CASE ANALYSIS OF CHOLELITHIASIS

INTRODUCTION
GENERAL OBJECTIVES OF CASE STUDY
 The general objective of conducing the case analysis is to
identify the case of Cholelithiasis and to explore it nursing plan
and managements, and provide nursing care following nursing
spirituality management.
 Cholelithiasis involves the presence of gallstones, which are
concretions that form in the biliary tract, usually in the
gallbladder. Cholelithiasis refers to the presence of one or more
gallstones in the common bile duct (CBD). Treatment of
gallstones depends on the stage of disease.
CASE PRESENTATION
A 45-year-old female presents with a complaint of abdominal
pain for the past 3 days. She localizes the pain to her epigastric
area and states that it radiates to her right upper quadrant. She
notes that it became markedly worse after eating dinner last
night. She recalls a past history of similar pain, but has never
had any diagnostic workup.
Her past medical history is significant for hypertension and
hypercholesterolemia. She is status post a total abdominal
hysterectomy 1 year ago.
She does not smoke, drink alcohol, or use drugs.
Her ROS is positive for abdominal pain, nausea, one episode of
vomiting, and a subjective fever.
Her VS are BP 155/90, HR 110, RR 14, T 100.6, SpO2 98% on
RA.
Her physical exam reveals an overweight woman in no acute
distress. Her chest and cardiovascular exams are normal except
for mild tachycardia. Her abdominal exam is significant for
tenderness to palpation to her epigastric and right upper
quadrants without rebound tenderness. Bowel sounds are
normal.
 You order basic blood work, fluids, and an anti-pyretic. You are
contemplating ordering a CT scan and decide to attempt to
visualize her right upper quadrant via ultrasound at the bedside.
MANAGEMENT AND OUTCOME
NURSING DIAGNOSIS
 Acute pain and discomfort related to surgical
incision
 Impaired skin integrity related to altered biliary drainage after
surgical intervention
 Imbalanced nutrition, less than body
 requirements, related to inadequate bile secretion
 Deficient knowledge about self-care activities related to
incision care, dietary modifications

PLANNING AND GOALS

The goals for the patient include:
 Relief of pain
 Adequate ventilation intact skin and
 improve biliary drainage
 Anxiety related to hospital admission
 optimal nutritional intake
 absence of complications
 understanding of self-care routines.
PLANNING(IDENTIFICATION PHASE)
 Postoperative:
 Place the patient in the low Fowler’s position.
 Provide Intravenous fluids.
 Provide water and other fluids and soft diet is started when
bowel sounds return.
 Relieving pain:
Administer analgesic agents as prescribed to relieve the pain
 Help the patient to turn, cough, breathe deeply,
and ambulate as indicated.
 Use of a pillow or binder over the incision during these
maneuvers.
 Improving respiratory status
Remind patients to take deep breaths and cough every hour to
expand the lungs fully and prevent atelectasis.
Promote early ambulation. Early ambulation
prevents pulmonary complications as well
Monitor elderly and obese patients must closely for respiratory
problem.
 Promoting skin care and biliary drainage:
observed for indications of infection, leakage of bile into the
peritoneal cavity, and
obstruction of bile drainage, clay colored stool and vital sign.
 note and report right upper quadrant abdominal, pain, nausea
and vomiting, Observe for jaundice.
 changes frequently the outer dressings and protection of the
skin from irritation.
 Maintain a careful record of fluid intake and output
 Improving nutritional status
Encourage the patient to eat a diet low in fats and high in
carbohydrates and proteins
immediately after surgery.
At the time of hospital discharge, there are usually no special
dietary instructions other
than to maintain a nutritious diet and avoid excessive fats.
 Monitoring and managing potential complications
 Closely monitor vital signs and inspects the surgical incisions
and drains, if in place, for
evidence of bleeding.
 Periodically assesses the patient for increased tenderness and
rigidity of the abdomen and
report to the surgeon.
 Instructs the patient and family to report to the surgeon any
change in the color of stools
because this may indicate complications.
 After laparoscopic cholecystectomy, assesses the patient for loss
of appetite, vomiting, pain,
distention of the abdomen, and temperature elevation.
 These may indicate infection or disruption of the gastrointestinal
tract and should be reported to the surgeon promptly.
 Instruct verbally and in writing about the importance of
reporting these symptoms promptly
after discharge.
 Teaching Patients Self-Care
Instruct the patient about the medications that are prescribed
(vitamins, anticholinergics, and antispasmodics) and their
actions.
Inform the patient and family about symptoms that should be
reported to the physician,including jaundice, dark urine, pale-
colored stools, pruritus, or signs of inflammation and infection,
such as pain or fever.
 Emphasize importance of keeping follow up appointments.
Asses the knowledge of patient and family of the therapeutic
regimen. (medications, gradual return to normal activities)
 Emphasizes the importance of keeping follow-up appointments
and reminds the patient and family of the importance of
participating in health promotion activities and recommended
 health screening.
Shower can be taken 48 hours after surgery.
No restrictions to physical activities.
Gradually increase activities at a comfortable and individual
pace.
NURSING SPIRITUALITY NEED OF THE PATIENTS
 The interventions initiated to meet patients' spiritual needs
included respect for privacy; helping patients to connect;
helping patients to complete unfinished business; listening to
patients' concerns; comforting and reassuring; using personal
religious beliefs to assist patients and observation of religious
beliefs
 Mortality
 Some observational studies suggest that people who have
regular spiritual practices tend to live longer. Increased levels of
negative thoughts are associated with an increased incidence of
disease. A research study involving older adults showed that
those who attended church were half as likely to have elevated
levels of religious commitment may improve stress control by
offering better coping mechanisms, richer social support, and
the strength of personal values and worldview.
 Coping
Patients who are spiritual may utilize their beliefs in coping with
illness, pain, and life stresses. Some studies indicate that those
who are spiritual tend to have a more positive outlook and a
better quality of life. For example, patients with cholelithiasis
who found comfort from their religious and spiritual beliefs
were more satisfied with their lives, were happier, and had less
pain. Spirituality is an essential part of the “existential domain”
measured in quality-of-life scores. Positive reports on those
measures—a meaningful personal existence, fulfillment of life
goals, and a feeling that life to that point had been worthwhile—
correlated with a good quality of life for patients with advanced
disease
Some studies have also looked at the role of spirituality
regarding pain. One study showed that spiritual well-being was
related to the ability to enjoy life even in the midst of symptoms,
including pain. This suggests that spirituality may be an
important clinical target
 Recovery
Spiritual commitment tends to enhance recovery from illness
and surgery. For example, a study of heart transplant patients
showed that those who participated in religious activities and
said their beliefs were important complied better with follow-up
treatment, had improved physical functioning at the follow-up
visit, had higher levels of self-esteem, and had less anxiety and
fewer health worries . In general, people who don't worry as
much tend to have better health outcomes. Maybe spirituality
 enables people to worry less, to let go and live in the present
moment.

 Support patient within their own faith

The point of providing spiritual care is not to convert patients to
your religion; it’s to connect them with the divine if they want
it. Remember as you interact with them that they are a captive
audience, often confined to a hospital bed they don’t want to be
in.

 Use the gifts of presence and touch

Your presence alone can provide this care to a person who is
hurting. You are simply representing God in that moment by
just being there.

 SUMMARIZE
I learned many things from the case study which are as following:
Identified the complete health need, and spiritual need. Provide
comprehensive nursing care by using diagnosis, planning and goals.
Analyze the concept and approach to nursing spirituality. Identified
the factors influencing nursing practice. Identified the plan,
implement and evaluate the educational need of the patient and patient
family. Identified the nursing spirituality needs of the patients.