Araullo University- PHINMA College Of Nursing Case Analysis Emergency Department I.

Introduction: Gallstones may be found anywhere in the biliary system. They may cause pain and other symptoms or remain asymptomatic for years. Choledocholithiasis is the term used to describe gallstones that have migrated to the common bile duct (CBD). Gallstones are classified as cholesterol or pigment stones. Usually it is asymptomatic until a stone becomes lodged in the cystic tract. If the obstruction is unrelieved, biliary colic (intermittent painful episodes) and cholecystitis can ensue.

II.

Biography : Name: Patient xyz Age: 61 years old Sex: Male Birthdate: September 11, 1953 Birthplace:Tarlac City Marital Status: Married Address: Sta Monica Aliaga Nueva Ecija Occupation: Farmer Religion: Roman Catholic Room: Emergency Room Date and time of Admission: February 5, 2014 Attending Physician: Dr. Manangbao

III. IV.

Chief Complaint: Complain jaundice History of Present Illness: 5 months PTA started to notice jaundice Past Medical History: According to Mr.Xyz, he has not been hospitalized before.

V.

VI.

Past Surgical History: According to Mr.Xyz, he has not been hospitalized before.

VII.

Allergies/ Medications: He has no allergies to any foods and medications given to her upon hospitalization. The following are the medications given upon hospitalization as ordered by the Physician: Essentiale Capsule TID Vitamin K ampule TIV OD Smoking, Alcohol, Substance Abuse :

VIII.

Patient XYZ is a casual cigarette smoker.He also drinks alcohol but never been engaged in any substance abuse. IX. Social/ Work History: He works as a farmer before then he stopped farming when he had the disease. He usually stays at home to take a rest and to manage his farming business. Family History: Upon taking the interview, Patient xyz said he has no familial history of the disorder.

X.

XI.

Review Of System:

ANATOMY OF THE DISEASE

PATHOPHYSIOLOGY OF THE DISEASE Factors:Age and daily ingestion of street foods

Bacteria enters the digestive tract

Bacteria causes inflammation of gallbladder Gallbladders function became impaired

Redness and warmness

Gallbladder produces more unconjugated bile pigments Unconjugated bile pigments precipitate to form stones
Gallbladder produces more

Some of the bile pigments are absorbed in the blood Kidney separates the bile pigments from the blood

Stones moved/formed in unconjugated bile pigments the common bile duct Obstruction of common bile duct Gallbladder still contracts in presence of fatty acids to release bile even there is obstruction Gallbladder becomes distended

Urinary excretion of bile pigments

Tea-colored urine because of presence of bile pigments

Bile can no longer move to the duodenum

Bile is absorbed by the blood

Right upper quadrant pain

Gives yellowish discoloration of the skin and mucous membranes (jaundice)

XII.PhysicalExamination : PHYSICAL ASSESSMENT I. Vital Signs Temperature Pulse Rate Respiratory Rate Blood Pressure II. Level of Consciousness III. BODY PARTS A. GENERAL APPEARANC E NORMAL FINDINGS Patient appears symmetrical with absence of skin discoloration - Light to Dark - Feels warm - No swelling - Evenly distributed - Color- Ranges from black to gray, slightly Elderly-may have white hairs due to aging. brown D. NAILS Transparent, smooth and convex Transparent, smooth and convex Normal ACTUAL FINDINGS Jaundice

Actual Findings 36.8 degree celsius 74 beats per minute 18 cycles per minute 120/80 mmHg Conscious and Coherent Explanation ABNORMAL -Bile absorbed by the blood gives the skin a yellowish color and itching. ABNORMAL Bile absorbed by the blood gives the skin a yellowish color and itching. Normal findings

B. SKIN

Yellowish discoloration

C. HAIR

Evenly distributed; no presence of lesions.

E. SKULL AND HEAD

F. EYES

Normal cephalic, symmetrical facial structure, absence of tenderness over the maxillary sinuses. Evenly placed

With symmetrical facial structure and no tenderness

Normal

Yellowish discoloration

ABNORMAL The bile absorbed by the blood gives it a yellow color.. Normal

G. EARS

Hears clearly

Can hear clearly

H. NOSE AND SINUSES

Symmetric and straight, uniform color

Not tenderness No lesions and is symmetric. Lips are moist and pink, no masses . The tongue is midline and no horseness of voice

Normal findings

I.

MOUTH

J. NECK

K. THORAX AND LUNGS

Lips are moist and pink, no masses, gums are pink and smooth, The tongue is midline and without any hoarseness of voice. With normal range of motion, can turn the head against force of the hand, no swelling. - Position of sternum is level with ribs - no masses No palpitations, normal PR should be 60- 100 in adult Absence of pain, lumps, discharge, or any surgery. Extremities should be symmetrical and the skin is warm without any fracture. Hair covers the legs, the venous pattern is normally visible, both legs are symmetrical and without any swelling. Gross motor skills involve the large muscles of the body that enable such functions as sitting upright, lifting, and throwing a ball. Fine motor skills involve the small muscles of the body

Normal findings

With normal range of motion, no swelling noted and can turn his neck left and right. Lung sounds are clear upon auscultation

Normal findings

Normal findings

L. HEART

M. BREAST AND AXILLA N. UPPER EXTREMETIE S O. LOWER EXTREMRTIE S

No palpitations. Pulse rate within normal rate (74 beats per minute) No pain, lump, discharge seen. No fracture proportional No swelling, fracture, and symmetrical

Normal findings

Normal findings

Normal findngs

Normal findings

P. GROSS MOTOR FUNCTIONS

Can hold large objects

Normal

Q. FINE MOTOR TEST

Can write and grasp small objects

Normal

R. SENSORY FUNCTION

that enable such functions as writing, grasping small objects, and fastening clothing. With normal senses. Can see clearly, can hear accurately, no altered taste, can smell normally. Contour is normally flat to rounded smooth and symmetric

S. ABDOMEN

With blurring of vision as verbalized by the patient, can hear clearly , no aleration in taste and smell. Noted presence of redness and verbalized pain on border of upper and lower quadrant upon palpation

Blurring of vision is a part of his aging.

ABNORMAL Inflammation of the gallbladder causes redness and pain

XIII.

Diagnostic and Laboratory Test: CBC ,BT CT,PT,PTT FBS BUN,CREA TOTAL BILIRUBIN B1 B2 SGPT, SGOT, ALKALINE PHOSPHATE CXR AP ECG 12 LEAD LIVER FUNCTION TEST Drug Study DOSAG E/ FREQU ENCY/ ROUTE TID., PO CLASSIFICATION INDI -CATION CONTRAINDICATION SIDE EFFECTS NURSING RESPONSIBILTY

XIV. DATE GENERI C/ TRADE NAME

020514

Essen tiale Caps ule

Hepatic protectors

Acute, subacute & chronichepati tis; toxic metabolic liver disease s, intoxication s (eg fromdrugs); infection, fattydegene ration of the

Do not administer in case of hypersensitivit y to any component. Solution for intravenous injection should not be given to premature

abdominal pain,nausea, diarrheaand allergicreaction( skin rash)

Do not use Essentialein hypersensitivity or allergy to any ingredientsof the preparation. Theapplication of Essentialein newborn children isnot safe. During pregnancy women

liver due toalcohol, hypernutriti on, DM,kwashior kor, pregnancy;ch olestasis; pre& post-op care,esp in liver/gallbla dder surgery

babies and children as part of Essenciale forte caps. 300 mg.

arerecommended to consulttheir health care provider prior to takingEssentiale.

020514

Vitami nK

TIV, OD

hypoprothro mbinemia secondary tofactors limitingabso rption orsynthesis of vitamin K, e.g.,obstruct ive jaundice, biliaryfistula , sprue,ulcerat ive coilitis,celia c disease,intes tinalresectio n, cysticfibrosi s of thepancreas, and regional enteritis

Hypersensitivit y to anycomponent of thismedication

Pain, swelling,andtende rness at the injectionsite mayoccur. The possibilityof allergicsensitivit yincluding ananaphylactoid reaction,should be keptin mind.

Watch for signs of flushing, weakness, tachycardia and hypotension; may progress to shock

XV.

Nursing Care Plan

ASSESSMENT

DIAGNOSIS

PLANNING

IMPLEMENTATION

RATIONALE

EVALUATION

SUBJECTIVE: Masakit yung tiyan ko. As verbalized by the patient.

OBJECTIVE: Guarding of the affected side. - Facial grimace - Pain scale of 4/5 - Distended abdomen - irritability Vital signs: -

Acute pain After 1 hour of -Monitored patient related to nursing for pain or other inflammation interventions, discomfort using as evidenced the patients pain scale. by verbal perception of - position patient in response discomfort will a low fowlers decrease as position documented by pain scale; Non-verbal indicators such as facial grimacing will diminish; the - Instructed patient patient will to take deep verbalize breaths understanding regarding different measures in managing his -administered discomfort. analgesic

- For patients pain assessment.

-to minimize pressure on right upper quadrant of his abdomen.

After 1 hour of nursing interventions, the patient rated 2/5 by pain scale; facial grimacing diminished; and verbalized measures in managing discomfort.

-as pain management GOAL IS MET

BP-120/80 mmHg T-36.8 C PR-74 bpm RR-18 cpm

-medication to relieve pain as ordered by the physician

Araullo University PHINMA Education Network College of Nursing

Case Analysis

Obstructive Jaundice secondary to Choledocholithiasis with Cholelithiasis

Members: Valdez, Brendo David, Jennica Jane Marbas, Abby Joy

Paolo Caba, RN Clinical instructor