CASE ANALYSIS

ON
CHOLELITHIASIS S/P CHOLECYSTECTOMY

In partial fulfillment of the requirements in

NCM 114 Related Learning Experience

Prepared by:

BSN 3B (Group 1)

Allyssa Anastacio
 December 2021

i. Introduction
Cholelithiasis or commonly known as Gallstones, are hardened deposits of

digestive fluid that can form in the gallbladder. The gallbladder is a tiny organ located

underneath the liver and it holds a digestive fluid known as bile that is released into your

small intestine (Tanaja J. et. al., 2021). Gallstones were claimed to be more common in

women (Female, Fertile, Fat, Fair, and Forty) while for men, ages 60 plus and some risk

factors for gallstones are related to diet, while other factors are not as controllable.

Uncontrollable risk factors are things like age, race, sex, and family history.

But Gallstones may cause no signs or symptoms. However, if a gallstone lodges

in a duct and causes a blockage, the resulting signs and symptoms may include:

Sudden and rapidly intensifying pain in the upper right or center portion of your

abdomen and just below your breastbone, back pain between your shoulder blades,

and pain in right shoulder (Gallstone pain may last several minutes to a few hours) and

nausea or vomiting.
ii. Objectives
The goal of this study is to gain knowledge and to give the appropriate care and

nursing management to the patients who have had an open cholecystectomy using the

information provided by the patients.

Specific Objectives

At the end of the study, I will be able to:

 Cognitive

To analyze all the data given by the patient to make appropriate nursing

management.

 Psychomotor

To develop an appropriate nursing care plan to the patient who have had an

open cholecystectomy.

 Affective

To build a good patient-nurse interaction.

iii. Scope and Limitations

The study presented is about the patient who have had a successful open
cholecystectomy. This study will guide the nursing students to know how to do
postoperative care of Open Cholecystectomy. The information collected for the study is
limited to the patient's data, medical records, and information provided by the patient
through online interview but still, the patient’s confidentiality will be prioritized. I develop
and design the appropriate nursing care plan and management for the patient based on
the information gathered.
I. Personal Data

A. Demographic Profile
Name: R.L.
Address: P52-16 14th 17th st. VAB, Pasay City
Age: 60 years old

Sex: Male
Civil Status: Single
Religion: Roman Catholic
Birthday: October 22, 1965
Birthplace: Danao Panglao, Bohol
Educational Attainment: Grade 3
Occupation: Construction
Hospital: Our Lady of Peace Hospital
Room and Bed No.: SP-01
Case No.: 21-55998
Attending Physician: Dr. Rolando G. Baria, Dr. Ferdinand C. Distor
Chief Complaint: Pain in right upper quadrant (RUQ)
Medical Diagnosis: Calculous Cholecystitis

II. Medical History

A. History of Present Illness:
In November 2020, while drinking alcoholic beverages, the patient vomits, but he
and his partner assumed this was typical and did not seek medical assistance
immediately.  However, even after the patient quit drinking, he still had intermittent dull
pain in his right upper quadrant radiating to his right back, with a pain scale of 4/10; the
pain was triggered by eating. As a result of vomiting a small bit of what he had eaten, he
lost his appetite.

Because of this on January 12, 2021, the patient decides to seek medical advice
with the physician. Then the patient had ultrasound (Cholelithiasis) and cbc test (all are
normal findings). The physician advises him to take Ursofalk and Ursodeoxycholic acid
or ursodiol to see if the gallstones will be gone.

But after a months of taking the medication (Ursofalk and Ursodeoxycholic acid
or Ursodiol), the patient returns to the doctor and reports no difference in his symptoms.
As a result, on July 13, 2021, the patient had another ultrasound, which still revealed
Cholelithiasis, therefore the specialist has already advised him to undergo surgery
because the drugs have had no impact on him and the gallstones were bigger than
before.

He began to have pain in his lower back when he was sitting and standing one
month prior to his diagnosis. However, once the patient is able to walk, the pain
subsides. The patient had a cbc taken on November 24, 2021, and the results were
completely normal, but an ultrasound revealed a pleural effusion, necessitating
thoracentesis.

Prior for open cholecystectomy on November 26, 2021, patient was given a
dextrose. November 28, 2021 the patient was discharge from the hospital and was
given medication of Cefuroxime 500mg (1tab, 2x a day) and Mefenamic acid 500MG
(1cp, 4x a day) as need for pain.

B. Past Medical History:

The patient did not have the usual childhood diseases such as measles and
chicken pox and stated he has no known food or drug allergies. He also has no history
of injuries or any accidents, no trauma and his mental health is good. But at the age of
49, the patient had a chicken pox. He has no history in injuries or any accidents, no
trauma and his mental health is good.
LEGENDS
C. Family Medical History
Alive
Male
Female
Gallstones
Pleural Effusion
Father Mother
Unknown

Sibling 1 Mr. R.L Sibling 2

D. Sociocultural History

The patient is 2nd among his 2 siblings, He easily have conversation w/ anybody.
He is easy to be with. The patient usually was the one who provides financially for him
and his live-in partner. Sometimes, her wife also contributes to their financial by doing
sideline by doing laundry to their neighbors. Mrs. A.P is residing permanently at Pasay
City for more than 10 years with his live-in partner. Their house is made with mixed
 cement/concrete and has 1 floor, 3 bedrooms, 1 main door, 1 window, and 1 bathroom
near the kitchen.

Their water source is Maynilad and their electricity source is Meralco. Their
garbage waste is always collected every day. The patient’s house is 10-minute walk
away from the nearest church and uses jeepneys and tricycle as their transportation
when going to the hospital.

III. Patterns of Functioning

BEFORE DURING ANALYSIS AND

HOSPITILIZATION
Even though he is aware
Health-Perception/ that he has a gallstone,
Health Management the patient continues to
Pattern see himself as a healthy
man and remains
optimistic. Mr. R.L is
entirely following to his
treatment plan by doing
all of his health care
provider's directions, such
as avoiding high-
cholesterol meals, taking
his medicine on a regular
basis, and having a
monthly check-up to
manage and treat his
illness.
Before the patient knew
Nutritional/Metabolic about his condition. Mr.
Pattern R.L loves to eat oily foods
that were cooked by his
live-in partner such as
adobong baboy, liempo,
and grilled foods. He
HOSPITILIZATION INTERPRETATION
After surgery, the patient Patient has a better
obtains a greater sense of perception about
hope about his condition. health and
And still entirely following management.
to his treatment plan by Patient really
doing all of his health care understand the
provider's directions, such importance of
as avoiding high- consultation and
cholesterol meals, taking taking his medication
his medicine on a regular regularly.
basis, and having a
monthly check-up to
manage and treat his
illness.
The patient’s live-in The patient's eating
partner makes sure that habits/ nutritional
his meal for every day is pattern had
monitored and made w/ improved and
no oil. Mr. R.L doesn’t become more
mind changes to his meal disciplined.
plan, because since then
 loves drinking alcohol
beverages 4-5 days a
week. And he eats three
times a day and drinks 6-
8 glasses of water daily.
And Mr. R.L don’t have
any food and drug allergy.
But when the patient
started to feel symptoms
and were informed about
his condition. He started
to stop drinking and
discipline himself when it
comes to his meals.
The patient urinates 8–10
Elimination Pattern times a day, with yellow
urine and no discomfort.
Brown color in feces and
defecates twice a day
with no discomfort.
Mr.R.L. is capable of
Activity/Exercise Pattern performing basic activities
of daily living (ADLs),
such as eating, dressing,
getting into and out of a
bed or chair, bathing or
washing, and toileting.
And his exercise consists
of a long walk from his
home to his workplace, as
well as lifting cement from
his work.
The patient goes to bed
about 9 p.m. and wakes
Sleep-Rest Pattern
up at 6 a.m. He gets 8
hours of sleep, but he
wakes up in the middle of
the night because of
disturbance of other
roommates and then falls
back asleep. And also
sleeps at afternoon.
he also loves eating
vegetables and fruits. He
still eats three times a day
and drinks 6-8 glasses of
water daily. And Mr. R.L
don’t have any food and
drug allergy.
The patient urinates still There are no
urinates 8–10 times a day, changes in patient’s
with yellow urine and no elimination pattern.
discomfort. Brown color in
feces and defecates twice
a day with no discomfort.
Because of his suture, the The patient's
patient started to have a activity/exercise
need of assistance when pattern changes
performing basic activities after his surgery
of daily living (ADLs), such because his suture.
as eating, dressing, And understand that
getting into and out of a exercise is helpful to
bed or chair, bathing or him.
washing, and toileting. To
keep his wounds from
opening, he only walks for
brief periods of time.
The patient still goes to The patient's sleep-
bed about 8 p.m. but then rest schedule has
has difficulty sleeping changed slightly
because of his wound and because of his
wakes up at 6 a.m. He wound.
gets 8-9 hours of sleep,
but still, he wakes up in
the middle of the night
because of the
disturbance of other
roommates and then falls
 back asleep. And still also
sleeps at afternoon.

He is well-oriented of the He is still well-oriented of Patient’s cognitive/

Cognitive/Perceptual time and date, able to the time and date, able to perceptual pattern is
Pattern state his full name, state his full name, good.
address and able to tell address and able to tell
some stories about his some stories about his
past events. past events.

The patient sees himself Since the gallstones were The patient's self-
Self-Perception/ Self a healthy man though he removed and his meal perception pattern
Concept Pattern already knew about his plan was changed, the improved since his
condition and a good patient perceives himself gallstones were
partner to his live-in to be healthier. removed.
partner.

The patient was happy Because they believed Patient’s role-

Roles-Relationships and contented with his they had overcome relationship pattern
Pattern role as a loyal partner to another barrier, the has been healthier.
his live-in partner. He is patient's connection with
also the one who his live-in partner has
provides money to their improved. And, despite
costs; occasionally, his the fact that he did not join
live-in partner does as his friends in drinking
well. Patient has a good alcoholic beverages, his
relationship with his friendship with them is still
friends. But when the time strong.
they knew about Mr. R.
L’s condition. He and his
partner did have a little
argument because of
financial problem.

The patient is The patient is There is no alteration

monogamous and monogamous and in the pattern.
Sexuality-Reproductive
heterosexual, which heterosexual, which
Pattern means he has just one means he has just one
sexual partner and is sexual partner and is
attracted to people of the attracted to people of the
opposite gender. He has opposite gender. He has
no sexual dysfunction or no sexual dysfunction or
discomfort during sexual discomfort during sexual
intercourse. He and his intercourse. He and his
live-in partner currently live-in partner currently
doesn’t have child but has doesn’t have child but has
1 miscarriage. 1 miscarriage.
 When he and his live-in
Coping-Stress partner had fights or little
Tolerance Pattern arguments, the patient
claimed that his coping
mechanism was to drink
alcohol beverage with his
friends till he forget his
problems and sometimes
did overwork just to
extend his time not
seeing his partner.
The patient has never
Values-Beliefs Pattern been involved in any
religious activities. He
only attends church every
Sunday and continue to
trust in God and the
power of prayer in their
lives.
The patient’s cope The patient's coping
mechanism is not alcohol mechanism has
beverages anymore, been improved.
instead he let himself
have rest such as
sleeping and have an
open communication with
his partner.
The patient still has never Patient’s values and
been involved in any beliefs pattern had
religious activities. He still been improved.
only attends church every
Sunday and his faith to
God increases, since the
operation to him was
success and was been
paid with the help of other
people.
 IV. Concept Mapping

Predisposing Factors: Precipitating Factors:

Cholelithiasis/
 Age (60 years old)  High cholesterol diet classified
Gallstones fast foods such as burgers,
 Gender (Female)
 Fertile (Have 3 children) french fries, cheesy and
cracker foods.

- Final Diagnosis

- Risk factors

- Pathophysiology
Cholesterol
- Nursing Diagnosis Enlarged Gallbladder
gallstones are
(8.0 x 3.0 cm)
- Medication formed

- Serious conditions

- Intervention
Temporary More persistent
- Diagnostic Test
obstruction of obstruction of cystic
the cystic duct duct

Independent:

-Position the patient in supine position

- Promote adequate rest Acute High eosinophils,

Cholecystitis monocytes, and
- Monitor intake and output
neutrophils
- Encourage patient to Drink plenty of clear fluids such as water.

-Provide cognitive-behavioral therapy for pain management: Distraction, guided

imagery and patterning unhelpful thinking (Encourage patient not to concentrate on
her discomfort.). Acute pain secondary to
Dependent:
biliary obstruction as
evidenced by positive
- Administer IV fluids as ordered by doctor
murphy sign.
- Administer the appropriate medication (Analgesic) as ordered by the doctor.
Ketoprofen & Buscopan
Generic Name Classific Dosage/ Mechanism of Indication Contraindication Adverse Nursing Responsibili
and Brand ation Frequency Action Reactions
Name
Nursing Care Plan 
ACTUAL
Assessment Diagnosis Planning Intervention Evaluation
Subjective: Acute pain After 30 minutes of Independent: Goal Met
“Masakit ang secondary to nursing intervention -Position the patient in
upper right biliary the patient's supine position After 30 minutes of
abdomen ko” as obstruction as abdominal pain will - Promote adequate rest nursing interventions, the
verbalized by the evidenced by gradually decrease - Monitor intake and output patient indicates a
patient positive murphy and the pain scale will - Encourage patient to Drink change where the pain
sign. drop to a 3/10. plenty of clear fluids such as scale decreased to 3/10
Objective: water. and the now comfortable
(+) Facial -Provide cognitive- in any position.
Grimace behavioral therapy for pain
(+) Groaning management: Distraction,
(+) murphy sign guided imagery and
Patient is always patterning unhelpful thinking
in guarding (Encourage patient not to
position concentrate on her
discomfort.).

P- Unhealthy diet Dependent:

Q- Sharp pain - Administer IV fluids as
R- Upper right ordered by doctor
Abdomen - Administer the
S- Pain Scale: Appropriate medication
6/10 (Analgesic such as
T- Intermittent Ketoprofen) as ordered by
the doctor.
VS:
BP-120/80 mmHg
TEMP: 36.4°c
PR: 91 bpm
RR: 20 cpm

Assessment Diagnosis Planning Intervention Evaluation

Subjective: Knowledge After 8 hours of -Assist the patient Goal met
deficit related nursing health readiness for the health
“Kaunti na lang to amount of teaching teaching. After 8 hour of nursing intervention
ang aking nutritional intervention the patient verbalized that she followed
kinakain upang body intake. patient will - Grant a calm and all of the recommended
maiwasan ko ang verbalized and peaceful environment interventions and was able to
pagsakit ng aking demonstrate without interruption. demonstrate
tiyan” as behaviors to behaviors”Nauuawaan at nasuod
verbalized by the maintain health - Provide an atmosphere kopo lahat ng tinuro sa akin,
patient. and appropriate of respect, openness, kumakain na rin po ako ng kanin.”
weight. trust, and collaboration. in order to maintain health and
appropriate weight.
Objective: - Check the availability of
supplies and equipment.
-Medium size of
Body -Plan with the client her
-Weight – 48kg desired meals.
-Height- 153cm
-BMI-20.51 - Encourage the client to
(normal) maintain the intake of the
healthy foods like Low-
fat dairy food, Fresh
fruits and vegetables
needed by her body to
maintain ideal body
weight.

Basic Meal Plan:

Breakfast
-1/2 cup of rice
-1 med. Poached egg
- Breads & Cereal 2
slices

Noon
- ½ cup steamed rice
- 1 cup fresh spinach
- Sweet Potatoes
-1 pc of Boiled Fish

Dinner
- 1 cup of cereal
-1 medium apple

- Monitor patient’s weight

for changes.

- Instruct patient to
make a note every meal
of what she ate by
writing it down on a piece
of paper.

Collaborative:

Reffered the patient to a

dietitian/nutritional
support team as
indicated.