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Wesleyan UniversityPhilippines

HOSPITAL
INTRODUCTION
In 1948, the Argentinean surgeon PABLO MIRIZZI, described a patient with
partial obstruction of the common hepatic duct secondary to impacted biliary
stone in the cystic duct or in the infundibula of the gallbladder, associated to
an inflammatory response involving the cystic duct and the common hepatic
duct. This presentation became known as Mirizzi syndrome.
Mirizzi syndrome is a rare complication of prolonged cholelithiasis, with
prevalence from 0.05% to 2.7% among patients with calculosis of the
gallbladder. It presents a spectrum that varies from extrinsic compression of
the common hepatic duct to the presence of cholecystobiliary fistula. For this
reason, the disease represents a dangerous alteration in the anatomy during
the performance of cholecystectomy, by predisposing the patients to the risk
of an inadvertent lesion of the common hepatic duct.
Chronic complications of symptomatic gallstone disease, such as Mirizzi
syndrome, are rare in Western developed countries with an incidence of less
than 1% a year. These currently bizarre complications, are being
encountered in 1% to 2% of patients with symptomatic cholelithiasis
according to some recent series. However, in underdeveloped countries;
particularly in Latin-America, Mirizzi syndrome is a more common condition
with a reported incidence ranging from 4.7% to 5.7%. The importance and
implications of this condition are related to their associated, and potentially
serious, surgical complications such as bile duct injury, and to its modern
management when encountered during laparoscopic cholecystectomy. The
pathophysiological process leading to the subtypes or stages of Mirizzi
syndrome, has been explained as an inflammatory phenomenon secondary
to a pressure ulcer caused by an impacted gallstone at the gallbladder
infundibulum. The impacted gallstone together with the inflammatory
response, causes first external obstruction of the bile duct, and eventually
erodes into the bile duct evolving into a cholecystocholedochal or
cholecystohepatic fistula with different degrees of communication between
the gallbladder and bile duct.
I chose this case study in the hope of gaining more insights, realizations and
helpful management to lessen the vivacity of the disease, the surgery and its
1 | Case Study MIRIZZIS SYNDROME

Wesleyan UniversityPhilippines
HOSPITAL
post-operative management of the patient as well as of imparting basic
knowledge on the disease, its medical management, the factors contributing
to its occurrence and the normal anatomy & physiology of the affected
system. And lastly, may this study serve as a comprehensive tool for better
understanding of the nurses role in the incidence of such case that may help
her/his develop new skills in rendering holistic nursing care.

GENERAL OBJECTIVES
This case study aims to acquire knowledge and skills in providing a
systematic, rational method of planning and providing nursing care to a
Patient with this kind of case. This also aims to develop the awareness of
health care providers about this particular kind of case.
SPECIFIC OBJECTIVES

To be able to collect and organize relevant and intact information about


this particular kind of case.
To be able to use critical thinking skills and knowledge in interpreting
assessment data that would be necessary in identifying actual and
potential problems on how to manage a Patient with this disease.
To be able to develop an individualized and fruitful nursing care plan
with this particular kind of case and carry out appropriate interventions
to meet desired goals and objectives.
To apply all the theories, concept, knowledge and skills learned in the
entire lecture by means of assessing the signs and symptoms,
diagnosing the problems and implementing the prevention and
treatment of the problem.
To evaluate outcomes of the effectiveness of care to determine what
nursing actions need to be modified or improved.

DEFINITION OF TERMS

GALLBLADDER: is a small pouch that sits just under the liver. The
gallbladder stores bile produced by the liver. After meals, the

2 | Case Study MIRIZZIS SYNDROME

Wesleyan UniversityPhilippines
HOSPITAL

gallbladder is empty and flat, like a deflated balloon. Before a meal,


the gallbladder may be full of bile and about the size of a small pear.
GALLSTONE: Gallstones are pieces of solid material that form in the
gallbladder. These stones develop because cholesterol and pigments in
bile sometimes form hard particles.
CYSTIC DUCT: It transmits bile between ducts that are important for
the digestion process and the gallbladder.
HEPATIC DUCT: A duct that carries bile from the liver into the
common bile duct which conveys it to the duodenum.
CHOLELITHIASIS: Cholelithiasis is the medical name for hard deposits
(gallstones) that may form in the gallbladder.
MIRIZZI SYNDROME: benign obstruction of the hepatic ducts due to
spasm and/or fibrous scarring of surrounding connective tissue; often
associated with a stone in the cystic duct and chronic cholecystitis.

BIOGRAPHIC DATA
NAME: Ms. C
AGE: 51 years old
GENDER: Female
DATE OF BIRTH: December 17, 1963
PLACE OF BIRTH: Murcon, Llanera, Nueva Ecija
RELIGION: Roman Catholic
STATUS: Single
NATIONALITY: Filipino
PRIMARY DIALECT: Tagalog
EDUCATIONAL ATTAINMENT: College graduate
CHIEF COMPLAINT: Right upper quadrant pain
HISTORY OF PRESENT ILLNESS
As for her present illness, she was admitted into this hospital because of
cholelithiasis with few weeks history of on and off abdominal pain, negative
jaundice, negative fever, productive cough and diagnosed with positive to
Bronchiectasis.
PAST MEDICAL HISTORY
3 | Case Study MIRIZZIS SYNDROME

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She had no Diabetes Mellitus and no hypertension. She had not experience
any accident and injuries. She also added that she had asthma when he was
child until now.
PERSONAL/ SOCIAL HISTORY
She is a non-smoker.
FAMILY HISTORY
The patient has no family history of hypertension and diabetes mellitus.

IMMUNIZATION
The patient verbalized that she has a complete immunization during her
childhood.
MEDICATION
She took Salbutamol nebule; one nebule as needed for asthma attack.
ADVERSE REACTION
There is no adverse Reaction.

PHYSICAL ASSESSMENT
(Upon admission done by Resident on Duty)

General

METHOD OF
ASSESSMENT
Inspection

Vital Signs
HEENT

Inspection and palpation

FINDINGS
Conscious and Coherent
BP:120/80mmhg,RR:20,PR:82bpm
Temperature: 36.0
Pupil is equally round and
reactivated to light, Ears of equal
size & similar appearance, no
redness in the nasal

4 | Case Study MIRIZZIS SYNDROME

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Mucosa and
Chest

Inspection, palpation
auscultation
Auscultation

Positive Crackles bilateral

Extremities

Inspection, Auscultation,
Palpation
Inspection and Palpation

Skin

Inspection

Positive epigastric pain and


Murphys sign
Negative cyanosis, negative
edema, Full and equal peripheral
pulses
No rashes, skin warm and dry,
negative jaundice and negative
erythema noted

Cardiovascu
lar
Abdomen

Normal rate, negative murmurs

LABORATORY AND DIAGNOSTIC RESULTS


HEMATOLOGY
DATE COLLECTED: NOVEMBER 23, 2015
TIME: 2:28 PM
COMPONENT
RBC COUNT

RESULT
4.88

Hematocrit (Hct) 0.42


Hemoglobin
(Hgb)
Platelet Count

137
271

White Blood Cell 10.8


Count (WBC)
Segmenters

0.68

NORMAL VALUES
INTERPRETATION
12
Male: 4.5-6.0 x 10 /L
Within
Normal
Female:
4.0-5.5
x Values
1012 /L
Male: 0.40-0.54
Within
Normal
Female: 0.37-0.47
Values
Male: 120-170g/L
Within
normal
Female: 110-150 g/L
Values
150-450 x 109/L
Within
Normal
Values
Adults: 5-10 x 109/L
Increased
Children: 6.2-17.0 x
109/L
0.50-0.70
Within
Normal

5 | Case Study MIRIZZIS SYNDROME

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HOSPITAL
Lymphocytes

0.21

0.20-0.40

Monocytes

0.07

0-0.10

Eosinophils

0.04

0-0.05

Values
Within
Values
Within
Values
Within
Values

Normal
Normal
Normal

COAGULATION STUDIES
DATE COLLECTED: NOVEMBER 24, 2015
TIME: 10:46 AM
TEST

RESULT

Prothrombin
Time

11.4 SECONDS

EXPECTED
VALUES
9.8 12.1 seconds

95.5%

70 130%

Percent Activity

INTERPRETATION
Within Normal
Values

1.02

0.8 1.2

Within Normal
Values

33.9 SECONDS

31.9 SECONDS
(CONTROL)

Within Normal
Values

INR
Partial
Thromboplastin

Within Normal
Values

URINALYSIS
DATE COLLECTED: OCTOBER 24, 2015
TIME: 6:45 PM
PHYSICAL EXAMINATION:
Color Light Yellow
6 | Case Study MIRIZZIS SYNDROME

Specific Gravity 1.020

Wesleyan UniversityPhilippines
HOSPITAL
Transparency Clear

pH 7.0

CHEMICAL EXAMINATION:
Glucose Negative
Protein- Negative
MICROSPIC EXAMINATION:
Red Blood Cells 1-2/HPF
Urates/PO4 Few
PUS cells 2-4/HPF
Mucus Threads Few

Amorphous

CLINICAL CHEMISTRY
DATE COLLECTED: OCTOBER 24, 2015
TIME: 6:41 PM
TEST

RESULT

CREATININE
SODIUM
POTASSIUM

0.74 mg/dL
152.8 mg/dL
4.31 mg/dL

NORMAL
VALUES
0.70 1.20
135.0 145.0
3.50 5.10

INTERPRETATIO
N
Within Normal
Values
Slightly Increased
Within Normal
Values

NORMAL
VALUES
0.00 - 200.00
0.00 - 40.00
0.00 - 199.00
74.00 - 106.00
0.00 - 120.00

INTERPRETATIO
N
Within Normal
Values
Within Normal
Values
Within Normal
Values
Within Normal

CLINICAL CHEMISTRY
DATE COLLECTED: OCTOBER 25, 2015
TEST

RESULT

CHOLESTEROL
SL
HDL
CHOLESTEROL
TRIGLYCERIDE
SL
CLUCOSE PAP

126.52
39.70
51.12
100.59
76.59

7 | Case Study MIRIZZIS SYNDROME

Wesleyan UniversityPhilippines
HOSPITAL
LDL

Values
Within Normal
Values

CLINICAL CHEMISTRY
DATE COLLECTED: OCTOBER 24, 2015
TIME: 6:41 PM
TEST

RESULT

TOTAL
BILIRUBIN
DIRECT
BILIRUBIN
INDIRECT
BILIRUBIN

1.07
0.53
0.54

NORMAL
VALUES
0.30 1.20
0.00 0.20
0.30 1.00

INTERPRETATIO
N
Within Normal
Values
Increased
Within Normal
Values

HBT ULTRASONOGRAPHY
DATE: OCTOBER 9, 2015
FINDINGS:
The liver is normal in size. The visualized surfaces are smooth and
intact. The parenchyma shows a homogenous echo pattern. There are
cystic foci in the left hepatic lobe, predominantly in the medial
segment, the largest measuring 3.9 x 2.6 cm. The intra-hepatic ducts
are not dilated
The gallbladder is normal in size with multiple intraluminal stones. The
walls are not thickened. The common bile duct is not dilated.
The pancreas is normal in size and echo pattern with no focal lesions
noted.
IMPRESSION:
SIMPLE HEPATIC CYSTS, LEFT LOBE.
CHOLELITHIASES.
NEGATIVE SONOGRAPHIC FINDINGS IN THE PANCREAS.

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HOSPITAL
CHEST XRAY PA (NOVEMBER 11, 2015)
IMPRESSION: Pneumonia with partial regression

CLINICAL MANIFESTATIONS:
SIGN AND SYMPTOMS

On and off right upper quadrant abdominal pain

PATHOPHYSIOLOGY
NON-MODIFIABLE
MODIFIABLE
-

AGE
(51
- LACK OF PHYSICAL ACTIVITIES
GENDER
- FATTY FOODS

CHANGE BILE COMPOSITION


INCREASED INTRALUMINAL

YEARS

)
(FEMALE)

DECREASED CONTRACTILITY

OF BILE FLOW
PRESSURE

STIMULATES SMOOTH MUSCLE

CONTRACTION
CONTRACTIONS OF SUBSTANCE IN BILE/CHOLESTEROL

TENSION

9 | Case Study MIRIZZIS SYNDROME

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PRECIPITATION OF SUBSTANCE

RIGHT UPPER QUADRANT


STORES MIGRATE IN GALL BLADDER
ABDOMINAL PAIN

OBSTRUCTION OF THE BILE FLOW


RADIATING TO BACK

IMPAIRED HEPATIC UPTAKE


NO BILE REACHES THE GIT
BILIRUBIN/CHOLESTEROL

CHOLESTEROL SALTS
ESCAPE OF SOLUBLE BILIRUBIN
INTESTINE
DECREASED BILE
IN THE SKIN
IN DEODENUM

ON UPPERGASTROINTESTINAL TRACT

EMULSIFICATION OF FATS

NO BILE IN SMALL

FOR FAT DIGESTION

CLAY COLORED

STOOL
NAUSEA AND
VOMITING

IMPACTED CYSTIC DUCT

MECHANICAL OBSTRUCTION OF THE HEPATIC DUCT

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INFLAMMATION

ISCHEMIA/ NECROSIS

COMPLICATION: MIRIZZI SYNDROME

COURSE IN THE WARD


DAY 1 (NOVEMBER 23, 2015)
The Patient was admitted at Fourth Floor Ward. She was oriented to time,
place and person, all her vital signs are normal. She looks weak, with
complaint of right upper quadrant pain, with productive cough prior to
admission and with admitting orders from Dr. EB as follows:

Low fat, low salt diet, high protein


TPR every shift and Vital signs every 4, record please
DIAGNOSTICS: CBC, Blood Typing
Incorporate to chart all previous laboratory results

TREATMENTS: D5LRS IL for 12 hours once on NPO


Cefoxitin 2 grams anst 1 hour prior to surgery
Omeprazole 40mg IV stat dose once on NPO

She also ordered to refer to Dr. A for CP CLEARANCE and for PULMO comanagement to Dr. S. She also ordered for open cholecystectomy with
unroofing of hepatic cyst on November 24, 2015 at 9:00AM, secure consent
for the procedure and informs Dr. EP or Dr. D for anesthesia. She also added

11 | C a s e S t u d y M I R I Z Z I S S Y N D R O M E

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to notify Dr. S for CP Clearance. Dr. EB examined the patient at 8:00PM and
ordered the following:

NPO at 4:00AM
IVF at 4:00AM
Follow up CP EVALUATION care of Dr. Serrano
Refer Accordingly

Dr. S examined the patient at 10:05PM and the patient was CP Cleared and
he ordered the following:

Continue Acetylcysteine (Fluimucil) 600mg per tablet dissolved with


glass of water once a day at hours of sleep
Ipratropium + Salbutamol per nebule one nebule every 8 hours; for
chest clapping after each nebulization
Advised deep breathing and coughing exercises post-op

DAY 2 (NOVEMBER 24, 2015)


We received telephone order from Dr. EB she ordered for PT, PTT STAT. Then
the patient was brought to Operating room at 2:30pm. After 2 hours at
recovery room the patient brought back to fourth Floor Ward at 9:00pm. The
OR Nurse endorsed that the patient is NPO temporarily, with first bottle of
D5LRS IL for 12 hours, IVF to follow of D5LRS IL for 16 hours and D5NM IL for
16hours, with neb and IV meds of Ketorolac 30mg IV every 8 hours for 4
doses, Nubain 5mg IV every 6 hours as needed for severe pain,
Metoclopramide (Plasil) 10mg IV as needed for vomiting, Diphenhydramine
50mg IV as needed for pruritus, Flat on bed until, monitor I and O. After the
surgery the patient was okay, she was afebrile and her vital signs are
normal.

DAY 3 (NOVEMBER 25, 2015)


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The patient was looks good than yesterday. She was afebrile and her vital
signs are all normal. Dr. EB had her rounds at around 10:00 AM and Dr. EB
assess the patient with positive bowel sounds thats why she ordered the
following:

May have General liquid to Soft diet


To consume present IVF and IV meds
May start: Cefuroxime 500mg per capsule one capsule BID for 5 days
Ketorolac 10mg per tablet one tablet as needed for pain
Remove IFC
Encouraged ambulate and deep breathing exercises
May go home at AM tomorrow
Take home meds as above

Dr. S also made his rounds right after Dr. EB made her rounds. Dr. S
examined the patient and ordered the following:

Okay to discharge tomorrow AM


HOME MEDS:
- Acetylcysteine (Fluimucil) 600mg per tablet; one tablet OD at
HS for 5 days
- Ipratropium + Salbutamol per nebule; one nebule as needed
for difficulty of
breathing per nebulization.

DAY 4 (NOVEMBER 26, 2015)


Dr. EB informs the ward that she cant make her rounds thru phone call with
order of may go home.

MEDICAL MANAGEMENT:
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PRE-OPERATIVE
TREATMENT

Nothing per orem at 4:00am


Intravenous fluid of D5LRS IL for 12 hours once on NPO
Cefoxitin 2 grams ( ) ANST 1 hour prior to surgery
Acetylcysteine (Fluimucil) 600mg per tablet dissolved with glass of
water once a day at hours of sleep
Ipratropium + Salbutamol per nebule one nebule every 8 hours; for
chest clapping after each nebulization
Omeprazole 40mg IV stat dose once on NPO
IVF at 4:00AM
For PT, PTT

POST-OPERATIVE

Nothing per Orem temporarily


IVF to follow: D5LRS IL for 16 hours
D5NM IL for 16hours
Medication:
Ketorolac 30mg IV every 8 hours for 4 doses
Nubain 5mg IV every 6 hours as needed for severe pain
Cefoxitin 1 gram IV at 11PM then discontinue
Metoclopramide (Plasil) 10mg IV as needed for vomiting
Diphenhydramine 50mg IV as needed for pruritus
Flat on bed for 6 hours
Encourage deep breathing and coughing exercise
May have General liquid to Soft diet
To consume present IVF and IV meds
Remove IFC
Ambulate
May start: Cefuroxime 500mg per capsule one capsule BID for 5 days
Ketorolac 10mg per tablet one tablet as needed for pain

SURGICAL MANAGEMENT:
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Open Cholecystectomy, Intraoperative Cholangiogram Common Bile


Duct Exploration

NURSING MANAGEMENT:

Complains Pain
1 Encourage deep breathing exercise
2 Provide relaxation technique
3 Encourage to rest
Complains of difficulty of breathing
1. Breathing techniques
2. Proper positioning
3. Energy-conservations techniques

COMPREHENSIVE DRUG STUDY:


NAME OF
DRUG
CEFOXITIN
Classification:
ANTIBIOTIC
Dosage:
2 GRAMS

ACTION

Bactericidal:
Inhibits synthesis
of bacterial cell
wall, causing cell
death.

SIDE EFFECTS

*No side effects


were manifested by
the patient*

INDICATION

Peritonitis and
other intraabdominal and
intrapelvic
infection.
Surgical infection.

Route:
IV
Frequency:
STAT

15 | C a s e S t u d y M I R I Z Z I S S Y N D R O M E

NURSING
CONSIDERATIO
N
Obtain ANST
before
administering the
drug.
Report severe
diarrhea, difficulty
breathing, unusual
tiredness or
fatigue, pain at
injection site.

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NAME OF
DRUG

ACTION

OMEPRAZOLE

Gastric acidpump inhibitor:


Suppresses
gastric acid
secretion by
specific inhibition
of the hydrogenpotassium ATPase
enzyme system
at the secretory
surface of the
gastric parietal
cells; blocks the
final step of acid
production

Classification:
Proton pump
inhibitor
Dosage:
40MG
Route:
IV
Frequency:
STAT

NAME OF
DRUG

ACTION

KETOROLAC

Anti-inflammatory and
analgesic activity;
inhibits prostaglandins
and leukotriene
synthesis

Classificatio
n:
ANTIPYRETIC
NSAIDS

SIDE EFFECTS

*No side effects


were manifested by
the patient*

INDICATION

NURSING
CONSIDERATIO
N

Relief symptoms of
acute and recurrent
diabetic gastro
paresis.

Asses if the
patient has
history of allergies
to
metoclopramide.

Short term therapy


(4-12weeks) for
adults with
symptomatic
gastro-esophageal
reflux who fail to
respond to
conventional
therapy

SIDE EFFECTS

*No side effects were


manifested by the
patient*

INDICATION

Short-term
management of pain
(up to 5 days)

Frequency:
EVERY 8
HOURS

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Monitor BP
carefully during IV
administration.
Assess
knowledge/teach
appropriate use of
this medication,
interventions to
reduce side
effects and other
symptoms to
report.

NURSING
CONSIDERATIO
N
Assess pain (note
type, location, and
intensity) prior to
and1-2 hour
following
administration.
Be aware that
patient may be at
risk for CV events, GI
bleeding, renal
toxicity, monitor

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Dosage:
30MG

accordingly
Protect drug vials
from light.

Route:
IV

Administer every 6
hours to maintain
serum levels and
control pain

NAME OF
DRUG
ACETYLCYST
EINE
Classification
:
MUCOLYTIC
AGENT

ACTION

Mucolytic that
reduces the
viscosity of
pulmonary
secretions

SIDE EFFECTS

*No side effects were


manifested by the
patient*

INDICATION

For abnormal
viscid and
thickened
mucous
secretions.

NURSING
CONSIDERAT
N

Bronchial tapping
Monitor for
bronchospasm

Frequency:
OD AT HS
Dosage:
1 tab 600 mg
Route:
PO

NAME OF
DRUG

ACTION

SIDE EFFECTS

INDICATION

17 | C a s e S t u d y M I R I Z Z I S S Y N D R O M E

NURSING
CONSIDERATIO
N

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IPRATROPIUM
PLUS
SALBUTAMOL
Classification:
ANTIASTHMATIC
Frequency:
EVERY 8
HOURS
Dosage:
ONE NEBULE
Route:
PER
NEBULIZATIO
N

NAME OF
DRUG
CEFUROXIME
Classification:
ANTIBIOTIC
Frequency:
BID

Reduces
bronchospasm
through both
anticholinergic
and
sympathomimeti
c mechanisms.
Simultaneous
administration of
both drugs
produces a
greater
bronchodilator
effect than when
either drug is
used alone at
recommended
dosages.

ACTION

Second-generation
cephalosporin that
inhibits cell-wall
synthesis,
promoting osmotic
instability; usually
bactericidal.

*No side effects


were manifested by
the patient*

Management of
reversible
bronchospasm
associated with
obstructive airway
diseases in patients
who require more
than a single
bronchodilator

Instruct patient to
contact health care
professional
immediately if
shortness of breath
is not relieved by
medication or is
accompanied by
diaphoresis,
dizziness,
palpitations, or
chest pain.
Advise the patient
to rinse mouth
with water after
using the nebulizer
to minimize dry

SIDE EFFECTS

*No side effects were


manifested by the
patient*

INDICATION

NURSING
CONSIDERATIO
N

Pharyngitis, tonsillitis,
infections of the
urinary and lower
respiratory tracts, and
skin and skinstructure infections

Determine history of
hypersensitivity
reactions to
cephalosphorins,
penicillins and
history of allergies
particularly to drugs
before therapy is
initiated.

Dosage:
1 tab 500 mg

Notify prescriber
about rashes or

Route:

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PO

superinfections

NAME OF
DRUG

ACTION

METOCLOPRAMI
DE

It blocks
dopamine
receptors and
makes the GI
cells more
sensitive to
acetylcholine,
leading to
increased GI
activity and rapid
movement of
food through the
upper GI tract.

Classification:
ANTI-EMETICS
Frequency:
AS NEEDED
FOR NAUSEA
AND VOMITING
Dosage:
10MG
Route:
IV

SIDE EFFECTS

*No side effects


were manifested
by the patient*

INDICATION

Prevention of
chemotherapyinduced emesis,
treatment of
postsurgical and
diabetic gastric
stasis, facilitation of
small bowel
intubations in
radiographic
procedures,
management of
esophageal reflux,
treatment and
prevention of
postoperative
nausea and
vomiting when
nasogastric
suctioning is
undesirable

19 | C a s e S t u d y M I R I Z Z I S S Y N D R O M E

NURSING
CONSIDERATIO
N
Assess client for
abdominal pain
distention, bowel
sound.
Assess client for
extrapyramidal
reactions
Monitor for tardive
dyskinesian

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NAME OF
DRUG

ACTION

DIPHENHYDRAMIN
E

Action on blood
vessel, GI,
respiratory tract by
antagonizing the
effects of
histamine for H1Receptor site
decreases allergic
response by
blocking histamine
caused increased
heart rate,
vasodilation
secretions;
significant CNS
depressant and
anticholinergic

Classification:
ANTI-HISTAMINE
Frequency:
AS NEEDED FOR
PURITUS
Dosage:
50MG
Route:
IV

NAME OF
DRUG

ACTION

SIDE EFFECTS

*No side effects were


manifested by the
patient*

SIDE EFFECTS

INDICATION

NURSING
CONSIDERATIO
N

It is used for the


symptomatic relief of
allergic conditions
including urticarial and
angioedema.
Diphenhydramine is
used for its
abtimiscarinic
properties in the
control of parkinsonism
and drug-induce
dextrapyramidal
disorders

Monitor
cardiovascular status
especially with
preexisting
cardiovascular
disease.

INDICATION

NURSING
CONSIDERATIO
N

20 | C a s e S t u d y M I R I Z Z I S S Y N D R O M E

Monitor for adverse


effects especially in
children and the older
adult.
Supervise ambulation
and use side-rails as
necessary

Wesleyan UniversityPhilippines
HOSPITAL
NALBUPHINE
HYDROCHLOR
IDE
Classification:
ANALGESIC
Frequency:
EVERY 6
HOURS
Dosage:
5MG

acts as an
agonist at
specific opioid
receptors in
the CNS to
produce
analgesia,
sedation but
also acts to
cause
hallucinations
and is an
antagonist at
receptors

Route:
IV

CNS: Light
headedness,
dizziness, insomnia,
confusion, irritability,
psychosis, ataxia,
depression,
hallucination.
CV: CHF, orthostatic
hypotension,
dyspnea.
GI: Nausea, anorexia,
constipation, dry
mouth.
GU: Urinary retention

Relief of moderate
to severe pain
Preoperative
analgesia, as a
supplement to
surgical anesthesia,
and for obstetric
analgesia during
labor and delivery

*No side effects were


manifested by the
patient*

Reassess patients
level of pain at
least 15 and
30minutes after
parenteral
administration
Monitor circulatory
and respiratory
status, bladder
and bowel
function. If
respirations are
shallow or rate is
below 12
breaths/minute,
with hold dose and
notify prescriber

NURSING CARE PLAN:


Assessmen
t

Subjective:
Ang sakit
talaga ng
tahi ko pag
gumagalaw
ako, as
verbalized by
the patient.

Nursing
Diagnosi
s
Pain and
discomfort
related to
Surgical
Incision

Planning

Long Term:
After 4 days to
7 days of
nursing
intervention the
client will be
able to be free
of pain.
Short Term:

Implementati
on
1. Accept
clients
descriptio
n of pain.
Acknowle
dge the
pain
experienc
e and
convey

21 | C a s e S t u d y M I R I Z Z I S S Y N D R O M E

Rationale

1.Pain was a
subjective
experience and
cannot be felt by
others

Evaluation

PLAN
ACHIEVED!
DISCHARGEDO
UTCOME: After
1 week of
nursing
intervention
the client had
been free of

Wesleyan UniversityPhilippines
HOSPITAL
Objectives:
-The patient
manifested:
-pain scale
of 8/10
-grimace
muscle
guarding
-Post surgical
incision
-Vital signs
as follow:
BP- 130/90
PR- 86
RR-22cpm
TEMP- 37
degree
celcius

Assessmen
t

After 12hours of
nursing
intervention the
client will be
able to:
a) reduce
pain from
a grade
of 8/10 to
4/10
b) verbalize
non
pharmac
ologic
methods
to
provide
relief.

Nursing
Diagnosi
s

Planning

acceptanc
e of
clients
response
to pain.
2. Relaxation
technique
s: deep
breathing
exercise
3. Therapeut
ic:
-Provide a
quiet
environme
nt
Administe
r
analgesic
if
indicated

Implementati
on

22 | C a s e S t u d y M I R I Z Z I S S Y N D R O M E

pain.

2.To reduce
tension

3.To minimize
stress that
patient is
experiencing

To provide relief
through drug
interaction

Rationale

Short Term:
After 12 hours
of nursing
intervention
the client had
been able to:
a.) reduce
pain
from a
grade of
8/10 to
4/10
b.) verbaliz
e non
pharma
cologic
method
s to
provide
relief

Evaluation

Wesleyan UniversityPhilippines
HOSPITAL
Subjective:
Nahihirapan
ako huminga
lalo na pag
sumasakit
yung sugat
ko, as
verbalized by
the patient.
Objectives:
-Unable to
breath
normally
-holding
breath
-Post surgical
incision
-Vital signs
as follow:
BP- 130/90
PR- 86
RR-24cpm
TEMP- 37
degree
celcius
Spo2- 96%

Ineffective
breathing
pattern
related to
pain on
abdominal
surgical
incision

Short-term:
After 1 hour of
nursing
interventions,
the patient will
demonstrate
improved
breathing
pattern.

Long-term:
After 4 hours
of nursing
intervention the
patient will
establish
effective
breathing
pattern.

1. Administe
r
suppleme
ntal
oxygen
via nasal
cannula
as
ordered.
2. Monitor
vital signs
and
specially
the pulse
oximeter
3. Encourage
/ assist
with deepbreathing
exercises
and
pursed-lip
breathing
as
appropriat
e
4.

Elevate
head of
bed, place
client in
semifowlers
position.

5. Administe
r
23 | C a s e S t u d y M I R I Z Z I S S Y N D R O M E

-Maximizes
available oxygen,
especially while
ventilation is
reduced because
pain

-Promotes
maximal
ventilation and
oxygenation

-To verify the


improvement
and maintenance
of oxygen
saturation

- To promote
physiological/psy
chological ease
of maximal
inspiration

-To promote
deeper
respiration

Short-term:
After 1 hour of
nursing
interventions,
the patient
shall have
demonstrated
improved
breathing
pattern.

Long-term:
After 4 hours
of nursing
interventions,
the patient
shall have
established an
effectivebreat
hing pattern

Wesleyan UniversityPhilippines
HOSPITAL
medicatio
n
prescribed
by the
physician
such as
analgesics
.

DISCHARGE PLANNING:
TAKE HOME MEDICATIONS

The patient will continue Acetylcysteine (Fluimucil) 600mg per tablet;


one tablet dissolved with glass of water once a day at hours of sleep by
mouth. Take this medication at 8PM for 5 days.
The patient will continue Ipratropium + Salbutamol per nebule; one
nebule as needed for difficulty of breathing per nebulization.
The patient will continue Cefuroxime 500mg per tablet; one tablet two
times a day by mouth. The patient will take this medication at 8AM and
6PM for 4 days.
The patient will continue Ketorolac 10mg per tablet; one tablet as
needed for pain
Follow up check-up: After 1 week.
HOME CARE

Be sure to eat plenty of fresh fruits, vegetables and fluids. Avoid fatty
foods.
Dont do any strenuous physical activities, heavy lifting or sports for 12 weeks after surgery.
Ambulate as frequently as tolerated.
Gently wash the skin around your incision daily with mild soap and
water.

24 | C a s e S t u d y M I R I Z Z I S S Y N D R O M E

Wesleyan UniversityPhilippines
HOSPITAL

If there is gauze dressing on your incision, change it daily or as often


as necessary to keep it dry and clean.

WHEN TO CALL YOUR DOCTOR:

Yellowing of your skin or eyes (jaundice)


Chills
Fever above 101.5F or 38.5C
Redness, swelling, increasing pain, pus, or a foul smell at the incision
site
Nausea and vomiting
Increasing abdominal pain

REFERENCES:
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2413250/
Abou-Saif A, Al-Kawas FH. Complications of gallstone disease: Mirizzi
syndrome, cholecystocholedochal fistula, and gallstone ileus. Am J
Gastroenterol. 2002;97:249254
Mirizzi PL. Syndrome del conducto hepatico. J Int de Chir 1948; 8:731.
Brunner, L & Suddhart, D. (2010) Textbook of Medical-Surgical Nursing. 12th edition.
http://www.scribd.com/doc/48409374/Cefoxitin-Metronidazole-scribd
http://www.mayoclinic.org/diseases-conditions/gallstones/basics/causes/con-20020461

25 | C a s e S t u d y M I R I Z Z I S S Y N D R O M E

Wesleyan UniversityPhilippines
HOSPITAL

26 | C a s e S t u d y M I R I Z Z I S S Y N D R O M E