Kingdom of Saudi Arabia ‫ال ل ك ـــــة ال عر بية السع و دية‬

Ministry of Higher Education ‫وزارة الت عل ي م ال ع ــــــــــــــالي‬

Taibah University ‫جا مع ة طيبة‬
College of Applied Medical ‫كلي ة الع لو م الط بية الت طبيقي ة‬
Sciences ‫ين ب ــ ـــــع‬
Yanbu

Case Study Form

Medical- Surgical Nursing 2

for Student’s 5th level

Student name AHAD AWAD AL RAFAI

Code number 4154152

Date 17/11/2021

Area of training Femal surgical

Under Supervisor

1442-1443
Sociodemographic data

Special unit…………………..

… … … … … … …………………
MOSLAMA ALALWANI
Patient’s name:…… 53…
Hospital No… 802…
2 ……

Date of admission…………1… … … ……………..

5/11/2021
Stay period:…………….

Age:…6…
5Y…………. Sex…F…
em…al…………….

Level of education…no…
t e…
du…
cat…
ed………….. No…
Occupation…… n …….

…a…
Marital status…m …………………
rried
… … ……….
Muslim
Religious…

Present History:

-Diagnosis/ Present illness: ………

Ac…
ut…
e C…
ho…
lecy…
sti…
tis ……………………………………….

-Chief complaints on admission: …P…

ai…
n th…
e r…
igh…
t u…
ppe…
r A…
bd…
om…
ina…
l ,p…
ain…
in…
the…rig…
ht…
sh…
ou…
lde…
r …

-Associated signs and symptoms: …n…

aus…
ea…
, vo…
mi…
ting…,…
fat… e …
igu… , pa…
in … …
in bac…
k, …
abd…
om…
ina…
l p…
ain……

-Onset / Duration / Frequency: ……s… … … ………/…

uddenly /
… … … ……………………………
continuous

-Predisposing factors: …E… … … … ……………………………………………………….

at fat food

…………………………………………………………………………………………….

-Reliving measures and its effect: ……… … ………… ………………………………….

take a sedative

…………………………………………………………………………………………….
Past History:
❖ Medical:

-Diagnosis / Duration: ……
DM…
/ …………………………………………………………….

-Diagnosis / Duration: …………………………………………………………………….

❖ Surgical:

-Name of surgery / Duration:……………………………………………………………..

-Name of surgery / Duration:……………………………………………………………..

Allergy history ............ No…

n …………………………………………………………

Family history:
-Diagnosis / Relation:………N…
on………………………………………………………

-Diagnosis / Relation:……N…
on…………………………………………………………
 Life style habit -

Patient’s physical assessment

1- Respiratory system Free of increased airway reactivity,-nocturnal oxygen desaturation, thromboembolic

disease, acute chest syndrome (ACS), sickle cell chronic lung disease (SCCLD), and pulmonary hy-pertension.

2- Cardio-vascular system -

3-Peripheral vascular -

4-Neurological assessment

5-Gastro-intestinal system

6-Urinary system

7- Musculoskeletal system

8- Skin assessment

9- Head\hair -

10- Eyes

11-Ears

12- Nose Free of epistaxis -

Free of any mucosal pallor, yellow tissue coloration, radiographic abnormalities, delayed tooth
13- Mouth eruption disorders of enamel and dentin mineralization, changes to the -s-uperficial cells of the
tongue, malocclusion,or hyperce-mentosis.
14- Neck Mild neck pain due to old age -
15- Activity and rest Difficulty moving due to old age -
Definition of disease:
acute inflammation of the gallbladder, causes
pain, tenderness, and rigidity of the upper right abdomen
that may radiate to the midsternal area or right shoulder and is associated with nausea,
vomiting, and the usual signs of an acute inflammation. An empyema of the gallbladder
develops
gallbladder.if the gallbladder becomes filled with purulent fluid (pus).
Path physiology\ types :
There are two major types of gallstones: those composed predominantly of pigment and
those composed primarily of cholesterol. Pigment stones probably form when unconju-
gated pigments in the bile precipitate to form stones; The risk of developing such stones is
increased in patients with cirrhosis, hemolysis, and infections of the biliary tract. Pigment
stones cannot be dis- solved and must be removed surgically.
Etiology
According to patient According to literature

1-Fatty eating 1- Fatty eating

2-gallstones or biliary sludge
3- shock
4-immune deficiency
5- vasculitis
6- tumor

Clinical manifestations

According to patient According to literature

1- biliary colic with excruciating upper 1-fullness
right abdominal pain that ra- diates to the
back or right shoulder.

2-nausea
3- Vomiting

4- high white blood cell 2-abdominal distention

3-fever
4-biliary colic with excruciating upper right
abdominal pain that ra- diates to the back
or right shoulder.
5-nausea
6-vomiting
7- little or no appetite
8- high white blood cell
Complications
According to patient According to literature
1- Infection within the gallbladder.
2- Death of gallbladder tissue
do not have complications 3- Torn gallbladder.
4- Empyema (pus in the gallbladder)
5- Gangrene
Diagnostic measures

Lab investigation:

According to literature According to patient

Normal
Lab Investigation Patient's Results Comment
Range
Potassium 3.2 3.5-5.1mmol/L L

UREA 2.6 3.5-7.2mmol/L L

CREATININ 30.6 50.4-98.1umol L

L
ALBUMIN 28 34-48g/l

WBC 17.4 4-10 H

NEU 13.4 2-7 H

RBC 3.9 3.8-4.8 Normal

HGB 10.8 11.5-15g/dl L

32.9
HCT 36-46% L

ESR 42 0-20 mm/1HR H

ALT 60 0-55U/L H

Radiological examination:

According to literature According to patient

Check for
Type of examination Patient's Results
what done
MRI of abdomen

X/Ray of abdomen

U/S of abdomen
CT abdomen W IV contrast medium

X-Ray of chest
Medical management according to patient

No. Drug name Route Dose / Frequency Side effect if present

1 Meropenem IV 1000mg/every 8hrs
2 Subcutaneous
Clexane 40mg/every 24hrs
3 Zofran IV 8mg/every 8hrs

4 FLAGYL IV 500mg/every 8hrs

5 Esomeprazol IV 40mg/every 24hrs
6 NOVORAPID Subcutaneous 1units/every 8hrs

Surgical management

According to patient According to literature

It hasn't been done yet 1- laparoscopic cholecystectomy
 Objectives Nursing intervention
Nursing Diagnosis Rational Evaluation
(SMART) Ng implementatio Ng standard
Acute pain After 2 hours of 1-Observe and 1-Assists in comfortable and
document location, differentiating cause The patient became
related to nursing reported that the
severity (0–10 scale), of pain, and provides
inflammation of interventions, Done
and character of information about
pain was relieved.
the gallbladder the patient will pain (steady, disease progression
evidenced by a improve and the intermittent, colicky). and resolution,
pain will relieve 2-Note response to development of
report of pain and pain Done medication, and complications, and
descriptions, intensity will be report to physician if effectiveness of
and pain lessened from pain is not being interventions.
intensity 9/10. 9/10 to 3/10. relieved. 2-Severe pain not
3-Promote bedrest, relieved by routine
Done allowing patient to measures may
assume position of indicate developing
comfort. complications or
need for further
4-Use soft or cotton intervention.
Done
linens; calamine 3-Bedrest in low-
lotion, oil bath; cool Fowler’s position
or moist compresses reduces intra-
as indicated. abdominal pressure;
5-Control however, patient will
Done environmental naturally assume
temperature. least painful position.
Done 6-Encourage use of 4-Reduces irritation
relaxation and dryness of the
techniques. Provide skin and itching
diversional activities. sensation.
5-Cool surroundings
aid in minimizing
dermal discomfort.
6-Promotes rest,
redirects attention,
may enhance coping.
 Objective Nursing intervention
Nursing Diagnosis Rational Evaluation
(SMART) Ng implementatio Ng standard
Deficient After an hour of nurse-
patient interaction the
Done 1. Provide explanations of 1. Information can decrease
reasons for test procedures and anxiety, thereby reducing The patient
knowledge
patient will Verbalize
understanding of
preparation needed.
2. Review disease
sympathetic stimulation.
2.patient can make - Provides expresses his
related to
disease prognosis, and
process, potential Done
process/prognosis. Discuss
hospitalization and
knowledge base from which
informed choices. Effective
understandin
condition,
complications. prospective treatment as
indicated. Encourage
communication and support at this
time can diminish anxiety and
g of disease,
prognosis,
questions, expression of
concern.
promote healing. and process,
potential
treatment,
Done 3. Review drug regimen, 3.Gallstones often recur,
possible side effects. necessitating long-term therapy.
4. Instruct patient to avoid 4. Prevents/limits recurrence of complications
self-care food/fluids high in fats (e.g., gallbladder attacks.
Done whole milk, ice cream, butter,
evidence by fried foods, nuts, gravies,
pork), gas producers (e.g.,
Verbalization cabbage, beans, onions,
carbonated beverages), or
of the gastric irritants (e.g., spicy
foods, caffeine, citrus).
problem. Done 5. Suggest patient limit gum 5.Promotes gas formation, which
chewing, sucking on can distension/discomfort. increase
straw/hard candy, or smoking. gastric