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Care of the Adult Population

NURS 3101P

Cholecystitis Case study

March, 2023

Soria Choc

Submitted to: Ms. Shantel Neal

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Table of Contents

Introduction …………………………………………………………...…… page 3

Preface………………………………………………………………………. pages 4

Biodata, chief complaints, and history of present illness.…………………… page 5

History of Present Illness, Medical history and Family history………………page 6

Lifestyle and Socioeconomic history………………………………………… page 7

Socioeconomic, Environmental history and Psychological……………………page 8

Psychological…………………………………………………………….……page 9

Review of system/physical assessment of client……………………………….pages 9-11

Family needs, strengths, weakness, opportunities, and threat ...........................page 12

2 Actual problems, 1 potential problem..………………………………………pages 12

Nursing care plan..……………………………………………………………..pages 13-14

Teaching plan…………………………………………………………………...pages 15-19

Recommendations………………………………………………………………pages 19

Appendices……………………………………………………………………...pages 20

References……………………………………………………………………...pages 21
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Introduction
The liver the largest organ in the human body is located in the upper right quadrant of the

abdominal cavity, it is below the diaphragm, and above the stomach, right kidney, and the

intestines. The liver has a cone like shape, and has a dark reddish-brown colour and weighs about

3 pounds. The liver has two lobes which are divided into segments that consist of lobules that are

connected by ducts. These small ducts then connect to larger ducts to form the hepatic duct. The

hepatic duct is responsible to transport bile that is produced by the liver cells to the gallbladder

and duodenum. The liver also holds 13% or one pint of the body’s blood supply at any given

time (Mayo Clinic, 2021). The liver is responsible for the regulation of most chemical levels in

the blood and excretes a product called the bile. This helps carry away waste products from the

liver. The liver processes the blood that leaves the stomach and intestines. It then breaks down,

balances, creates nutrients and also metabolizes drugs into forms that are not toxic and easier for

the body to use. Other functions of the liver include converting excess glucose into glycogen for

storage this glycogen can later be converted back to glucose for energy and to balance and make

glucose as the need arise. Regulation of blood levels of amino acids, which form the building

blocks of proteins and processing of haemoglobin for use of its iron contents the liver also stores

iron which is released if the body should need it. Another important function is resisting

infections by making immune factors and removing bacteria from the bloodstream, so when cells

in the liver becomes damaged it is unable to carry out its normal functions and edema due to

fluid retention, abdominal pain, jaundice, nausea and dark urine are some symptoms that can

occur. One problem that can affect the liver is Hepatocellular Carcinoma it is the most common

type of primary liver cancer that starts in cells called hepatocytes. People who have cirrhosis

which is a result of being infected by Hepatitis B or C viruses are more prone to Hepatocellular

carcinoma(Mayo Foundation for Medical Education and Research, 2021).

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Preface

This case study is being done to offer A. C. a holistic approach to the care he is

receiving. A. C. have been diagnosed with Cholecystitis which has caused him to be admitted in

the hospital on February 2nd, 2023 for observation and surgery. This study will provide a history

of his present illness, medical and family history, lifestyle, socioeconomic, psychological,

physical assessment and environmental history. The main source of information is A.C. himself.

I must acknowledge his courage for accepting to discuss his illness and for sharing with me their

personal information and I reassured him that his identity would remain anonymous and

confidential for his protection and privacy. A nursing care plan has been created along with a

teaching plan, to identify and address the patient’s needs and recommendations made to assist

the patient with knowledge so he can make informed choices.

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Biodata

A. C. is a 28-year-old male patient and single person who used to live in Orange Walk

Town in the Orange Walk District. However, A.C. is a prisoner at Kolbe Foundation, Belize

Central Prison 10 years ago (2014) and is yet to be released until 2035. A. C. was born on the

fifteenth of September, 1994. He is of Belizean nationality, by normal vaginal delivery to parents

of Hispanic descent and is the third child of 4 siblings. A. C. states he has no religion but his

family members are Catholic. He states that his two friends he met at the central prison cover his

hospital bills. He states he prefers public health services as much as possible where the cost will

be much cheaper than the private. The primary source of information for this case study is A.C.

himself.

Chief complaints

A. C states that on February 1st, 2023, the security officers at Kolbe Foundation brought him to

the hospital because he was experiencing sharp pain in the upper right side of his abdomen that

radiate towards the lower back. He states that he has been having pain about nine months ago,

that usually occurs when he eats fatty food, drink milk, coffee, eat cheese, pepper. But because

of his history the Dr. Zul admitted him to the hospital for cholecystectomy and observation.

History of present Illness

A. C. stated that the morning before he got admitted at Karl Heusner Memorial Hospital

while doing laundry, he felt a sharp sudden pain at the lower posterior of the torso which he

states was a 9 on a scale of 1-10 accompanied by fever, vomiting and diarrhoea on that same day

he came to see the doctor because the pain was too strong. A.C. says that nine months ago he

started with a mild pain which he states was a 3 on a scale of 1-10, and he did not pay attention
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to it because he thought it wasn’t that serious. Upon assessment, the doctor ordered some tests

and ultrasound which revealed that she has cholecystitis. He was kept for three days and

discharged with medications.

Medical history

A.C. says that the only medical history of illness that he knows of is that of right pinkie

necrotic finger due to an incident that occurred when he was seventeen years old. He stated that

when the incident occurred, he went to visit Orange Walk Hospital, however, the doctor was not

present at the time. The finger got swollen and had discoloration. He went to visit the doctor for

the second time but he was being told that the finger needs to be amputated. A.C strongly refused

amputation. Hence the reason he ends up with necrotic right finger. He states he has no history of

any allergies to food or medications.

Family history

A.C. states that indeed he has family history of illness, he explained that one of his sisters

suffers from cholecystitis as well. His mother suffers from stroke and was diagnosed with stroke

seven years ago. According to A.C, his father or sisters does not have any history of illness that

he knows of.

Lifestyle

A.C. says he does not use any form of recreational drugs; he usually smokes colonial

cigarette every night before he falls asleep. He does not drink alcohol and does not use any

herbal supplements, and drinks coffee most of the time. A normal breakfast at Kolbe foundation
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includes, one cup of fever grass with four ounces of bread. Lunch includes one cup of white rice

without any meat or gravy and one cup of water. His dinner, includes eight ounces of bread with

one cup of coffee and snacks include biscuit and ideal. The prisoners usually cook food and since

A.C works at the shop as a cashier, he shops for his groceries and his basic needs. He is able to

keep himself well groomed, by bathing, getting hair cut done every week, and brushing his teeth.

He states that his bowel and bladder are active and he is able to ambulate without any difficulty.

He states that he has difficulty falling asleep because he thinks too much about his future. He

questions himself “how will my love ones react when I return home after so many years in

prison? What will it be like when I get released from here?” The remedy he used is work out a

lot so that he can make his body exhausted for rest. His daily routine from six months ago

includes of working at the prison shop from 4:30 am to 3:00 o’clock pm. He states that he does

not keep money with him; he has an account at Kolbe Foundation where he saves his money.

Socioeconomic history

A.C. states that in regards to cultural beliefs and practices he does not follow any health,

cultural or religious practices, but tries to be good person. According to him, he changes into a

bad person whenever he socializes with friends on the street with gangs. However, he believes

there is high power or authority and that God exist. Overall, he does not believe that his illness or

his care and recovery is affected by any cultural of ethnic beliefs.

At present A.C is a prisoner at the Kolbe Foundation Central Prison whom is sentenced

for twenty years to jail due to double murder he committed when he was nineteen years old. He

and his partner share one room and have access to pipe water and electricity. A.C. says that he

was only able to complete his education up to std.5 as his parents could not afford to send all of

them to school. He works at the prison shop as a cashier, he knows a little about carpentry and
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he does construction at Kolbe Foundation. He stated that he hasn’t experience any accidents at

his work place, or hazards with potential for his future disease or accident. He states that he does

not need to change his job because of the surgery he had and says he cannot afford to lose his

position as a cashier. So, he is relieved that he does not have an actual physical disability.

Environmental history

A possible risk factor is that A.C. would have to be disrespected by other prisoners and

stated that he easily loose temper to fight back, however, he is currently taking rehabilitative and

educational programs which assist him a lot while he is incarcerated. Therefore. According to

A.C, Kolbe Foundation partially have what all his needed utilities including electricity and

water; they share an outdoor sewage system with septic tank and it is connected to water. He

stated that indeed they have type of environmental infestations including cockroach, and there is

no noise pollution, the community is usually quiet, and there is no burning of bush by the

neighbours. They take their garbage to the garbage dump outside the neighbourhood to be

disposed of properly.

Psychological

According to A.C., the impact of his condition is stressful because she does not want to

leave her children but she tries not to show it. She states that her children understands her

condition as she explained it to them. She says she receives tremendous family support and that

helps a lot. She prays a lot too that she will be healed. She mentioned that the doctors were

offering to treat her with Chemotherapy but she refused because she doesn’t think that will help

and it will cause her more suffering and she does not want to go through that. Also, that will be

an additional medical expense her husband will have to endure.

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Review of System/Physical Assessment of client

I. Nutritional Status
Patient is on soft diet due to cholecystectomy surgery done. Hartman’s 500mls every 8 hours.

II. Integumentary
Patient with skin on face, neck and extremities with even pale skin tone. There are no

signs of cyanosis, or erythema noted. skin turgor is normal, no signs of tenting, nil scars, lesions,

edema or birthmarks visible. Tattoo to the anterior upper thorax and posterior upper thorax.

Patient skin is warm to touch but afebrile. Scalp and hair are clean with even hair distribution, no

flaking of scalp noted, texture of hair thin and shiny. Nail beds with pink undertone no brittle

nail noted, with capillary refill greater than 2 seconds.

III. HEENT

Head is norm cephalic no tenderness or masses felt; brown straight hair evenly distributed on

scalp, no signs of alopecia, lice, nits or dandruff seen.

Eyes are symmetrical, eye lashes are evenly distributed, pupils equal round react to light

accommodation, the conjunctiva and sclera are white.

Ears appears symmetrical and equal in size. The outer cantus of the eye is in line with the

upper pinna of the ear. No discharge, swelling, redness, wax and foreign objects visible. No

tenderness noted over the tragus and mastoid process on palpation.

Nose is midline and patent. The nasal mucosa is pink and moist. The nasal septum is midline,

no discharge, bleeding, edema or nasal flaring seen. The sinuses are non-tender and translucent.
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Mucous membranes are pink and moist.

Mouth lips are midline, without cyanosis or cracking. Teeth are full and present; gums are pink

and moist, no swelling, bleeding or lesions seen. The tongue is pink, moist and uvula is midline,

the tonsils are not visible beyond the tonsillar pillars. Throat no c/o pain, difficulty swallowing,

or cough but patient does c/o nausea and vomiting.

Vital signs- on admission- T-97.4 F, P- 96 bpm, R- 16 bpm , B/P- 90/50 mm/Hg, SPO2-98 %

Glucose- 56 mg/dl; Labs: Hb-9.6 g/dl, Haematocrit- 28.8%, Bun- 8mg/dl, Creatinin-5.33mg/dl

IV. Respiratory

The chest is symmetrical with equal bilateral chest movements. The breathing effort is

adequate, nil signs of respiratory distress. Sternum is midline and flat. Upon percussion of

the lung’s resonance sounds heard. The lungs are clear anteriorly and posteriorly with no

added breath sounds upon auscultation.

V. Cardiovascular

Pulsations of jugular veins are present without distention. Carotid pulses were palpated

and equal in intensity with the carotid pulse being synchronous with the apical pulse. Patient

has ectomorph body type which allows for the pulsation of the aorta in the epigastric region

to be visible. Heart sounds are regular and rhythmic, nil bruits or, murmurs, heard upon

auscultation.

VI. Gastrointestinal
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Skin visible on the abdomen was smooth and uniform in colour, there were no visible

lesions. Patient’s abdomen was flat, non- tender on palpation, bowel sounds present. On

palpation large hepatomegaly was palpable.

VII. Genitourinary

A. C. states he passes urine normal with no pain or burning the urine is light yellow.

Penis and scrotum appear normal, pubic area with hair evenly distributed, no signs of pubic

lice, or hydrocele and no visible discharge seen.

VIII. Musculoskeletal

A. C. was able to perform range of motion without any difficulty. He moved the joints of

neck, shoulders, elbows, wrists and knees. The patient is able to ambulate without difficulty

and with a steady gait. He was able to stand erect with no signs of scoliosis, lordosis, or

kyphosis visible.

IX. Neurologic

A.C. was alert and oriented, aware of his surroundings. He responded to sensation when

lightly touched on different parts of his body, using pain assessment and stereognosia.

Speech was clear.

X. Extremities

He was able to move both his upper and lower extremities without any difficulty and had

good range of motion. Pedal pulse was palpable and capillary refill greater than 2 seconds

with nil edema seen.

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Family needs, strengths, weaknesses, opportunities, and threats

Following the completion of the interview with J. R. that the family’s basic needs such as

food, water, shelter, sleep, clothing and relationship are being met by the husband who has a job

and a stable income. The strengths within this family is that J. R. and her husband did not

hesitate in seeking medical care. Also, the willingness of their family members to offer

assistance and support. The weakness would be the lack of psychological help for the children

and husband and even J. R. herself.

Actual problems and potential problem

1. Acute Pain related to the disease process evidenced by pt. guarding upper Rt. Quadrant of

abdomen.

2. Altered nutrition less than body requirement related to nausea as evident by pt. having

frequent episodes of vomiting and anorexia.

Potential

1. Risk for altered family process related to fear of death and leaving children behind.

Nursing Care Plan

Name: A.C

Age: 28 years

Dx: Cholecystitis
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Assessment Diagnosis Planning Intervention Rationale Evaluation

Subjective: Actual 1.Provide pt. with 1.Allows pt. to relax Goal met:
1.Acute Pain Throughout
Pt. states her non-pharma- and divert attention Throughout
related to the her hospital
husband stay, the cological ways to away from pain. her hospital
disease process
found her as evidenced by patient will reduce pain. Eg. stay, the
pt. guarding report having
unconscious Music, massage. patient had
upper right less episodes
and her 2.Give analgesics as 2.Analgesics helps decrease
quadrant of of pain.
sugar was abdomen. prescribed. with pain episodes of

low, she also Tramadol 50mg PO, management and pain and

states she PRN, Prednisone provide comfort. rated her

has upper 25mg PO, BID. 3.Ongoing evaluation pain 0 on a

abdominal 3. Evaluate for pain will aid pt. in scale of 1-

relief and inform receiving maximum
pain rated 10.
M.O. so medication
7/10. pain relief without
regimen can be
adjusted as interfering with
Objective: necessary. ADL’s
2.Altered Throughout
Pt. appears
1. To reduce episodes Goal met:
pale with nutrition less than her hospital 1. Give medication
stay pt. will Throughout
capillary body require- of nausea and
Maxalon 10 mg IV her hospital
ment related to have decrease
refill greater vomiting.
symptoms of q8h as ordered. stay pt.
than 2 secs. nausea as evident
nausea and 2. High caloric iron tolerated
No signs of by pt. stating she 2. Encourage pt. to
tolerate small,
respiratory has frequent rich foods will
eat high caloric iron frequent
episodes of nutrient rich
distress. provide needed
foods. rich foods in small portions of
Skin, vomiting and
nutrients and increase full diet.
afebrile and anorexia. amounts more
blood Hb and energy
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warm to frequently. levels.

touch.
3. Evaluate 3. To determine pt.
Stable Vital
effectiveness of response to treatment.
Signs
Patient is antiemetic drugs.
Potential
NPO by
1.Risk for altered Pt. will
choice due to Goal
family process identify 1.Give Pt. referral to 1.To provide
fear of partially
related to fear of individuals additional support to
vomiting. support group
dying and leaving and support met: Pt. was
Pt. guarding clergy, PNP assist family in coping
children behind. groups in her
her upper able to
community with terminal illness.
right identify
and seek 2.Encourage pt. to 2.Expressing her
quadrant of
assistance in support
abdomen. express her feelings feelings will allow her
coping with
V/S taken as persons in
the death of anger. to proceed with
follows: her
process. resolving the stages of
T- 97.4F
community
P- 96 bpm 3.Encourage pt. to the grieving process.
R- 16 bpm but was
voice difficulties of 3.Helps the family to
B/P- 90/50 ashamed to
the treatment and communicate and
SPO2 -98%
seek
Glucose- possibility of death. accept the reality of
56mg/dl assistance.
the situation.
Hb- 9.6 g/dl

TEACHING PLAN
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Topic:  Hepatocellular Carcinoma

Date: June 12th, 2022

Time/ duration: 9:00 am; 20 minutes

Number of audiences: 5

Education level of audience: Varying educational levels

Venue: General Medical Ward, Female room, Karl Heusner Memorial Hospital

Teaching Aids: Flip charts

Teaching Methodology: Lecture, Discussion, and Question and Answer

Aim:  To provide patient and family members with information about Hepatocellular Carcinoma

Objectives: After 20 minutes of health teaching members will be able to:

1. Explain what Hepatocellular carcinoma is.

2.  Discuss the cause and effects of hepatocellular carcinoma.

3.  State possible treatments for hepatocellular carcinoma.

4. Discuss pain management, nutritional requirements and the risk for altered family
processes.

Hepatocellular Carcinoma

What is Hepatocellular Carcinoma?

Hepatocellular carcinoma is one of the most common type of liver and accounts for

about 85%-90% of all primary liver cancers, (John Hopkins Medicine, 2019). It occurs most

often in people with chronic liver diseases, such as cirrhosis which occurs secondary to hepatitis

B or hepatitis C infection.

What are the risk factors for Hepatocellular carcinoma?

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Risk factors for hepatocellular carcinoma, is greater in people with long-term liver

diseases, if the liver is scarred by infection with hepatitis B or hepatitis C, or in people who drink

large amounts of alcohol and people who have fatty liver, Cirrhosis, Certain inherited liver

diseases such as hemochromatosis and Wilson's disease, Diabetes, and exposure to aflatoxins,

(John Hopkins Medicine, 2019).

How is Hepatocellular carcinoma diagnosed?

It can be diagnosed through blood tests to measure liver function; Imaging tests, such as

CT, Ultrasound and MRI. Also, Liver biopsy can be done in some cases, to remove a sample of

liver tissue for laboratory testing.

How is it Treated?

Some treatments for Hepatocarcinoma includes: chemotherapy or radiation directly to

cancer cells. Using a catheter that's passed through your blood vessels and into your liver,

doctors can deliver chemotherapy drugs (chemoembolization) or tiny glass spheres containing

radiation (radio embolization) directly to the cancer cells. Surgery to remove tissues, or Liver

transplant, (John Hopkins Medicine, 2019).

Signs and Symptoms

Majority of people don’t show any signs and symptoms in the early stages of primary

liver cancer but, when they do appear, it includes: Weight loss, loss of appetite, Upper abdominal

pain, Nausea and vomiting, General weakness and fatigue, Abdominal swelling, Yellow

discoloration of your skin and the whites of your eyes (jaundice), White, chalky stools
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What causes Hepatocellular Carcinoma?

Liver cancer transpires when liver cells have changes in their DNA, this is called

mutation. A cell's DNA is the material that provides instructions for every chemical process in

our body. When these DNA mutations occur, it causes changes in these instructions. One result

is that cells may begin to grow out of control and eventually form a tumor which is a mass of

cancerous cells. The cause of liver cancer is known, such as with chronic hepatitis infections. But

sometimes liver cancer happens in people with no underlying diseases and is idiopathic (Mayo

Foundation for Medical Education and Research, 2021).

Can liver cancer be prevented?

Yes, by drinking alcohol in moderation or not drinking at all, maintaining a healthy

weight, getting vaccinated against Hep. B and preventing Hep C infection.

Diagnosis is made through blood tests, ultrasound, CT or MRI and liver biopsy.

Treatments includes Radiation, Chemotherapy, surgery ( liver transplant), localized treatment

such as freezing cancer cells

What is supportive (palliative) care?

Palliative care is specialized medical care that focuses on providing relief from pain and

other symptoms of a serious illness. A special team of doctors, nurses and other specially trained

professionals provide the care which aims to improve the quality of life for people with cancer

and their families.

Coping and support

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It is important to keep friends and family close to help you deal with your liver cancer.

They will also provide the practical that support you'll need, in helping to take care of your house

if you're in the hospital. They can also provide overwhelming emotional support when you feel

like you can no longer cope. It is important to find someone to talk with, in Belize we have

Psychiatric Nurse Practitioners, social workers, clergy member or cancer survivors group that

can also be helpful.

How can pain be relieved?

Pain can be treated with medications derived from opium (opioids). These are

prescription medications used to treat moderate to severe pain in cancer patients or patients with

other severe injuries that require relief. Some examples of opioids include morphine (Kadian, Ms

Contin, others) and oxycodone (OxyContin, Roxicodone, others) and Tramadol, (Mayo Clinic,

2021).

Some people may prefer to use Integrative therapies. They may find pain relief through

acupuncture, massage, physical therapy, relaxation exercises, meditation and hypnosis.

Why is a high caloric diet important?

Patients may suffer from anorexia lose their strength just when their need for calories

goes into overdrive. The body requires more energy to fight the disease so it is important for the

person to maintain a healthy diet. They need to eat a lot of fruits and dark green vegetables,

foods that are high in fiber, such as whole-grain breads, cereals, and pasta. Lean meats, such as

beef, pork trimmed of fat, and poultry chicken or turkey without skin, liver is also a good source
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of iron. While it is important to eat high calorie meals it is also important that these patients eat

in small portions and more frequently to prevent emesis so nutrition can be maintained.

Evaluation

Briefly state what is Hepatocellular Carcinoma?

State at least 2 risk factors of hepatocellular carcinoma.

State 2 ways liver cancer can be prevented?

How is Hepatocellular carcinoma diagnosed?

Explain 2 ways pain can be relieved?

Why is a high caloric diet important?

Recommendations

1. Because J. R. has a low Hb, and recurrent hypoglycaemia it is recommended that she

does not stay at home alone at any given time.

2. It is also recommended that due to her anorexia and emesis, she tries to eat small frequent

meals avoiding sugary and fatty foods.

3. It will be good for her and her husband to have counselling done with the children as a

family to help them cope with the potential loss of a parent.

Appendices
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Cholecystitis

Cholecystitis Surgery

References

Clinic, M. (n.d.). Gastrointestinal cancer. Retrieved June 25, 2022, from

https://gitailor.com/clinical-care-toolkit/hepatocellular-carcinoma/hcc-pathophysiology/

Hepatocellular carcinoma (HCC): Causes, symptoms, treatments & prognosis. Cleveland

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Clinic. (n.d.). Retrieved June 26, 2022, from

https://my.clevelandclinic.org/health/diseases/21709-hepatocellular-carcinoma-hcc

Johns Hopkins Medicine. (2019, November 19). Liver: Anatomy and functions. Johns Hopkins

Medicine. Retrieved June 26, 2022, from

https://www.hopkinsmedicine.org/health/conditions-and-diseases/liver-anatomy-and-

functions

Mayo Clinic. (2021, February 12). Cancer pain: Relief is possible. Mayo Clinic. Retrieved June

26, 2022, from

https://www.mayoclinic.org/diseases-conditions/cancer/in-depth/cancer-pain/art-

20045118

Mayo Foundation for Medical Education and Research. (2021, May 18). Liver cancer. Mayo

Clinic. Retrieved June 26, 2022, from

https://www.mayoclinic.org/diseases-conditions/hepatocellular-carcinoma/cdc-

20354552#:~:text=Liver%20cancer%20begins%20in%20the,type%20of%20primary

%20liver%20cancer.