University of the Cordilleras Level 3 CASE PRESENTATION 1st Semester SY 2011-2012


Statement of Objectives A. General Objectives This case analysis aims to increase the understanding and knowledge of student nurses on how care and manage effectively patients with Calculous Cholecystitis. B. Specific Objectives Specifically, this case analysis aims to: 1. Explain anatomy and physiology of gallbladder. 2. Define Calculous Cholecystitis and its effects to the body as a whole. 3. Illustrate and explain the pathophysiology of Calculous Cholecystitis in relation to the signs and symptoms manifested by the client. 4. Describe and identify the common signs and symptoms of Calculous Cholecystitis 5. Discuss the medical and surgical interventions for the management of Calculous Cholecystitis; 6. Formulate appropriate nursing care plans to address the signs and symptoms manifested by client. Client¶s Profile Name: Patient X Age: 67 years old Birth Date: June 12, 1944 Sex: Female Ethnic Background: Ilocano Civil Status: Widowed Address: Carmen East, Rosales Pangasinan Religion: Roman Catholic Occupation: Housewife Educational Background: Elementary Graduate Admitting Diagnosis: Acute Cholelithiasis Final/Principal Diagnosis: Calculous Cholecystitis Admitting Physician: Andrew Douglas M.D Date and Time Admitted: Aug 3, 2011; 3:45pm Chief Complaint Severe right abdominal pain radiating at the scapula. History of Present Illness On the second week of December 2009, Patient X felt mild pain at the right upper quadrant of her abdomen. She disregards it thinking that it¶s not serious and thought it is just an episode of indigestion. After three days of self medication of Buscopan, she felt better. After two weeks, the pain recurred at a higher pain scale of 5/10. Because of this, she went to seek medical advice. She went to Tayug Hospital and she was instructed to have an ultrasound of the whole abdomen. After 2 days, the result was released and they found out that there were stones in her gallbladder. She was advised by the doctor to undergo surgery, cholecystectomy. The patient refused the surgery due to fear and financial incapability. She was given medications as an alternative (the patient already forgot the name of medications prescribed).




V. According to her.She was instructed by the doctor to increase fluid intake and have a low fat diet. She got pregnant at the age of 15 and used birth control pills after she gave birth to her 4th child at the age of 25. and flu. admission. with admitting diagnosis of Acute Cholelithiasis. They live frugally as farmers in an agricultural town in Rosales. dinugugaan and dried fish. hence. She is also a member of the Pastoral Council. Last July 16 2011. Social and Environmental History Patient X is an active member of Senior Citizen Association and was elected president. she wasn¶t able to follow the doctor¶s order and still continued with her usual lifestyle. This was characterized to be progressive pain with a pain scale of 8 out of 10. She drinks 4 to 5 glasses of shoktong occasionally. her sister suffered also from cholecystitis. August 3 2011. It radiated on the right arm especially at the scapula. VII. VIII. Patient X had her menarche when she was 14 years old and her menopause was at the age of 47. She was sent home after 2 weeks of confinement and laboratory procedures. 2 . She plays ³bingo´ and ³tongit´ as her past time. Her father died because of cardiac arrest and her mother died because of pneumonia. Patient X is also a proud grandmother of 8 and the matriarch of her extended family. Pangasinan where the main crops are tobacco. Two days prior to admission. Patient X experienced again an excruciating pain and was rushed by her son to BGHMC with a final diagnosis of Calculous Cholecystitis. Unfortunately. three days prior to admission. the patient again experienced right upper quadrant pain which lasted until the present condition. Patient X said that she still felt the pain after the check-up but it is tolerable. Her family also buys over the counter drugs for fever and pain. She loves to cook and eat pork dishes like adobo. pain recurred with a pain scale of 10 out of 10. Patient X¶s mother was a manghihilot and she passed her knowledge to her. She just took medications that were prescribed by the doctors to alleviate the pain she felt. the patient was admitted at Tayug Hospital. Now. All of her sons live with her together along with their wives and children. VI. Family Health History According to Patient X they have family history of hypertension on her father¶s side. 2011. Past Medical History Patient X experienced common illnesses such as cough. she had her measles when she was a year old and had chickenpox when she was 10 years old. Patient X practices hilot and uses herbal medicines. This prompted Patient X to seek consultation. corn and eggplants. She loves gardening and made this as her hobby. She reported that she does smoke up to a pack of Alcampara per day for 30years. Lifestyle and Health Practices The patient has sedentary lifestyle. On July 19. colds. She also added that cholecystitis is common to their family.

capillaries sometimes evident. Symmetrical facial movements (smile. appeared weak and in constant complains of pain. details of the iris are visible. Palpebral fissures equal in size. Her organization of thoughts were logically in sequence and coherent like place (verbalized she was in the hospital). Cornea: Transparent. with thin grayish white ring around the margin. pinna recoils after it is folded. Smooth skull contour.IX. equal in size (3-7mm in diameter). not tender. when lids open. Patient X has generalized jaundice. no infestation noted. mobile. Illuminated pupil constricted and when looking at near objects. smooth and pink Lacrimal Gland: No edema or tenderness noted. B. No shadows of light in the iris. Bulbar Conjunctiva: transparent. client blinked when the cornea was touched indicating that the trigeminal nerve is intact. elevate eyebrows or close eyes tightly) Eyebrows: Hair evenly distributed skin intact and coarse. and upper and lower borders of cornea are slighlty covered. When looking straight ahead. Eyes 3. External ear: distal third contains hair follicles. no visible sclera above corneas. Ears . parietal and occipital prominences). Head to Toe Assessment 1. Smooth. Stands 5 feet and 2 inches and weighs 50 kilos. frown. Lacrimal sac and nasolacrimal duct: No edema or tearing noted. Pupils: black in colour. round. Patient¶s speech was audible. Rounded (normocephalic and symmetrical with frontal. and person (identified her watcher as her son). Vision: Able to read newsprint. puff the cheeks. Health Assessment A. She openly accommodated our inquiries and responds appropriately to questions. dry crumen Acuity: normal voice tones audible. Head Evenly distributed hair. uniform consistency and absence of nodules and masses. Both eyes coordinated and move in unison with parallel alignment. She was properly groomed as evidenced by unsoiled printed dress she was wearing and nails were kept short. curled slightly outward Eyelids: Skin intact. shiny and smooth. General Survey The patient appears appropriate for her stated age. moderate pace. thick and silky. time (verbalized it was early morning). understandable. lids close symmetrically. Eyelashes: equally distributed. iris flat and round. symmetrically aligned and equal movement. aligned with outer canthus of eye. sclera appeared yellowish Palpebral conjunctiva: Shiny. firm. Auricles: colour same as facial skin. sound was heard 3 2. no discharge. client can see objects in the periphery. smooth border.

Umbilicus: midline. Skin intact and uniform temperature. Chest wall intact with no tenderness and lesions noted. Chest symmetric. Coordinated and smooth movements with no discomfort. smooth. nipples everted. and rise freely with swallowing Absence of bruit. Bilateral symmetry of vocal fremitus and most heard clearly at the apex of the lungs. spaces are equal on both sides Thyroid Gland: not visible on inspection. y Anteroposterior to transverse diameter in ratio of 1:2. with prominent veins at the base. No discharges or flaring noted. midline. Tongue: central position. air moves freely as the client breathed through the nares. soft. Neck 7.dark coloured urine. Capillary refill of 3-4s. ability to purse lips Teeth: dentures smooth and intact. Chest and Breast 8. slightly rough. Vesicular and bronchovesicular breath sounds. Thorax when percussed resonates except over scapula. Lips: smooth texture. BP=140/90. 5. tin whitish coating. Head centered. Vomits the food she eats. 16 per minute. areola and nipples has darker colour. lobes are small. Maxillary and frontal sinuses were not tender. moist. moves freely. Spinal column is straight. gray-coloured stool Urinated 6x per day. rhythmic respirations (RR=22-25cpm). and mass noted. Nose and Sinuses Straight. and no discharges noted CPR= 60-80bpm. right breast is slightly larger than the left breast. striae noted. raised papillae. inverted Defecated 1x per day. y Uniform skin colour. centrally located. dimpling. Gastro-Intestinal Tract (GIT) 10. tenderness. 4. no lesions. Mucosa pink. Lymph nodes are not palpable Trachea: central placement in midline of neck. pink. glands ascends during swallowing but is not visible. smooth and no palpable nodules Posterior part of the hard palate has a yellowish colour tone Uvula positioned in the midline of soft palate Tonsils: Pink and smooth Gag Reflex was present Muscles equal in size. Quiet. No murmurs heard. Spine vertically both ears. no tenderness. bowel sounds-high pitched. clear and no lesions noted. Gastro-Urinary tract 4 . no chest pain noted Abdomen: lighter in colour than the rest of the body. No lesions and tenderness noted. Full and symmetric chest expansion when client took a deep breath (thumbs separate 4cm). grayish-white striae noted on both breast. not tender. Mouth 6. Cardiac 9.

heart. smooth texture. No involuntary movements noted Skin appears thin and translucent. Another therefore the name for the film right side would be produced by x magnified. gross distention of the gallbladder - Abnormal Perichole cystic fluid was observed. small portions of anteriorly (wit h the patient¶s the chest on the gastrointestinal film cassette). thyroid therefore gland. the patients left body and side is against produce an the film. rays are a form On the lateral of radiation that can penetrate the view. Rest of the lung fields is clear. no edema noted. Lateral CP sinuses are sharp. dry and flaky skin. There are infiltrates on both lung bases.11. loosed its elasticity and wrinkled. convex curvature approximately 160 degrees. 2011 Ultrasound -Parenteral hyper alimentatio n. and hangnails. rays is radiograph. image on an xray film. Integumentary Patient was able to do ADLs & self-care activities with assistance. nail beds). generalized hyperthermia (38. organs and By structures within convention on the chest for the PA View. Ultrasound produces sound waves that are beamed into the body causing return echoes that are recorded to "visualize" structures beneath the skin. longitudinal bands. 2011 DIAGNOSTIC Chest X-ray REFERENC E A chest x ray is a PA and procedure used Lateral view to evaluate are obtained. symptoms of the x-rays disease. and the minimizing bones of the the cardiac chest area.0C). Diagnostics DATE August 3. Musculoskeletal 12. IMPLICATION Normal August 3. noted skin turgor (moves back slowly) Nails: noted splits . Chest x enter the patient rays include posteriorly views of the and exit lungs. lips. X magnification. 5 DESCRIPTION RESULT Heart is within normal limit in size. generalized jaundice. . ares of lighter pigmentation (palms. yellowish colour X. tract.

0 Normal Normal Normal Abnormal (Slightly Elevated. A part of a urinalysis can be performed by using urine dipsticks.025 Pus cell. A urinalysis (or "UA") is an array of tests performed on urine and one of the most common methods of medical diagnosis. no gallbladder perforation -Thickening of the gallbladder wall Color. Squamous ± Negative BacteriaNegative Normal Normal 6 . 2011 Urinalysis The ability to measure different echoes reflected from a variety of tissues allows a shadow picture to be constructed.June 27. in which the test results can be read as color changes.68 Specific Gravity1. The technology is especially accurate at seeing the interface between solid and fluid filled spaces.010 Pus cell2-4 Abnormal Abnormal Albuminnegative Reaction.1.4. Presence of infection) Squamous ± Negative BacteriaNegative August 3. 2011 CBC (Complete Blood Count) A complete blood count (CBC) is a series of tests used to evaluate the composition and concentration of the cellular components of blood.Light or pale Yellow CharacterClear Colordark Yellow CharacterSlightly turbid Albuminnegative Reaction6.010.5 pH Specific Gravity1.

The test is performed to help diagnose blood disorders.WBC A white blood cell count is a determination of number of WBC or leukocytes/unit volume in a sample of venous blood. 5.2 The result is above normal which indicates Infection. Hematocrit 0. 1507 .0-10.0 12. Hemoglobin is an important component of red blood cells that carries oxygen and carbon dioxide to and from tissues. anemia or abnormal dehydration.37 The client¶s result of hematocrit is slightly below range which indicates that the patient¶s RBC is low in proportion to whole blood. The oxygen carrying capacity of the blood is also determined by the Hemoglobin concentration.40 Measures the percentage of RBC in a blood volume. and the effectiveness of those transfusions. blood transfusion decisions for severe symptomatic anemias. 0. Hemoglobin 120-160 g/L 125 g/L Hemoglobin is within normal range. such as polycythemia.38-0. The hemoglobin determination test is used to screen for diseases associated with anemia and in determining acid-base balance.

Platelet Count The smallest formed elements in blood that promote blood clotting after an injury. Potassium 4. The test is performed to determine if blood clots normally.70 The result is above normal limits. The result is within normal range. Neutrophils is greater in amount as compared to other WBC component because in a normal inflammatory response. and to diagnose and monitor a severe increase or decrease in platelet count 275 400x10^9/ L The result is within normal range Neutrophils 0.18-0.32 mmol/L 3. Hence.10-0.6 umol/L 60-120 umol/L The result is within normal range. Lymphocytes 0.22 0. the neutrophils are the first ones to be release and act on the injured site. Creatinine 77.5-5 mmol/L The result is within normal range 8 .78 0. evaluate platelet production.48 . they are greater in number.

Drugs Name Generic Name: Sulbactam Ampicillin Brand name: Omnipen Classification of dosage Classification: Anti-infective Frequency: every 8 hours Dosage: 750mg Route: IV Mechanism of Action Destroys bacteria by inhibiting bacterial cell-wall synthesis during microbial multiplication. Monitor for physical and psychological drug dependence. an enzyme that can inactivate ampicillin. Monitor CBC and liver function testresults. Assess patient¶s response to drug 30 minutes after administration. Treatment/Management A. Withhold drug and contact prescriber if respirations become shallow or slower than 12 breaths per/min. Addition of sulbactam enhances drug¶s resistance to beta-lactamase. XI. Inhibits reuptake of serotonin and norepinephrine in CNS Nursing Implication Monitor for signs and symptoms of hypersensitivity reaction.4 mmol/L 136-145 mmol/L The result is below normal range which may indicate that the patient is dehydrated or has lost fluids due to the disease condition.Sodium 132. Monitor respiratory status. Significance used to treat infections caused by bacteria and other microorganisms a substance produced by one microorganism that selectively inhibits the growth of another Generic name: Tramadol Hydrochloride Brand name: Ultram Classification: Analgesic Frequency: evry 8 hours PRN for pain Dosage: 50mg Route:IV Is used similarly to codeine. to treat moderate to moderately severe pain and most types ofneuralgia. including trigeminal neuralgia 9 . Watch for bleeding tendency and hemorrhage.

report signs and symptoms (peripheral edema. and 10 Monitor blood pressure to evaluate drug efficacy. chronic stable angina pectoris. Stay alert for oliguria. progressive azotemia. and decreasing peripheral resistance. Treats Essential hypertension. Inhibiting or diminishing secretion.Generic Name: Omeprazole Brand name: Prilosec Classification: Antisecretory drug. and renal failure in patients with severe heart failure whose renal Mainly to treat high blood pressure. Instruct patient to swallow capsules or tablets whole and not to chew or crush them. Also increases urinary flow and enhances excretion of chloride. Antiulcer drug Frequency: OD Dosage: 1 tab 40mg Route: Oral Reduces gastric acid secretion and increases gastric mucus and bicarbonate production. magnesium. creating protective coating on gastric mucosa and easing discomfort from excess gastric acid. especially at start of therapy. and vasospastic angina (Prinzmetal¶s angina) Blocks the entry of calcium into the muscle cells of the heart and the arteries Generic Name: Losartan Potassium Brand Name: Cozaar Classification: Antihypertensi ve Frequency: OD Doasage: 50mg tab Route: Oral Blocks vasoconstricting and aldosterone-secreting effects of angiotensin II at various receptor sites. thereby decreasing myocardial contractility. diarrhea. Assess for heart failure. Assess liver and kidney function tests and electrolyte levels. relaxing coronary and vascular muscles. as certain drugs that inhibit or diminish gastric secretions Generic Name: Amlodipine Besylate Brand name: Norvasc Classification: Antihypertensive drug Dosage: 5mg 1tab Frequency to start in AM OD Route: Oral Inhibits influx of extracellular calcium ions. Caution patient to avoid driving and other hazardous activities until he knows how drug affects concentration and alertness. secretion inhibitory an agent that so acts. Evaluate fluid intake and output. emesis. calcium. Assess vital signs. Check for abdominal pain. Tell patient to take 30 to 60 minutes before a meal. dyspnea) to prescriber promptly. including vascular smooth muscle and adrenal glands. . Monitor heart rate and rhythm and blood pressure. preferably in morning. or constipation.

will need additional K. plasma thromboplastin component.phosphate. Generic Name: Vitamin K Classification Anticoagulant Brand name: Frequency:O Aqua-Mephyton D Dosage:10mg Route:IV Promotes hepatic synthesis of active prothrombin. Observe for jaundice and kernicterus. Observe for signs of local inflammation. Hypertonic Solution     11 . and Stuart factor Observe for bleeding (usually occurs on second or third day). used to treat losses from lower GI tract and burns. Know that in black patients. B. does provide calories. Vitamin K may also play a role in maintaining strong bones and preventing osteoporosis. Make factors that regulate blood clotting. function depends on the reninangiotensinaldosterone system. Drug isn¶t indicated for stroke prevention in black hypertensive patients with LVH. Protect drug from light. IV Fluids Name D5LRS (5% Dextrose in Lactated Ringer¶s Solution) Classification  Components 130 mEq of sodium ion = 130 mmol/L 109 mEq of chloride ion = 109 mmol/L 28 mEq of lactate = 28 mmol/L 4 mEq of potassium ion = 4 mmol/L 3 mEq of calcium ion = 1. losartan and other ACE inhibitors may be ineffective when used alone.5 mmol/L Use and Effects Closely resemble the electrolyte composition of normal blood serum and plasma. Results of serial PT and PTT should be assessed. proconvertin. Significance Lactated Ringer's fluid provides electrolytes and is a source of water for hydration.

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