Divine World College of Laoag School of Nursing Laoag City

In partial fulfillment of the requirements in NCM 102 (Concept in ABNORMAL METABOLISM)

A case study in

CHOLELITHIASIS
Presented by: Juvel Rafael Camille Pan Irvin Ross Molina Aimen Gallegos Gemaryvive Quiaoit Ma. Ofelia Editha Morales Noemi Maruqiun Aaron Dondoyano Paul Galat

BSN III-C Group 11

Presented to: Mrs. Carol Domingcil

Clinical Instructor

February, 2010 PERSONAL DATA

Name of Patient: Jose Rizal Address: Paoay, Ilocos Norte Hospital number: 1087495 Sex: Male Age: 47 years old Date of Birth: August 13, 1961 Civil Status: Single Educational Attainment: High School Undergraduate Occupation: Construction Worker Chief of complaint: Right abdominal pain Admitting Diagnosis: T/C Cholelithiasis R/O Acute Pancreatitis Final Diagnosis: Cholelithiasis Date and time of admission: January 24, 2010@ 4:30 PM Attending Physician: Dr. Bonifacio

ANATOMY AND PHYSIOLOGY

THE DIGESTIVE SYSTEM

The digestive system is made up of the digestive tracta series of hollow organs joined in a long, twisting tube from the mouth to the anusand other organs that help the body break down and absorb food. The major functions of the GI tract are categorized as four distinct processes:

Ingestion is the consumption of food and other substances through the mouth, as they pass by chewing and swallowing into the GI tract. Digestion is the process of metabolism by which ingested substances are mechanically and chemically converted for use by the body. Digestion is further categorized into three distinct phases: cephalic phase in which taste and smell stimulate the nervous system to prepare the body for eating and digestion; gastric phase in which passage of food into the stomach stimulates the release of gastric juices and pH balancing mechanisms throughout the system; intestinal phase in which excitatory and inhibitory reflexes control the passage of partially digested food into and through the intestines.

Absorption is the movement of metabolized nutrients and water from the digestive system into the circulatory and lymphatic capillaries by osmosis, active transport, and

diffusion through the cells in the walls and surrounding layers of the intestines and their supporting circulatory systems. Excretion or egestion is the elimination of undigested, mostly solid material from the GI tract by defecation. Fluid products of metabolism throughout the body are also excreted by organ systems not directly part of the GI tract and digestive system, such as the kidneys, skin, and lungs. In addition to processing nutrients as the principal pathway of the digestive system, the GI tract is also a prominent part of the immune system, providing various levels of defense against pathogenic microorganisms and potentially toxic substances throughout the path of digestion. Many diseases and disorders of the GI tract can result in feeding difficulties in children and infants.

PARTS OF THE DIGESTIVE SYSTEM Upper GI Tract The upper GI tract consists of the mouth, pharynx, esophagus, and stomach. This is where ingestion and the first phase of digestion occur.

The mouth includes the tongue, teeth, and buccal mucosa or mucous membranes containing the ends of the salivary glands, continuous with the soft palate, floor of the mouth and underside of the tongue. Chewing (mastication) is the mechanical process by which food, constantly repositioned by muscular action of the tongue and cheeks, is crushed and ground by the teeth through the muscular action of the lower jaw (mandible) against the fixed resistance of the upper jaw (maxilla). Saliva excreted in the oral cavity by three pairs of exocrine glands (parotid, submandibular, and sublingual) is mixed with chewed food to form a bolus, or ball-shaped mass. Two types of saliva: thin watery secretion that wets the food thick mucus secretion that lubricates and causes the food particles to stick together to form the bolus.

The pharynx is contained in the neck and throat and functions as part of both the digestive system and the respiratory system.

Three sections of the pharynx: nasopharynx behind the nasal cavity and above the soft palate; oropharynx behind the oral cavity and including the base of the tongue, the tonsils, and the uvula hypopharynx or laryngopharynx includes the junction with the esophagus and the larynx, where respiratory and digestive pathways diverge. The swallowing reflex is initiated by touch receptors in the pharynx as the bolus of chewed food is pushed to the back of the mouth. Swallowing automatically closes down the respiratory or breathing pathway as an anti-choking reflex. Failure or confusion of reflexes at this point can result in aspiration of solid or liquid food into the trachea and lungs.

The esophagus is the hollow muscular tube through which food passes from the pharynx to the stomach. It is also lined with mucous membrane continuous with the mucosa of the mouth and into which open the esophageal glands. The esophagus is surrounded by relatively deep muscles that move the swallowed bolus of masticated food through peristaltic action, piercing the thoracic diaphragm to reach the stomach. The stomach is a hollow muscular organ, located below the diaphragm and above the small intestine that receives and holds masticated food to begin the next phase of digestion. Two smooth muscle valves, the esophageal sphincter above and the pyloric sphincter below, keep stomach contents contained. The stomach is surrounded by stimulant (parasympathetic) and inhibitor (orthosympathetic) nerve plexuses which regulate both secretory and muscular activity during digestion. With a volume of as little as 50 mL when empty, the adult human stomach may comfortably contain about a liter of food after a meal, or uncomfortably as much as 4 liters of liquid.

Lower GI Tract The lower GI tract includes the small intestine and large intestine, beginning after the stomach and terminating at the anus. Its function is to complete the digestion and absorption of nutrients and to prepare waste products for elimination from the digestive system.

The small intestine is where most digestion takes place. It is structurally divided into three parts: the duodenum, the jejunum, and the ileum. Among humans over five years old, the small intestine tends to vary in length from 4-7 meters (13 to 23 feet). The duodenum is where most of the breakdown of food in the small intestine occurs. It is here that Brunners glands produce an alkaline secretion to protect the duodenum from acidic chyme entering from the stomach and to activate intestinal enzymes enabling digestion and absorption. The jejunum begins at the ligament of Treitz in the duodenojejunal flexure and continues to the ileum. The inner surface or mucous membrane of the jejunum is covered by villi (small finger-like structures) much longer than found in the duodenum or ileum, contained in many large circular folds (plicae circulares) which provide extensive surface area for absorption of nutrients. The villi can increase intestinal absorptive surface area by a factor of 30; the microvilli extensions of the villi increase surface area by an additional factor of 600. Villus capillaries collect amino acids and simple sugars. Villus lacteals or lymphatic capillaries absorb dietary fats. The ileum is the final and longest section of the small intestine. Like the jejunum, the wall of the ileum has many folds and villi to increase both adsorption of enzymes and absorption of nutrients. It also has an increasing number of goblet cells. The ileum is responsible for the final stages of protein and carbohydrate digestion, as contents are pushed along by peristaltic waves of smooth muscle contractions. There is no absolute demarcation between the jejunum and the ileum, but the ileum tends to have more fat inside the mesentery and has a relatively decreasing diameter. Unlike the rest of the small intestine, the ileum has abundant Peyers patches, lymphoid follicles similar to lymph nodes, which function as an important component of the immune system response to pathogenic organisms in the GI tract.

The Large Intestine, commonly referred to by the name of its longest component, the colon, this is the last part of the digestive system. Its principal function is to absorb remaining water from the waste products of digestion as it compacts the accumulated waste for periodic elimination by defecation. While food is not broken down further at this stage, the fluid absorption function of the large intestine does act to gather in vitamins created by beneficial bacteria or flora inhabiting the colon. Instead of the predominance of evaginations of villi found in the small intestine, the large intestine has increased invaginations of glands and an abundance of goblet cells.

Three parts of the large intestine:

The cecum is a pouch at the beginning of the large intestine, separated from the ileum of the small intestine by the ileocecal valve and joining the colon at the cecocolic junction in the lower right quadrant of the abdomen. The cecum is host to a large number of bacteria which aid in the final enzymatic processing of material not completely digested in the small intestine. The colon consists of four parts named for their relative orientation in the abdomen: (1) the ascending colon, (2) the transverse colon, (3) the descending colon, and the (4) sigmoid colon. By the time chyme has reached the colon, almost all nutrients and most of the water have already been absorbed by the body. It is here that the chyme is mixed with mucus and bacteria to become feces. The waste products of bacterial metabolism include some nutrients used by the cells lining the colon for their own nourishment. The colon ends at the junction of the sigmoid colon and (5) the rectum. The rectum is the last part of the large intestine, beginning at and continuous with the colon, and terminating at anus. The rectum provides temporary storage for feces. Stretch receptors of the nervous system located in the rectal walls stimulate the desire to defecate. As peristaltic waves propel the feces into the anal canal, external and internal sphincters allow the final exit of waste material from the GI tract. Four concentric layers of tissue if GI tract The mucosa (moist linings of mucous membranes) is the first main layer, consisting of the primary epithelium (tissues lining the cavities and surfaces of structures throughout the body), the lamina propria (containing capillaries, lymph vessels, and glands with ducts opening on to the epithelium), and the muscularis mucosae (a thin layer of smooth muscle). The submucosa consists of fibrous connective tissue, separating the mucosa from the surrounding muscles, and includes fine bundles of nerve plexuses. The muscularis externa (external muscle layer) generally has two distinct layers of smooth muscle, the inner (circular) and outer (longitudinal). In the stomach, there is a third layer (inner oblique) responsible for the churning or mechanical breakdown of food. In the esophagus, part of the external muscle layer is skeletal muscle rather than smooth muscle. The pyloric and anal sphincters are also formed by the inner layer of the muscularis externa. The serosa (serous membrane) consists of layers of connective tissue continuous with the peritoneum, which forms the lining of the abdominal cavity and serves as conduit for blood vessels, lymph vessels, and nerves serving the contained organs.

Accessory Organs of the GI tract The liver secretes bile, produced by its hepatocytes, into the duodenum of the small intestine via the biliary system. Bile acts as a kind of detergent, emulsifying fats to promote enzyme action in the intestines. Epithelial cells in the liver add a watery solution rich in bicarbonates that act to dilute and neutralize acids at this stage of digestion. Cholesterol is also released with the bile and is important for the metabolism of fat soluble vitamins as well as maintenance of normal cell membranes throughout the body. The gallbladder is connected to the liver and the duodenum by the biliary tract. The gallbladder stores the bile (or gall) secreted by the liver until its release is triggered by the digestive process. The interior of the gallbladder has a simple columnar epithelial lining characterized by recesses or pouches, which provide the volume for storage. The pancreas is another relatively large gland that functions as part of both the digestive and endocrine system. Its exocrine function is to produce and secrete pancreatic juice rich in digestive enzymes. Its endocrine functions include the production of important hormones, such as insulin (which helps regulate metabolism at the global and cellular level), glucagon (which acts opposite insulin), and somatostatin (which acts to suppress the release of various other GI hormones and lower the rate of gastric emptying as digestion approaches completion). The pancreatic duct joins the common bile duct, together entering the major duodenal papilla through the hepatopancreatic ampulla..

The Digestive hormones

Gastrin - is in the stomach and stimulates the gastric glands to secrete pepsinogen(an inactive form of the enzyme pepsin) and hydrochloric acid. Secretion of gastrin is stimulated by food arriving in stomach. The secretion is inhibited by low pH . Secretin - is in the duodenum and signals the secretion of sodium bicarbonate in the pancreas and it stimulates the bile secretion in the liver. This hormone responds to the acidity of the chyme. Cholecystokinin (CCK) - is in the duodenum and stimulates the release of digestive enzymes in the pancreas and stimulates the emptying of bile in the gall bladder. This hormone is secreted in response to fat in chyme. Gastric inhibitory peptide (GIP) - is in the duodenum and decreases the stomach churning in turn slowing the emptying in the stomach. Another function is to induce insulin secretion.

THE GALLBLADDER

Gallbladder, muscular organ that serves as a reservoir for bile, present in most vertebrates. In humans, it is a pear-shaped membranous sac on the undersurface of the right lobe of the liver just below the lower ribs. It is generally about 7.5 cm (about 3 in) long and 2.5 cm (1 in) in diameter at its thickest part; it has a capacity varying from 1 to 1.5 fluid ounces. The body (corpus) and neck (collum) of the gallbladder extend backward, upward, and to the left. The wide end (fundus) points downward and forward, sometimes extending slightly beyond the edge of the liver. The different layers of the gallbladder are as follows:

The gallbladder has a simple columnar epithelial lining characterized by recesses called Aschoff's recesses, which are pouches inside the lining. Over the epithelium there is a layer of connective tissue (lamina propria). Above the connective tissue is a wall of smooth muscle (muscularis externa) that contracts in response to cholecystokinin, a peptide hormone secreted by the duodenum. There is, in essence, no submucosa separating the connective tissue from serosa and adventitia, but there is a thin lining of muscular tissue to prevent infection.

Function The function of the gallbladder is to store bile, secreted by the liver and transmitted from that organ via the cystic and hepatic ducts, until it is needed in the digestive process. The gallbladder, when functioning normally, releases bile through the biliary ducts into the duodenum to aid digestion by promoting peristalsis and absorption, preventing putrefaction, and emulsifying fat.

READINGS Gallstones (Cholelithiasis) Gallstones (often misspelled gall stones, or gall stone) are stones that form in the gall (bile).

Bile is a watery liquid made by the cells of the liver that is important for digesting food in the intestine, particularly fat. Liver cells secrete the bile they make into small canals within the liver. The bile flows through the canals and into larger collecting ducts within the liver (the intrahepatic bile ducts). The bile then flows within the intrahepatic bile ducts out of the liver and into the extrahepatic bile ducts-first into the hepatic bile ducts, then into the common hepatic duct, and finally into the common bile duct. From the common bile duct, there are two different directions that bile can flow.

The first direction is on down the common bile duct and into the intestine where the bile mixes with food and promotes digestion of food. The second direction is into the cystic duct, and from there into the gallbladder (often misspelled as gall bladder).

Once in the gallbladder, bile is concentrated by the removal (absorption) of water. During a meal, the muscle that makes up the wall of the gallbladder contracts and squeezes the concentrated bile in the gallbladder back through the cystic duct into the common duct and then into the intestine. (Concentrated bile is much more effective for digestion than the unconcentrated bile that goes from the liver straight into the intestine.) The timing of gallbladder contraction-during a meal-allows the concentrated bile from the gallbladder to mix with food. Gallstones usually form in the gallbladder; however, they also may form anywhere there is bile; in the intrahepatic, hepatic, common bile, and cystic ducts. Gallstones also may move about within bile, for example, from the gallbladder into the cystic or common duct.

Two main types of gallstones:

Stones made out of cholesterol. Gallstones made out of cholesterol are by far the most common type. Cholesterol gallstones have nothing to do with the cholesterol levels in the blood. Stones made from too much bilirubin in the bile. Bile is a liquid made in the liver that helps the body digest fats. Bile is made up of water, cholesterol, bile salts, and other chemicals, such as bilirubin. Such stones are called pigment stones.

Risk factors for Gallstones 1. Gender. Gallstones form more commonly in women than men. 2. Age. Gallstone prevalence increases with age. 3. Obesity. Obese individuals are more likely to form gallstones than thin individuals. 4. Pregnancy. Women who have been pregnant are more likely to form gallstones than women who have not been pregnant. Pregnancy increases the risk for cholesterol gallstones because during pregnancy, bile contains more cholesterol, and the gallbladder does not contract normally. 5. Birth control pills and hormone therapy. The increased levels of hormones caused by either treatment mimics pregnancy. 6. Rapid weight loss. Rapid weight loss by whatever means, very low calorie diets or obesity surgery, causes cholesterol gallstones in up to 50% of individuals. Many of the gallstones will disappear after the weight is lost, but many do not. Moreover, until they are gone, they may cause problems. 7. Crohn's disease. Individuals with Crohn's disease of the terminal ileum are more likely to develop gallstones. Gallstones form because patients with Crohn's disease lack enough bile acids to solubilize the cholesterol in bile. Normally, bile acids that enter the small intestine from the liver and gallbladder are absorbed back into the body in the terminal ileum and are secreted again by the liver into bile. In other words, the bile acids recycle. In Crohn's disease, the terminal ileum is diseased. Bile acids are not absorbed normally, the body becomes depleted of bile acids, and less bile acids are secreted in bile. There are not enough bile acids to keep cholesterol dissolved in bile, and gallstones form. 8. Increased blood triglycerides. Gallstones occur more frequently in individuals with elevated blood triglyceride levels.

9. Failure of the gallbladder to empty bile properly (this is more likely to happen during pregnancy). 10. Medical conditions that cause the liver to make too much bilirubin, such as chronic hemolytic anemia, including sickle cell anemia. 11. Liver cirrhosis and biliary tract infections (pigmented stones). 12. Diabetes 13. Bone marrow or solid organ transplant 14. Rapid weight loss, particularly eating a very low-calorie diet. 15. Receiving nutrition through a vein for a long period of time (intravenous feedings). Symptoms of Gallstones The majorities of people with gallstones have no signs or symptoms and are unaware of their gallstones. (The gallstones are "silent.") Their gallstones often are found as a result of tests (for example, ultrasound or X-ray examination of the abdomen) performed while evaluating medical conditions other than gallstones. Symptoms can appear later in life, however, after many years without symptoms. Thus, over a period of five years, approximately 10% of people with silent gallstones will develop symptoms. Once symptoms develop, they are likely to continue and often will worsen. Gallstones are blamed for many symptoms they do not cause. Among the symptoms gallstones do not cause are:

dyspepsia (including abdominal bloating and discomfort after eating), intolerance to fatty foods, belching, and flatulence (passing gas or farting).

When signs and symptoms of gallstones occur, they virtually always occur because the gallstones obstruct the bile ducts. The most common symptom of gallstones is biliary colic. Biliary colic is a very specific type of pain, occurring as the primary or only symptom in 80% of people with gallstones who develop symptoms. Biliary colic occurs when the extrahepatic ducts-cystic, hepatic or common bile-are suddenly blocked by a gallstone. (Slowly-progressing obstruction, as from a tumor, does not cause biliary colic.) Behind the obstruction, fluid accumulates and distends the ducts and gallbladder. In the case of hepatic or common bile duct obstruction, this is due to continued secretion of bile by the liver. In the case of cystic duct obstruction, the wall of the gallbladder secretes fluid into the gallbladder. It is the distention of the ducts or gallbladder that causes biliary colic.

Characteristically, biliary colic comes on suddenly or builds rapidly to a peak over a few minutes.

It is a constant pain, it does not come and go, though it may vary in intensity while it is present. It lasts for 15 minutes to 4-5 hours. If the pain lasts more than 4-5 hours, it means that a complication - usually cholecystitis - has developed. The pain usually is severe, but movement does not make the pain worse. In fact, patients experiencing biliary colic often walk about or writhe (twist the body in different positions) in bed trying to find a comfortable position. Biliary colic often is accompanied by nausea. Most commonly, biliary colic is felt in the middle of the upper abdomen just below the sternum. The second most common location for pain is the right upper abdomen just below the margin of the ribs. Occasionally, the pain also may be felt in the back at the lower tip of the scapula on the right side. On rare occasions, the pain may be felt beneath the sternum and be mistaken for angina or a heart attack. An episode of biliary colic subsides gradually once the gallstone shifts within the duct so that it is no longer obstructing.

Biliary colic is a recurring symptom. Once the first episode occurs, there are likely to be other episodes. Also, there is a pattern of recurrence for each individual, that is, for some individuals the episodes tend to remain frequent while for others they tend to remain infrequent. The majority of people who develop biliary colic do not go on to develop cholecystitis or other complications. Diagnosis of Gallbladder

Lab tests to check for jaundice and signs of liver inflammation Blood Amylase level to check for pancreatic inflammation Ultrasound: Uses sound waves to image the intra-abdominal organs including the gallbladder CT scan: Computer constructed x-ray images of the abdominal organs

Heida scan: Uses a low level radioactive tracer that is taken up by the gallbladder to measure gallbladder function. MRCP: A type of MRI scan that visualizes the common bile duct to check for bile duct obstruction. ERCP: A test where a scope is passed via the mouth into the common bile duct allowing dye to be injected into the common bile duct. X-ray pictures are then taken. This test gives the most accurate assessment of the common bile duct. It also is sometimes required to extract stones from the common bile duct.

Treatment

If silent gallstones are discovered in an individual at age 65 (or older), the chance of developing symptoms from the gallstones is only 20% (or less) assuming a life span of 75 years. In this instance, it is reasonable not to treat the individual. Among younger individuals, no treatment also might be appropriate if the individuals have serious, life-threatening diseases, for example, serious heart disease, that are likely to shorten their life span. On the other hand, in healthy young individuals, treatment should be considered even for silent gallstones because the individuals' chances of developing symptoms from the gallstones over a lifetime will be higher. Once symptoms begin, treatment should be recommended since further symptoms are likely and more serious complications can be prevented. Cholecystectomy. Cholecystectomy (removal of the gallbladder surgically) is the standard treatment for gallstones in the gallbladder. Surgery may be done through a large abdominal incision or laparoscopically through small punctures of the abdominal wall. Laparoscopic surgery results in less pain and a faster recovery. Sphincterotomy and extraction of gallstones. Sphincterotomy involves cutting the muscle of the common bile duct (sphincter) at the junction of the common bile duct and the duodenum in order to allow easier access to the common bile duct. After the sphincter is cut, instruments may be passed through the endoscope and up into the hepatic and common bile ducts to grab and pull out the gallstone or to crush the gallstone. Oral dissolution therapy. It is possible to dissolve some cholesterol gallstones with medication taken orally. The medication is a naturally-occurring bile acid called ursodeoxycholic acid or ursodiol (Actigall, Urso). Extracorporeal shock-wave lithotripsy. ESWL generators produces shock waves outside of the body that are then focused on the gallstone. The shock waves shatter the gallstone, and the resulting pieces of the gallstone either drain into the intestine on their own or are extracted endoscopically as in sphincterotomy.

Prevention There is no known way to prevent gallstones. If you have gallstone symptoms, eating a low-fat diet and losing weight may help you control symptoms. Possible Complications Blockage of the cystic duct or common bile duct by gallstones may cause the following problems:

Acute cholecystitis Cholangitis Cholecystitis - chronic Choledocholithiasis Pancreatitis

Alternative Names Cholelithiasis; Gallbladder attack; Biliary colic; Gallstone attack; Bile duct stone; Bile calculus; Biliary calculus

PATHOPHYSIOLOGY

Obesity

Pregnancy Oral contraceptive Estrogen therapy

Liver disease

Ileac diseased or intestinal bypass

Inflammation of gallbladder

synthesis of fatty acids

Obstruction at the ileum Altered absorption mucosal layer of

level of estrogen

Infiltration of hepatocytes

fats

in

Alteration in the flow of bile and foods Increased absorption of bile salts

synthesis of bile acids

Imbalances in composition of bile

the

Backflow of fats and bile

Infrequent contraction Liver excrete more cholesterol in bile

gallbladder

Accumulation of fats and bile in common duct

Malabsorption disorder Incomplete emptying of gallbladder

RR, PR, BT, WBC, Fever, Pain

Increased cholesterol in bile Interferes absorption of bile salts Decreased gallbladder movement

Reabsorption of bilirubin Increased concentration of bile solubility of cholesterol

Prolonged exposure to concentrated bile

Jaundice

Bile permits low solubility component to come out

Chemical irritation of the organ

Precipitation of substances contained in bile

FORMATION OF CALCULI
Gallstones in the bile duct

bile stasis

bile accumulates in the liver

bacterial proliferation

abnormal fat digestion

cholestatic

Biliary cirrhosis

Gallbladder and duct infection

diarrhea

Rupture of gallbladder

cholecysttitis

peritonitis

death

FAMILY BACKGROUND Manong Rizal is a 47 yrs old construction worker. He is single and lives with his mother with his 4 siblings. His father died at the age of 50 because of stab wound. Since then he take the responsibility of taking good care of his mother. They live in Paoay, Ilocos Norte. The family lives in a concrete bungalow house surrounded with fence. There are some fruit bearing trees surrounding the house. The house is well kept, according to Manong Rizal his mother does most of the household works since shes the only one who most spends her time in their house. Their source of water for cooking, washing dishes and clothes, and watering the plants comes from the faucet which they pay every month and they buy purified water for drinking. The family is equipped with television, DVD, and radio where the family turns on during leisure time. Manong Rizal belongs to an extended type of family. They are all living in the same roof even the partners of his siblings who are married and they have a good relationship with each other. The head of the family is still his mother but most of the times in regards of decision making them all involve their selves giving all their sides to come out with a good decision that cannot affect bad to others. The family members are all Roman Catholics. According to Manong Rizal they seldom go to the church but they fear and have faith in GOD. They are pure Ilocano in blood and by heart and they were raised by their mother very well. They were taught by their mother how to respect older persons by greeting and respecting them. The family has a good and harmonious relationship according to Manong Rizal. They seldom have misunderstanding and whenever it happens they do not let the day pass without settling it over. They also have a good relationship with their neighbors and other family in their barangay. The family sometimes involves their selves in barangay programs.

Socio Economic and Cultural With regards to socio economic condition of the family. They are involved in the breaking down of expenses especially in paying the monthly bills but still they have a personal savings for them. Manong Rizals monthly income as a construction worker is Php 4, 000. 1 st his sister who is a kubrador has a estimated monthly income of Php 5,000 together with his husband. 2nd his younger brother who is a farmer has a monthly income of Php 5,000. 3rd the 4th child of the family has a monthly income of Php 8,000 she is a housekeeper together with her husband who is a tricycle driver. For the youngest of the family, a sales lady who has a monthly income of Php 3,000.The family has no other profitable businesses at home and since his mother is now 67 years old. years old, she cant do things which may help to contribute as a source of income. According to him, they all help each other fairly in paying their monthly bills Her child living with her budgets the money. With regards to food, they spent an average of Php 8000.00 a month. The amount is allotted for rice, pork fish and vegetables. In terms of electricity, they usually pay for about Php 1500.00 monthly. In paying water bills the amount allotted is Php 1000,00. About Php 2000.00 are intended for their health such as vitamin supplements and other drugs taking by the family especially the kids. Educations for the kids in the family were provided by their parents. For their savings, they have their own way to save.

Breakdown of Expenses
1000 4000 1500 water electricity food 4000 8000 education others savings 5000

HEALTH HISTORY Family health history The family has a history of hypertension which according to him as he recall, his grandmother was diagnosed to have a hypertension in her times. Other members of the family like his 4 siblings also diagnosed to have hypertension. At first they were taking their drugs for their maintenance but because not enough funds, they gradually stopped taking those drugs, in fact they are not submitting their selves for check up. According to him, as he recall, no one of his great grandparents has cholelithiasis like of what he is carrying now. His father was died because of an accident, he was been stabbed by unknown person. The family experiences common childhood illnesses like mumps, measles and chicken fox. As traditionally practiced by their ancestors for the relief of mumps, they use the aniel powder which according to them an effective one because it shortens the day of the mumps to return to its normal condition. For measles, as practiced by their grandparents as a relief, they exposed the affected area to a burned onion peels in a closed area, which according to him they found it effective because the spots becomes smaller. For chicken pox, they use drugs which they cant recall, and they dont step outside their house, they stay inside their house until the disease has gone to protect their body for more infection. Common illnesses like cough and cold, head ache, fever which they managed by taking OTC drugs as a relief. They also experienced minor injuries like nablo which they submit their selves to the mangablon, they also experienced scratches which they managed it by flooding it by boiled guava leaves which they found it effective because it increases the time of healing. According to Manong Rizal, he cant remember what are those vaccines that he received during his childhood but he assures that he is not fully immunized as also his brothers and sisters.

Past health history The disease he had experience during his childhood days were mumps, measles, chicken fox which managed by her mother using their traditional and cultural methods in relieving this kind of sickness. He also experienced common illnesses like cough and colds, fever, and head ache which they managed by taking OTC drugs as a relief. He also experienced minor injuries like scratches which they managed by flooding with boiled guava leaves and washing it with soap. He never gone hospitalizations nor undergone any minor surgeries before. Manong Rizal can consume 1 pack of cigarette a day. He is a construction worker, according to him for them to be able to relieve their tiredness they use to drink every after work. In terms of eating habits, he is not choosy in foods, he eats what is served in their table but what he loves the most is adobo. He usually dont take his breakfast in their house instead he take it in his working area and sometimes he misses to take his meals in his work. According to Manong Rizal he is not fully immunized but he can remember that during his childhood he receives some vaccines but he cant recall what specific vaccine it is.

Present health history The patient condition started 3 weeks prior to admission Manong Rizal experienced fever, nausea and vomiting, belching and flatulence but he just ignore it instead he continuous going to work. The condition becomes worst because of ignorance. He then experienced episodes of nausea and vomiting, sudden onset of pain on the right upper quadrant of the abdomen and fever. He was then rushed to the MMMH with an admitting diagnosis of T/C cholelithiasis R/O acute pancreatitis on January 24 2010.

LEVELS OF COMPETENCIES

Before illness

During Illness Before Hospitalization During hospitalization

Analysis

A. Physical Competency Mr. Jose was physically competent in performing his activities of daily living such as doing his personal hygiene, and going to work. He does exercises every morning, and he loves walking. B. Emotional Competency He is open to his family. Whenever they have problems they tell it to one another. And he appreciates simple things. C. Social Competency He loves socializing with He seldom going out with his friends because of his He is socializing with His condition was the other patient but not a hindrance in not merely. dealing with other He was not expressive of what he felt instead he continues going to work. He is not comfortable during his hospitalization due to the environment, he easily got disturbed and irritated because of the noise and he cannot express well about his condition. There is a change in the emotional aspects of Mr. Jose. he became easily disturbed and irritated, and he seldom talks about his feelings. He does not gave to much attention to his condition prior to his hospital admission. Eventhough he feels abdominal pain he continues going to work. He lies on his bed most of the time, cannot do his work by his own, he seeks assistance to his watchers. There is an alteration in his physical competence due to body weakness and discomfort.

people around him, he cracks jokes with them and he also participates to some social gatherings and activities at their barangay. D. Mental Competency

condition, he often stays at home.

people. He just had a limitation on doing it because of his condition.

He can recognize, He can recognize, recall place, person, recall place, things and events. He person things and can still recap what event. He can had happened before. also relate things that just had happened before. His memory is still sharp, and knows what he is talking and answering to a question. E. Spiritual Competency He stands firm in faith despite trials and difficulties in life. Thus, he attends mass every Sunday. And he has fear in God. He did not forget to pray and ask guidance from God and for his forgiveness.

He is very approachable. He understands our purpose to him and answer to our questions without hesitations. He can relate things that happened before and those events that had recently took place.

There is no alteration in his intellectual competency since he can still recall thing on the past and just recently happened.

He did not forget to pray and ask guidance for his early and fast recovery.

There is no change with regards to spiritual aspects of him. His faith to god remained strong despite of his illness

APPRAISAL January 25, 2010 Mr. Jose was lying on bed, awake and conversant with an IVF of PNSS 1 L at 500 cc level regulated to 21 gtts/min. He feels abdominal pain however he can tolerate it. Vital signs taken as follows: BP - 120/80 BT 36.50C RR - 18 PR - 75 January 26, 2010 Mr. Jose was lying on bed, awake and conversant with an IVF of D5NM 1 L at 100 cc level regulated to 21 gtts/min. Still, he was in bearable abdominal pain with a scale of 4/10. He was on NPO in preparation for his abdominal ultrasound today. Vital signs taken as follows: BP - 130/80 BT 36.80C RR - 20 PR 78 January 27, 2010 Mr. Jose was sitting on bedside chair, awake and conversant with an IVF of D5NM I L at 300 cc level regulated to 21 gtts/min. Just like the past days, he feels discomfort in his abdomen but it is milder today. Vital Signs taken as follows:

BP - 130/80 BT 36.30C RR - 20 PR 80

PHYSICAL ASSESSMENT The physical assessment was done last January 25, 2010 at 1:00 PM. It was a cephalocaudal physical examination. A. General Condition Jose Rizal was lying on bed, awake and conversant with an IVF of PNSS 1 L at 500 cc level regulated to 21 gtts/min. He feels pain in his abdomen however he can tolerate it. Vital Signs taken as follows: BP - 120/80 BT 36.50C RR - 18 PR - 75 B. Cephalocaudal Assessment I. HEAD a. Cranium/skull Normocephalic in shape symmetrical b. Hair Black in color thin distribution c. Scalp No lesions noted hard d. Eyes Thin eyebrows Yellowish sclera and conjunctiva Pupils reaction to light-constrict e. Nose Without discharges, flaring and deviations Nasal opening are symmetrical, equal in size With patent airway f. Mouth

 dark lips complete set of teeth, yellowish in color Tonsils and throat not inflamed and with no discharges II.NECK Can move within normal range of motion which is 1800

III. CHEST/THORAX/LUNGS a. Chest Expansion is symmetrical Normal in shape with respiratory rate of 18 b. Breast Symmetrical IV.ABDOMEN In pain (tolerable) V. EXTREMITIES a. Upper extremities With good capillary refill (able to return in 2-3 seconds) With active range of motion With dirty and long fingernails b. Lower extremities With active range of motion With good capillary refill ((able to return in 2-3 seconds) VI. SKIN/INTEGUMENTARY Dark in color

MEDICAL MANAGEMENT Diagnostic Procedures Hematology Result CBC Hemoglobin Hematocrit Red Blood Cells Mean Cell Volume Mean Cell HGB MCHC Concentration White Blood Cells Differential Count Segmenters Lymphocytes Monocytes Eosinophils Basophils Platelet Count 159.00 g/L 0.45 5.240 10^12/L 85.50 fL 30.3 pg 35.00 g/dL 6.56 10^9/L 0.64 0.29 0.06 0.01 0.00 216 10.^9/L Range 140-175 0.41-0.50 4.5-5.9 80-100 27-32 31-35 4.50-11.00 .50-.70 .20-.40 .02-.08 .01-.04 0.00-0.001 150-450 Interpretation Normal Normal Normal Normal Normal Normal Normal Normal Normal Normal Normal Normal Normal

Analysis: A complete blood count is one of the most routinely preferred test in clinical laboratory and one of the most valuable screening and diagnostic technique. It identifies the total number of blood cells as well as the hemoglobin, hematocrit. CBC may reveal considerable data about the patient including diagnosis, prognosis, treatment, response and recovery. The result shows normal findings.

Chemistry Test Glucose FBS BUN Creatinine Blood Uric Acid AST ALT Amylase Sodium Potassium Calcium Magnesium Lipid Profile Cholesterol Triglycerides HDL LDL Analysis: The result shows that there is an increased level of glucose. Increased levels may indicate diabetes mellitus, stress, steroid use, pancreatitis, chronic liver disease and hypokalemia. DM being the one of the complications maybe the reason for the increased level of glucose, likewise, the stress hes feeling. Another abnormal finding is the blood uric acid which was increased. This blood test evaluates where there is excessive production and destruction of cells, it also identifies clients at risk for renal calculi. Increased levels may indicate renal failure, gout, alcoholism, excessive dietary purines, arthritis and stress. Another abnormal finding is the HDL Cholesterol where in there is a low level. The decreased level of HDL cholesterol may indicate malnutrition, malabsorption, hyperthyroidism, liver disease and sepsis. Abdominal UTZ Abdominal ultrasound is an imaging procedure used to examine the internal organs of the abdomen, including the liver, gallbladder, spleen, pancreas, and kidneys. The blood vessels that lead to some of these organs can also be looked at with ultrasound. It is performed to determine the cause of abdominal pain, learn why there is swelling of an abdominal organ and look for stones in the gallbladder or kidney. Result 6.92 mmol/L 6.23 mmol/L 90.06 umol/L 483.86 umol/L 21.81 u/L 20.51 u/L 94.10u/L 139.00 mmol/L 3.50mmol/L 0.91 mmol/L 4.15 mmol/L 1.51 mmol/L 0.89 mmol/L 2.54 mmol/L Range 4.2-6.4 1.7-8.3 44.2-150.3 200-420 Up to 35 Up to 45 28-100 136-150 3.4-5.3 0.70-1.05 <5.17 <2.28 >1.55 <3.36 Interpretation High Normal Normal High Normal Normal Normal Normal Normal Normal Normal Normal Low Normal

Preparation for the procedure depends on the nature of the problem and age. Usually patients are asked to not eat or drink for several hours before the examination. The procedure usually takes less than 30 minutes. There is little discomfort. The conducting gel may feel slightly cold and wet. Result/Impression: Liver, pancreas, spleen, left kidney are unremarkable Cholelithiasis Hydronephrotic change right as a result of small nephrolithiasis Intravenous Therapy Intravenous solutions contain dextrose or electrolytes mixed in various proportion with water. It is administered to provide water, electrolytes and nutrients to meet daily requirements; to replace water and correct electrolyte deficit; and to administer medications and blood products. It is an efficient method of supplying fluids and electrolytes directed to the extracellular components especially the venous system. 1. Plain Normal Saline Solution 1000 cc x 21 gtts/ min Date ordered: January 24, 2010 Date Administered: January 24, 2010 This is considered as isotonic solution wherein it is used to correct an extracellular volume deficit. This was indicated to provide salts and other electrolyte needed to maintain electrolyte. 2. D5NM 1000 cc x 21 gtts/ min Date ordered: January 25, 2010 Date Administered: January 26, 2010 This is considered as hypertonic fluid wherein the total osmolality exceeds the extracellular fluid. The dextrose is easily metabolized, hence the solution will dispersed as hypotonic fluids. Nursing Responsibilities: Responsibilities Rationale

1. Review doctors order for the type of -to prevent inserting the wrong IVF intravenous fluid to be administered 2. Identify the client - to prevent inserting the IVF to the

wrong patient 3. Explain the procedure to the patient - to gain the cooperation of the client and eliminate doubts of the patient

4. Observe aseptic technique in inserting -to prevent infection the IVF 5. Compute and regulate for the infusion - to prevent fluid overload rate 6. Check for air bubbles in the tubing - to prevent the occurrence of air embolism

7. Change or stop the solution before it -to prevent air embolism empties 8. Protect the insertion site 9. Document the procedure done - to prevent needle dislodgement - to serve as evidence with the quality of care given, it serves as a legal document as a basis for the continuity of care for health care providers.

Diet Therapy 1. Low Fat This was indicated for the patient because fatty foods may bring on an episode. Furthermore, his body cannot emulsify fat since his gallbladder is not functioning normally in which the bile is stored. Date ordered: January 24, 2010 Nursing Responsibilities 1. Inform the client and the watcher about the prescribed diet. 2. Emphasize the purpose of diet therapy. Rationale For the patient to be aware and gain cooperation. And to get real results. To gain cooperation from the client and family. 3. Instruct the watcher to remind the client For the client not to eat whatever he wants. about her diet. 4. Regulate IVF properly (as ordered), for To meet the nutritional supplementation of nutritional supplementation. the client.

2. NPO (Nothing per Orem) This was indicated in preparation for his abdominal ultrasound. Date Ordered: January 24, 2010 Nursing Responsibilities 5. Inform the client and the watcher about the prescribed diet. 6. Emphasize the purpose of diet therapy. Rationale For the patient to be aware and gain cooperation. And to get real results. To gain cooperation from the client and family. 7. Keep all foods or fluids out of patients To lessen patients interest and to prevent sight. stimulation of vagal nerves. 8. Instruct the watcher to remind the client For the client not to eat and drink secretly. about her diet. 9. Regulate IVF properly (as ordered), for To meet the nutritional supplementation of nutritional supplementation. the client.

DRUG STUDY Generic Name: Metoclopramide Hydrochloride Brand Name: Emex Classification: Prokinetic Agent (GI Stimulant) Dosage, Route, Frequency: 10 mg, IV q 80 Mechanism of action: Potent central dopamine receptor antagonist. Increases resting tone of esophageal sphincter and tone and amplitude of upper GI contractions. As a result, gastric emptying and intestinal transit are accelerated with little effect if any,on gastric, biliary or pancreatic secretions. Enhances GI motility and is an effective antinauseant. In diabetic gastroparesis, indicated by relief of anorexia, nausea, and vomiting, persistent fullness after meals. Desired Effect: To prevent nausea and vomitting Adverse Effect: CNS: mild sedation, fatigue, restlessness, agitation, headache, disorientation GI: nausea, constipation, diarrhea, dry mouth Skin: maculopapular rash Body as a whole: periorbital edema Side Effects: acute dystonia such as trembling hands and facial grimacing

Nursing Responsibility Report immediately the onset of restlessness.

Rationale For immediate care.

Avoid driving and other potentially hazardous Because it causes mild sedation. activities for few hours after drug administration. Be aware that during early treatment period, To prevent the patient to get panic. serum aldosterone maybe elevated; after prolonged administration period, it returns to

pretreatment level. Offer sips of administration. liquid especially after Because it causes dry mouth.

Generic Name: Omeprazole Brand Name: Losec Classification: anti-ulcer; proton pump inhibitor Dosage, Route, Frequency: 40 grams IV OD Mechanism of action: Suppresses gastric acid secretion relieving gastrointestinal distress and promoting ulcer healing. Desired Effect: To suppress gastric acid secretion. Adverse Effect: CNS: headache. Dizziness, fatigue GI: diarrhea, abdominal pain, nausea Urogenital: hematuria, proteinuria Skin: rash Side Effects:

Nursing Responsibilities

Rationale

Report for severe diarrhea; drug must be For immediate care and to avoid further discontinued. problems. Give before food; preferably breakfast and For better absorption. capsules must be swallowed whole.

Generic Name: Tramadol Hydrochloride Brand Name: Ultram Classification: narcotic analgesic Dosage, Route, Frequency: 50 mg IV q 80 Mechanism of action: Inhibits the uptake of norepinephrine and serotonin , suggesting both opioiid and non opiod mechanism of pain relief. Effective agent for control of moderate to moderately severe pain. Desired Effect: To relieve pain. Adverse Effect: CNS: drowsiness, dizziness, headache, confusion, sleep disturbance, seizure CV: palpitation, vasodilaton GI: nausea, constipation, vomiting, diarrhea, abdominal pain, anorexia Body as a whole: sweating, anaphylactic reaction, withdrawal syndrome Skin: rash Special senses: visual disturbances Urogenital: urinary retention

Side Effect: signs and symptoms of hypersensitivity

Nursing Responsibility

Rationale

Monitor ambulation and take appropriate Because the patient may feel dizzy and drowsy. safety precautions. Use seizure precautions esp. for patients who Because the patient may experience episodes have history of seizure. of seiure. Discontinue drug and notify physician if s/sx For immediate care. of hypersensitivity occur.

NURSING CARE PLAN 1 NURSING DIAGNOSIS: Acute pain related to biliary spasms as manifested by complaint of pain, facial grimace and guarding behavior. NURSING INFERENCE: Because of the gallstone formation, the stone increases in size that causes pressure the gallbladder so the bile is concentrated that leads to the inflammation of the gallbladder that causes pain are it usually occurs 4-6 hours after eating fatty foods. NURSING GOAL: After 2-3 days of nursing interventions, the patient may verbalize methods that provide relief. NURSING INTERVENTIONS: 1. Promote bed rest, allowing patient to assume position of comfort. RATIONALE: Bed rest in semi-fowlers position reduces intra abdominal pressures, however, patient will naturally assume least painful position. 2. Note response to medication and report to physician if pain is not being relieved. RATIONALE: Severe pain not relieved by routine measures may indicate developing complication/ need for further intervention. 3. Observed and document location, severity and characteristics of pain. RATIONALE: Assist in differentiating cause of pain and provides information about disease progression /resolution, development of complications and effectiveness of interventions. 4. Encourage use of relaxation techniques such as deep breathing exercise RATIONALE: Promotes rest, redirects attention, may enhance coping.

5.

Make time to listen to complaints and maintain frequent contact with the patient. RATIONALE: Helpful in alleviating anxiety and refocusing attention which can relieve pain.

NURSING EVALUATION: After 2-3 days of rendering nursing interventions, the patient may report pain is relieved and controlled are demonstatre use of plavation skills and diversional activities as indicated for individual situation.

NURSING CARE PLAN 2 NURSING DIAGNOSIS: Altered Nutrition, Less than body requirements related to loss of nutrients; impaired fat digestion due to obstruction of bile flow. NURSING INFERENCE: One of the signs and symptoms of Cholelitiasis was a decreased fat emulsification because of the obstructed bile flow. NURSING GOAL: After 2 to 3 days of rendering nursing interventions, the patient will be demonstrate or verbalize progressive weight gain toward goal. NURSING INTERVENTIONS: 1. Estimate/ Calculate caloric intake. RATIONALE: Identifies nutritional deficiencies or needs. 2. Provide oral hygiene before meals. RATIONALE: A clean mouth enhances appetite. 3. Consult with patient about like/ dislikes, foods that cause distress and preferred meal schedule. RATIONALE: Involving patient in planning enables patient to have a sense of control and encourages patient to eat. 4. Ambulate and increase activity as tolerated. RATIONALE: Contributes to overall recovery and sense of well being and decreases possibility of secondary problems related to immobility. NURSING EVALUATION: After 2 to3 days of rendering nursing interventions, the patient will demonstrate progressive weight gain toward goal.

NURSING CARE PLAN 3 NURSING DIAGNOSIS: Risk for fluid volume deficit and electrolyte imbalance related to vomiting NURSING INFERENCE: Because of the obstruction of different stones in the gallbladder, reverse peristalsis occurred that leads to vomiting. NURSING GOAL: After 1 to 2 days of nursing interventions, the client will report and demonstrates fluid and electrolyte balance. NURSING INTERVENTIONS: 1. Maintain accurate I and O, noting output less than intake. RATIONALE: Provides information about fluid status/ circulating volume and replacement needs. 2. Eliminating noxious sights/ smells from environment. RATIONALE: Reduces stimulation of vomiting center. 3. Perform frequent oral hygiene with mouthwash. RATIONALE: Decreases dryness of oral mucous membrane. 4. Monitor for signs and symptoms of increased/ continued vomiting. RATIONALE: Prolonged vomiting can lead to deficits in sodium, potassium and chloride. NURSING EVALUATION: After 1 to 2 days of rendering nursing interventions, the client demonstrates fluid balance evidenced by individually adequate urinary output and absence of vomiting.