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Holy Angel University
Angeles City
College of Nursing
A case study on
CHOLELITHIASIS
Submitted by
Demando, Rovina Ana
Dizon, Noeliza
Dizon, Shara Joyce
Dizon, Stephen Zyrus
Gambaloza, Jerisa
Gatpolintan, John Arzen
Submitted to
Mr. Ryan P. Manabat, RN
I. I N T R O D U C T I O N
Description of the Disease
Cholelithiasis is the presence of one or more calculi (gallstones) in
the gallbladder. In developed countries, about 10% of adults and 20% of
people > 65 yr have gallstones. Gallstones tend to be asymptomatic. The
most common symptom is biliary colic; gallstones do not cause dyspepsia
or fatty food intolerance. 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.
Gallstones are made
of cholesterol, calcium
bilirubinate, or a mixture
of cholesterol and bilirubin
pigment. They arise
during periods of
sluggishness in the
gallbladder due to
pregnancy, hormonal
contraceptives, diabetes
mellitus, Chron's disease,
cirrhosis of the liver, and pancreatitis, obesity and rapid weight loss. Their
development is insidious, and they may remain asymptomatic for
decades. Migration of gallstones may lead to occlusion of the biliary and
pancreatic ducts, causing pain (biliary colic) and producing acute
complications, such as acute cholecystitis, ascending cholangitis, or acute
pancreatitis.
Cholelithiasis is a common health problem, affecting about 1 out of
every 1,000 people and is the fifth leading cause of hospitalization among
adults and accounts for 90% of all gallbladder and duct diseases. The
prognosis is usually good with treatment unless infection occurs, in which
case the prognosis depends on its severity and response to antibiotics.
Prevalence of cholelithiasis is affected by many factors including ethnicity,
gender, comorbidities, and genetics. In the United States, about 20 million
people (10-20% of adults) have gallstones. Every year 1-3% of people
develop gallstones and about 1-3% of people become symptomatic.
In an Italian study, 20% of women had stones, and 14% of men had
stones. In a Danish study, gallstone prevalence in persons aged 30 years
was 1.8% for men and 4.8% for women; gallstone prevalence in persons
aged 60 years was 12.9% for men and 22.4% for women.
Excision of the gallbladder (cholecystectomy) to cure gallstone
disease is among the most frequently performed abdominal surgical
procedures.
Objectives
The student’s chose this case study primarily because of interest to
gain further understanding regarding the disease condition. This will also
help in providing current and accurate information concerning the latest
approaches for the treatment of cholelithiasis and its complications.
Moreover, it will initiate participation of client and family members in the
therapy for the disease. This will also help in ensuring that the client
understand treatment options and provide clarification when necessary.
The student nurses have the following objectives in this case study:
Recognize the disease condition; understand risk
factors, pathophysiology, signs and symptoms, and its
underlying complications.
Gather complete data upon assessment of the patient
that will help on the accomplishment of the case study.
Formulate nursing diagnosis related to the stress of the
illness.
Identify the nursing responsibilities for the patient with
cholelithiasis.
Understand the pharmacology of treating cholelithiasis.
II. N U R S I N G H I S T O R Y
1. Personal History
Demographic Data
This is the case of Mrs. Tweety, 30 years old, female,
Filipino. She was born on January 11, 1978 in Quezon City.
She is presently residing at 1608 Tamarind St., Clarkview,
Brgy. Malabanias, Angeles City. She is the fourth child of Mr.
and Mrs Pooh. . She is now married to Mr. Bugs Bunny and is a
mother to two children. She was admitted at Angeles Medical
Center on August 4, 2008 at 11:48 pm.
Socio-Economic and Cultural Factors
Ms. Tweety is currently a program supervisor at
Sutherland Global Services. Her hospitalization expenses are
covered by her insurance company and her needs are
adequately compensated as she and her husband are both
working. She graduated a four year course in Marketing
Management from Angeles University Foundation. She is born
a Roman Catholic. She is considered a modern woman; she
works and at the same time she is a mother to two children.
Mostly for light pains or discomforts she takes pain relievers
and consults a clinic if she and/or her other family members
experience some health problems. As a working mother and
depending on her schedule at work she is barely the one
cooking food and if ever she has the time she cooks foods
which are easily done for example fried foods. And when at
work she eats any food that is available at the place or
sometimes passes by fast foods to order.
2. Family-Health Illness History
Grand FatherGrand FatherGrand
Mother
Grand Mother
FatherMother
A1 A4tweetyA3A2
Legend: Blue = male = DeceasePink = female
= AMI= DM
=HPN
This Diagram shows the family health –illness history of the
patient. Both grand mother and grand father in her father's side
died of old age. On her mother's side her grand father died of old
age and her grandmother died due to myocardial Infarction. His
father exhibited good health while her mother is hypertensive.
Her other siblings also did not manifest any hereditary or existing
disease. In the family she was the only person who manifested
cholecystolithiasis. The diseases which are present on her
mother's side of the family has no relation to her condition, but
the Diabetis Mellitus of her grand father may or may not be
related to her having Cholecystolithiasis.
2. History of Past Illness
She acquired chicken pox and measles when she was
young. Mrs. Tweety was hospitalized before for two times
already. Those include both her delivery to her two children. But
aside from that she was never brought to hospital for conditions
which are related to her condition now.
3. History of Present Illness
During the past 7 months (starting January) the patients
has been experiencing pain on her right upper side part of the
abdomen which she ignored. And she verbalized that it was a
tolerable pain and when she sleeps the pain is alleviated and due
to her work she did not had a check up or medical examinations
done. Two months(June 2008) before the hospitalization, she had
experienced an intense pain but instead of going to the hospital
for check up she just took pain relievers. She had experienced
nausea and vomiting. Two days prior to admission the patient
again experienced intense pain while at work accompanied by
fever (august 4, 2008) and by 11 pm of August 4(Monday) the
patient was admitted at Angeles Medical Center.
III. P H Y S I C A L A S S E S S M E N T
(I P P A – C E P H A L O C A U D A L )
August 4, 2008 (upon admission, based on the patient's chart)
Patient Is conscious, coherent but in distress
Vital signs:
BP- 90/60
T- 38
P-80
R-18
Pale palpebral conjunctiva
Normal abdominal Bowel sound, soft (+) epigastric and right upper quadrant
tenderness
No cyanosis, no edema, (+) jaundice
August 5, 2008(patient's chart)
Patient is conscious and coherent with IVF of 1L D5LRS regulated at 30
gtts/min
Vital signs:
BP-100/70
T-37.1
P-87
R-21
August 6, 2008 (Nurse- Patient Interaction)
Patient is awake, conscious and coherent but appears weak
with ongoing IVF of 1 L D5LRS regulated at 30 gtts/min
Vital signs:
BP-110/80
T-36.7
P-78
R-19
REVIEW OF SYSTEMS
HEAD
Hair and Scalp: Client has evenly distributed short, thick, coarse, no
infestation.
Skin and Face: Client has a rounded, smoothly contoured skull. Skull has
uniform consistency. No nodules, masses or depression palpated. Facial
features are symmetric.
Eye and Vision: Client’s eyebrow has evenly distributed hair. Eyebrows are
symmetrically aligned and with equal movement. Eyelashes are evenly
distributed and curled slightly outward. Skin of the eyelids is intact and
without discharge. Lids close symmetrically, bilaterally. Sclera appears
yellowish. Corneas are transparent, shiny and smooth with details of iris
visible. Pupils are black, equal in size, round and have smooth border with
round iris. They constrict when illuminated with a penlight. They constrict
when looking at near objects and they dilate when looking at far objects.
Ears: Auricles are symmetrical, aligned with the outer cantus of the eye and
have the same color as the facial skin. They are mobile, firm, not tender, and
recoil after being pulled or folded. No cerumen noted. Client can hear voice
tones.
Nose and Sinuses: Nose is symmetric and straight. There is no discharge,
flaring, lesions and tenderness.
Mouth: Lips is pale, soft, moist, smooth and symmetrical in contour. Client is
able to purse lips. There is the presence of dental plaque and caries. Tongue
is at the center, pink, moist slightly rough with thin whitish coating. It moves
freely without tenderness.
NECK
Neck Muscles: Muscles are equal in size and head centered. Head
movements are coordinated and smooth with no discomfort.
Lymph Nodes: They are not palpable.
UPPER EXTREMITIES
Skin and Nails: Skin is yellowish in color and moist in skin folds with no scars
of lesions noted. When pinched, skin goes back to previous state. Nail plates
are convex, colorless and smooth in texture. No dirt is accumulated under
the nails.
Muscle Strength and Tone: Muscles are equal in size on both sides of the
body without tremors. They are firm with coordinated movements.
Bones and Joints: There are no deformities, tenderness or swelling noted.
CHEST
Heart: Client has regular heartbeat pattern (strong).
ABDOMEN
Skin: Skin is yellowish color and there are no scars noted.
LOWER EXTREMITIES
Skin and Toenails: Skin is yellowish and moist in skin folds with no dryness
noted at the sole of the feet. When pinched, skin goes back to previous
state. Nail plates were convex, colorless and smooth in texture. No dirt is
accumulated under the toenails.
Muscle Strength and Tone: Muscles are equal in size on both sides of the
body without tremors. They are firm with coordinated movements.
Bones and Joints: There are no deformities, tenderness or swelling noted.
IV. D I A G N O S T I C A N D L A B O R A T O R Y P R O C E D U R E S
Diagnostic/
Laboratory
Procedure
Indications or
Purpose
Date Ordered
Date Results
were released
Results Normal Values
(units used in
the hospital)
Analysis and
Interpretation of
Results
HBT—Pancreas
–Ultrasound
To detect
pancreatitis,
evidenced by
pancreatic
enlargement
with increased
echoes.
To detect
pancreatic
cancer, defined
mass of a mass
in the head of
the pancreas
that obstruct
the pancreatic
D.O= 08/05/08 Abnormally
contracted
gallbladder with
a lithiasis at the
neck.
Intrahepatic
and
extrahepatic
ducts are not
dilated.
Unremarkable
liver and
pancreas.
Normal size,
position,
contour and
texture of the
pancreas.
Abnormally
contracted
gallbladder with
a lithiasis at the
neck.
Just tell what
lithiasis is and
how it affect the
gallbladder
duct.
To detect
anatomic
abnormalities
as a
consequence of
pancreatitis.
(-) for ascites
Hematology
Hct
To determine
the percentage
of total blood
volume
composed of
RBC
D.O= 08/05/08 41.4 % M=40-54 %
F=37-47 %
The result is
within the
normal values.
Platelet
To test the
ability of the
blood to clot
D.O= 08/05/08 304 x 109/L 140- 440 x
109/L
The result is
within the
normal values.
WBC Used to detect
infection, it
determines
number of
circulating
WBC’s per cubic
millimeter of
blood
D.O= 08/05/08 7.7 x 109/L 4.3- 10 x 109/L The result is
within the
normal values.
Granulocytes Phagocytes
present in
circulation that
kills bacteria
during infection
D.O= 08/05/08 73 % 44.2- 80.2 % The result is
within the
normal values.
Lymphocytes Produce
antibodies
responsible for
immune
D.O= 08/05/08 27 % 28.0- 48.0 % The results is
below the
normal values.
It means that
responses. the blood has
low antibodies
that are
responsible for
immune
responses.
Hgb To determine
the oxygen
carrying
capacity of the
blood. It
evaluates the
hemoglobin
content of
erythrocytes.
D.O= 08/05/08 13.0 g/dL M=14 -18 g/dL
F= 12 – 18 g/dL
The result is
within the
normal values.
NURSING RESPONSIBILITIES
Hematology
Prior:
1. Verify doctor’s order
2. Explain the importance of the procedure
3. Explain the procedure to the patient
4. Tell the patient that no fasting is required
5. Assure him that collecting blood sample take less than 3 minutes
6. Inform the patient that he will be experiencing mild pain on the site of injection
During:
1. Assist the patient.
After:
1. Apply pressure or a pressure dressing to the punctured site
2. Check the venipuncture site for excessive bleeding
3. Fill up the laboratory form properly and sent it to the laboratory for testing
3. Instruct patient not to take anything per orem 2 hours prior to blood extraction
4. Inform that he will be experiencing mild pain on the site where the needle is inserted
HBT- Pancreas- Ultrasound
Prior:
1. Inform the patient that the procedure assesses the pancreas.
2. Inform the patient that the procedure is performed in a specialized area by a technologist and usually
takes approximately 30 to 60 minutes. The room may be darkened for better visualization of the
pancreas.
3. Obtain the history of suspected or existing disease of the pancreas.
4. Obtain the results of tests and procedures done to diagnose disorders or treatments to the pancreas.
5. Inform the patient that the procedure is painless and carries no risks.
6. Note recent administration of barium because residual barium can obscure the organ to be examined.
There should be a 24-hour waiting period between administration of barium and this test.
7. Inform the patient to withhold food for 8 hours, but to drink increased amounts of fluids to distend the
stomach before and during the procedure.
During:
1. Ask the patient to put on a hospital gown.
2. Place the patient in a supine position on the examining table; other position may be used during the
examination.
3. Expose the abdomen and drape the patient.
4. Apply conductive gel to the epigastric area and move the transducer over the skin; the sound wave
images are projected on the screen and stored electronically for future viewing or reproduced on a film.
Ask the patient to lie still during the procedure because movement produces unclear images.
5. If necessary for better visualization of the pancreas and abdominal organs, ask the patient to inhale
deeply, regulate breathing, hold her breath or drink water.
After:
1. When the study is completed, remove the gel from the skin.
2. Instruct the patient to resume normal activity, medication, and diet, unless otherwise indicated.
3. Inform the patient that an abnormal examination may indicate the need for additional studies.
4. Evaluate test results in relation to the patient’s symptoms and other tests performed.
Diagnostic/
Laboratory
Procedure
Indications or
Purpose
Date Ordered Results Normal Values
(units used in
the hospital)
Analysis and
Interpretation of
Results
Hematology
Hgb
To determine
the oxygen
carrying
capacity of the
blood. It
evaluates the
hemoglobin
D.O: 08 /06/ 08 13.1 g/dl M=14 -18 g/dL
F= 12 – 18 g/dL
The result is
within the
normal values.
content of
erythrocytes.
Hct To determine
the percentage
of total blood
volume
composed of
RBC
D.O: 08 /06 /08 43.4 g/dl M=40-54 %
F=37-47 %
The result is
with in the
normal values
Platelete To test the
ability of the
blood to clot
D.O: 08 /06/ 08 307x109/L 140-440x4/L The result is
with in the
normal values
WBC Used to detect
infection, it
determines
number of
circulating
WBC’s per cubic
millimeter of
blood
D.O: 08 /06 /08 12.2x109/L 4.3-10.0x9/L The result is
above the
normal values.
It indicates
infection
Granulocytes Phagocytes
present in
circulation that
kills bacteria
during infection
D.O: 08 /06 /08 71% 44.2-80.2% The result is
with in the
normal values
Lymphocytes Produce
antibodies
responsible for
allergic
reactions
D.O: 08/ 06/ 08 27.6% 28.0-48.0% The result is
below the
normal values.
It means that
the blood has
low antibodies
that are
responsible for
immune
responses
IV. T H E P A T I E N T A N D H I S I L L N E S S
Anatomy and Physiology
The gallbladder stores bile, which is released when food containing
fat enters the digestive tract, stimulating the secretion of cholecystokinin
(CCK). The bile emulsifies fats and neutralizes acids in partly digested
food. After being stored in the gallbladder, the bile becomes more
concentrated than when it left the liver, increasing its potency and
intensifying its effect on fats.
The anatomy of the biliary tree is a little complicated, but it is
important to understand. The liver's cells
(hepatocytes) excrete bile into canaliculi, which
are intercellular spaces between the liver cells.
These drain into the right and left hepatic ducts,
after which bile travels via the common hepatic
and cystic ducts to the gallbladder. The
gallbladder, which has a capacity of 50 milliliters
(about 5 tablespoons), concentrates the bile 10 fold by removing water
and stores it until a person eats. At this time, bile is discharged from the
gallbladder via the cystic duct into the common bile duct and then into
the duodenum (the first part of the small intestine), where it begins to
dissolve the fat in ingested food.
The liver excretes approximately 500 to 1000 milliliters (50 to 100
tablespoons) of bile each day. Most (95%) of the bile that has entered the
intestines is resorbed in the last part of the small intestine (known as the
terminal ileum), and returned to the liver for reuse.
The many functions of bile are best understood by knowing the
composition of bile:
1. Bile Salts (cholates, chenodeoxycholate, deoxycholate): these are
produced by the liver's breakdown of cholesterol. They function in
bile as detergents that dissolve dietary fat and allow it to be
absorbed. Hence, disruption of bile excretion disrupts the normal
absorption of fat, a process called malabsorption. Patients develop
diarrhea because the fat is not absorbed (steatorrhea) , and develop
deficiencies of the fat-soluble vitamins (A, D, E, and K).
2. Cholesterol and phospholipids-while only 4% of bile is cholesterol,
the secretion of cholesterol and its metabolites (bile salts) into bile
is the body's major route of elimination of cholesterol.
Phospholipids, which are components of cell membranes, enhance
the cholesterol solubilizing properties of bile salts. Inefficient
excretion of cholesterol can cause an increased serum cholesterol.
This predisposes to vascular disease (heart attacks, strokes, etc.)
3. Bilirubin-while this comprises only 0.3% of bile, it is responsible for
bile's yellow color. Bilirubin is a product of the body's metabolism of
hemoglobin, the carrier of oxygen in red blood cells. Disruption of
the excretion of this component of bile leads to a yellow
discoloration of the eyes and skin (jaundice).
4. Protein and miscellaneous components
Bile production and recirculation is the main excretory function of
the liver. Tumors that obstruct the flow of bile from the liver can also
impair other liver functions. Therefore, it is necessary to understand
these other functions to understand the symptoms that these tumors
can cause. These include:
Metabolic functions, such as the maintenance of glucose (blood
sugar) levels
Synthetic functions, such as the synthesis of serum proteins such
as albumin, blood clotting (coagulation) factors, and complement (a
mediator of inflammatory responses)
Storage functions, such as the storage of sugar (glycogen), fat
(triglycerides), iron, copper, and fat soluble vitamins (A, D, E, and K)
Catabolic functions, such as the detoxification of drugs
The gallbladder has an epithelial lining characterized by
recesses called Aschoff's recesses, which are pouches inside the lining.
Under the epithelium there is a layer of connective tissue, followed by a
muscular wall that contracts in response to cholecystokinin, a peptide
hormone secreted by the duodenum.
PATHOPHYSIOLOGY(BOOK BASED)
Predisposing Factors Precipitating factors
Hormonal factors in pregnancy
Gender(female)
GeneticsOld Age(>40 yrs old)
Race(Native Americans
Increase in estrogen level
Increase in cholesterol and bile and decrease in gal;lblader movement
Increase in estrogen
Gallbladder stasis
Physical Activity Prolonged Immobility Sedentary lifestyle
Obesity Diet
Decrease contractility of the gallbladder
Gallbladder stasis
High level of choleste-rol in the body
High fat, lowfiber diet
Weight loss dieting, decrease caloric intake
Decrease contractility of the gallbladder and spasm of the sphincter
Gallbladder stasisAlteration in the composition of the bile
Bile become supersaturated with cholesterol of calcium, deficient bile salts and lecithin
Solute precipitate from solution as solid crystals
Crystals fuse to form stones
Cholesterol gallstones become colonized with bacteria and can illicit gallbladder mucosal inflammation
Unconjugated bilirun from insoluble precipitates with calcium and enter bile together with other electrolytes
Bile contains relative high proportion of cholesterol and becomes supersaturated with it and crystals form
Lytic enzyme from bacteria and leukocytes hydrolyze bilirubin conjugates and fatty acids
Cholesterol stones may accumuilate a substantial proportion of calcium bilirubinate and other calcium salts
Cholesterol stones
Calcium bilirubinate crystallizes into and forms jet black stones
Pigment stones
Perscence of gall stones
Obstruction in the gall bladder
Prescence of food in the gastrointestinal tract stimulates gallbladder to contract against an obstructing gallstone
Mixed stons
Obstruction in the common bile duct
Jaundice
Pain in right upper quadrant
Increase pressure within gallbladder
Guarding behavior
Obstruction of bile flow in the intestine
Decrease bile flow in the intestines(bile salts) Decrease bile flow in the intestine(bile acids)
Decrease secretion of water in the intestine Decrease digestive function(emulsification of fats)
Decrease peristalsis
Waste and gas couldn't move along and out of the body
Flatulence(prescence of an axcessive amount of air or gas in the stomach and intestinal tract
Distension of organs
pain
Bloated feeling
Belching(compensatory mechanism of the body by expelling or releasing gas from the stomach through the mouth
Unable to metabolize fats
Indigestion
Intolerance to fatty foods
Nausea and vomiting(compensatory mechanism of the body to relieve feeling of indigestion by throwing up stomach content by mouth
b. Synthesis of the disease
Cholelithiasis, the presence of stones of calculi (gallstone) in the
gallbladder resolves from changes in bile components. Gallstones are
made of cholesterol, calcium bilirubinate, or a mixture of cholesterol and
bilirubin pigment. They arise during periods of sluggishness in the
gallbladder resulting from pregnancy, use of oral contraceptive, diabetes
mellitus, Cron’s disease, and cirrhosis of the liver, pancreatitis, obesity,
and rapid weight loss. Up to 25% of all people have gallstones
(cholelithiasis), composed of cholesterol, lecithin and bile acids. These can
cause colicky shooting abdominal pain, usually in relation with the meal,
as the gallbladder contracts and gallstones pass through the bile duct.
Surgery (cholecystectomy, removal of the gallbladder) is the most
common treatment for gallstones. It can be performed laparoscopically,
and it is in fact one of the most common procedures done through the
laparoscope.
Causes, incidence, and risk factors:
Cholelithiasis is usually discovered by routine X-ray study, surgery, or
autopsy. Virtually all gallstones are formed within the gallbladder. Bile is
a solution composed of water, bile salts, lecithin, cholesterol and some
other small solutes. Changes in the relative concentration of these
components may cause precipitation from solution and formation of a
nidus, or nest, around which gallstones are formed.
While these stones may be as small as a grain of sand, they may become
as large as an inch in diameter depending on how much time has elapsed
from their initial formation. In addition, depending on the main substance
that initiated their formation (e.g., cholesterol), they may be yellow or
otherwise pigmented in color.
Cholelithiasis is a common health problem worldwide with an approximate
incidence of 1 out of 1,000 people. The prevalence is greater in women,
Native Americans, and people over the age of 40.
People traditionally considered at an increased risk of cholelithiasis are
people who are 4 F's:
Female
Fat (obesity)
Fair (Caucasian, but this is disputed by recent studies)
Forty (middle-aged)
Bilary colic
This is when a gallstone blocks either the common bile duct or the
duct leading into it from the gallbladder. This condition causes severe
pain in the right upper abdomen and sometimes through to the upper
back. It is described by many doctors as the most severe pain in
existence, between childbirth and a heart attack. Other symptoms are
nausea and vomiting, diarrhea, bleeding caused by continuous vomiting,
and dehydration caused by the nausea and diarrhea. Another more
serious complication is total blockage of the bile duct which leads to
jaundice, which if it is not corrected naturally or by a surgical procedure
can be fatal as it causes liver damage. The only long term solution is the
removal of the gall bladder.
Predisposing factors:
Age - elderly people are prone to gallstone formation because of
weakened immune system and deteriorating body organs.
Diabetic - are prone to gallstone formation because of impaired protein
synthesis and fatty acid storage.
Genetic - family with a history of cholelithiasis has a high risk of acquiring
the disease condition.
Precipitating factor:
Increase cholesterol intake- can trigger gallstone formation because too
much cholesterol alters the bile composition resulting to gallstone
formation.
Risk Factors
Family history of gallstones.
Genetic factors. Some ethnic groups are more susceptible, such as
Native Americans and Hispanics.
Obesity.
Excess alcohol consumption
Oral contraceptives.
High fat, low fiber diet.
Rapid weight loss.
Women who have had many children.(multiparity)
Hemolytic disorders such as sickle cell anemia, hereditary
spherocytosis.
Liver cirrhosis.
Diabetes.
Female gender.
Inflammatory bowel disease such as crohns.
Signs and symptoms:
Symptoms usually manifest after a stone, which is greater than 8 mm,
blocks the cystic duct, or the common bile duct.
Biliary colic- right upper quadrant pain that feels like cramping, which is
cause by a block in the opening of the gallbladder.
Cholangitis- If the common bile duct is blocked for a period of time,
certain bacteria may grow in the stagnant bile producing symptoms of
cholangitis.
Jaundice- a yellow pigmentation of the sclerae, skin, and deeper tissues
cause by excessive accumulation of bile pigments in the blood. The
accumulation is due to the continuous blockage of bile to the intestines
where it is partly excreted as waste.
Pancreatitis- stones blocking the lower end of the common bile duct
where it enters the duodenum may obstruct secretion from the pancreas
producing pancreatitis.
Note: Often there are no symptoms.
Additional symptoms that may be associated with this disease:
stools, clay colored- bilirubin is secreted in the system and not
excreted
nausea and vomiting- compensatory mechanism of the body to
relieve feeling of indigestion by throwing up stomach content by mouth
heartburn- because of vomiting
gas/flatus, excessive - decrease in peristalsis because of decrease
in water in the intestine.
abdominal indigestion- decrease ability to emulsify fats,intolerance
to fatty foods leading to indigestion
abdominal fullness, gaseous-decrease in peristalsis because of
decrease in water in the intestine.
PATHOPHYSIOLOGY(CLIENT CENTERED)
Predisposing/Non Modifiable Precipitating/Modifiable
Bile become saturated with cholesterol
Increase cholesterol/
intake of fatty foods, low fiber Age
Concretion of bile constituents
buildup of bile constituents
Nausea and vomiting
(June, 2008)
Fat intolerance
Decreased digestion and absorption of fats
Race
Changes of bile composition
Decreased capacity to dissolve fats
Gender
Crystalline structures are formed
Cholelithiasis
RUQ colicky pain(January, 2008
June 2008,August 2-3, 2008)
Bile stasis become a medium for bacterial growth
InflammationEndogenous
pyrogens
Release of chemical mediatorsReset of
hypothalamus
Fever (August4 ,200
8)
obstruction
Conjugated bilirubin
Escape from liver into the blood strea,m
Jaundice(August 4, 2008)
Infection
Stimulates the gallbladder to produce more bile.
Stimulates the secretion of Cholecystokinin
Indigestion of fats
Predisposing
Age
Cholesterol Stauration increases with age, usually 20 to 60
year old persons are at more risk(black,2005). As an individual gets
older, more and more cholesterol accumulates in the body system-
as a result of increased hepatic cholesterol secretion and derease
bile acid and lecithin synthesis, thereby increasing the chances of
developing gallstones(Smeltzer)
Gender
The usual adult female ratio roughly four times more women
than men develop gallstones(Phipps, 1995) presumably in part
because the effect of estrogen on cholesterol metabolism.
Race
Highest rate for occurrence of gallstones are in the US and the
Philippines. A majority of native Americans have gallstones by the
age of 60(Phipps,1995). Among the Filipinos, 70 percent of men and
women have had gallstones by age 30
Also a lithogenic gene is hypothesized to exist in all racial
group ethnicity.
Precipitating factors
Increase cholesterol/ intake of fatty foods, low fiber.
e.g. meat, egg, butter, cheese, salad dressing, steak and fried
foods.
This leads to further increase of cholesterol produced by the
bile( increased hepatic cholesterol secretion) making it more prone
to develop stones
Signs and symptoms with rationale
Nausea and vomiting(June 2008)
Because of changes in bile concentration(supersaturation with
cholesterol versus the decreased amount of lecithin and bile salts),
fats that are needed to be emulsified in the small intestine are not
properly digested and absorbed leading to indigestion manifested
by nausea and vomiting especially after a heavy meal of fried foods.
Right upper quadrant pain(January, 2008, June 2008August 2-3,
2008)
Along with the subsequent formation of stones in the
gallbladder, mucosal irritation of the latter occurs with the
supersaturated bile and as a result, the gallbladder contract in
trying to expel the stones
Fever(August 4, 2008)
A common response to inflammation caused by the
stimulation of the hypothalamus by endogenous pyrogens, which
are released from circulating neutrophils and macrophages.
Jaundice( August 4, 2008)
With the obstruction of the common bile duct, bile backflows
into the liver where conjugated bilirubin enters into the
bloodstream. Ther will be increased serum bilirubin as manifested
by yellowish skin discoloration ranging from mild to moderate
depending to the extent of obstruction
S U R G I C A L M A N A G E M E N T
Pre-operative diagnosis: Cholecystolithiasis
Proposed Operation: Cholecystectomy
Date of the procedure done: August 05, 2008
Since the first recognized case of cholelithiasis over 1500 years ago,
numerous treatments have been used. These are primarily medical and
surgical.
Bile salts taken orally may dissolve gallstones in those with a functioning
gallbladder, but the process may take 2 years or longer, and stones may
recur after the therapy is discontinued.
Medical dissolution, using both high-dose and low-dose
chenodeoxycholic acids (CDCA, chenediol) was an approach
investigated in the early 1980s. However, it was successful in only around
14% of cases, required a long period of administration as well as a
lifetime of maintenance therapy.
Urodeoxycholic acid (UDCA, ursodiol), a more contemporary medical
therapy, is successful in only 40% of cases. Both CDCA and UDCA
therapies are useful only for gallstones formed from cholesterol.
Other chemical methods include contact dissolution in which a catheter is
passed through the abdominal wall and into the gallbladder and methyl
tert-butyl ether, a volatile chemical, is then instilled. This chemical
rapidly dissolves cholesterol stones but potential toxicity, stone
recurrence, and other complications limit its utility.
Electrohydraulic shock wave lithotripsy (ESWL) has also been
employed to treat cholelithiasis. The principal underlying this modality is
that electromagnetically produced high-energy shock waves, when
focused on a specific point in a liquid medium, can produce
fragmentation. However, its application is limited if there are a large
number of stones present, if the stones are very large, or in the presence
of acute cholecystitis or cholangitis. It can also be used in association with
UDCA to improve its effect.
Despite these medical approaches, modern advances in surgical
management have revolutionized the treatment of cholelithiasis. In
general, surgery is indicated for symptomatic disease only.
In the past, open cholecystectomy was the usual procedure for
uncomplicated cases. This operation necessitated a medium to large
abdominal surgical incision just below the right lower rib in order to gain
access to the gallbladder. After this operation, a patient typically spent 3-
5 days in the hospital recovering.
Currently, laparoscopic cholecystectomy is the gold standard for care
of symptomatic cholelithiasis and is one of the most common operations
performed in hospitals today. Using this approach, a patient with
symptomatic cholelithiasis may have their gallbladder removed in the
morning and be discharged from the hospital on the same evening or the
next morning.
In addition, gallstones blocking the common bile duct may be visualized
and removed during the laparoscopic procedure. The impact of this
surgical treatment method has supplanted medical approaches to the
treatment of gallstones, because it has a complication rate of less than
1%.
Incision
Laparoscopic surgical techniques uses narrow instruments,
including a camera, which is introduced into the abdomen through small
puncture holes. If the procedure is expected to be straightforward,
laparoscopic cholecystectomy may be used. A laparoscopic camera is
inserted into the abdomen near the umbilicus (navel). Instruments are
inserted through 2 more small puncture holes. The gallbladder is found,
the vessels and tubes are cut, and the gallbladder is removed.
Laparoscopic Cholecystectomy as seen through laparoscope
Procedure
If the gallbladder is extremely inflamed, infected, or has large
gallstones, the abdominal approach (open cholecystectomy) is
recommended. A small incision is made just below the rib cage on the
right side of the abdomen. The liver is moved to expose the gallbladder.
The vessels and tubes (cystic duct and artery) to and from the gallbladder
are cut and the gallbladder is removed. The tube (common bile duct) that
drains the digestive fluid (bile) from the liver to the small intestine
(duodenum) is examined for blockages or stones. A small flat tube may be
left in for several days to drain out fluids if there is inflammation or
infection.
Nursing responsibilities prior operation:
Monitor vital signs for signs of developing shock
Check for the type of blood
Assess the women emotional state and coping abilities
Determine the couples informational needs
Instruct the patient to stop smoking (if smoking)
Instruct the patient not to eat or drink
Gather some info. About client’s health history and allergies
Instruct the pt. to remove glasses, contact lenses, dentures,
hearing aids, jewelry and hair ornaments
Nursing responsibilities during operation:
Be aware on what is to be done during the course of operation
Ready for troubleshooting of problems
Alertness in exchanging sterile instruments use by the doctor
or surgeon
Familiarity with the emergency procedures
Nursing responsibilities after operation
Most patients who undergo laparoscopic cholecystectomy can
go home the day of surgery or the next day, and resume a
normal diet and activities immediately. Most patients who
undergo open cholecystectomy require 5-7 days of
hospitalization, are able to resume a normal diet after one
week, and normal activities after 4-6 weeks
V. T H E P A T I E N T A N D H I S C A R E
1. Medical Management
a. Intravenous Fluid
Medical Management General DescriptionIndication(s) or
Purpose(s)
Date
Ordered
Client’s Response to
the Treatment
D5LRS 1L x
30gtts/min
D5LRS (5% dextrose in
Lactated Ringer’s
Solution belongs to
the hypertonic
solutions; a
combination of two
solutions (D5 W and
LR).
Enable to maintain
hydration and for fluid
and electrolyte
imbalance.
08-04-08
The patient was
hydrated.
Is the patient
dehydrated? Isn’t it
the fluid was just for
preoperative
procedure?
Nursing Responsibilities:
Before:
1. Verify doctor’s order.
2. The 10 rights of the patient must be observed when administering medication.
3. Explain the procedure to the patient and why it has to be done.
During:
1. Instruct patient to relax especially the hand where the needle is to be inserted (to avoid reinsertion
and facilitate easy insertion)
2. Check IV level and the patency of the tubing if it is infusing well.
After:
1. Press the site where the needle was inserted and secure it with micropore.
2. Check the site of hand where the needle is inserted if bulging is not visible. If so, reinsertion is to be
undertaken.
3. Advice patient to avoid scratching the site less movement of the hand where the needle was
inserted to keep it in place.
4. Instruct patient and significant others to inform the nurse on duty if bulging of the site is visible, if
there is back flow of blood of if IVF is not infusing well.
5. Observe the IV site at least every hour for signs of infiltration or other complications fluid or
electrolyte overload and air embolism.
6. IVF regulation should be checked and monitored upon receiving patient.
7. Always check the doctor’s order for new orders regarding the IVF supplement of the patient.
8. Always check if the IVF is infusing well and intact.
9. Monitor the patient’s skin integrity.
b. Drugs
Name of Drugs
General Action Indication or Purpose
Date
Ordered
Client’s
Response
Paracetamol Antipyretic/Analgesic
Responsible for
reduction of fever.
To relieve fever. 08-04-08 The patient’s
temperature
decreases to
its normal.
Omeprazole
Antacid
Acts in the acidic
conditions of the
stomach destroying
the ability of the
parietal cells to
produce gastric acid.
Decreased the
amount of acid in the
stomach in which the
patient will be ready
for the surgical
procedure.
08-04-08
The patient
was relieved.
From what?
How about no
complaint of
epig pain was
made? =)
Nubain
Analgesic/ Antipyretic
A synthetic narcotic
agonist-antagonist
analgesic of the
To relieve discomfort.
.
08-04-08
The patient
was comforted.
(focus on pain
phenanthrene series. scale)
Cefazolin
Antibiotic
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.
To control bacterial
infections.
08-05-08
The patient
was relieved?
from the drug
which
controlled the
infection.
Just state the
manifestations
of infxn
Plasil
Anti-emetic
Increases the tone and
amplitude of gastric
(especially antral)
contractions, relaxes
the pyloric sphincter
and the duodenum and
jejunum, resulting in
accelerated gastric
emptying and
To moderate nausea
and vomiting.
08-05-08
The patient
was restrained
to nausea and
vomiting.
You may just
say no
complaint of
nausea.
intestinal transit. It
increases the resting
tone of the lower
esophageal sphincter.
Parecoxib
Analgesic
Reduce mediators of
pain and inflammation.
To control pain or
discomfort.
08-06-08
The patient
was relieved
from pain.
Cefalexin Cephalosporin
Antibiotic
Kills bacteria by
interfering with the
ability of bacteria to
form cell walls. The
bacteria therefore
break up and die.
To destroy the
formation of bacteria.
08-06-08 The patient
was free from
the invasion of
bacteria.
Celestamine Antihistamine/
Antiallergics
combines the anti-
inflammatory and anti-
allergic effects of the
To prevent allergic
reactions.
08-06-08 The patient
complimented
with allergic
reactions.
corticosteroid
betamethasone (a
derivative of
prednisolone) with the
antihistaminic activity
of dexchlorphenamine
maleate.
You may say
itchiness was
relieved
Stugeron Anti-emetic
interfering with the
signal transmission
between vestibular
apparatus of the inner
ear and the vomiting
centre of the
hypothalamus. The
disparity of signal
processing between
inner ear motion
receptors and the
visual senses is
abolished, so that the
To moderate nausea
and vomiting
08-06-08 The patient
was restrained
to nausea and
vomiting.
confusion of brain
whether the individual
is moving or standing
is reduced.
Ranitidine Antacid/ Anti-ulcerant
Competitively inhibits
action of histamine on
the H2 at receptor
sites of parietal cells,
decreasing gastric acid
secretion.
Decreased the
amount of acid in the
stomach.
08-06-08 The patient
was relieved.
Epig pain?
Nursing Responsibilities
Prior:
1. Verify doctor’s order.
2. Remember the 10 Rights of giving medication.
3. Explain to patient the importance and purpose of drugs.
4. Document the indication for therapy, onset of symptoms, other agents used and anticipated treatment
period.
5. Assess stomach pain, noting characteristics frequency of occurrence and things that alter it.
During:
1. Check patient identification before administering the drug.
2. Recheck the order and note the expiration date of the drug.
3. Give the drug and stay with the patient’s side while taking the drug in order to make if the patient
comply with medication prescribed.
After
1. Monitor vital signs
2. Maintain adequate hydration.
3. Report as scheduled to determine extent of healing and expected length of therapy
4. Document the drug given.
c. Diet
Type of Diet
Date
Ordered
Date
Started
Date
Changed
General Description Indication(s) or
Purpose(s)
Client’s response
and/or reaction to the
activity/exercise
NPO 08/04/08 to
08/05/08
Nothing Per
Orem/Nothing Via
Mouth. A patient
care instruction
advising that the
patient is prohibited
from ingesting food,
beverage, or
medicine. It is
usually posted above
the bed of a patient
who is about to
undergo surgery or
To prevent aspiration
of food and fluid
before and during
surgery
(Cholecystectomy).
The patient complies
with the diet.
special diagnostic
procedures requiring
that the digestive
tract is empty or who
is unable to tolerate
food and fluids by
mouth (MOSBY’S
DICTIONARY of
medicine, nursing
and allied health).
Soft Diet 08/06/08-
08/07/08
A diet that is soft in
texture, low in
residue, easily
digested, and well
tolerated. The diet
is most commonly
intended for patient
who undergone
surgery
To provide the
essential nutrients
need by the body in
the form of liquids
and semisolids such
as milk, fruit juices,
eggs cheese and etc.
The soft diet is
designed to decrease
The patient complies
with the diet.
(Cholecystectomy). peristalsis and avoid
irritation of the
gastrointestinal tract.
Nursing responsibilities:
Prior:
1. Food and fluid intake should be avoided when NPO.
2. Verify doctor’s order
3. Discuss the importance of the ordered diet
During:
1. Provide comfort measures such as stretching of bed linens and assist the client to a comfortable
position
2. Support the patient if he/she has hard time it taking diet.
After:
1. Monitor client’s reaction
2. Assess for patient’s condition, how he respond to the diet
3. Record procedure done
D. Activity
Type of Exercise
Date
Ordered
Date
Started
Date
Changed
General Description Indication(s) or
Purpose(s)
Client’s response
and/or reaction to the
activity/ exercise
Complete Bed Rest 08/04/08-
08/05/08
Lying on bed and no
ambulation
To facilitate relaxation
and comfort to the
patient after surgery.
The patient complies
with the
exercise/activity.
Deep Breathing
Exercise
08/06/08-
08/07/08
Movements used to
improve pulmonary
gas exchange or
To improve ventilation
and gas exchange.
The patient complies
with the
exercise/activity.
maintain respiratory
function, especially
after prolonged
inactivity or general
anesthesia.
Incisional pain after
surgery in the chest
or abdomen often
inhibits normal
respiratory
movements
(MOSBY’S
DICTIONARY of
medicine, nursing
and allied health).
To promote lung
expansion
Nursing Responsibilities:
Prior:
1. Check the doctor’s order.
During:
1. Provide comfort measures such as stretching of bed linens.
2. Assess patient’s level of the patient.
3. Assure the safety of the patient.
4. Stop the exercise immediately if there are any physiologic changes.
5. Let the patient take a rest a few minutes to prevent fatigue.
After:
1. Assess patient responses to the exercise/activity.
VII. N U R S I N G C A R E P L A N S
1. Impaired Physical Mobility
Cues Nursing
Diagnosis
Scientific
Explanation
Objective Nursing
Interventions
Rationale Evaluation
S: 0
O: the patient
may manifest
Limited range
of motion
Inability to
perform
simple
activities
without the
aid of other
people such
Impaired
physical
mobility
related to
pain as
evidenced by
discomfort
Cholecystecto
my, the
surgical
removal of the
gallbladder,
performed to
treat
cholelithiasis
and
cholecystitis.
Under general
anesthesia,
the gallbladder
is excised and
cystic duct
After 2-3
hours of
nursing
intervention,
the patient
will be able to
participate in
activities that
can provide
safety
measures
through the
health
teachings.
Established
rapport
Monitor and
record vital
signs
Identify
diagnosis that
contributes to
immobility
Assess
degree of
To gain trust
and
confidence of
patient
Provide a
baseline data
of the patient
Ascertain
contributing
or causative
factors
To determine
After 2-3
hours of
nursing
interventions,
the patient
will
participate in
activities that
can provide
safety
measures
through the
health
teachings.
as turning
and moving
Uncoordinate
d movements
resulting from
slow activities
performed
Verbalization
of difficulty in
moving and
performing
simple
activities
Identify a pain
scale of 8 (0-
10) being
perceived by
the patient
ligated; the
common duct
is searched,
and any
cholecystecto
my is done as
a laparoscopic
procedure.
This procedure
can cause pain
on the RUQ
due to the
surgical
incision after
the surgery.
pain by
listening to
patients
description of
pain during
movement
Determine
degree of
immobility
Encourage
verbalization
of feelings
and thoughts
patient's
description of
pain felt
To identify
individual
therapeutic
treatment
appropriate to
the client
based on his
level of
immobility
To assess
patients
understandin
g of disease
during
movement
Irritability and
facial
grimaces in
doing little
movements
Observe non-
verbal cues
and
movements
Assist patient
to reposition
self on a
more
comfortable
position
Support
affected body
parts with
pillow,
mattress and
water bed.
condition
To note any
incongruence
with reports
of abilities
To aid
patients
comfort
ability despite
disease
condition
To maintain
position and
reduce risk of
pressure
ulcers
Provide rest
periods in
between
while
performing
therapeutic
treatment
regimen
Discuss
discrepancies
in movement
when patient
is aware and
aware of
observation
and methods
in dealing
with
immobility
due to pain
To prevent
fatigue and
conservation
of energy
To motivate
patient in
practicing the
provided
treatment
regimen
felt
2. Impaired Tissue Integrity
Cues Nursing
Diagnosis
Scientific
Explanation
Objective Nursing
Interventions
Rationale Evaluation
S=
O=patient
may
manifest:
pain and
numbness
on the
surgical
incision site.
Chilling,
Perspiration
, Dyspnea,
Immobility,
Restlessnes
Impaired
Tissue
Integrity
related to
cholecystecto
my as
evidence by
destruction of
skin and
tissue layers.
Impaired
Tissue
Integrity
occurs when
there is
disruption of
skin and
tissues. Due
to
cholecystecto
my, a surgical
removal of the
gallbladder it
is done to
remove
gallstones or
After 3 hours
of nursing
intervention
the patient
will be able
to
participate
willingly in
activities
that can
promote
healing and
prevent
complication
with
assistance.
Assist with
general
hygiene and
comfort
measures.
Warn against
tampering
with the
wound or
dressings.
Maintain
infection
control
To promote
comfort and a
sense of well-
being.
To avoid
potential for
infection.
To reduce the
risk of
spreading
disease.
Patient was
able to do
the desired
activities
with
assistance.
s to remove an
infected of
inflamed
gallbladder in
order to
relieve pain
and infection.
standards
and
emphasize
the
importance of
handwashing.
Position
patient for
comfort and
minimal
pressure on
bony
prominences.
Change her
position at
least every 2
hours.
These
measures
reduce
pressure,
promote
circulation
and avoid
skin
breakdown.
To avoid skin
injury.
To prevent
the spreading
of
microorganis
Monitor
frequency of
turning and
skin
condition.
Remind
patient not to
scratch.
Clean and
dress the
surgical
incision site
using the
principles of
sterility or
medical
asepsis.
Encourage
ms.
To avoid skin
injury.
To prevent
the spreading
of
microorganis
ms.
To hasten
wound
healing and
increase
resistance.
patient to
increase
protein and
vitamin C
intake.
3.Knowledge Deficit
Cues Nursing
Diagnosis
Scientific
Explanation
Objective Nursing
Interventions
Rationale Evaluation
S = O
O = The
patient may
manifest
inaccurate
Knowledge
deficit
related to
unfamiliarity
with
information
Deficiency of
cognitive
information
related to
specific topic
to make
After 2 hours
of nursing
intervention
the patient
will be able
to participate
Ascertain
level of
knowledge
including
anticipatory
needs
To know the
level of
knowledge of
the patient
Patient was
able to
participate in
activities on
how to follow
accurate
follow
through of
instruction,
inadequate
performance
of test
resources as
evidenced by
lack of
immediate
recognition of
the patient’s
condition
inform
choices
regarding
condition,
treatment,
lifestyle
change.
in activities
on how to
follow
accurate
instruction.
Identify
support
person/ SO
requiring
intervention
Provide an
environment
that is
conducive to
learning
Give health
teachings
about the
To give
health
teaching to
the SO if the
patient is not
that coherent
Providing
good
environment
to the patient
enables him
or her
participate
and can
easily
understand
and
comprehend
health
teachings
instruction.
illness, in the
level of
patient’s
understandin
g
To give
health
teaching in a
simple
manner in a
way that the
patient will
understand it
to his/her
level of
capabilities
4.Risk for Infection
Cues Nursing
Diagnosis
Scientific
Explanation
Objective Nursing
Interventions
Rationale Evaluation
S = O
O = The
patient may
manifest
fever,
Chills,
flushed skin,
diaphoresis,
the wound
may be
inflamed,
with edema,
erythema,
and pus
Risk for
infection
related to
post surgical
procedure
Risk for
infection
means that
the person
has increased
possibility of
being
invaded by
pathogenic
microorganis
m. It will
cause
decrease
production of
WBC leading
to weak
After 2 hours
of nursing
interventions
, the patient
will be able
to participate
in activities
that will
verbalize
understandin
g of different
intervention
to reduce the
risk for
infection.
Establish
rapport
Monitor and
record vital
signs
Assess
patient’s
condition
To gain
patient’s
trust and
cooperation
To have
baseline data
on the
treatment
process
To note for
etiology
precipitating
factors that
causes risk
The patient
was able to
participate in
activities
that will
verbalize
understandin
g of different
intervention
to reduce the
risk for
infection.
draining. immune
defenses.
Broken skin
or
traumatized
tissues or
stasis of body
fluids in the
wound
predisposes
the person to
invasion of
pathogens
coming from
environment,
thus
increasing
the risk for
infection.
Note for signs
and
symptoms of
sepsis ( fever,
chills,
diaphoresis
and altered
level of
consciousness
Maintain
sterile
technique in
cleansing the
wound
Stress proper
hand washing
for infection
To assess
contributing
factors and
immediately
provide the
necessary
intervention
To reduce
existing risk
factors
To maintain
aseptic
technique
techniques by
all caregivers
between
therapies
Encourage
patient to
increase
protein and
vitamin C
intake
To hasten
wound
healing and
increase
resistance
5.Risk for Ineffective Breathing Pattern
Cues Nursing
Diagnosis
Scientific
Explanation
Objective Nursing
Interventions
Rationale Evaluation
S = “mika
allergy ku,
mengalbag
ya ing lupa
ku
.
O = The
patient
manifested
swelling on
face
especially
eyes,
itchiness on
wrist.
Risk for
ineffective
breathing
pattern
related to
allergy as
evidenced
the presence
of swelling.
Most acute
pulmonary
deterioration
is preceded
by a change
in breathing
pattern.
Respiratory
failure can be
seen with a
change in
respiratory
rate, change
in normal
abdominal
and thoracic
After 2 hours
of nursing
interventions
, the patient
will be able
to participate
in activities
that will help
her to be
free from any
further
allergic
reactions.
Establish
rapport
Monitor and
record vital
signs
Provide
comfort
measures
such as
stretching of
To gain
patient’s
trust and
cooperation
To have
baseline data
on the
treatment
process
To protect
the pt. from
having
wrinkled bed
sheets, this
Patient was
able to
participate in
activities
that will help
her to be
free from
any further
allergic
reactions.
patterns for
inspiration
and
expiration,
change in
depth of
ventilation
(Vt), and
respiratory
alternans.
Breathing
pattern
changes may
occur in a
multitude of
cases from
hypoxia,
heart failure,
diaphragmati
c paralysis,
airway
bed linens
Assess
patient’s
condition
Note for signs
and
symptoms of
alterations in
depth of
breathing.
can lead to
bed sore.
To note for
etiology
precipitating
factors that
causes risk
for
ineffective
breathing
pattern
To assess
contributing
factors and
immediately
provide the
necessary
intervention
obstruction,
infection,
neuromuscul
ar
impairment,
trauma or
surgery
resulting in
musculoskele
tal
impairment
and/or pain,
cognitive
impairment
and anxiety,
metabolic
abnormalities
(e.g., diabetic
ketoacidosis
[DKA],
uremia, or
Instruct the
pt. to put a
pillow to
support the
incision site
when
coughing or
sneezing & to
turn side to
side.
Instruct to
avoid eating
foods(seafood
s) and
exposing self
to
environmental
factors(dust,
To assist
client to
explore
methods for
alleviation or
control of
pain
To limit the
impact on
client’s
breathing
that may
require
avoidance or
modification
of lifestyle
and
thyroid
dysfunction),
peritonitis,
drug
overdose,
and pleural
inflammation.
severe
weather,
perfumes,
animal fur,
household
chemicals,
second-hand
smoke) that
will trigger the
allergic
reaction and
to be aware of
NSAID’s (Non
Steroidal Anti-
Inflammatory
Drugs)
environment.
VII. H E A L T H T E A C H I N G S
Cholelithiasis is the fifth leading cause of hospitalization among adults
and accounts for 90% of all gallbladder and duct diseases (Disease hand
book; Lippincott Williams and Wilkins). No one is exempted from acquiring
the disease no matter what is your race, gender or status in life.
The group provided some health teachings and ways to prevent
complications and to prevent acquiring cholelithiasis. First dietary change,
diet is very important in maintaining a healthy body. Proper diet and right
information about healthy foods is a great help in maintaining healthy body
and gallbladder. As certain saying goes “What you eat, is what you get”. If
proper diet is maintained and nutritious foods are only being taken by
individuals they are least likely to acquire the disease and other kind of
diseases.
Cholesterol is the primary ingredient in most gallstones. Some doctor’s
also suggest avoiding eggs, either because of their high cholesterol content.
A recent study of residents of southern Italy found that a diet rich in sugars
and animal fats and poor in vegetable fats and fibers was a significant risk
factor for gallstone formation. Eggs, pork, and onions were also reported to
be the most common triggers.
Most studies report that vegetarians are at low risk for gallstones. In
some trials, vegetarians had only half the gallstone risk compared with meat
eaters. Vegetarians often eat fewer calories and less cholesterol. They also
tend to weigh less than meat eaters. All of these differences may reduce
gallstone incidence
Coffee increases bile flow and therefore might reduce the risk of
gallstones. In a large study of men, those drinking two to three cups of
regular coffee per day had a 40% lower risk of gallstones compared with
men who did not drink coffee. In the same report, men drinking at least four
cups per day had a 45% reduced risk. People at risk for gallstones who wish
to consider increasing coffee drinking to reduce risks should talk with a
doctor beforehand.
Constipation has been linked to the risk of forming gallstones. When
constipation is successfully resolved, it has reduced the risk of gallstone
formation. Wheat bran, commonly used to relieve constipation when
combined with fluid, has been reported to reduce the relative amount of
cholesterol in bile of a small group of people whose bile contained excessive
cholesterol (a risk factor for gallstone formation). The same effect has been
reported in people who already have gallstones. Doctors sometimes
recommend two tablespoons per day of unprocessed Miller’s bran; an
alternative is to consume commercial cereal products that contain wheat
bran. Bran should always be accompanied by plenty of fluid.
Second, Lifestyle also adds up on the possibility of acquiring the
disease. Obese women have high risk of forming gallstones compared with
women who are not overweight. Weight loss plans generally entail reducing
dietary fat but it should be done gradually. Exercise also help in maintaining
appropriate body figure that lessen the susceptibility of having the disease.
Third, Vitamin intake, Vitamin C is needed to convert cholesterol to bile
acids such conversion reduce gallstone risk. Fourth, herbs may also be
helpful to reduce gallstone formation. Milk thistle extracts in capsules or
tablets may be beneficial in preventing gallstones. In one study, silymarin
(the active component of milk thistle) reduced cholesterol levels in bile,
which is one important way to reduce gallstone formation. People in the
study took 420 mg of silymarin per day.
VIII. L E A R N I N G D E R I V E D
It is important that one has knowledge about the body’s function and
responses toward certain stimuli in the environment; this is to understand
how different factors affect health and wellness of a person. Health teaching
is a vital care to clients/patients, and a nurse must understand the conditions
affecting the human body to initiate appropriating teaching plans.
In this study, it is focused on the Colelithiasis which is one of the
most common gastrointestinal disorders. It is the presence of gallstones in
the gallbladder. It can occur anywhere within the biliary tree, including the
gallbladder and the common bile duct. It is caused by stones form when
there is too much cholesterol or bilirubin in the bile. Other stones form if
there are not enough bile salts or if the gallbladder fails to empty properly.
Symptoms usually start after a large stone blocks the cystic duct or the
common bile duct. Stones blocking the lower end of the common bile duct
(where it enters the duodenum) may obstruct secretion from the pancreas,
producing pancreatitis. This condition can also be serious and may require
hospitalization.
Modern advances in surgery have revolutionized the treatment of
gallstones. In general, surgery is used only if you have symptoms. In the
past, open cholecystectomy (gallbladder removal) was the usual procedure
for uncomplicated cases. Today, a minimally-invasive technique called
laparoscopic cholecystectomy is most commonly used. This procedure uses
smaller surgical cuts, which allows for a faster recovery.
This study helped the students understand the importance of taking
care of one self, each part belongs to an intersystem of physiologically
functioning body- the human body. Furthermore, it is stressed that person
should be aware on whatever they feel within their body. Every individual
should be conscious to what is happening within their environment that can
be a factor of getting any diseases that could harm them.
The student nurses were able to meet their objectives. They were able
to understand the pathophysiology of the disease which is the Colelithiasis
and its pharmacology. They had also gathered data upon assessment that
had helped in the accomplishment of the study. This case study contributed
a lot in the knowledge of the student nurses which can be helpful for their
intended course.
R E F E R E N C E S
Stedman's Medical Spellchecker, © 2006 Lippincott Williams & Wilkins.
Professional Guide to Diseases (Eighth Edition), Copyright © 2005
Lippincott Williams & Wilkins. Professional Guide to Diseases (Eighth Edition),
Copyright © 2005 Lippincott Williams & Wilkins.
Medical-Surgical Nursing: Health and Illness Perspectives by Wilma J. Phipps
www.wrongdiagnosis.com/medical/cholecystolithiasis.htm
http://medical-dictionary.thefreedictionary.com/cholecystolithiasis
http://answers.yahoo.com/question/index?qid=20060831234007AAwH6VA