailyAllergies : Nil

Cont…

• Mode on Admission : Walk in• Mental Status : Orientated• Level of Conciousness : Concious• Emotional Status : Anxious

Physical Examination

FRONT BACK

PICTURE 1:PHYSICAL EXAMINATION

Pain on and off at the right upper quadrant

ACTIVITIES OF DAILY LIVING

BREATHINGDo not have any problem in breathing.

ELIMINATION BOWELDo not have any problem in open bowel

andno changes noted.Also do not take any medication for bowel movement.

Cont…. BLADDER Do not have any problem in passing urine

anddo not get up frequently at night to pass

urine.

EATING AND DRINKINGDo not have any allergies and do not haveproblem with eating and drinking.

PERSONAL HYGIENEAble to maintain his person hygiene

Cont…. MOBILITY Able to move around.

COMMUNICATION, HEARING AND VISIONCan communicate as well during the

interview. Able give feedback beside his hearing and visions are Normal.

SLEEPINGDo no have any problem in sleeping

ANATOMY AND PHYSIOLOGY

OF GASTROINTESTINAL

SYSTEM

PICTURE 2:THE ORGAN OF THE DIGESTIVE SYSTEM

GALL BLADDER A small pear-shaped sac attached to

the posterior surface of the liver by connective tissue

that is located under the liver.

Gall bladder is divided into 3 parts:

1)Fundus or expanded end 2) Body or main part 3) neck

PICTURE 3:PICTURE OF GALLBLADDER

Functions Of The Gall Bladder

Reservoir for bile

Concentration of the bile by up to 10 or 15 fold, by absorption of water

through the walls of the gall bladder

Release of stored bile.

When the muscle wall of the gall bladder contracts bile passes through the

bile ducts to the duodenum.

Contraction is stimulated by:

- The hormone Cholecystokinin (CCK), secreted by the duodenum

- The presence of fat and acid chyme in the duodenum.

- Relaxation of the hepatopancreatic sphincter (of Oddi) is caused by CCK

and is a reflex response to contraction of the gall bladder.

Composition Of BileAbout 500mls of bile are secreted by liver daily.Bile consists of:

-Water -Mineral salts -Mucus -Bile pigments, mainly bilirubin -Bile salts, which are derived from the primary bile acids, cholic acid and chenodeoxycholic acid.

CholesterolFatty acidsElectrolytes

DEFINITION OF

CHOLELITHIASIS

Cholelithiasis is the formation of stone (calculi) within the gall bladder or biliary duct system. (Lemone.P,Burke.K (2004)Medical-Surgical Nursing, 3rd ed. United States,Pearson Education.P574.)

Cholelithiasis is presence of gall stones in the bladder

or bile ducts. (Weller.B.F(2003)Nurses’ Dictionary,23rd ed. London, BailliereTindal.P85.)  

   

 

Calculi, or gall stones, usually form in the gall bladder from the solid constituents of bile;

they vary greatly in size, shape and composition. (Smeltzer.S.C, Bare.B (2004) Medical-Surgical Nursing,10th ed. United States, Lippincott Williams &Wilkins.P1126.)

STATISTIC

Jan Feb March April May June0

2

4

6

8

10

12

FemaleMale

Statistic of Patient With Cholelithiasis in ISH From January-June 2009

ETIOLOGY

Etiology

Cirrhosis Hemolysis-(History of Thalassemia) Infections of biliary tract Ileal resection or disease Rapid weight loss High Cholesterol

Risk Factors1. Family history of Cholelithiasis.

2. Race or ethnicity - Native American have higher incidence

3. Cystic fibrosis -A hereditary disorder with accumulation of excessively thick

and tenacious mucus and abnormal secretion of sweat and

saliva.

4. 5F (i) Female - estrogen increases the concentration of cholesterol in bile

(ii) Fat -Obesity also slows down the emptying of the gallbladder

iii) Fertile -estrogen is increases in the body, it cause concentration of

cholesterol in bile and slowed gallbladder movement.

(iv) Forty -Especially, women. Because changes of the hormone and

slow down of the digestion process.

(v) Fair -People who is fair have more chances to get cholelithiasis.

COMPLICATION1)Cholecyctitis -Inflammation of the gall bladder due to cholelithiasis.

2)Pancreatitis-If gall bladder stone blocking the lower end of the common bile duct where it enters the duodenum may obstruct secretion from the pancrease.

3)Cholangitis-When the common bile duct is blocked for a substantial period of time, certain bacteria may findtheir way up behind the stone and cause inflammation of the bile duct.

PATHOPHYSIOLOGY

Cholesterol / Fat

Normal constituent of bile is insoluble in water.

Decrease bile acid synthesis and increasecholesterol synthesis in the liver.

Resulting bile supersaturated with cholesterol

Form cholesterol stone

Pain at right upper quadrant of abdomen

CHOLELITHIASIS

PATHOPHYSIOLOGY OF CHOLELITHIASIS

CLINICAL MANIFESTATION

1)Asymptomatic

2)Symptomatic Abdominal -Epigastric discomfort -chronic, steady spasmodic pain at right upper quadrant

after a meal(especially after a large meals or fatty meals) contraction of gall bladder cause friction with gall stone. -Pain may radiate to the back or below the right shoulder

blade the thoracic nerve supply is surrounding the area

Heart burn sensation*less bile juice is release from the gall bladder, so

indigest fatty food cause the sensation.

Sweat and pallor*Due to excruciating pain cause by the stone.

Nausea and vomiting*poor digestion of the food intake

Jaundice*excessive bilirubin in the blood

Itching of skin*high urea in the body so it will cause itching of the skin

Stool clay in color*cystic duct is block, the bile can’t supply to the

duodenum

Urine dark in color*cystic duct is block, the bile that contain high bilirubin

that secrete from the liver will direct from the blood vessels go to kidneys to filter out

Investigation

INVESTIGATIONDate of Received : 22/04/2009Date of Report : 23/04/2009

HAEMATOLOGY EXAMINATIONTotal RBC : 5.5 M/cmm (M=4.5-6.0,F=4.0-5.5)Haemoglobin : 16.2 g/dl (M=12.5-17.5,F=11.5-15.5)PCV : 48 % (M=40-50,F=37-45)MCV : 87 fl (82-98)MCH : 29 pg (27-33)MCHC : 34 % (31-35)RDW : 13.3 % (11.0-16.0)Total WBC : 12,600 /cmm (4,000-11,000)

DIFFERENTIAL COUNT ABSOLUTE VALUEPolymorphs : 61 % (50-70) 7686 /cmm (2000-7500)Lymphocytes : 35 % (20-40) 4410 /cmm (1000-4000)Monocytes : 3 % (2-6) 378 /cmm (200-1000)Eosinophils : 1 % (1-4) 126 /cmm (20-600)Basophils : 0 % (less than 1%) 0/cmm (<100)

LIPIDS STUDIESTotal Cholesterol : 276 mg/dl ( <200 )

Triglycerides : 122 mg/dl ( <150 )

HDL – Cholesterol : 50 mg/dl ( >40 )

LDL – Cholesterol : 202 mg/dl ( Optimal <100 )

Total Chol./ HDL-Chol. : 5.5( Risk Indicated if >4.5 )

LIVER FUNCTION TESTTotal Protein : 7.4 gm/dl ( 6.4-8.3 )

Albumin : 4.8 gm/dl ( 3.9-5.0)

Globulin : 2.6 gm/dl ( 2.1-3.6 )

A/G Ratio : 1.8 (1.0-2.2)

Total Bilirubin : 1.0 mg/dl( up to 1.2 NB : <10.0 )

SGOT/AST : 19 U/L ( 8-37 )

Cont…

SGPT/ALT : 41 U/L ( 5-44 )

SAP : 102 U/L( >15yrs : 40-150 <15yrs : <750 )

Gamma GT : 67 U/L( M 12-64 F 9-36 )

RENAL FUNCTION TEST

Sodium : 140 mmol/L( 132 – 143 )

Potassium : 4.2 mmol/L( 3.5 – 5.1 )

Chloride : 106 mmol/L( 98 – 107 )

Urea : 27 mg/dl( Adults <50yrs: M 19-44 F 15-40 )

Creatinine : 0.9 mg/dl( M 0.7-1.3 F 0.6 – 1.1 )

Cont…

Uric Acid : 3.8 mg/dl( M 3.5 -7.2 F 2.6-6.0 )

Calcium : 9.4 mg/dl( 8.4 – 10.2 )

Phosphorus : 3.8 mg/dl( 2.4 – 4.7 )

HISTOLOGY REPORT

Date : 28/5/2009 Clinical historyGall stones GROSSSpecimen fixed overnight.Consist of a rigid gall bladder measuring 5.5cmx4.5cm in dimension.It contains 3 perforated areas in the wall which is thick and haemorrhagic.Representative sections sumitted in two blocks

HISTOLOGYSections show a gall bladder with extensive ulcerations of the mucosa which is replaced by abundantrecent haemorrhages in the ulcerated areas,accompanied by someAcute Inflammatory infiltrates as well.The residual epitheliallining show reactive nuclear changes but no atypia.The wall is much thickened by oedema,fibrosis and multiple Aschoff-Rokitansky sinuses.

INTERPRETATIONGall bladder – Acute haemorrhagic cholecystitis

Pre-Op Management

Pre Op-Management

1. Explain to the patient regarding the surgery that would be done to the patient.

R: To give additional knowledge to the patient. I: I explain the surgery of open cholecystectomy that would be done to the

patient 2. Monitor vital signs of the patient and obtained the patient data such as

weight, lab investigations result or radiological result, case notes and the medication chart.

R: As a baseline data for further interventions and as a references for any treatment done.

I: I check the patient’s vital signs before going for open cholecystectomy and provide the case notes.

3. Make sure the consent of the patient is written before the surgery. R: To have an agreement and cooperation between patient and medical

staff.I: I check the consent from the case notes and make sure it is written

before the surgery. 4. Do the checklist for the surgical interventionsR: to prepare the patient before the operation.I: I check the patient for the shaving part, any dentures and also any

history of implant done. 5. Keep patient NBM (nil by mouth) at least 8 hours before the surgery.R: To prevent the complication during surgery such as nausea and

vomiting, aspiration in lung because of the effect of anaesthesia.I: I explain to the patient that he have to fast before the operation at

least 8 hours. He fasting at 12 midnight.

6. Bowel elimination and micturation must be empty before the surgery.

R: To comfort the patient and to reduce the risk of infection due to involuntary muscles of the elimination organ.

I: I inform to the patient that he must empty the bowel and his bladder before he goes for surgery.

7. Provide all the information regarding the patient in the case notes,

medication chart and other report for the surgery.R: For future references and the treatment from the doctor.I: I send the patient with complete data of the patient inside the case

notes to the operation theater.

Post-Op Management

Post-Op Management

1. Received the report from OT (Operation theater) staff for the information regarding the surgery that have been done.

R: For implement the proper treatment after the surgical intervention.I: I listen the report that been pass over to the staff nurse. The patient

has done Open Cholecystectomy. 2. Observe the dressing site for blood stain and present of drainage

tube. R: To obtain baseline data to plan appropriate nursing interventions.I: I observe the dressing and the drainage of the patient for any

leakage, the amount etc. 3. Monitor vital signs of the patient hourly for 6 hours until stable. R: To detect any abnormalities after surgical interventions.I: I check the vital signs of the patient hourly until it is stable.

4. Observe any signs and symptoms of bleeding and infection at the wound site frequently.

R: As prophylactic interventions from any complication such as hypotension.I: I check the dressing site and the amount of drainage frequently and

written in Intake and output chart. 5. Allow sips of water and increase the amount gradually.R: To prevent dehydration and comfort the patient.I: I encourage the patient to take sips of water and increase the amount

gradually.

6. Inform the patient to rest in bed at least 6 hours after the surgical intervention.

R: To reduce the patient pain and excessive bleeding.I: I explain to the patient that he must rest at least 6 hours after the

operation.

7. Advice the patient to support the abdomen when coughing.R: To prevent the pressure exerted at the wound site that cause

bleeding and ruptured.I: I instruct the patient to support the abdomen when coughing. He

have to put both hand to hold the pressure at the wound site. 8. Monitor intake and output of the patient strictly.R: To detect amount of oral intake, drainage and urine of the patientI: I check patient’s intake and output of the patient in the I/O chart.

Medication

Medication

Tab Dormicum 7.5mg ONIV Maxolon 10mg TDS IV Augmentin 1.2gm 8hTab Ciprofloxacin 500mg BDTab Panadeine II/II TDS PRN

Generic Name Midazolam DBL

Group Sedatives

Date On 25/5/2009

Date Off 27/5/2009

Dose order 7.5mg ON

Route Oral

Indication Conscious sedation prior to short surgical,diagnostic,therapeutic or endoscopic procedures,induction of anaesth,preliminary to administration of other anaesth agents,sedation in ICU,pre-op sedation

Adverse Reaction Muscle stiffness.induration,headache,pain,redness,apnoea,nausea,vomiting,coughing,drowsiness,phlebitis,resp depression,variation in BP and pulse rate.

Contraindication Myasthenia gravis,neuromuscular disorder,shock/coma,acute alcohol intoxication,acute narrow angle glaucoma.

Dormicum

IV Maxolon

Generic Name Metoclopramide

Group Antiemetic

Date On 25/5/2009

Date Off 27/5/2009

Dose Order 10mg TDS

Route Intravenous

Indication Dyspepsia,flatulence,digestive disorder associated with hiatus hernia,peptic ulceration,reflux oesophagitis,gastritis,duodenitis,cholelithiasis,nause&vomiting

Adverse Reaction Rarely extrapyramidal reactions,tardive dyskinesia,raised serum prolactin levels,mild sedation

Contraindication -

IV Augmentin

Generic Name Clavulanate

Group Penicillins

Date On 25/5/2009

Date Off 27/5/2009

Dose Order 1.2gm 8hourly

Route Intravenous

Indication Resp tract,skkin,soft tissue,GUT infection,septicemia,peritonitis,post-op infection & osteomyelitis

Adverse Reaction Diarrhoe,indigestion,nausea,vomiting,candidiasis,rash,cholestatic jaundice,crystaluria,haemolytic anemia,CNS disturbances.

Contraindication Hypersensitivity to penicillins,possible cross sensitivity with other beta-lactams.History of penicillin-associated cholestatic jaundice/hepatic dysfunction

Tab Ciprofloxacin

Generic Name Cifran

Groupinfections Antibiotics

Date On 27/5/2009

Date Off 28/5/2009

Dose Order 500mg BD

Route Oral

Indication Resp tract,ocular,abdominal ,skin&soft tissue,bone&joint;otitis media,sinusitis,UTI&kidney infections:genital infections including adnexitis,gonorrhea&prostatitis;septicemia.

Adverse reaction GI,CNS&CVS disturbances including dizziness,skin reactions,acute renal failure secondary to interstitial nephritis,haematuria,crystalluria,joint swelling,visual disturbance.

Contraindication Hypersensitivity to quinolones.Children,adolescents,pregnancy,lactation.Drugs that inhibit peristalsis

Tab Panadeine

Generic Name Codeine Phospate

Group Analgesics & Antipyretics

Date On 26/5/2009

Date Off 27/5/2009

Dose Order 2Tab TDS PRN

Route Oral

Indication Headache,dysmenorrhea,musculoskeletal pain,myalgias,neuralgias,after dental work or tooth extraction.Condition accompanied by discomfort & fever,as in common cold & viral infection

Adverse Reaction Allergic reactions,GI upsets,constipation,CNS disturbances,dry mouth

Contraindication -

Nursing Care Plan

Pre-Operation1. Alteration in comfort; Pain related to inflammation

of the gallbladder

2. Alteration in emotional status; Anxiety related to lack of understanding regarding to the surgical intervention (open cholecystectomy)

Post-Operation3. Alteration in comfort; Pain related to surgical incision

(open cholecystectomy).

4.Potential infection related to surgical incision

5. Knowledge deficit related to home care management

Next Slide

Nursing Care Plan

1

Date & Time : 25 / 05 / 2009 @ 09.30pm

Nursing Diagnosis: Alteration in comfort; Pain related to inflammationof the gallbladder. Supporting data:1. Patient verbalized that the pain is at his right upper

quadrant of abdomen.2. Patient’s facial expression shows that he is in pain.

Goal: Patient’s pain will be reduced gradually within 1hour after nursing intervention carried out and during hospitalization.

Nursing Intervention

1.Assess patient’s general condition, facial expression and complain.-The characteristics of pain : mild, moderate,severe, worst-Location of pain: right upper quadrant of the abdomen-Frequency of painR) - As a baseline data and to plan further nursing intervention.(I) I assessed Mr.A’s level of pain by using the pain scale. Patient said that the pain scale is 6 and the location is right upper quadrant of the abdomen.

2) Monitor Mr.A’s vital sign.R) Increase reading in vital sign may indicate pain

experience.I ) I did check Mr.A’s vital sign and the reading is

140/90mmHg.

3) Administer medication as ordered by Dr. K,sedatives – Tab Dormicum 7.5mg.

R) To reduce pain in patient.(I) I administer the medication on the night duty under

SRN supervission.

4) Advice patient to rest in bed.R) To reduce or minimize mobility which might indicate pain.(I) I encourage Mr.A to rest in bed and advice him not

to move too much because it will indicate pain.

5) Provide divertional therapy for the patient such as turn on the television.R) To divert patient’s mind from thinking of their pain. I ) I encouraged Mr.A to watch television so that he will not think about his pain. I help Mr.A to turn on the television.

6) Provide condusive environment to the patient.R) To give patient calmness and not to think of the pain.(I) I advice the wife not to allow too many visitor in so that

it can maintain not to be too crowded or too noisy.

Date & Time: 25/ 05 / 2009 @ 10.30pm

Evaluation :Patient pain had reduced after the nursing intervention carried out and during hospitalization.

Supporting Data:- Patient verbalized less pain at the right upper quadrant of the abdomen.- Patient appear more comfortable.

Back

Nursing Care Plan 2

Date & Time: 26 / 05 / 2009 @ 8.00am

Nursing Diagnosis:Alteration in emotional status; Anxiety related to lack ofunderstanding regarding to the surgical intervention (open cholecystectomy).

Supporting data: 1. Patient’s facial expression showed that he was very anxious

and keep asking about the surgery.2. Mr.A also verbalized that he felt very anxious because this

is the first time he is going for an operation.

Goal:Mr.A will feel less anxious, more calm and give co-operation within 1 to 2 hours after nursing intervention carried out and during hospitalization.

Nursing Intervention:1. Assess the patient level of knowledge by asking the question

regarding the surgical interventions (Cholecystectomy) that would be done.

R)To obtain baseline data to plan appropriate nursing interventions.

(I)I assess the patient level of knowledge by asking the patient how far he knows about the procedure that would be done to him.

2) Reinforce doctor’s explaination about his disease and surgery.R) To provide patient’s further understanding and reduce anxiety.(I) I explained to Mr.A again about the explaination given by the

doctor. I explained to patient about the purpose of the operation.

3) Encourage patient to express doubt and worries regarding his disease and procedure(open cholecystectomy)

R) To provide confident in patient.(I) I asked Mr.A to express about anything that he don’t

understand and encourage him to ask more questions.

4) Answer patient’s question by using simple words.R) For patient better understanding.(I) I answered Mr.A question by using simple word and

avoid using medical terms.

5) Explain to patient the purpose of every procedure performed such as skin preparation (shaving at umbilical area).R) To relay patient’s anxiety for better co-operation .(I) I explained Mr.A about the purpose of skin preparation is to prevent from infection during operation.

6) Provide divertional therapy such as watching television and reading newspaper.

R) To divert patient mind from thinking about the disease.(I) I switch on the television for my patient and tuned to

the channel that he request.

7) Encourage family member to accompany patient.R) To provide family emotional support and reduce

anxious.(I) I encouraged his wife to stay with him, this will make

him more supportive and confidence.

Date & Time: 26 / 05 / 2008 @ 9.00am

Evaluation :Mr.A appear less anxious and more calm.

Supporting data: 1) Mr.A facial expression looked more calm.

Back

Nursing Care Plan

3

Date & Time: 26 / 05 / 2009 @ 2.00pm

Nursing Diagnosis: Alteration in comfort; Pain related to surgical incision (open cholecystectomy).

Supporting data: 1. Mr.A complain of pain at the surgical site.2. Patient’s facial expression show that he is in pain.

Goal: Patient will verbalize pain tolerated within 1 hour after nursing intervention carried out and during hospitalization.

Nursing Intervention:

1) Assess patient’s general condition and the severity of pain mild, moderate, or severe through facial expression and verbalization.

R) To plan appropriate nursing intervention.(I) I assess Mr.A severity of pain by his verbalization and

facial expression. Mr.A told me that his pain is moderate at incision site.

2) Check patient’s vital sign every hourly for 6 hours.R) Increase in blood pressure and tachycardia may indicate

pain.(I) I checked Mr.A’s vital sign, it is slightly high, blood

pressure 140/90 mmHg and pulse is 90 bpm.

3) Administer analgesic as prescribed by the doctor.

R) To reduce pain.

(I) Patient was in PCA(patient controlled analgesia)-pethidine 25mg for 2days post op.

4) Position patient in position that patient desire.

R) To reduce pain and tightness at the surgery site.

(I) I encouraged Mr.A to lie in his desires position because it make him feel more comfortable and Mr.A had told me that he prefer to lie in recumbent position.

5) Encourage patient to do deep breathing exercise.

R) To reduce the pain by relaxing the sphincter muscle.

(I) I teached Mr.A the way to do deep breathing exercise and I encourage him to do it when he felt the pain.

6) Encourage patient to rest in bed.R) Excessive movement will increase pain.(I) I advised Mr.A to rest in bed and I put his all

his belonging near to his reach.

7) Provide divertional therapy to the patient.

R) To divert patient’s mind from thinking of the pain.

(I) I help Mr.A to switch on the television and tuned to the channel that he wants to watch.

8) Inform doctor if the pain still persists.

R) For further treatment and management.

(I) Staff nurse did not inform doctor because patient pain had reduced.

Date & Time: 26 / 05 / 2009 @ 3.00pm

Evaluation :Mr.A verbalized pain had reduced after themedication was given and he is resting without any complication.

Supporting Data:1) Patient looks comfortable and no complain.2) Patient’s vital sign back to normal range, blood

pressure 120/80 mmHg and pulse 84 bpm.

Back

Nursing Care Plan

4

Date: 26/5/2009Time: 3pm

Nursing Diagnosis: Potential infection related to surgical incision.

Supporting data :1.Mr A had done open cholecystectomy2.Patient had incision wound at the abdomen

Goal :Mr A will be not experiences from any sign and symptom of infection after nursing intervention given and during hospitalization.

Nursing Intervention :

1) Assess Mr A’s incision site such as sign and symptom of infection, skin condition,redness, swelling, warm, pain, discharge, high body temperature.

R) As a baseline data and to plan appropriate nursing intervention.

I) I assess my patient’s incison site and vital sign. He has not show sign and symptom of infection.

2) Monitor and record Mr A’s vital sign especially temperature every hourly for 6hour followed by 4hourly or as ordered by doctor.

R) Raised of temperature indicates that body response to infection.

I) I monitored and recorded Mr A’s vital sign every hourly post operation for 6hours and then 4hourly.

3) Observe patient’s dressing site during observation and when change shift.

R) To detect any discharge,oozing,smell or odour from the dressing site and to prevent bacterial growth.

I) I check patient’s dressing site during observation and inform staffnurse to record in the nurses report.

4) Maintain aseptic technique when handling patient’s wound.

R) To prevent from introducing microorganism to patients wound.

I) I perform hand washing before checking the dressing site.

5) Advise patient do not touch at incision site.

R) To prevent cross infection.

I ) I advise my patient do not touch at incision site.

6)Ensure dressing is dry intact and change dressing if there is any discharge

R)To prevent infection. I) I check the patient dressing site and changed the

dressing if wet or oozing.

7) Inform doctor if any sign and symptoms infection detected.

R) For further management. I) I did not inform doctor because my patient free from

infection

Date & Time: 28 / 05 / 2009 @ 9.45am

Evaluation :Patient signs of infection is not detected with evidence of patient verbalization. His temperature is in normal range, 36.4⁰C.

Supporting data :1. Patient’s body temperature is within normal

range(36.4⁰C).2. Patient did not have any sign and symptom of

infection

Back

NursingCare Plan

5

Date: 29/5/2009Time: 9am

Nursing Diagnosis: Knowledge deficit related to home caremanagement .

Supporting data :

1. Patient ask a lot of questions about home care management.2.Patient’s facial expression shows confused and worried.

Goal :Patient’s knowledge will increase especially related to home care management after nursing intervention given and during hospitalization.

Nursing Intervention:

1)Assess patient’s level of understanding and knowledge regarding home care.

R) To ensure patient’s level of understanding about his own disease more details.

(I) I asked Mr.A whether he knows about care of wound, diet and ask him to verbalize.

2) Instruct patient regarding way to reduce the risk for recurrent gallbladder attack such as consume low to moderate fat diet.

R) For more understanding about healthy diet.

(I) I asked Mr.A to avoid consuming foods or fluids that is high in fat such as butter, cake, ice cream and fried foods.

3) Provide health education to the patient regarding the prevention and the self care management.

R)To ensure continuous care at home.(I)I provide some health education to the patient regarding his self care management before he discharged. The health education I give was related to the wound care, diet, activity and the continuous treatment with the doctor.

4) Explained to patient regarding the name, dose, and time to consume the medication that prescribed by the doctor.R) For patient’s better understanding and prevent from wrongly consuming medication.(I)I explained to Mr.A that tablet Ciprofloxacin to be taken one tablet per day and tablet Panaedine to be taken when necessary.

5)Advice Mr.A to inform or seek for medical treatment if there are any sign and symptom of infection is present. E.g. fever,lose stool, recurrent episode pain, nausea and vomiting.R) To prevent from any infection and inflammation.(I)I advice Mr.A that if any sign and symptom of abnormal present, quickly go to the hospital. E.g. fever, lose stool, nausea and vomiting and abdominal pain.

6) Explain the importance of follow up with the doctor.R) To maintain healthy life style and also for early

detection of any abnormalities.(I) I advice and reminded Mr.A about the importance of

follow up to check the incision site with his doctor.

7) Advice patient to take small amount of food but frequently.

R) For easy and better food digestion and to prevent from bowel upset.

(I) I had advice and encourage Mr.A to take small amount of food but frequently.

8)Advice patient not to apply any ointment or traditional

medication to the incision site.

R) To prevent from any infection.

(I) I had advice Mr.A not to apply any ointment or

traditional medication to the incision site and also had

explain to him why not to do so.

Date & Time: 29 / 05 / 2009 @ 9.45am

Evaluation :Mr.A verbalized that he understand and had gainknowledge about home care management after explaination given before discharge.

Supporting data :1. Mr.A able to explain back health education that had been

given.

Back

Health Education

Diet

Medications

Right dose

Right time

Right route

Right drug

ActivityI remind Mr.A stay at home and rest during the medical leave.

I advice Mr.A to avoid strenuous activity and heavy lifting to prevent increase intra-abdominal pressure. No gardening, digging or other any force that can cause increase intra-abdominal pressure.

Wound Care

I adviced Mr.A always change his clothes when it is wet or dirty to prevent create a source of infection.I remind Mr.A don’t apply any ointment, powder or traditional medicine to the wound site to prevent infection.

Follow UpI reminded Mr.A to come for follow up on date to assess his recovery status.

I advice him that he can come to hospital anytime if he have any complication on his condition or sign and symptom of infection occur.

Discharge

Discharge

Date : 29th May 2009Time : 1pm

Mr A was discharge on 29th May 2009 after seen by Dr K. I have reinforced again the health education that I have gave before regardinghis disease and home care management of post operation which includes diet, medication, wound care, activity and follow up on 4th June 2009.Patient was ambulating well.

MEDICATIONS

- Panadeine II/II PRN- Ciprofloxacin 500mg Daily

Mr A discharge with accompanied by his wife.He thanked all the staff and student nurses.

Followup

The doctor had given follow up as below:

• Date : 4th June 2009• Day : Monday• Place : Dr. K clinic• Time : 11.00 am

On Follow Up day

Before the follow up day I have called my patient and reminded him to come for his appointment with Doctor K at clinic.

But he unable to come because he got something to be settle up and his appointmet was postpone to 8th June 2009,11am at Doctor K’s clinic.

On 8th June 2009,Mr A came alone and he looked comfortable and well being.

Doctor K was examine him and told him that the wound healing is very good.

Doctor K advice him to take low fat, small amount but frequent meal as I mention to him before. He also understand and follow the advice.

Lastly,Doctor K didn’t prescribe any medication for Mr A.

Summary

My patient, Mr.A, 40years old,male,admitted in Ipoh Specialist Hospital (ISH) on 25 / 05 / 2009 at 8.25pm. He admitted into the hospital with the complaint of pain on and off at right upper quadrant of abdomen. He was admitted under Dr.K (general surgeon). Mr A was admitted into ward 7B.On the 26 / 05 / 2009 at 9.00am he went to operation theater for open cholecystectomy procedure under General Anaesthesia(GA).

During hospitalization, Dr.K prescribed some medication for Mr.A, such as;

1) Tab Dormicum 7.5mg ON 2) IV Maxolon 10mg TDS 3) IV Augmentin 1.2gm 8h 4) Tab Ciprofloxacin 500mg BD 5) Tab Panadeine II/II TDS PRN

After 2 days of operation,on 29 / 05 / 2009 at 1.00pm, patient were discharged by Dr.K and were given with the follow up appointment card which is on 4 / 06 / 2009. There are also some medication that prescribed by Dr.K for Mr.A to take home, such as;

1) Panadeine II/II PRN 2)Ciprofloxacin 500mg Daily

Mr.A was punctual on his follow up appointment on the 8 / 06 / 2009 in the morning at 11 am. After Dr.K had check on it, doctor said the incision site all is healing very well and there is no sign and symptom of infection.Doctor K did’nt prescribed any medication during his follow up.

Conclusion

Conclusion

As a student nurse, I am happy to do this case study.

I learnt a lot about Cholelithiasis and enhance a lot of knowledge about the sign and symptoms and treatment for patient with cholelithiasis. I was also able to achieve all the learning objectives. While I was studying on this case I became closer with my patient because I had to have a good relationship with my patient in order to understand him better.

Not only with the patient I had a good bond with the doctors, staff, sisters, pharmacist in the hospital because I always referred to them when I had any doubts and problem in completing my case study. They all gave me support and courage to complete my case and be with my patient till he was discharged.

I am very glad I have finally completed this case study and now the knowledge I have about

Cholelithiasis are a lot and I will never forget till the end of my life.I have learnt a lot from this case study and hope to remember till the end life.

References

References

Lemone.P,Burke.K (2004)Medical-Surgical Nursing, 3rd ed. United States,Pearson Education.P574

Weller.B.F(2003)Nurses’ Dictionary,23rd ed. London, Bailliere Tindal.P85 Smeltzer.S.C, Bare.B (2004) Medical-Surgical Nursing,10th ed. United

States, Lippincott Williams &Wilkins.P1126 http://www.merck.com/mmpe/sec03/ch030/ch030b.html MIMS Annual Malaysia, Dims, P.J, (Full Prescribing Information) 16th

Edition (2004) Sdn.Bhd

THANK YOU

ANY QUESTION????