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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

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Page 1: Cholelithiasis Sample

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

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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

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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.

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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.

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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

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work she eats any food that is available at the place or

sometimes passes by fast foods to order.

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2. Family-Health Illness History

Grand FatherGrand FatherGrand

Mother

Grand Mother

FatherMother

A1 A4tweetyA3A2

Legend: Blue = male = DeceasePink = female

= AMI= DM

=HPN

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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

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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

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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.

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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).

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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.

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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

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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.

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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

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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

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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

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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.

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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.

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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

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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

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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

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(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

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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.

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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

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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

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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

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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.

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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.

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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.

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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.

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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

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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

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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.

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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.

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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

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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.

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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

Page 39: Cholelithiasis Sample

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.

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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

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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

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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?

 

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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.

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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.

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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

 

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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.

 

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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.

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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.

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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.

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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.

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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.

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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.

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(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

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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.

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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

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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.

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After:

1. Assess patient responses to the exercise/activity.

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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.

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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

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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

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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

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felt

Page 63: Cholelithiasis Sample

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.

Page 64: Cholelithiasis Sample

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

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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.

Page 66: Cholelithiasis Sample

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

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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.

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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

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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.

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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

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techniques by

all caregivers

between

therapies

Encourage

patient to

increase

protein and

vitamin C

intake

To hasten

wound

healing and

increase

resistance

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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.

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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

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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

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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.

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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

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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.

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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

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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.

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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