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

I.

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. Clients 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 its 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).
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II.

III.

IV.

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

IX.

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

3. Ears

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

5. Mouth

6. Neck

7. Chest and Breast

8. Cardiac 9. Gastro-Intestinal Tract (GIT)

10. Gastro-Urinary tract

11. Musculoskeletal 12. Integumentary

Patient was able to do ADLs & self-care activities with assistance; No involuntary movements noted Skin appears thin and translucent; loosed its elasticity and wrinkled; generalized jaundice; ares of lighter pigmentation (palms, lips, nail beds); no edema noted; dry and flaky skin; generalized hyperthermia (38.0C); noted skin turgor (moves back slowly) Nails: noted splits , longitudinal bands, and hangnails; convex curvature approximately 160 degrees; smooth texture; yellowish colour

X.

Diagnostics DATE August 3, 2011 DIAGNOSTIC Chest X-ray REFERENC E A chest x ray is a PA and procedure used Lateral view to evaluate are obtained. organs and By structures within convention on the chest for the PA View, symptoms of the x-rays disease. Chest x enter the patient rays include posteriorly views of the and exit lungs, heart, small portions of anteriorly (wit h the patients the chest on the gastrointestinal film cassette), tract, thyroid therefore gland, and the minimizing bones of the the cardiac chest area. X magnification. rays are a form On the lateral of radiation that can penetrate the view, the patients left body and side is against produce an the film, image on an xray film. Another therefore the name for the film right side would be produced by x magnified. rays is radiograph. Ultrasound produces sound waves that are beamed into the body causing return echoes that are recorded to "visualize" structures beneath the skin.
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DESCRIPTION

RESULT
Heart is within normal limit in size. There are infiltrates on both lung bases. Rest of the lung fields is clear. Lateral CP sinuses are sharp.

IMPLICATION Normal

August 3, 2011

Ultrasound

-Parenteral
hyper alimentatio n, gross distention of the gallbladder -

Abnormal

Perichole cystic fluid was

observed,

June 27, 2011

Urinalysis

The ability to measure different echoes reflected from a variety of tissues allows a shadow picture to be constructed. The technology is especially accurate at seeing the interface between solid and fluid filled spaces. A urinalysis (or "UA") is an array of tests performed on urine and one of the most common methods of medical diagnosis. A part of a urinalysis can be performed by using urine dipsticks, in which the test results can be read as color changes.

no gallbladder perforation -Thickening of the gallbladder wall

Color- Light or pale Yellow CharacterClear

Colordark Yellow CharacterSlightly turbid Albuminnegative Reaction6.5 pH Specific Gravity1.010 Pus cell2-4

Abnormal

Abnormal

Albuminnegative Reaction- 4.68 Specific Gravity1.010- 1.025 Pus cell- 0

Normal

Normal

Normal

Abnormal (Slightly Elevated. 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.

Squamous Negative BacteriaNegative

Normal Normal

WBC

A white blood cell count is a determination of number of WBC or leukocytes/unit volume in a sample of venous blood. Hemoglobin is an important component of red blood cells that carries oxygen and carbon dioxide to and from tissues. The hemoglobin determination test is used to screen for diseases associated with anemia and in determining acid-base balance. The oxygen carrying capacity of the blood is also determined by the Hemoglobin concentration.

5.0-10.0

12.2

The result is above normal which indicates Infection.

Hemoglobin

120-160 g/L

125 g/L

Hemoglobin is within normal range.

Hematocrit

0.38-0.40 Measures the percentage of RBC in a blood volume. The test is performed to help diagnose blood disorders, such as polycythemia, anemia or abnormal dehydration, blood transfusion decisions for severe symptomatic anemias, and the effectiveness of those transfusions.

0.37

The clients result of hematocrit is slightly below range which indicates that the patients RBC is low in proportion to whole blood.

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Platelet Count

The smallest formed elements in blood that promote blood clotting after an injury. The test is performed to determine if blood clots normally, evaluate platelet production, and to diagnose and monitor a severe increase or decrease in platelet count

275

400x10^9/ L

The result is within normal range

Neutrophils

0.78

0.18-0.70

The result is above normal limits. Neutrophils is greater in amount as compared to other WBC component because in a normal inflammatory response, the neutrophils are the first ones to be release and act on the injured site. Hence, they are greater in number.

Lymphocytes

0.22

0.10-0.48 .

The result is within normal range.

Creatinine

77.6 umol/L

60-120 umol/L

The result is within normal range.

Potassium

4.32 mmol/L

3.5-5 mmol/L

The result is within normal range

Sodium

132.4 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.

XI.

Treatment/Management A. 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. Addition of sulbactam enhances drugs resistance to beta-lactamase, an enzyme that can inactivate ampicillin. Inhibits reuptake of serotonin and norepinephrine in CNS

Nursing Implication Monitor for signs and symptoms of hypersensitivity reaction. Watch for bleeding tendency and hemorrhage. Monitor CBC and liver function testresults. Assess patients response to drug 30 minutes after administration. Monitor respiratory status. Withhold drug and contact prescriber if respirations become shallow or slower than 12 breaths per/min. Monitor for physical and psychological drug dependence.

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

Generic Name: Omeprazole Brand name: Prilosec

Classification: Antisecretory drug; Antiulcer drug Frequency: OD Dosage: 1 tab 40mg Route: Oral

Reduces gastric acid secretion and increases gastric mucus and bicarbonate production, creating protective coating on gastric mucosa and easing discomfort from excess gastric acid.

Assess vital signs. Check for abdominal pain, emesis, diarrhea, or constipation. Evaluate fluid intake and output. Tell patient to take 30 to 60 minutes before a meal, preferably in morning. Instruct patient to swallow capsules or tablets whole and not to chew or crush them.

Inhibiting or diminishing secretion; secretion inhibitory an agent that so acts, 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, thereby decreasing myocardial contractility, relaxing coronary and vascular muscles, and decreasing peripheral resistance.

Monitor heart rate and rhythm and blood pressure, especially at start of therapy. Assess for heart failure; report signs and symptoms (peripheral edema, dyspnea) to prescriber promptly. Caution patient to avoid driving and other hazardous activities until he knows how drug affects concentration and alertness.

Treats Essential hypertension, chronic stable angina pectoris, and vasospastic angina (Prinzmetals 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, including vascular smooth muscle and adrenal glands. Also increases urinary flow and enhances excretion of chloride, magnesium, calcium, and
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Monitor blood pressure to evaluate drug efficacy. Assess liver and kidney function tests and electrolyte levels. Stay alert for oliguria, progressive azotemia, and renal failure in patients with severe heart failure whose renal

Mainly to treat high blood pressure.

phosphate.

function depends on the reninangiotensinaldosterone system. Know that in black patients, losartan and other ACE inhibitors may be ineffective when used alone. Drug isnt indicated for stroke prevention in black hypertensive patients with LVH.

Generic Name: Vitamin K

Classification Anticoagulant

Brand name: Frequency:O Aqua-Mephyton D Dosage:10mg Route:IV

Promotes hepatic synthesis of active prothrombin, proconvertin, plasma thromboplastin component, and Stuart factor

Observe for bleeding (usually occurs on second or third day). Results of serial PT and PTT should be assessed. Observe for jaundice and kernicterus. Observe for signs of local inflammation. Protect drug from light.

Make factors that regulate blood clotting. Vitamin K may also play a role in maintaining strong bones and preventing osteoporosis.

B. IV Fluids Name D5LRS (5% Dextrose in Lactated Ringers 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 = 1.5 mmol/L

Use and Effects Closely resemble the electrolyte composition of normal blood serum and plasma; will need additional K; does provide calories; used to treat losses from lower GI tract and burns.

Significance Lactated Ringer's fluid provides electrolytes and is a source of water for hydration.

Hypertonic Solution

 

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