Cholelithiasis Case 1

8/6/2019 Cholelithiasis Case 1

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I.

INTRODUCTION

Cholecystitis is an inflammation of the gallbladder wall

and nearby abdominal lining.Cholecystitis is usually causedby a gallstone in the cystic duct, the duct that connectsthegallbladder to the hepatic duct. The presence ofgallstones in the gallbladder is calledcholelithiasis.Cholelithiasis is the pathologic state of stones or calculiwithin thegallbladder lumen. A common digestive disorderworldwide, the annual overall cost ofcholelithiasis is

approximately $5 billion in the United States, where 75-80%ofgallstones are of the cholesterol type, and approximately10-25% of gallstones arebilirubinate of either black or brown pigment. In Asia, pigmented stones predominate,althoughrecent studies have shown an increase in cholesterol stonesin the Far East.

Gallstones are crystalline structures formed by concretion

(hardening) or accretion(adherence of particles,accumulation) of normal or abnormal bileconstituents.According to various theories, there are four possible explanations for stone formation.First, bile mayundergo a change in composition. Second, gallbladderstasis may lead tobile stasis. Third, infection maypredispose a person to stone formation. Fourth, geneticsand

demography can affect stone formation.Risk factors associated with development of gallstones

include heredity, Obesity,rapid weight loss, through diet orsurgery, age over 60, Native American or MexicanAmericanracial makeup, female gender-gallbladder disease is more


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common in womenthan in men. Women with high estrogenlevels, as a result of pregnancy, hormonereplacementtherapy, or the use of birth control pills, are at particularly

high risk forgallstone formation, Diet-Very low calorie diets,prolonged fasting, and low-fiber/high-cholesterol/high-starchdiets all may contribute to gallstone formation.

Sometimes, persons with gallbladder disease have few orno symptoms. Others,however, will eventually develop oneor more of the following symptoms; (1) Frequentbouts ofindigestion, especially after eating fatty or greasy foods, or

certain vegetablessuch as cabbage, radishes, or pickles, (2)Nausea and bloating (3) Attacks of sharp painsin the upperright part of the abdomen. This pain occurs when a gallstonecauses a

blockage that prevents the gallbladder from emptying(usually by obstructing the cysticduct). (4) Jaundice(yellowing of the skin) may occur if a gallstone becomesstuck in thecommon bile duct, which leads into the intestineblocking the flow of bile from both thegallbladder and theliver. This is a serious complication and usually requiresimmediatetreatment.

The only treatment that cures gallbladder disease issurgical removal of thegallbladder, called cholecystectomy.Generally, when stones are present and causingsymptoms,or when the gallbladder is infected and inflamed, removal ofthe organ isusually necessary. When the gallbladder isremoved, the surgeon may examine the bileducts,sometimes with X rays, and remove any stones that may belodged there. The ductsare not removed so that the liver can


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continue to secrete bile into the intestine. Mostpatientsexperience no further symptoms after cholecystectomy.However, mild residualsymptoms can occur, which can

usually be controlled with a special diet and medication.II.NURSING ASSESSMENT

A. Personal History

Mr. Aproniano Castro is a 56 year old male, a Filipinocitizen who resides at PulongSantol, Porac Pampanga. Hewas born on January 22, 1950 at Pulong Santol, hisreligious

affiliation is Roman Catholic and he is married to Mrs.Brigida M. Castro. Heis a jeepney driver bound in Porac- Angeles route. He is also the president of theirjeepneysassociation. Mr. Castro usually works for 10 to 12 hours aday usually around7am to 7 pm. He always sleeps around 9in the evening and wakes up at 6 in the morning.His wifewas the one who prepares him the breakfast and the snack.

He has day-offs butuses this day in working as the presidentof the jeepney association. He usually eatsinstant food andlove eating foods which has condiment like patis, vinegarand soysauce. He also love eating vegetable salads andfatty salty food. He is not also choosy onthe food he eatsbecause he really eat a lots. He seldom drinks alcohol andsmoke.Regarding the finances about health he is using his

wifes PHILHEALTH card tocompensate the financesneeded. Family Health and Illness HistoryB. Family Health and Illness History

According to Mr. Castro that the familial disease heknows that they have in theirfamily was the hypertension


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that is on his fathers side. His father died because ofheartattack and her mother died of natural cause. He alsoadded that cholecystitis is prone totheir family, because of

one of his siblings also had acquired this disease.C. History of Past and Present IllnessThis is the second time Mr. Castro been admitted into this

hospital (Porac DistrictHospital). On his first admission intothis hospital he had undergone throidectomyoperation,which is almost 3 years ago. He had not experience anyaccident and injuries,even though his job is prone to

accident particularly vehicular accident. He also addedthathe had an ashtma when he was 7 years old that lasts whenhe is 21 years old, hisashtma just stopped when he startdrinking alcohol beverages as he said.

As for his present illness, he was admitted into thishospital because of cholecystitis,he was admitted lastFebruary 13, 2006. He was been diagnosed withcholecystitis withmultiple cholelithiasis a month prior toadmission due to severe epigastric pain andweight loss andwas advised to remove his gallbladder. He just did not havehischolecystectomy done immediately due to financial problem. When the money neededfor his operation wasenough he then goes to Porac District Hospital last February13,2005 for his operation. He was diagnosed and surgicallyoperated by Dr.Serrano.According to Mr. Castro. Uponadmission he had undergone some laboratoryexaminationsuch as UTZ, Chest X-ray, U/A, CBC, FBS, BUN,Creatinineand ECG. Hisinitial medication were H2bloc andCefuroxime.


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D. Physical Examination

Physical Assessment done by the attending physician

reveals that patient is;

afebrile

with pink palpebral conjunctiva

(-) cyanosis

(+) NABS

non tender abdomenVital Signs upon admission (February 13, 2006)BP- 130/90RR-19PR-84Temp-36.5oCPhysical Assessment done by the student reveals that

patient is;afebrile

with pink palpebral conjunctiva

(+) dry lips

(+) paleness

(+) dryskin

decreased skin turgor

(-) bowel movement


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(-) weaknessVital Signs taken and recorded as of February 15, 2006 areas follows;

BP- 140/90PR- 85RR- 21

Temp- 36.4oC

III.

ANATOMY AND PHYSIOLOGY

Gallbladder, muscular organ that serves as a reservoirfor bile, present in most

vertebrates. In humans, it is a pear-shaped membranoussac on the undersurface of theright lobe of the liver justbelow the lower ribs. It is generally about 7.5 cm (about 3in)long and 2.5 cm (1 in) in diameter at its thickest part; ithas a capacity varying from 1 to1.5 fluid ounces. The body

(corpus) and neck (collum) of the gallbladderextendbackward, upward, and to the left. The wide end(fundus) points downward and forward,sometimes extendingslightly beyond the edge of the liver. Structurally, thegallbladderconsists of an outer peritoneal coat (tunicaserosa); a middle coat of fibrous tissue andunstriped muscle(tunica muscularis); and an inner mucous membrane coat

(tunicamucosa).The function of the gallbladder is to store bile, secreted by

the liver and transmittedfrom that organ via the cystic andhepatic ducts, until it is needed in the digestive process.Thegallbladder, when functioning normally, empties through the


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biliary ducts into theduodenum to aid digestion by promoting peristalsis and absorption, preventingputrefaction, andemulsifying fat. Digestion of fat occurs mainly in the small

intestine, bypancreatic enzymes called lipases. The purposeof bile is to; help the Lipases to Work, byemulsifying fat intosmaller droplets to increase access for the enzymes, Enableintake offat, including fat-soluble vitamins: Vitamin A, D, E,and K, rid the body of surpluses andmetabolic wastesCholesterol and Bilirubin.

V.

DIAGNOSTIC AND LABORATORY PROCEDURE

1. Complete Blood Count (CBC)

This is to determine blood components and the

response to

flammatory process and streptococcal infection.Date Ordered: February 13, 2006Date Result In: February 13, 2006Results:


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WBC

-

10.9 g/l

RBC-

5.5 g/l

Lymphocyte -

27

Conclusion:

WBC is slightly elevated based on the normal value of

4.3-10 g/l whichconfirms the presence of infection.

2. Fasting Blood Sugar

This is to measure the blood glucose levels.Date Ordered: February 13, 2006Date Result In: February 13, 2006Results:

94.8 mg/dlConclusion:

The result is within normal range based on the normal

value of < 126

mg/dl.

3. Creatinine

This is the indicator of the renal function

Date Ordered: February 13, 2006

Date Result In: February 13, 2006

Results:

1.0 mg/dl

Conclusions:


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The result is within normal range based on the normal

value of 0.60-1.7

mg/dl.

4. BUNThis is an indicator of renal function andperfusion, dietary intake of

CHON and the level of protein metabolism

Date Ordered: February 13, 2006Date Result In: February 13, 2006Results:10.7 Mg/dl

Conclusions:The result is within normal range based on the normal

value of mg/dl.

5. Urinalysis

Urinalysis yields a large amount of informationabout possible disorders ofthe kidney and lower urinarytract, and systematic disorders that alter urine

composition.Urinalysis data include color, specific gravity, pH, and the presence of protein, RBCs,WBCs, bacteria,Leukocyte, esterase, bilirubin,glucose, ketones, casts andcrystals.

Date Ordered: February 10, 2006Date Result In: February 10, 2006Results:Color- yellow

Specific Gravity- 0.010

Sugar/ Albumin- negative

Pus cells- 0.1 hpf

Conclusions:


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The results are normal but there is a presence of pus

cells in the urine

which means that there is also the presence of

infection.


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c. Medical/ Surgical Management

1. Chest X-ray- this is used to rule out respiratorycauses of referred pain.

2. Intake and Output- I&O measurement provide an othermeans ofassessing fluid balance. This data provide insightinto the cause ofimbalance such as decrease fluid intake orincrease fluid loss. Thesemeasurement are not that


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accurate as body weight, however, because ofrelative risk oferrors in recording.

3. Electrocardiogram- The ECG is an essential tool in

evaluating cardiacrhythm. Electrocardiography detects andamplifies the very smallelectrical potential changes betweendifferent points on the surface of thebody as a myocardialcell depolarize and repolarize, causing the heart tocontract.4. O2 Inhalation- Oxygen therapies are used to

provide more oxygen to the

body into order to promote healing and health.

5. Intravenous Rehydration- when the fluid loss issevere or life

threatening, intravenous (IV) fluids are used for

replacement.

6. ultrasound (Also called sonography.) - a diagnostic imagingtechniquewhich uses high-frequency sound waves to createan image of theinternal organs. Ultrasounds are used to

view internal organs of theabdomen such as the liverspleen, and kidneys and to assess blood flowthroughvarious vessels.7. hepatobiliary scintigraphy - an imaging technique of

the liver, bile ducts,

gallbladder, and upper part of the small intestine.

8. cholangiography - x-ray examination of the bile

ducts using anintravenous (IV) dye (contrast).

9. percutaneous transhepatic cholangiography (PTC) - aneedle isintroduced through the skin and into the liver where


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the dye (contrast) isdeposited and the bile duct structurescan be viewed by x-ray.

10. endoscopic retrograde cholangiopancreatography (ERCP)

- a procedurethat allows the physician to diagnose and treat problems in the liver,gallbladder, bile ducts, and pancreas.The procedure combines x-ray andthe use of an endoscope.A long, flexible, lighted tube. The scope isguided through the patient's mouth and throat, then through theesophagus,stomach, and duodenum. The physician can examinetheinside of these organs and detect any abnormalities. A

tube is thenpassed through the scope, and a dye is injectedwhich will allow theinternal organs to appear on an x-ray.

11. computed tomography scan (CT or CAT scan) - adiagnostic imagingprocedure using a combination of x-raysand computer technology toproduce cross-sectional images(often called slices), both horizontallyand vertically, of thebody. A CT scan shows detailed images of any partof thebody, including the bones, muscles, fat, and organs. CTscans aremore detailed than general x-rays.

12. Cholecystectomy- removal of the gallbladder. This procedure may beperformed to treat chronic or acutecholecystitis, with or withoutcholelithiasis, to remove amalignancy or to remove polyps.

13. Cholecystotomy- the establishment of an opening into thegallbladder toallow drainage of the organ and removal ofstones. A tube is then placedin the gallbladder toestablished external drainage. This is performedwhen thepatient cannot tolerate cholecystectomy.


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14. Choledochoscopy- the insertion of a choledoscope

into the common bile

duct in order to directly visualize stones and facilitate

their extraction.

VIII. DISCHARGE PLANNING


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M

-

Instructed the patient to continue medication as ordered

1. Cephalexin 500 mg cap 3 x day (8am-1pm-8pm) for 1week2. Mefenamic Acid 500 mg cap 3 x day (am-1pm-8pm) for 1weekE

-

Instructed the patient to do exercise as tolerated such

as walkingT

-

Instructed the patient to continue the medication

H

-

1. Encouraged patient to increase fluid intake

2. Encouraged patient to eat foods rich in Vitamin andNutritious

ds3. Encourage patient to avoid salty and fatty foods4. Encourage patient to have enough restO

-

Instructed to come back for follow-up check-up onFebruary 23, 2006,

Thursday.

D

-


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Advised the patient to a diet as tolerated but preferably

avoiding salty

and

fatty foods.IX. Conclusion

Our patient, Mr. Aproniano Castro has a chiefcomplaint of epigastric pain.He was admitted in PoracDistrict Hospital and he was diagnosed of havingacholecystitis with multiple cholelithiasis based on thediagnostic procedure conductedin him like the CBC, U/A,

12-L ECG, FBS, BUN, Crea, X-ray and UTZ. Due totheresult the surgeon decided for a surgery to remove thegallbladder which is known asthe cholecystectomy. We arehappy to say that most of our group mates witnesstheoperation. The following day we were given the chanceto visit and assess ourpatients condition. Fortunately, thepatient had recovered at once he is no longercomplaining ofepigastric pain. What he was complaining is if he couldalready eathis food for he is on a liquid diet! And of coursethe pain of his operative site which isjust normal for severaldays after undergoing the operation.

Since cholecystitis is the inflammation of the gallbladder which is usuallyaccompanied by gallstones orcholelithiasis these gallstones may block the way oftoxicsubstances that really needs to go out, but due to thisblockage this toxicsubstances are not then being expelledand are just being stored in the bladder for aperiod of time.This then causes inflammation of the gallbladder. Thetreatmentusually done is the cholecystectomy.


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In order to lower the risk of having this kind of conditioneach and every oneof us must be conscious in our diet. Weshould try to avoid foods which are rich insalt and fats,

especially those foods which contains many seasonings.Though there isa saying thatMas masarap pag bawalwhich always pertains to the food wereeating we should stillbe conscious on our health especially if we want to livelongerand also to avoid those life-threatening diseaseswhich not only shorten our life butcauses us some financialproblem. Remember also the saying Mahal ang

magkasakit . Just like on what our patient hadexperience he still has to collect

money for the operation he had underwent causing them tohave debt with differentpersons. Let us not enjoy ourselveswith the delicious food were eating that is rich insalts andfats but we should enjoy living because we have a healthycondition.

X. BIBLIOGRAPHY

Books

Joyce M. Black,PhD, RN, CPSN, CWCN & Jane

Hokanson Hawks, DNSc, RN, BC,

Medical- Surgical Nursing 7th edition, pg.1302-1314.

Nursing 2004 Drug Handbook, 24th edition

Doenges, Moorhouse, & Murr, Nurses pocket guide 9th

edition.Online Resources


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www.facs.org

http://tjsamson.client.web-health.com/web-

health/topics/GeneralHealth/generalhealthsub/generalh

ealth/liver&gallbladder/what_gallbladder.html

http://www.emedicine.com/emerg/topic97.htm

http://www.emedicine.com/radio/topic163.htm

http://www.healthsystem.virginia.edu/uvahealth/adult_liver/ch

ole.cfm

http://www.emedicine.com/EMERG/topic98.htm

Microsoft Encarta 2004

Nursing Care Plan Content CD-ROM

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Cholelithiasis Case 1