CASE PRESENTATION CHOLELITHIASIS

X

CHOLELITHIASIS
The gallbladder stores and concentrates bile produced by the liver . Cholelithiasis is the presence of stone in the gallbladder. Stones occur when cholesterol supersaturates the bile in the gallbladder and precipitates out of the bile.

OBJECTIVES OBJECTIVES OF THE STUDY
At the end of this study, the NCM501204 group A12 students of Liceo de Cagayan University will be able to: 1. Define Cholelitiasis. 2. Identify the developmental theory of the patient 3. Discuss the health history of the patient w/c include the family past medical history 4. Identify the history of present illness 5. Discuss the medical management of the disease. 6. Show the physical assessment of the patient. 7. Discuss the pathophysiology of the disease. 8. Enumerate and discuss the nursing management 9. Identify the drugs administered to the patient 10. Discuss the discharge plan w/c includes the referral and follow up.

SCOPE & LIMITATION
This study is limited only on the physical assessment and 2 days care of the patient w/c was conducted during our hospital exposure at BPH-Talakag last July 9-10, 2007, BPH97-3 shift. All the data gathered were only based on the interview w/ the patient, physical assessment and observations; and from the chart of the patient

PATIENT S PROFILE
NAME :X AGE :X SEX : female BIRTHDAY :X BIRTH PLACE : X RELIGION :X NATIONALITY : FILIPINO CIVIL STATUS : MARRIED ADDRESS :X OCCUPATION : X NAME OF HUSBAND: X OCCUPATION : X # OF CHILDREN: 7 living, 1 deceased

GROWTH & DEVELOPMENTAL TASK
SIGMUND FREUD (1856-1939) (1856Psychosexual Theory ERIK ERIKSON Psychosocial Theory JEAN PIAGET Cognitive Development ROBERT HAVIGHURST Developmental Task Theory

HEALTH HISTORY

Family History Past Medical History Social History

HISTORY OF PRESENT ILLNESS

MEDICAL MANAGEMENT
Doctor s Order: July 08, 2007 1. Soft diet 2. Ketorolac 1 amp IVTT RTC q 6 3. Ranitidine 1 amp q 6 IVTT 4. Metronidazole 500 mg q 6 IV infusion 5. Cefuroxime 750mg q 6 IVTT 6. Metochloramide HCl 1 amp IVTT now then q 8 for nausea and vomiting 7. Nalbuphine HCl 1 amp now then q 6 for severe pain 8. Continue D5LR IVF @ 30 gtts/min 9. For CBC

July 09, 2007 1. To continue medications Ranitidine 1 amp q 6 IVTT Metronidazole 500 mg q 6 IV infusion Cefuroxime 750mg q 6 IVTT Metochloramide HCl 1 amp IVTT now then q 8 for nausea and vomiting Nalbuphine HCl 1 amp now then q 6 for severe pain 2. To consumed Ketorolac 3. Continue D5LR IVF @ 30 gtts/min 4. For CBC

NURSING SYSTEM REVIEW CHART

X X X X X X X X

PATHOPHYSIOLOGY OF CHOLELITHIASIS
Cholelithiasis, in the presence of one or more gallstones, is the most common disorder of the biliary tract. Precipitating factors: Female Fat Fertile Forty Predisposing factors: factors: Burns Use of total parenteral nutrition Paralysis ICU care Major trauma

Gallstone
liquid bile contains too much cholesterol, bile salts, or bilirubin, under certain conditions it can harden into stones Cholesterol stones Pigment stones

Gallstones can block the normal flow of bile

hepatic ducts

cystic duct

common bile duct

Bile trapped in these ducts

Other ducts open into the common bile duct If a gallstone blocks the opening to that duct, digestive enzymes can become trapped in the pancreas CHOLELITHIASIS Signs & Symptoms: Pain in RUQ abdomen Stools, clay-colored clayNausea and vomiting Heartburn Gas or excessive flatus Abdominal indigestion Abdominal fullness, gaseous Complications: Acute or chronic cholecystitis Choledocholithiasis Cholangitis Empyema Gallstone ileus Acute pancreatitis

IDEAL NURSING MANAGEMENT:
NURSING DIAGNOSIS: Pain, acute Fluid Volume, risk for deficient Nutrition: imbalanced, risk for less than body requirements

Date& Time July 9 , 2007

SOAPIE

S : Sakit akung koto-koto maam , as verbalized by kotothe patient. O : Guarding behavior especially on the affected site Restlessness SelfSelf-focusing Facial grimaces A : Acute Pain related to obstruction or inflammation processes on the gallbladder as evidenced by facial grimaces and guarding on the affected site. P : At the end of 30 minutes patient will relieve or lessen the pain felt in the right upper quadrant.

I : Independent:
*Observed and documented the location, severity and character of pain. *Placed the patient in semi-fowler s position. semi-

*Instructed the patient on diaphragmatic breathing
when experiencing pain. *Make time to listen to and maintained frequent contact with the patient.

Dependent:
*Administered analgesic (Nalbuphine HCL) as prescribe by the physician. E : At the end of 1 hour patient verbalized and demonstrated relieved from pain.

Nagsukaha ko maam, lain kayo akong paminaw as verbalized by the patient. O : Pallor Poor skin turgor dry mouth nausea and vomiting weak in appearance A : Risk for deficient fluid volume related to excessive losses of fluids through normal route like vomiting. P : At the end of 30 minutes patient will be able to report relief of nausea and vomiting and maintain hydration.

S :

I : Independent: *Monitored total intake and output. *Increased fluid intake at least 6-8 glasses of water per 6day. *Provided with clean environment and eliminating noxious sights and smells by doing bedside care. Dependent: Dependent: *Administered antiemetics (metochlopromide) as prescribed by the physician *Administered IV fluids (D5LR 1L) as prescribed by the physician. E : After 1-hour patient reported relief of nausea and vomiting and 1provided with adequate hydration.

S :

Dili ko ganahan mokaon kai aku ra gihapon masuka mam, as verbalized by the patient. O : Nausea and vomiting Loss of appetite Poor muscle tone Weight loss A : Risk for imbalanced nutrition: less than body requirements related to nausea and vomiting and loss of appetite. P : At the end of 30 minutes patient will report relief of nausea and vomiting.

I : Independent: *Asked patient on what were her food preferences . *Provided oral hygiene like mouthwash before meals. *Provided a pleasant atmosphere at mealtime by doing bedside care and removed all noxious stimuli by limiting watchers in the ward as much as possible. *Emphasized importance of well-balanced nutritious wellfood intake. Dependent: *Encouraged to eat soft, low fat diet (fruits and vegetables, fish, etc.) as ordered by the physician. E : At the end of 1 hour patient was able to understand the importance of proper nutrition and demonstrated a positive response towards the implemented interventions.

DRUG STUDY: Ranitidine Cefuroxime Metronidazole Metochlopramide Nalbuphine hydrochloride Aluminum Magnesium Hydroxide Ketorolac

Discharge Plan ( Referral & Follow-up) Follow-

Evaluation and Recommendation

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