Professional Documents
Culture Documents
INTRODUCTION
A. Brief description
Calculi or gallstones, usually form in the gallbladder from the solid constituents
of bile; they vary greatly in size, shape and composition.
Sign and symptoms are right-upper-quadrant (RUQ) pain or epigastric pain and
discomfort, nausea and vomiting, bloating, dyspepsia, jaundice, changes in the color of
urine and stool
Risk factors are obesity, women especially those with multiple pregnancy,
frequent changes in weight, rapid weight loss, diabetes and cystic fibrosis.
Tests to check your bile ducts for gallstones. A test that uses a special dye to highlight
your bile ducts on images may help your doctor determine whether a gallstone is causing
a blockage.
Tests may include a hepatobiliary iminodiacetic acid (HIDA) scan, magnetic resonance
imaging (MRI) or endoscopic retrograde cholangiopancreatography (ERCP). Gallstones
discovered using ERCP can be removed during the procedure.
Blood tests to look for complications. Blood tests may reveal an infection, jaundice,
pancreatitis or other complications caused by gallstones.
Treatment
Laparoscopic cholecystectomy
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Surgery to remove the gallbladder (cholecystectomy). Remove the gallbladder, since
gallstones frequently recur. Once your gallbladder is removed, bile flows directly from
your liver into your small intestine, rather than being stored in your gallbladder.
You don't need your gallbladder to live, and gallbladder removal doesn't affect your
ability to digest food, but it can cause diarrhoea, which is usually temporary.
Pharmacotherapy
Diseases of the gallbladder are common and costly. The best epidemiological screening
method to accurately determine point prevalence of gallstone disease is ultrasonography.
Many risk factors for cholesterol gallstone formation are not modifiable such as ethnic
background, increasing age, female gender and family history or genetics. Conversely,
the modifiable risks for cholesterol gallstones are obesity, rapid weight loss and a
sedentary lifestyle. The rising epidemic of obesity and the metabolic syndrome predicts
an escalation of cholesterol gallstone frequency. Risk factors for biliary sludge include
pregnancy, drugs like ceftiaxone, octreotide and thiazide diuretics, and total parenteral
nutrition or fasting. Diseases like cirrhosis, chronic hemolysis and ileal Crohn's disease
are risk factors for black pigment stones. Gallstone disease in childhood, once considered
rare, has become increasingly recognized with similar risk factors as those in adults,
particularly obesity. Gallbladder cancer is uncommon in developed countries. In the U.S.,
it accounts for only ~ 5,000 cases per year. Elsewhere, high incidence rates occur in
North and South American Indians. Other than ethnicity and female gender, additional
risk factors for gallbladder cancer include cholelithiasis, advancing age, chronic
inflammatory conditions affecting the gallbladder, congenital biliary abnormalities, and
diagnostic confusion over gallbladder polyps.
2
Of these people, there are approximately 300,000 cholecystectomies performed annually.
Ten percent to 15% of the population has asymptomatic gallstones. Of these, 20% are
symptomatic (biliary colic). Of the 20% who are symptomatic approximately 1% to 4%
will manifest complications (acute cholecystitis, gallstone pancreatitis,
choledocholithiasis, gallstone ileus). The incidence of gallstones increases with an
increase in age, with females more likely to form gallstones than males. Age 50 to 65
approximately 20% of women and 5% of men have gallstones. Overall, 75% of
gallstones are composed of cholesterol, and the other 25% are pigmented. Despite the
composition of gallstones the clinical signs and symptoms are the same.
With an annual rate of greater than a quarter of a million hospital admissions and an
associated cost of greater than two billion dollars, cholelithiasis and cholecystitis have a
tremendous impact on the health care system. Their diagnosis and associated symptoms
are one of the most common reasons for clinic visits and the second most common reason
for gastrointestinal-related hospital admissions in the United States. Minimally invasive
surgery has revolutionized the way these patients are managed. This technique provides a
safe and effective therapy that also results in reduced wound-related complications
compared with open cholecystectomy. This enhanced recovery has made the laparoscopic
cholecystectomy one of the most commonly performed abdominal surgeries in the United
States, with more than 500,000 performed each year.
The main reason why we choose this study is for the readers to have a broader knowledge about
Cholelithiasis of Gallbladder Hydrops. The researchers will also acquire knowledge about
how to give the best possible for the patient's condition, and to understand the concept therein.
IV. Objectives
1. General Objectives:
At the end of the rotation we the BSN- 3A, Group 1 will enhance our knowledge,
skills and attitude in the care and management of patient who had Cholelithiasis
of Gallbladder Hydrops utilizing the nursing process and will improve the health
status of the patient.
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2. Specific Objectives:
At the end of this case, the group will able to:
1. Assess the general health condition, routines of daily living as well as health
lifestyle factors affecting the health status of the client.
2. Recognize and prioritize nursing problems and create nursing diagnoses based
on assessment findings
3. Plan efficient nursing care to solve identified problems based from patient’s
condition and health needs.
4. Evaluate the effectiveness of nursing interventions rendered to be able to
improve patient’s condition for possible discharge.
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II. NURSING PROCESS
A. ASESSMENT
1. PERSONAL DATA
a. Demographic data
Name: Patient x
Gender: Female
Nationality: Filipino
b. Environmental status
She is a 44 years old female who lives in Don Basilio Gerona Tarlac. The house is
consists of 5 family members including her husband. They are nuclear type of family.
Their house is made of cement onsist of 3 rooms and 2 window located near the farm.
Their source of water is faucet for cooking and for house chores. They used
commercially available water for drinking.
She eats her meals on time three times a day. She usually eats fatty and salty foods.
Patient usually consumes 5-8 glasses of water a day. According to her she doesn’t drink
alcohol and smoke cigarettes. She’s a plain housewife and mostly spend her time in sari-
sari store that she owned, doing household chores and chatting with her neighbor.
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Family history of health and illneses
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2. History of Past Illness
Patient had her complete immunization when she was a child and she had chicken
pox when she’s 16 years old. Her last hospitalization was October 2018 at Paniqui
Hospital for 4 days, she experienced abdominal pain and fever. She was
diagnosed with cholecystolithiasis and had a fatty liver.
4. PHYSICAL ASSESSMENT
Weight- 82 kg
Height- 5’3
BMI- 31. 95 (obese)
13 Areas of Assessment
I. SOCIAL STATUS
She speaks tagalog and Ilocano, they are considered nuclear family with
patrecentric family based on authority. She is high school undergraduate according to
hert she has a good communication relation with neighbour and with her fellow
patient as testified by other patient in the ward. During the assessment she is
accommodating in answering questions. Patient has a good communication and
relation to her family members. And cellular phones and chatting is their means of
communication. According to patient’s mother she’s very close to every members in
their family since she is the youngest among siblings.
NORMS:
Social status includes family relationship that states patient’s support system in time
of stress and in time of need. It meets a fundamental human need for socialities
making life less stressful and social support buffers the negative effects of stress.
Thus indicating indirectly contributing to good health outcomes. (Fundamentals of
Nursing, Barbara Kozier, Seventh edition)
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Analysis/Interpretation:
She was seen in her laboratory gown weak in appearance pale in color with noted
facial grimace due to post operative incision. She is conscious during the assessment
and answer all the question being asked even though she’s having difficulties in
answering because of pain as verbalize by the patient. But was able to answer
correctly and sensibly with the names, time, date and objects being asked.
NORMS:
The content of the patient message should make sense. The ability to read
and write should match the educational level. The patient should be able to
correctly respond to the questions and to identify all objects as requested. The
patient should be able to evaluate and act appropriately in situations requiring
judgement. (health assessment and physical examination 3th edition by Mary
Ellen Zator Estes)
ANALYSIS:
Her current mental status is normal but noted difficulties in answering question
because of the pain. Indicates mental capabilities are still functioning well.
Norms:
A human’s emotional status depends on his or her ability to cope up and
be ready for whatever can happen in their life. She or he may not be ready to
be emotionally stable of unfortunate happenings in life.
(www.nursingceu.com)
Analysis:
Emotional status is normal.
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eyes are equally reacting to light when using penlight. She is wearing
reading glasses when she needs to read small words but still her vision is
20/20 because she can able to read the words being asked 20 feet away.
No exopthalmia, lesions, and bruits observed.
Norms:
Sense of smell
Norms:
The person can smell and identify the aroma of a given object like
perfume or any other. The person should be able to distinguish the foul and good
smelling.
Analysis:
Sense of hearing
For the auditory assessment the voice whisper test was used. Words were
whispered while the patient was instructed to repeat every words being whispered.
The procedure was then repeated to the other ear. The ear are symmetrical and
matches the color of the rest of the skin. After whisper test patient was able to
hear them clearly with negative deformities. No swelling, discharged and lesions
noted except for minimal earwax observed on both ears.
Norms:
The auditory of the person is normal if the patient don’t have any
tinnitinus or any ear problem. He should be able to hear in the minimum
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of 2 feet away. ( health Assessment and physical examination, Mary Ellen
Zator Estes)
Analysis:
Based on the given data, auditory acuity is normal.
Sense of taste
Examined using variety of food which taste salty, bitter, and sweet
(granules of sugar and coffee). She was able to differentiate each taste. She has
pale lips slightly dry and chaps. With dry saliva deposited on her side mouth, her
tongue is slightly pinkish with whitish buds. Foul odor is being noted with no
deformities that can affect her sense of taste.
Norms:
A person usually identifies the taste of bitter, sweet and sour. By the use of
our sense of taste we can fix or adjust the taste of our cooked food based on our taste
capacity. ( health assessment and physical examination, Mary Ellen Zator Estes)
Analysis:
Based on the assessment the sense of taste is normal.
V. Motor Stability
Her neck is symmetrical with head in central position. Movement through full
range of motion can be done with discomfort, and gait was assessed using the
heel to toe method. She can’t able operative inscision. She can also move her
shoulder laterally and medially as well as rotate her shoulder in the same
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manner with complains of pain. She can also bend her elbows and extend
beyond the neutral position. The patient can’t flex her knees because she’s
still in pain.
Analysis:
The motor stability is noted abnormal due to impairment with some physical
mobility due to pain cause by post operative incision.
Analysis:
Upon assessing body temperature during assessment and follow-up are
normal.
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February 05, 2019 (1:00 23 Above normal
pm)
February 06, 2019 (8::01 20 normal
am)
February 06, 2019 (4:29 24 Above normal
pm)
Norms:
Normal respiratory rate for adult is 12-20 cpm, average is 18. In terms of
pattern, normal respirations must be regular and even in rhythm. The normal
depth of respirations in non-exaggerated and effortless (Health assessment and
physical examination 3rd edition by Mary Ellen Zator Estes)
Analysis:
Respiratory status are beyond normal because pain and post anesthetic during
follow- up.
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Norms:
Normal cardiac rate for an adult is 60-100 beats per minute while the normal
blood pressure is 120/80 mmHg. The working capacity of the heart diminishes
with aging. The heart rate of older people is slow to respond to stress and slow
to return to normal after stress. Reduced arterial elasticity results in
diminished blood supply to the parts of the body especially the extremities.
(Health assessment and physical examination 3rd edition by Mary Ellen Zator
Estes)
Analysis:
The pulse rate during the assessment and follow-up are in normal range. the
blood pressure on the follow- up are above normal.
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XI. Reproductive Status
She had her first menstruation when she was 10 years old with 5 days duration
and consumes 5 pads in a day fully soaked, without abdominal cramps and
fundal pain every menstruation. She had her first sexual intercourse when she
was 16 years old. According to her she is sexually active and have sex once a
week due to the nature of her husband’s work. cramps.
Norms:
The first menstruation which is menarche occurs at an average of 9 to 17 years
old. (Maternal and Child Health Nursing 4th edition by Pilliterri)
Analysis:
Her menarche is normal because she had her menarche at 15 years old. The
reproductive status is normal.
XII. Sleep-rest Pattern
Prior to admission she normally sleeps 6 hours with nap in the afternoon.
During post operative/ admission she verbalized difficulty of sleeping due to
the environmental changes.
Norms:
Sleep refers to altered consciousness with general slowing of physiologic
process while rest refers to relaxation and calmness, both mental and physical.
A person usually sleeps for about 7 to 9 hours a day and takes a rest using
some of activities that will help you to relax including reading, watching
television and others.
Analysis:
Sleep-rest pattern is altered due to environmental factors.
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The skin and appendages is not normal due to presence of incision.
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Laboratory Hemoglobin Hemoglobin -Normal -Monitor and
assessment regulate the
Hematology of blood 131 120-153 g/L Intravenous
formation fluid
and to
Date detect any Hematocrit Hematocrit -Normal
blood -Monitor vital
February 0.418 0.350-
associated signs
05, 2016 0.450%
disorders.
RBC -Normal
RBC -
4.33
3.9-5.7 /L
MCV -Normal
MCV
95.5
80-96 fL
MCHC -Normal
MCHC
313
334-355 g/L
MCH -Normal
MCH
30.3
27.5-32.2
pg
WBC -Normal
10.3 WBC
4.5-10.5 /L
POLYS -Abnormal
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-Normal
LYMPHO
0.241 LYMPHO
(0.23-0.35) -Normal
PLATELET
221,000 PLATELET
150,000-
450,000
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electrolyte 135.0- -Normal
s and other 148.0
chemical. Potassium mmol/L
4.60
Potassiu
m
3.50-5.30
mmol/L
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Laboratory and Indication Date Findings
diagnosis
Liver
Imaging January 14, -Normal in sized
procedure used 2019 Proximal
HBT to diagnose common duct
Ultrasound problems of the -Normal in sized (0.4 cm
liver, gallbladder )
, pancreas,
Gallbladder
spleen and the -dilated (9.7x5.2cm)
kidneys
-within cystic duct
-Multiple intraluminal
Pancreas
-Normal in sized
Spleen
-Normal in sized
-No masses
Splenic vessels
-Not dilated
Both Kidneys
-Normal in sized
-Not dilated
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Laboratory and Indication Date Findings
diagnosis
Chest x-ray Lungs
produces images -Clear
of the hearth
Hearth
Chest AP lungs, airways ,
-Normal in size
blood vessels and
Diaphragm &
the bones of the
both
spine and chest. Costophrenic
An x-ray sulci
(radiograph) is a -Intact
noninvasive Visualized Bony
medical test that Structures
helps physicians -Unremarkable
diagnose and treat
medical
conditions.
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7. Anatomy and Physiology
A pear shape, hollow sac like organ, 7.5-10 cm in (3-4 in) long, lies in a shallow
depression on the inferior surface of the liver, to which it is attached by loose connective
tissue.
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b. Physiology of Gallbladder
1. It acts as storage depot of bile duct
2. Between meals, when the sphincter of Oddi is closed, bile produced by the
hepatocytes enters the gallbladder.
3. During storage, a large portion of the water in the bile is absorbed through the
walls of the gallbladder, so that the gallbladder bile is 5-10 times more
concentrated than that originally secreted by the liver.
4. When food enters the duodenum, the gallbladder contracts and the sphincter of
Oddi relaxes, allowing the bile to enter the intestine.
5. This response is mediated by secretion of the hormones Cholecystokinin-
Pancreozymin (CCK-PZ) from the intestinal wall.
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c. PATHOPHYSIOLOGY
Book-based
Modifiable Non- Modifiable
Lifestyle
-presence of jaundice
-dysuria
-fever
Laboratories
-abdominal X-ray
-ultrasound
-Cholecystography
-endoscopic retrogate
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Cholelithiasis
Pathophysiology
Gallstone formation occurs because certain substances in bile are present in
concentrations that approach the limits of their solubility. When bile is concentrated in
the gallbladder, it can become supersaturated with these substances, which then
precipitate from the solution as microscopic crystals. The crystals are trapped in
gallbladder mucus, producing gallbladder sludge. Over time, the crystals grow,
aggregate, and fuse to form macroscopic stones. Occlusion of the ducts by sludge and/or
stones produces the complications of gallstone disease.
The 2 main substances involved in gallstone formation are cholesterol and calcium
bilirubinate.
Cholesterol gallstones
More than 80% of gallstones in the United States contain cholesterol as their major
component. Liver cells secrete cholesterol into bile along with phospholipid (lecithin) in
the form of small spherical membranous bubbles, termed unilamellar vesicles. Liver cells
also secrete bile salts, which are powerful detergents required for the digestion and
absorption of dietary fats.
Bile salts in bile dissolve the unilamellar vesicles to form soluble aggregates called mixed
micelles. This happens mainly in the gallbladder, where bile is concentrated by
reabsorption of electrolytes and water.
Compared with vesicles (which can hold up to 1 molecule of cholesterol for every
molecule of lecithin), mixed micelles have a lower carrying capacity for cholesterol
(about 1 molecule of cholesterol for every 3 molecules of lecithin). If bile contains a
relatively high proportion of cholesterol to begin with, then as bile is concentrated,
progressive dissolution of vesicles may lead to a state in which the cholesterol-carrying
capacity of the micelles and residual vesicles is exceeded. At this point, bile is
supersaturated with cholesterol, and cholesterol monohydrate crystals may form.
Thus, the main factors that determine whether cholesterol gallstones will form are (1) the
amount of cholesterol secreted by liver cells, relative to lecithin and bile salts, and (2) the
degree of concentration and extent of stasis of bile in the gallbladder.
Calcium, bilirubin, and pigment gallstones
Bilirubin, a yellow pigment derived from the breakdown of heme, is actively secreted
into bile by liver cells. Most of the bilirubin in bile is in the form of glucuronide
conjugates, which are water soluble and stable, but a small proportion consists of
unconjugated bilirubin. Unconjugated bilirubin, like fatty acids, phosphate, carbonate,
24
and other anions, tends to form insoluble precipitates with calcium. Calcium enters bile
passively along with other electrolytes.
In situations of high heme turnover, such as chronic hemolysis or cirrhosis, unconjugated
bilirubin may be present in bile at higher than normal concentrations. Calcium
bilirubinate may then crystallize from the solution and eventually form stones. Over time,
various oxidations cause the bilirubin precipitates to take on a jet-black color, and stones
formed in this manner are termed black pigment gallstones. Black pigment stones
represent 10-20% of gallstones in the United States.
Bile is normally sterile, but in some unusual circumstances (eg, above a biliary stricture),
it may become colonized with bacteria. The bacteria hydrolyze conjugated bilirubin, and
the resulting increase in unconjugated bilirubin may lead to precipitation of calcium
bilirubinate crystals.
Bacteria also hydrolyze lecithin to release fatty acids, which also may bind calcium and
precipitate from the solution. The resulting concretions have a claylike consistency and
are termed brown pigment stones. Unlike cholesterol or black pigment gallstones, which
form almost exclusively in the gallbladder, brown pigment gallstones often form de novo
in the bile ducts. Brown pigment gallstones are unusual in the United States but are fairly
common in some parts of Southeast Asia, possibly related to liver fluke infestation.
Mixed gallstones
Cholesterol gallstones may become colonized with bacteria and can elicit gallbladder
mucosal inflammation. Lytic enzymes from the bacteria and leukocytes hydrolyze
bilirubin conjugates and fatty acids. As a result, over time, cholesterol stones may
accumulate a substantial proportion of calcium bilirubinate and other calcium salts,
producing mixed gallstones. Large stones may develop a surface rim of calcium
resembling an eggshell that may be visible on plain x-ray films.
Etiology
Cholesterol gallstones, black pigment gallstones, and brown pigment gallstones have
different pathogeneses and different risk factors.
Cholesterol gallstones
Cholesterol gallstones are associated with female sex, European or Native American
ancestry, and increasing age. Other risk factors include the following:
Obesity
Pregnancy
Gallbladder stasis
Drugs
Heredity
The metabolic syndrome of truncal obesity, insulin resistance, type II diabetes mellitus,
hypertension, and hyperlipidemia is associated with increased hepatic cholesterol
secretion and is a major risk factor for the development of cholesterol gallstones.
Cholesterol gallstones are more common in women who have experienced multiple
pregnancies. A major contributing factor is thought to be the high progesterone levels of
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pregnancy. Progesterone reduces gallbladder contractility, leading to prolonged retention
and greater concentration of bile in the gallbladder.
Other causes of gallbladder stasis associated with increased risk of gallstones include
high spinal cord injuries, prolonged fasting with total parenteral nutrition, and rapid
weight loss associated with severe caloric and fat restriction (eg, diet, gastric bypass
surgery).
A number of medications are associated with the formation of cholesterol gallstones.
Estrogens administered for contraception or for the treatment of prostate cancer increase
the risk of cholesterol gallstones by increasing biliary cholesterol secretion. Clofibrate
and other fibrate hypolipidemic drugs increase hepatic elimination of cholesterol via
biliary secretion and appear to increase the risk of cholesterol gallstones. Somatostatin
analogues appear to predispose to gallstones by decreasing gallbladder emptying.
About 25% of the predisposition to cholesterol gallstones appears to be hereditary, as
judged from studies of identical and fraternal twins. At least a dozen genes may
contribute to the risk. [3] A rare syndrome of low phospholipid–associated cholelithiasis
occurs in individuals with a hereditary deficiency of the biliary transport protein required
for lecithin secretion. [4]
Black and brown pigment gallstones
Black pigment gallstones occur disproportionately in individuals with high heme
turnover. Disorders of hemolysis associated with pigment gallstones include sickle cell
anemia, hereditary spherocytosis, and beta-thalassemia. In cirrhosis, portal
hypertension leads to splenomegaly. This, in turn, causes red cell sequestration, leading
to a modest increase in hemoglobin turnover. About half of all cirrhotic patients have
pigment gallstones.
Prerequisites for the formation of brown pigment gallstones include intraductal stasis and
chronic colonization of bile with bacteria. In the United States, this combination is most
often encountered in patients with postsurgical biliary strictures or choledochal cysts.
In rice-growing regions of East Asia, infestation with biliary flukes may produce biliary
strictures and predispose to formation of brown pigment stones throughout intrahepatic
and extrahepatic bile ducts. This condition, termed hepatolithiasis, causes recurrent
cholangitis and predisposes to biliary cirrhosis and cholangiocarcinoma.
Other comorbidities
Crohn disease, ileal resection, or other diseases of the ileum decrease bile salt
reabsorption and increase the risk of gallstone formation.
Other illnesses or states that predispose to gallstone formation include burns, use of total
parenteral nutrition, paralysis, ICU care, and major trauma. This is due, in general, to
decreased enteral stimulation of the gallbladder with resultant biliary stasis and stone
formation.
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Client based:
Non-Modifiable Modifiable
Diagnostic Test
Surgical Procedure
Cholecystectomy
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VI. Nursing Care Plan
B. IMPLEMENTATION
Cholecystectomy 02/06/2019 -surgical removal of -performed to treat -patient is in pain -Monitor the vital
with Intraoperative gallbladder cholelithiasis and due to procedure signs of the pt.
Cholangiogram cholecystitis done.
28
-it is consist of -billiary coli -Health teachings
excising the given about
gallbladder from the -billary pancreas appropriate diet of
posterior liver wall -gallbladder cancer the pt.
and ligating the
cystic duct, vein and -choledocholithiasis
artery the surgeon
usually approaches
the gallbladder
through a right
subcostal incision
Change position Activity tolerance To promote patient The patient was relived and
in bed every 2 comfort was comfortable
hours
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f. NURSING MANAGEMENT
(1)
Subjective:
Objective:
BP: 120/70
PR: 85 bpm
RR: 24 cpm
T: 36.1
Pale in appearance
Chest ultrasound : right massive pleural effusion and left minimal pleural effusion
Analysis:
Planning:
After 1 hour of nursing intervention the patient maintain an effective breathing pattern as
evidence by relax breathing, at normal rate and depth and doesn’t use any accessory
muscles
Intervention:
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Evaluation:
CONCLUSION
After our exposure in surgery ward, we the student nurses, had acquired
knowledge about the patient’s condition that will help us in our path to
become a registered nurse, after handling patient who has cholelithiasis of
gallbladder hydrops, we learned a lot about the manifestations, risks factors,
etiology, pathophysiology, proper management and treatment. The group
established good nurse-patient rapport, unity, teamwork and effective
collaboration with our group mates. We were able to enhance our skills,
knowledge, attitude and rendered appropriate nursing interventions based on
patient’s health problems and needs. The group emphasized and able to give
proper health teachings that will help to improve the general health condition
of the patient.
Based on the data compiled in this case study, we therefore conclude that all
the objectives and goals were achieved.
RECOMMENDATION
A. Student Nurse
To our fellow student nurses, to enhance our knowledge, attitude and skills in
having a proper nursing care management, a case study is a helpful instrument that will
serve as an educational companion to have a better understanding about specific cases
including our case cholelithiaisis. To establish a good rapport to the patient is also like
building an effective collaboration with your groupmates. Unity, teamwork, patience,
trust, prioritization, and focus are necessary things to accomplish a good case study.
B. Patient
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Patient must keep in mind the diet changes of decreased fat intake is prudent; this
may decrease the incidence of biliary colic attacks.to appropriate eating lifestyle: eating
nutritious foods like dark, green leafy vegetables, fresh fruits and high protein diet, avoid
eating salty, gas-forming and fatty foods. Drinking plenty of water to maintain the
hydration of the body and restricting lifting of heavy things or straining for 6 weeks is a
must. Walking daily should be performed. Following the regimen of discharge
medications is also important.
Healthcare providers have the great responsibility to help others, to keep them
healthy and free of danger. It is necessary to know all about the patient’s condition and
how to properly manage it that is why they can use this study in order for them to have
more knowledge on how to render the specific care to their patients.
Background
Acute cholecystitis is seen commonly in the emergency room and is a leading cause of
gastrointestinal-related hospital admissions. Cholecystectomy is the accepted standard of
care to manage cholecystitis; however, the timing of surgery has been the subject of
debate. In the past, conservative management with a course of antibiotics was thought to
reduce inflammation and facilitate definitive surgical management at a later date, usually
6 weeks after the initial presentation. This approach was felt to reduce operative risks and
was endorsed as recently as 2013 for grade II (moderate) and grade III (severe)
cholecystitis as outlined in the Tokyo guidelines. However, research has shown
convincingly that early laparoscopic cholecystectomy (ELC), defined as occurring 24 to
72 hours from time of admission, is preferred for treatment of acute cholecystitis in the
modern laparoscopic era. Surgery within 72 hours has become a benchmark after being
associated with lower costs and better outcomes, namely reduced complication and
mortality rates. When compared with delayed laparoscopic cholecystectomy (DLC), early
laparoscopic cholecystectomy has been shown to be safe, to have similar or better rates of
conversion to an open procedure, and to reduce duration of hospital stay. Looking at data
from 77 case-control studies, early laparoscopic cholecystectomy was also found to be
associated with statistically significant reductions in mortality, total complication rate,
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bile duct leaks, bile duct injuries, wound infections, conversion rates, length of hospital
stay, and blood loss. In a Canadian model, performing surgery early was also estimated to
save approximately $2129 per patient. The most recent consensus statement in the 2018
Tokyo guidelines reflects this by extending adoption of early laparoscopic
cholecystectomy for both grade II and grade III severity as the ideal preferred approach.
Methods
In 2014 all practising general surgeons in the Fraser Health Authority were approached to
complete an online survey about surgeon attitudes, preferences, and practice patterns
regarding management of acute cholecystitis. This was followed by a retrospective
database audit of records for all patients presenting with acute cholecystitis in Fraser
Health between April 2012 and June 2013 who underwent a surgical intervention from
April 2012 to December 2013. Baseline data were collected for the entire health authority
as well as for each individual hospital within the authority. Regional analysts collected
data as part of an approved quality audit using ICD and Canadian Classification of Health
Intervention codes.
Our educational intervention took place at Langley Memorial Hospital, a 166-bed facility
serving a population of approximately 130 000 in Langley, British Columbia. The
intervention began in May 2015 with the distribution of information by email to
emergency room physicians and with educational rounds for operating room nurses. A
practice algorithm for acute cholecystitis was then developed and distributed to staff in
the emergency room and operating rooms. The algorithm included a recommendation for
early surgical consultation for all confirmed or suspected cases of acute cholecystitis.
After the educational intervention, data were collected from electronic and paper charts
from July 2015 to June 2016. Outcomes included times from admission to surgery and
from booking to surgery, as well as preoperative American Society of Anesthesiologists
(ASA) scores and duration of operations, conversion to open surgery rates, length of stay,
and readmission rates.
Results
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Between April 2012 and December 2013, a total of 1329 patients were admitted to Fraser
Health sites with a diagnosis of cholecystitis, and 611 (46%) had an intervention on their
initial admission. Of these, 569 (93%) had laparoscopic cholecystectomies and the
remaining 48 (7%) had drainage procedures (either operative or radiologic). This left 718
patients (54%) who had no intervention for cholecystitis on their initial admission.
Among these patients, 359 (50%) went on to have a delayed cholecystectomy during the
study period. Average hospital length of stay in the ELC group receiving early treatment
was 5.8 days compared with 6.4 days for the DLC group receiving delayed treatment.
Before the educational intervention, 135 patients presented to Langley Memorial Hospital
with acute cholecystitis over 13 months, and 61 (45%) had an intervention on their initial
admission. Of these, 59 (97%) underwent cholecystectomies and 2 (3%) had drainage
procedures. This left 74 patients (55%) who had no intervention for acute cholecystitis on
their initial admission. Among these, 34 patients (25%) went on to have a delayed
procedure during the study period. Overall, management of acute cholecystitis at Langley
Memorial Hospital before the educational intervention was comparable to that seen at
other Fraser Health sites.
Management approaches
While our results suggest it would be worthwhile to increase access to early laparoscopic
cholecystectomy, some degree of caution must be exercised before instituting a strict
policy of ELC with rigid scheduling benchmarks, since such a policy could lead to
markedly increased after-hours surgery. Data regarding the safety of nighttime
laparoscopic cholecystectomy are somewhat conflicting; a retrospective review at two
large urban centres found an increased risk of conversion to an open procedure for
patients receiving laparoscopic cholecystectomies between 7 p.m. and 7 a.m. Another
slightly larger and more recent retrospective review found no increased risk of
complications for patients undergoing laparoscopic cholecystectomies after 5 p.m., and
statistically significant reduced length of stay among the nighttime laparoscopic
cholecystectomy group. While performing after-hours surgery may be safe, the long-term
impacts on the surgeon and operating room staff, which can include burnout, exhaustion,
and job dissatisfaction, must be considered. It is important to note that we were able to
achieve our increased rates of early cholecystectomy while adhering to a policy of
operating after 11 p.m. only if conditions were life- or limb-threatening.
Conclusions
34
after the educational intervention was appreciably shorter (2.57 days) than for patients in
the Fraser Health early cholecystectomy group (5.1 days). Interestingly, the hospital stay
after the educational intervention was also shorter than the 5.1 days seen in pooled data
for patients undergoing early cholecystectomy. One possible explanation for this
substantial reduction in length of stay is that our intervention focused on education for
both emergency room physicians and perioperative staff, which may have facilitated
more streamlined care for patients with acute cholecystitis and expedited their access to
surgery. This outcome is significant from both a system and a patient perspective.
Reducing hospital length of stay will reduce the costs associated with cholecystitis for an
already overburdened system. Less time in hospital also reduces the impact of acute
cholecystitis on patients by facilitating a faster return to baseline function and work.
INTRODUCTION
Gallbladder disease is classified into acute and acalculous, acalculous ones can be further
subclassified into gallbladder hydrops and acalculous cholecystitis. Gallbladder hydrops
is defined as an increase in the volume of the gallbladder without any inflammatory sign,
bacterial infection, or the presence of any abnormalities of biliary ducts or of the
gallbladder. The absence of inflammation is one of the characteristics of a good prognosis
and it differentiates gallbladder hydrops from acute acalculous cholecystitis.2 Gallbladder
hydrops is sometimes reported in children.3 We present the rare case of a male patient
with calculous gallbladder hydrops simultaneous with an episode of acute toxic hepatitis.
CASE PRESENTATION
A male patient, VA, from a rural area, aged 52 years, was admitted to the Department of
Internal Medicine for one week complaining for approximately 3–4 days before ad-
mission of moderate pain in the right upper quadrant, low fever, fatigue, general
weakness, symptoms stemming from an excessive food intake (meals abundant in animal
protein, fat, and alcohol), which appeared after a food restriction of 6 weeks (religious
fasting). The patient's his-tory included significant hypertension diagnosed in 2005, under
chronic treatment with antihypertensives. Physical examination revealed the following:
height 1.8 m, weight 124 kg and waist size 130 cm. Inspection showed a globular
abdomen, sensitive to deep palpation in the right upper quadrant, with impalpable liver
35
and spleen. Blood tests performed at admission, during hospitalization and at discharge
(the patient was hospitalized for a week): GGT 754 U/L, AST 381 U/L, ALT: 446 U/L,
direct Bi: 2.37 mg%, total Bi: 1.72 mg%, platelet count: 72,000/mm3; during
hospitalization: GGT 602 U/L, AST 145 U/L, ALT 274 U/L, direct Bi: 2.04 mg%, total
Bi: 2.94 mg%, platelet count: 96,000/mm3; and before discharge: GGT 558 U/L, AST:
96 U/L, ALT: 175 U/L, direct Bi: 0.42 mg%, total Bi: 0.8 mg%, platelet count:
151,000/mm3.Abdominal ultrasound revealed the following features: hepatomegaly with
homogeneous echostructure, slightly increased echogenicity with rear attenuation, with
no focal images, intrahepatic biliary duct dilation, or dilated suprahepatic veins. The
gallbladder looked dropsical, long axis: 12 cm, short axis: 4 cm, slender walls, with
images of hyperechoic infundibular calculi with a posterior shadow cone, the largest
having 14 mm. The portal vein had nor-mal size and hepatopetal flow in the main portal
vein. The main biliary duct also had normal size. One week after the discharge from the
Department of Internal Medicine the patient was admitted to a surgical department where
laboratory tests were repeated: ESR 7 mm/h, INR: 0.98, platelet count: 162,000/mm3,
direct Bi: 0.35 mg%, total Bi 0.81 mg%, AST: 25 U/L, ALT: 41 U/L, GGT: 64 U/L. The
patient underwent surgery (laparoscopic cholecystectomy) and the surgeon described the
following intraoperative aspects: distended gallbladder with signs of pericholecystic and
multiple lax cholecystojejunal posterior and infundibular adhesions. The gallbladder was
about 15 cm long and 5 cm in transverse diameter, with a thin wall, containing a semi-
transparent fluid (about 300 ml).
DISCUSSIONS
Cholelithiasis does not always have clinical symptoms and may be found occasionally
when performing an abdominal ultrasound. From an epidemiological point of view, about
1–4% of patients may experience yearly symptoms, the most common presentation is
biliary colic (56%), or acute cholecystitis (36%).4 More than 90% of the cases of acute
cholecystitis are due to cholelithiasis. Most patients are asymptomatic.5 Of the 1–4% of
cases, about 20% develop clinical symptoms.6 Such patients are often elderly ones and
some have bouts of acute cholecystitis with no previous bile symptoms.7–9 After an
attack of acute chole-cystitis, symptoms such as pain or inflammation are com-mon.10
Although gallstone disease is more common in the elderly, the incidence of acute
cholecystitis has dropped, because patients are operated on by laparoscopic chole-
cystectomy when gallstone symptoms occur.11 Regarding the frequency of acute
cholecystitis according to gender, 60% of patients are women and half of these cases are
due to gallstones, but the one occurring in men tends to be more severe.
36
hydrops).17Frequently, a slight increase in transaminases and bili-rubin can occur in
cases of acute calculous cholecystitis.18Here we had a large increase in serum
transaminases with normal bilirubin. According to the guidelines for acute hepatitis, ALT
(SGPT) values between 50–2,000 IU are considered significant, while in our case the
highest value was recorded for gamma-GT, which is suggestive for the effect of ethanol
on liver function.19 The toxic effect of ethanol on liver function is well known. We
consider this case an episode of acute hepatitis caused by acute alcohol consumption, and
not a chronic one. This was also proved by liver transaminase levels, which tended to
normalize within a short time of about a week, and by ultrasound ex-amination, which
revealed no hepatic steatosis typical for a chronic consumer of ethanol. Feverishness,
moderate pain in the right upper quad-rant, nausea are common symptoms of clinical
hepatitis and gallbladder disease. In uncomplicated acute chole-cystitis liver tests are
normal or slightly elevated.20 After a sparing diet, antibiotic treatment (ampicillin),
hepatopro-tective medication and bed rest, the clinical outcome and laboratory tests were
favorable.
Conclusion
A condition seen most often in children, gallbladder hydrops can be encountered in adults
less frequently, more-over it occurs simultaneously with an episode of acute toxic
hepatitis. Surgery was performed only after normalization of liver function tests and it
was not imposed urgently by the patient's clinical condition and laboratory test results.
This case demonstrates the need for flexible medical judgment at the bedside, and not a
strictly standardized one according to medical guidelines.
BIBLIOGRAPHY
a. Reference books
-Health assessment and physical examination 3rd edition Mary Ellen Zator
Estes
-Brunner and Suddarth textbook of Medical and Surgical Volume 1 twelfth
edition
-Brunner and Suddarth textbook of medical and Surgical Volume 2 10th
edition
-Nursing 92 drug handbook
-Lynda Juall Carpenito-Moyet, Hand of Nursing Diagnosis 12th edition
- Wolters Kluwer Nursing Drug hand Book 2017
37
Website
https://www.researchgate.net/profile/Maryna_Van_de_venter/publication/248
568168_Isolation_and_identification_of_a_novel_anti-
diabetic_compound_from_Euclea_undulata_Thunb/links/54bcd6e40cf253b50
e2d6855/Isolation-and-identification-of-a-novel-anti-diabetic-compound-
from-Euclea-undulata-Thunb.pdf "Inguinal hernia". Mayo Clinic. 2017-08-11
Ncbi.nlm.nih.gov
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urinary-system/
http://www.who.int/news-room/fact-sheets/detail/diabetes
https://www.sciencedirect.com/science/article/pii/S2214999615012643
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