CASE STUDY: OBSTRUCTIVE JAUNDICE

INTRODUCTION

This is the case of patient A.M., 75 years old, female residing in Tagudin, Ilocos Sur.
Admitted in Ilocos training and regional medical center surgical ward with a case of
Obstructive Jaundice.

Obstructive jaundice is a condition in which there is blockage of the flow of bile out of the
liver. This results in redirection of excess bile and its by-products into the blood, and bile
excretion from the body is incomplete. Bile contains many by-products, one of which is
bilirubin, a pigment derived from dead red blood cells. Bilirubin is yellow, and this gives the
characteristic yellow appearance of jaundice in the skin, eyes, and mucous membranes.
Symptoms of obstructive jaundice include yellow eyes and skin, abdominal pain, and fever.

Obstructive jaundice is the illness of elderly population which is also confirmed by the
information on the average age of our patients. The frequency of illness is higher among
female population, and the most frequent cause of obstructive jaundice are gallstones (54.1%
of patients). In 29.8% of patients the primary or secondary malignant disease was the cause of
blockage in gall flow and subsequent jaundice, and the most frequent malignant cause of
obstructive jaundice is pancreas cancer in 11.5% of patients.

Included with this study are the discussions of the thorough physical assessment of the
patient, anatomical and physiological parts, pathophysiology, laboratory and diagnostic
examinations and their corresponding findings and interpretations. Added to this, we also
have discussions of the patient’s activities, nursing care plan and drug study, our evaluation to
the render of care, the implications to nursing practice, education, and research, and finally
our recommendation.

PATIENT’S PROFILE

BIOGRAPHIC DATA
Patient A. M. is 75 years old female, was born on January 13, 1944 in Tagudin, Ilocos
Sur. She lives in Tagudin, Ilocos Sur. She is a Roman Catholic and a natural born
Filipino citizen. She is a widow and has 5 children. She graduated elementary at
Dardarat Elementary School. She can speak Iloko and Tagalog and she sometimes
understands English.
ADMISSION DATA
Patient A. M. was admitted at Ilocos Traning and Regional Medical Center due to
lumbar pain and difficulty of breathing on November 16, 2019 at 1:50pm. She was
accompanied by her son. She was admitted by Dr. Christopher Abaya with admitting
diagnosis of Obstructive Jaundice, R/O Gall bladder.
 CASE STUDY: OBSTRUCTIVE JAUNDICE

HISTORY OF PRESENT ILLNESS

Patient A.M. was apparently well 1 month prior to admission at Tagudin General
Hospital, the patient stated she had lumbar pain, graded sever (8/10); no relieving
factors, radiating to anterior abdomen (diffuse); continuous pain. The patient consulted
in Tagudin General Hospital and was prescribed Omeprazole and some unrecalled
medicines. She stated that the pain was not relieved. She was confined at Tagudin
General Hospital for 7 days. 1 week prior to admission at Ilocos Training and
Regional Medical Center, patient started to develop jaundice and had severe episodes
of vomiting after she eats food. The patient had intermittent fever, documented 38ᵒC,
with loss of appetite and weight loss. The pain progresses to 10/10 and she was
referred to Ilocos Training and Regional Medical Center, consulted in Emergency
room and was admitted.
PAST MEDICAL HISTORY
Patient A.M. was confined at Tagudin General Hospital on October 2019 with chief
complaint of lumbar pain. Patient A. M. has no history of diabetes mellitus,
hypertension, asthma, heart disease, cerebrovascular accident or history of trauma.

FAMILY HISTORY
There are no health problems in patient A. M.’s family such as diabetes mellitus,
hypertension, asthma, and cerebrovascular accident.
OB-GYNE HISTORY
G5P5. Patient A.M. delivered her 5 healthy babies in a Normal Spontaneous Delivery
with no complications.
LIFESTYLE AND HEALTH PRACTICES
1. Description of a typical day
Patient A. M. usually wakes up at 5:30 in the morning and usually eats breakfast with 3 in 1
coffee. She also cleans their house and their backyard after breakfast. She watches television
and listens to radio during her spare time. She eats lunch on-time. Her diet includes
vegetables, meats and fish. She eats dinner with her son’s family and watches television, after.
She sleeps at around 8:30 in the evening.
2. Nutrition and Elimination
Patient A. M. eats regular meal three times a day and 1 snack every afternoon. She drinks a
cup of 3 in 1 coffee every morning then eats her breakfast that consist of rice and meat or
vegetables. She can eat at least 1 cup of rice in lunch and dinner. Her usual menu are pork in
sour broth or “pork sinigang”, pork or chicken adobo, mixed vegetables simmered in
fermented fish sauce or “dinengdeng/inabraw, fried fish and “paksiw”. Her favorite dish is
tomato or okra with fermented fish sauce. They are using condiments like salt, soy sauce and
“magic sarap”. She drinks around 1.5 liters of water every day. Sometimes she drinks one
glass of soda. She can urinate 5-6 times a day and defecates regularly.
3. Activity – Exercise Pattern
Patient A. M. is independent in performing self-care activities such as bathing, grooming,
defecating and eating. She does not use any assistive devices in walking like canes or walker.
She stated that her form of exercise is cleaning their house and backyard.
 CASE STUDY: OBSTRUCTIVE JAUNDICE

4. Sleep and Rest Pattern

Patient A.M.’s usual sleep pattern is 8-9 hours per day. According to her, she wakes up at
around 5:30 in the morning and she doesn’t take a nap in the afternoon, she sleeps at around
8:30 in the evening. She stated that sometimes she wakes up at 2:00 or 3:00 in the morning
and continues her sleep after 15-30 minutes.
5. Medication and Substance use
Patient A.M. stated that she takes Biogesic
when she has fever or headache. She stated
that she just drinks a lot of water whenever
she catches a cold. Whenever she feels
stomach ache because of Loose Bowel
Movement (LBM), she takes Diatabs.
Patient A.M. is allergic to Flanax, a type of
pain reliever that causes her having a
difficulty of breathing and rashes. She
doesn’t smoke and doesn’t drink any
alcoholic beverages but patient A.M.’s son is
a smoker so she considered herself as a second-hand smoker.
6. Social Activities
Patient A.M. stated that she attends Wedding ceremonies, Funerals and Christening for
socialization but she does not participate any activities in their barangay.
7. Belief System
Patient A.M. is a Roman Catholic. She believes in God and prayers. She believes any
superstition before and consulted a quack doctor or ‘hilot’/‘albularyo’ when she was around
40 years old because of back pain. Patient A.M. attends Novena Mass every two weeks.
8. Education and Work
Patient A.M. graduated elementary at Dardarat Elementary School and she’s merely a
housewife.

ANATOMY AND PHYSIOLOGY

The biliary system consists of the organs and ducts that help to make and transport bile. These
include the bile ducts, gallbladder, and related structures.
The transportation of bile follows this sequence:
1. When the liver cells secrete bile, it is collected by a system of ducts that flow from the
liver through the right and left hepatic ducts.
 CASE STUDY: OBSTRUCTIVE JAUNDICE

2. These ducts ultimately drain into the common hepatic duct.

3. The common hepatic duct then joins with the cystic duct from the gallbladder to form
the common bile duct. This runs from the liver to the first section of the small intestine
(the duodenum).
4. But not all bile runs directly into the duodenum. About 50% of the bile produced by
the liver is first stored in the gallbladder. This is a pear-shaped organ located directly
below the liver.
5. Then, when food is eaten, the gallbladder contracts and releases stored bile into the
duodenum to help break down the fats.
Functions of the biliary system
The biliary system's main function includes the following:
1. To drain waste products from the liver into the duodenum
2. To help in digestion with the controlled release of bile
Bile is the greenish-yellow fluid (made of waste products, cholesterol, and bile salts) that is
secreted by the liver cells to do these 2 main functions:
1. Carry away waste
2. Break down fats during digestion
Bile salt is the actual component that helps break down and absorb fats. Bile, which is
excreted from the body in the form of feces, is what gives feces its dark brown color.

INITIAL ASSESSMENT
General survey/appearance
Received the patient lying on bed with a body positioning semi-dorsal recumbent with
elevated knee flex. The patient has an irritable behavior and distressed due to pain. Pain is
observed during inspection and it is expressed during breathing pattern at the same time with
vocal sound and facial grimace. Speaks in sentences when asked but in incomprehensible
speech or sounds. Chief complaint is abdominal pain and back pain. Vitals signs are- BP
120/70 mmhg. PR is 82 bpm and oxygen saturation is 99% with the use of pulse oximeter. RR
is 23bpm. Temp. is 36.2 C.
Glascow Coma Scale
To eye opening response: Open’s eye’s to verbal command, speech, sound or shout (3). To
verbal response: Has an incomprehensible sounds or speech (2). To
motor response: Has a purposeful movement to painful stimulus (5).
Skin
Patient’s skin is dark yellow brownish skin, dry, thin and elastic. No skin lesions are detected.
Skin on the left and right arm is punctured due to intravenous fluid infusion with noted edema
and pain. Skin on the right upper quadrant of the abdomen is incised due to biliary drainage
procedure. Poor skin turgor.
Hair
Patient’s hair color is black and white with a 4-5 inch length and it is clean and dry. Hair is
unevenly distributed. No signs of infections and infestations observed.
Nails
Patient’s nails on hands are pale lightened pink long nails and on foot is dark pink long nails.
No clubbing and has a complete and intact nail plate with the epidermis on both hand and
foot. Capillary refill is 2 seconds.
Head
The patient’s head is symmetrically round, hard and smooth without any lesions or bumps are
detected. Has a sagged face. Dark yellow brownish in color
 CASE STUDY: OBSTRUCTIVE JAUNDICE

Neck
The patient’s neck has no signs of complication nor irritation and motion while swallowing.
No deformities, asymmetry, masses is detected. Lymph nodes are not visible upon palpation.
Her thyroid gland is not visible.
Eye
The patient’s eye movements are slow and symmetry. Eyebrows are symmetrically aligned.
Involuntary blinks is 15-20 times per minute. Eyelids and palpebromolar groove shrinked on
both sides. Eye appears moist and smooth. Has a yellow sclera and conjunctiva. No swelling
or redness over lacrimal gland. Cornea is black.
Ear
Ears are symmetrically equal in size and shape and it is aligned with the outer canthus of the
eye. No complaints of ear pain. No presence of discharge, redness, and swelling detected.
Color of ear is the same with the color of the face. The patient can loudly and clearly hear the
verbal sounds, or voice sound is audible.
Mouth
Patient’s lips are dark pink and dry without any lesions suspected. Sides of tongue are yellow
color and on the lower right side of the tongue has a blacking. The tongue is centrally
positioned. Patient still can taste accurately from different kinds of food she ingested. Her
teeth are damage and decreased or lessen.
Nose
Patient’s nose is asymmetric, long, flat, and dry. Able to smell foods accurately. No presence
of feces on both nostril . No purulent drainage noted.
Chest/Lung
Respirations 23 breaths per minute. The patient has dyspnea. Symmetric chest wall expansion
and positive clear breath sound.
Abdomen
Abdomen is palpated with positive abdominal distension, firm, with pain and with an incised
skin and muscle through the right upper abdominal quadrant and the minor surgical procedure
is called biliary drainage. Has a passive abdominal movement caused by respirations.
Extremities
Upper
Patient’s hand is symmetrical in length and has no bruise, no deformity, and tremors are
detected and observed. Dark brown skin color, dry and mild temperature to touch. Right hand
has a positive pressure, bulging, and pain where the IV is attached. Capillary refill are 2
seconds. Hand’s movement is smooth and flexible. Has full equal pulses.
Lower
Patient’s feet is symmetrical in length and has no bruise, no deformity nor tremors are
detected and observed. Both thigh and leg muscles are skinny. Has a positive edema on both
foot/pedal. No capillary refill.

PATHOPHYSIOLOGY

PREDISPOSING FACTOR:

PRECIPITATING FACTOR: LIFESTYLE

AGE SECOND HAND SMOKER

 CASE STUDY: OBSTRUCTIVE JAUNDICE

Biliary obstruction

Dilated intrahepatic ducts Enlarged left lobe of liver

Suppressed hepatic bile

Swelling of the organ
flow

Pain radiating on the

Increased bilirubin in the
back
bloodstream
(Lumbar Pain)

Yellowish color of the

skin, sclera and mucous
membrane

(Jaundice)

LABORATORY TESTS

CLINICAL CHEMISTRY

DATE:NOV
16,2019(7:26PM) REFERENCE RANGES RESULT INTERPRETATION
TEST
Above normal
SGOT/AST 1-31 132.93U/L A high AST level is a sign of liver
damage
Above normal
SGPT/ALT 1-32 85.77U/L A high ALT level may indicate
liver damage from hepatitis,
infection,cirrhosis, liver cancer or
other liver disease
Above normal
 CASE STUDY: OBSTRUCTIVE JAUNDICE

TOTAL BILIRUBIN 2.0-21.0 409.75umol/L levels of bilirubin may indicate

different types of liver problems.
Occasionally, higher bilirubin
levels may indicate an increased
rate of destruction of red blood
cells (hemolysis).
Above normal
DIRECT BILIRUBIN 1.0-5.0 314.5umol/L levels of direct bilirubin in your
blood may indicate liver that isn't
clearing bilirubin properly.

THYROID FUNCTION AND TUMOR MARKERS

DATE:NOV 22,2019(1:05PM)
TEST NORMAL RESULT INTERPRETATION
VALUES
Normal
AFP <5.0ng/mL 3.61 This may mean your treatment is
working.
Normal
CEA <5.0ng/mL 4.15

Above normal
Ca 19-9 <35.0 U/ml 424.0 levels are often a sign of pancreatic
cancer. High levels can indicate other
types of cancer or certain noncancerous
disorders.

MISCELLANEOUS TEST

DATE:NOV
28,2019(3:46) RESULT NORMAL INTERPRETATION
TEST VALUES
Above normal
PROTROMBIN 16.6sec 10-14.0 Higher than the normal blood is taking longer
TIME than normal to clot and may be a sign of clotting
disorder, Lack of clotting factors,
Liver disease

CLINICAL CHEMISTRY

DATE:NOV
30,2019(10:18) RESULT NORMAL INTERPRETATION
PARAMETER VALUES
Above normal
WBC 15.33 4.00-10.00 higher of a certain type of WBC is a sign of an
x10^9/L underlying condition.
Above normal
Neutrophil 93.2% 50.0-70.0 high percentage of neutrophils in your blood is a
sign that your body has an infection.

Above normal
MCHC 36.7g/L 32.0-36.0 A high MCHC value is often present in conditions
where hemoglobin is more concentrated within
the red blood cells.
 CASE STUDY: OBSTRUCTIVE JAUNDICE

Above normal
RDW-SD 64.1 fL 35.0-56.0 it could be an indication of a nutrient deficiency.

COMPLETE BLOOD COUNT

DATE:22,2019(2:39PM)
TEST RESULT NORMAL INTERPRETATION
VALUES
Above normal
Red blood cell 5.80 4.0-5.4 A high RBC count is a sign of
x10^9/L erythrocytosis.
Above normal
Hemoglobin 176.0g/L 120-160 A high hemoglobin level indicates of liver
cancer.
Above normal
hematocrit 0.48 0.37-0.47 A higher than normal hematocrit can
indicate
polycythemia vera, that causes your body
to produce too many red blood cells
Above normal
White blood cell 12.37 4.0-10 A high white blood cell count may indicate
x10^9/L that the immune system is working to
destroy an infection.

DIFFERENTIAL COUNT

TEST RESULT NORMAL INTERPRETATION

VALUES
Above normal
Neutrophils 83.10% 55.0-65.0 A high neutrophils is a sign that your body has an
infection
Below normal
Lymphocytes 10.40% 25.0-35.0 Lymphocyte counts can occur after a cold or
another infection.
Above normal
Monocytes 6.20% 3.0-4.0 High levels of monocytes may indicate the
presence of chronic infection, an autoimmune or
cancer.
Below normal
 CASE STUDY: OBSTRUCTIVE JAUNDICE

Eosinophils 0.20% 2.0-4.0 low eosinophil count can be the result of

intoxication from alcohol.

PLATELET COUNT

TEST RESULT NORMAL VALUES INTERPRETATION

Below normal
RDW-CV 0.20% 0.110-0.160 RDW is low, there are
no hematologic
disorders associated
with a low RDW result.

EVALUATION

Unfortunately, the patient's diagnosis is not clearly understood. The patient's late diagnosed
and treatment caused many complications and poor prognosis. Furthermore, in 2 days shift,
nursing interventions rendered have addressed the problems as manisfed.

IMPLICATION

A. NURSING PRACTICE
After the case presentation, the study will equip the nurses to grasp and comprehend a deep
understanding on the nature of the disease in terms of the risk factors, signs and symptoms
and management, to be able for them to handle patients and to carry out appropriate nursing
intervention in the realization of nursing practice with regards to jaundice and its predisposing
factors.

B. NURSING EDUCATION
This case study would help in sharing data or information about the disease condition, which
is yellow colorations of the eyes and skin, unintentional weight loss, loss of appetite, lethargy,
fever and chills and easy bleeding or bruising and its management as well as needed for the
promotion of patient’s recovery. With these, the students as well as the instructors would gain
additional information about the disease in order to be efficiently equipped in rendering
nursing care in the future. The study will be informative to nursing students; it will enable
 CASE STUDY: OBSTRUCTIVE JAUNDICE

them to have prior knowledge and understanding about the disease. They will be able to
dictate signs and symptoms and possible nursing interventions or treatment of the disease.

C. NURSING RESEARCH
This case study would help in the nursing research as a source of data for example, in tracking
the population of persons with this condition. This information would help in creating
awareness on the disease and the need for treatment, sharing important information on the
early detection and prevention of the disease condition.

RECOMMENDATION

 Eat healthy. Fill your diet with plant fibers, whole grains and make sure that your body
is getting all the right nutrients.
 Take up to the recommended dose of any vitamins, medication, and supplements. The
concentrated dose of these substances can put a big strain on your liver. Replace
Vitamin C pills with an orange or lemon squeezed in some water.
 Avoid chemical usage. If you are spraying a toxic chemical in your home or any other
closed area, make sure it is well ventilated. Try to leave the room as soon as possible
and avoid any direct contact with the chemical. Other precautions can be helpful, such
as clothing covering your whole body, a face mask and goggles.
 Try to maintain a healthy weight. If your weight is healthy, work to maintain it. If you
need to lose weight, cut back on the number of calories you eat each day and increase
the amount of daily exercise. Get informed about healthy ways to lose weight and be
fit.
 Use supplements with caution. Consult your doctor about the risks and benefits of
dietary supplements and herbal remedies before you take them. Many of these
products can be harmful to your liver, particularly those containing combinations of
ingredients and marketed for body-building or weight loss.

Union Christian College

Widdoes St., City of San Fernando, La Union
School of Health Sciences
 CASE STUDY: OBSTRUCTIVE JAUNDICE

CASE STUDY:
Obstructive Jaundice
Submitted by:
Acena, Jobelle C.
Caluza, Zhyraine Iraj D.
Cristino, Lynn Holly B.
Estrañero, Ma. Freda R.
Gagarin, Jervin John I.
Guarin, Krishia Nel L.
Mariñas, Jasmin S.
Naga, Abdul Jalil S.
Sales, Mary Ann E.
Velasco, Janelle Mica S.D.
Williams, Marjorie Louise G.
BSN-III

December 10, 2019