CHOLECYSTECTOMY

(ACUTE CALCULOUS
CHOLECYSTITIS)
PRESENTED BY:
TABACO, BRYAN JOSHUA M.
TOLEDO, STEPHANIE E.
UBIA, MARIE CHARISMA T.
UDDIN, SHENA E.
 OBJECTIVES
Theof study
By the end aims
this case towe
study, provide
will be able to:
student nursesGENERAL and other health
-To identify risk factors that caused
care professionals cholecystitis
with an over
-To formulate significant nursing diagnosis with
view of the condition process
their significantly related nursing care plans.
-To foster the SPECIFIC
andcamaraderie
relative implication
among membersof with a
goal thatrendering
is to promote anoptimum
effective and
health of the
patient. efficient nursing care.
INTRODUCTION
Acute cholecystitis refers to a syndrome of right upper
quadrant pain, fever, and leukocytosis associated with
gallbladder inflammation, which is usually related to
gallstone disease (ie, acute calculous cholecystitis).
Complications include the development of gangrene and
gallbladder perforation, which can be life-threatening.

Calculous cholecystitis develops when the main

opening to the gallbladder, called the cystic duct, gets
blocked by a gallstone or a substance known as biliary
sludge. Biliary sludge is a mixture of bile, a liquid
produced by the liver that helps digest fats, and small
cholesterol and salt crystals.
EPIDEMIOLOGY
Calculous cholecystitis is the most common, and
usually less serious, type of acute cholecystitis. It
accounts for around 95% of all cases.
Uncomplicated cholecystitis has an
excellent prognosis, with a very low mortality.
Most patients with acute cholecystitis have a
complete remission within 1-4 days. In patients
who are critically ill with acalculous
cholecystitis and perforation or gangrene,
mortality can be as high as 50-60%.
PATIENTS PROFILE
NAME: Ms. M.R.
AGE: 41 y/o
SEX: Female
ADDRESS: San Andres , Manila
BIRTHPLACE: Leyte
NATIONALITY: Filipino
RELIGION: Roman Catholic
CIVIL STATUS: Single
BIRTHDAY: October 10, 1975
ADMISSION
Date of Admission: August 30,2017
Time: 6:30 p.m.
Diagnosis: Acute Calculous Cholecystitis
Chief Complaint: Abdominal Pain (right
upper quadrant)
HISTORY OF PRESENT
ILLNESS
In 2011, the patient was diagnosed with
Cholethiasis. From time to time, she experienced
bearable pain in the right upper quadrant of her
abdomen but did not go for any consultation. One
week prior to her admission she felt severe pain in
her right upper quadrant radiating to the back. She
did not have jaundice, no fever and no tea colored
urine. One day prior to admission she felt another
sharp and severe pain in the right upper quadrant
of her abdomen which prompted consultation.
PAST MEDICAL HISTORY

(+) Bronchial Asthma

(+) Appendectomy (1980)
(-) Allergies
(-) Diabetes Mellitus
 FAMILY HISTORY
(+) Hypertension Maternal
(+) Diabetes Mellitus Paternal
(+) Bronchial Asthma Paternal

PERSONAL AND SOCIAL HISTORY

(-) Smoking
(-) Alcoholic Beverage Drinker
(-) Illicit Drug Use
 PHYSICAL
ASSESSMENT
General Survey Conscious, coherent, not in cardiorespiratory distress.

Good skin turgor, no pallor, no jaundice, no lesions noted on

Skin
any part of the body.

Mild icteric sclerea, pink palpebral conjunctive, no

Head and neck
tonsillopharyngeal congestion.

Chest and lungs Symmetric lung expansion, no lagging, no retractions.

Adynamic precordium, normal rate, regular rhythm, no

Cardiac
murmur.

Flat, soft, normoactive bowel sounds, (+) epigastric pain

radiating to the back, (-) direct tenderness over the right lower
Abdomen
quadrant, no guarding, (-) obturator sign, (-) psoas sign, (-)
Rovsings sign.

Extremities No deformities: full equal pulses, no cyanosis, no edema.

ANATOMY AND PHYSIOLOGY
PATHOPHYSIOLOGY
Increase ingestion of fatty foods

Increase bile cholesterol

Formation of crystal

Cholelithiasis

Obstruction

Increase pressure in the gallbladder

 Cholecystitis

Infection

RUQ pain that

radiates to the
back Acute Calculous
Nausea Cholecystitis
Vomiting
Anorexia

Open cholecystectomy
Gall stones Pus
LABORATORY AND
DIAGNOSTICS
 BUN CREATININE
PREFERENCE
TEST RESULT INTERPRETATION
RANGE
60.00 45-104
CREATININE Umol/L Umol/L Normal

139.00 135-140
Na+ mmol/L mmol/L Normal

4.10 3.4- 4.82

K+ mmol/L mmol/L Normal
 CBC
PREFERENCE
TEST RESULT INTERPRETATION
RANGE

Hemoglobin 128 g/L 120-170 Normal

Hematocrit 0.41 0.37-0.54 Normal

RBC 4.70 x1012/L 4.1-5.1 Normal

MCV 87.9 f/L 60-96 Normal

MCH 27.2 pg 27-31 Normal

MCHC 31.0 33-36

WBC 18.3 x10g/L 4.5-11

NRBC 0.0% - Normal

 CBC Differential count
PREFERENCE
TEST RESULT INTERPRETATION
RANGE
Neutrophil 0.64 0.55-0.65 Normal

Lymphocytes 0.20 0.25-0.35

Basophil 0.01 0.00-0.01 Normal

Monocytes 0.12 0.04-0.13 Normal

Eosinophil 0.03 0.02-0.04 Normal

Platelet
514.0 x1012/L 150-400
Count
 Test Name Result Normal Values Interpretation

PROTHROMBIN 12.4 secs 11.3-15.3 NORMAL

TIME

PT 14.8 Ref. T
CONTROL

PT INR 1.00 INR

PT % 100% 70-100 NORMAL

ACTIVITY
 Test Name Result Normal Values Interpretation

APTT 25.8 sec 22.6-35.0 NORMAL

APTT 31.8 Ref.T

CONTROL
 DRUG STUDY: Cefuroxime
DRUG NAME ACTION RATIONALE
Cefuroxime Cefuroxime binds to one To treat severe or
or more of the penicillin- complicated infections
Brand Name:
binding proteins (PBPs)
Ceftin, Zinacef which inhibits the final
transpeptidation step of
Classification: peptidoglycan synthesis
in bacterial cell wall,
Therapeutic Class:
thus inhibiting
Antibiotic biosynthesis and
Chemical Class: arresting cell wall
Cephalosporin (second assembly resulting in
generation) bacterial cell death.

Dosage:
1.5 g IV every 8 hours
1
 POSSIBLE SIDE EFFECTS
CNS: Chills, Fever, headache, seizures

CV: Edema

GI: Abdominal cramps, diarrhea, elevated liver enzymes, hepatic failure, hepatomegaly,
nausea, vomiting

*** No side effects seen on the patient

2
 NURSING CONSIDERATION

-Monitor patient for allergic reactions.

2
 DRUG STUDY: Omeprazole
DRUG NAME ACTION RATIONALE
GENERIC NAME: Inhibits acid (proton) -Relieves symptoms
Omeprazole pump and binds to caused by excessive
hydrogen adenosine gastric acid
Brand Name: triphosphatase on
Omezol secretory surface of the -Suppresses gastric acid
of gastric parietal cells to secretion relieving
CLASSIFICATION:: block formation of gastric gastrointestinal distress
Anti Ulcer acid and promoting ulcer
Proton pump Inhibitor healing.
Antacids
Antireflux

DOSAGE and
FREQUENCY: 1
 SIDE EFFECTS NURSING CONSIDERATION

CNS: Agitation, asthenia, dizziness, Monitor patient for signs and symptoms of low
drowsiness, fatigue, headache, magnesium level such as muscle spasm,
tremors or seizures.

CV: Chest pain, hypertension, peripheral

edema
MS: Back pain

*** No side effects seen on the patient

2
 DRUG STUDY: Ketorolac
DRUG NAME ACTION RATIONALE
GENERIC NAME: Ketorolac reduces the For the short term treatment of
Ketorolac production of acute pain and post-operative
prostaglandins, chemicals pain
BRAND NAME: that cells of the immune
Ketovex system make that cause
the redness, fever, and
CLASSIFICATION: pain of inflammation and
Therapeutic Class: that also are believed to be
Analgesic, Anti- important in the production
inflammatory of non-inflammatory pain. It
Pharmacologic Class: does this by blocking the
Nonsteroidal anti- enzymes that cells use to
inflammatory drugs make prostaglandins
(cyclooxygenase 1 and 2).
DOSAGE and
FREQUENCY:
1
 NURSING
SIDE EFFECTS CONSIDERATION
CNS: Aseptic Meningitis, cerebral haemorrhage, Monitor any signs of
coma, dizziness, headache, psychosis, seizure,
stroke
allergies.

CV: edema, fluid retention, hypertension

*** No side effects seen on the patient

2
 DRUG STUDY: Paracetamol
DRUG NAME ACTION RATIONALE
GENERIC NAME: Decreases fever by
Paracetamol inhibiting the effects of Relief of mild-
Acetaminophen pyrogens on the
hypothalamus heat to-moderate
BRAND NAME: regulating centers & by a
Ifimol IV hypothalamic action leading pain;
to sweating &
CLASSIFICATION: vasodilatation. Relieves
Non-narcotic analgesic, pain by inhibiting
Antipyretic prostaglandin synthesis at
the CNS but does not have
DOSAGE and anti-inflammatory action
FREQUENCY: because of its minimal
300 mg TIV q4 effect on peripheral
prostaglandin synthesis.
1
 SIDE EFFECTS
CNS: Headache, dizziness
GI: Nausea, Vomiting, Abdominal pain,
diarrhea, constipation, dyspepsia,
enlarged abdomen
NURSING CONSIDERATION
Assess patients fever or pain: type
of reactions: rash; if this occurs, drug
may have to be discontinued.

RESP: Dyspnea, abnormal breath

sounds, pulmonary edema, hypoxia,
pleural effusion, stridor, wheezing,
coughing

*** No side effects seen on the patient

2
 DRUG STUDY: Azithromycin
DRUG NAME ACTION RATIONALE
GENERIC NAME: Azithromycin Treatment of patients with mild to
blocks moderate infections caused by
Azithromycin
transpeptidation susceptible strains of the
BRAND NAME: by binding to designated microorganisms..
Zithromax 50s ribosomal
subunit
of susceptible organisms and
CLASSIFICATION:
disrupting
Antibiotic RNA-dependent
Macrolide protein
synthesis at the
chain elongation step
DOSAGE and
FREQUENCY:
500 mg Tab OD x 3 days
1
 SIDE EFFECTS
CNS: Dizziness, convulsions,
headache, hyperactivity,
hypoesthesia, paresthesia,
somnolence and syncope
NURSING CONSIDERATION
Assess
History: Hypersensitivity to
azithromycin, erythromycin, or
any macrolide antibiotic.

GI: Nausea, vomiting, diarrhea,

loose stools, abdominal discomfort
(pain/cramps) and flatulence.

*** No side effects seen on the

patient

2
 DRUG STUDY: Hydrocortisone
DRUG NAME ACTION RATIONALE
GENERIC NAME: Enters target cells and
Hydrocortisone
Used for asthma,
binds to cytoplasmic
receptors; initiates many to relieve
BRAND NAME:
Solu-Cortef complex reactions that bronchospasm.
are responsible for its
CLASSIFICATION:
anti-inflammatory,
Therapeutic Class:
Corticosteriods (immunosuppressive)
glucocorticoid and salt
Pharmacologic Class: retaining
Glucocorticoids
(mineralocorticoid)
DOSAGE and FREQUENCY: actions.
100 mg IV q8
(-)ANST

1
 SIDE EFFECTS NURSING CONSIDERATION

CNS: Determine whether patient

Vertigo, headache, is sensitive to other
paresthesias, insomnia,
corticosteroids.
seizures, psychosis

CV:Hypotension, shock, Monitor patients weight, BP

and electrolyte level.

Inspect patients skin for

*** No side effects seen on the petechiae.
patient

2
DRUG STUDY: Rocunorium
DRUG NAME ACTION RATIONALE
GENERIC NAME: Esmeron is a fast-onset,
-It is used to calm
Rocunorium intermediate-acting,
nondepolarizing neuromuscular muscles during
blocking agent, possessing all
BRAND NAME: surgery
of the characteristic
Esmeron pharmacological actions of this
class of drugs (curariform). It
CLASSIFICATION: acts by competing for nicotinic
Neuro muscular blocking cholinoceptors at the motor
agent end-plate. This action is
Muscle Relaxant antagonized by
acetylcholinesterase inhibitors
eg, neostigmine, edrophonium
DOSAGE and
and pyridostigmine.
FREQUENCY:
4. 0 g IV inhalation

1
 SIDE EFFECTS NURSING CONSIDERATION

CNS: Flaccid paralysis Since Rocunorium

Cardiac: Tachycardia causes paralysis of the
Vascular: Hypotension respiratory muscles,
Resp: Bronchospasm ventilatory support is
mandatory for patients
*** No side effects treated, until adequate
seen on the patient spontaneous respiration
is restored.

2
DRUG STUDY: Bupivacaine HCl
DRUG NAME ACTION RATIONALE
GENERIC NAME: Local anesthetics block
Bupivacaine HCl the generation and the
Local
BRAND NAME
conduction of nerve
impulses, presumably by
anesthesia or
Marcaine
increasing the threshold analgesia for
CLASSIFICATION: for electrical excitation in
Anesthetics the nerve, by slowing the surgery
propagation of the nerve
DOSAGE and impulse and by reducing
FREQUENCY: the rate of rise of the
50 mg IV action potential.

1
 SIDE EFFECTS
CNS: Restlessness, anxiety, dizziness,
tinnitus, blurred vision or tremors may
occur, possibly proceeding to
convulsions, nausea, vomiting, rigors,
and miosis
NURSING CONSIDERATION
Careful and constant monitoring of
cardiovascular and respiratory vital
signs, and the patient's state of
consciousness should be performed
after each local anesthetic injection.

Cardio: depression of the myocardium,

decreased cardiac output, heartblock,
hypotension (or sometimes
hypertension), bradycardia, ventricular
arrhythmias and cardiac arrest.

*** No side effects seen on the patient

2
DRUG STUDY: Salbutamol
DRUG NAME ACTION RATIONALE
GENERIC NAME: Ipratropium bromide is a

Salbutamol
quaternary ammonium compound Management of
with anticholinergic

BRAND NAME:
(parasympatholytic) properties. In
preclinical studies, it appears to
reversible
Combivent UVD inhibit vagally mediated reflexes by
antagonizing the action of
bronchospasm
acetylcholine, the transmitter agent
CLASSIFICATION: released from the vagus nerve. associated with
Anti Asthmatic Anticholinergics prevent the
increase in intracellular obstructive
concentration of cyclic guanosine
DOSAGE and
FREQUENCY
monophosphate (cyclic GMP)
caused by interaction of
airway diseases.
2.5 ml Neb q8 acetylcholine with the muscarinic
receptor on bronchial smooth
muscle.

1
 SIDE EFFECTS
Headache, dizziness,
nervousness, tachycardia,
fine tremor of skeletal
muscles and
palpitations, nausea,
vomiting, sweating, weakness
and myalgia/muscle cramps
*** No side effects seen on
the patient
NURSING CONSIDERATION
Since the unit-dose vials
contain no preservative, it
is important that the
contents are used soon
after opening and that a
fresh vial is used for each
administration to avoid
microbial contamination.
Partly used, opened or
damaged unit-dose vials
should be discarded.
2
DRUG STUDY
DRUG NAME ACTION RATIONALE
GENERIC
NicardipineNAME: ItNicardipine
reversibly is
inhibits
a the Used for Inflammation
Management and
of moderate
Diclofenac enzyme, cyclooxygenase,
dihydropyridine calcium pain post operation
to severe hypertension
Brand Name: where immediate
thus resulting
channel in reduced
antagonist that
Cardipine
BRAND NAME: synthesis
inhibits theof correction of blood
Classification:
Dicofen prostaglandin
transmembrane precursors
influx of pressure is required; pre-
Antihypertensive calcium ions into cardiac and post-operative
CLASSIFICATION: muscle and vascular hypertension.
Therapeutic Class:
Nonsteriodal Anti- smooth muscle without
Cardiovascular Agent
Inflammatory Drugs changing serum calcium
Pharmacologic Class:
(NSAIDs
Calcium Channel Blocker ion concentrations.
DOSAGE and
Dosage: IV
FREQUENCY
75 mg IVDilute
infusion q6 to 10-20
mg/100 mL
1
DRUG STUDY
NURSING
SIDE EFFECTS CONSIDERATION
CNS: headache, dizziness, vertigo Evaluate therapeutic response by
assessing pain, joint stiffness, joint
GI: bleeding, ulceration swelling and mobility
epigastric pain, nausea, vomiting,
diarrhea, abdominal cramps, dyspepsia,
flatulence

*** No side effects seen on the patient

2
DRUG STUDY
DRUG NAME ACTION RATIONALE
DRUG NAME ACTION RATIONALE
Management of moderate
Nicardipine Nicardipine is a
Nicardipine Nicardipine is a calcium Management
to of moderate
severe hypertension
dihydropyridine
Brand Name: dihydropyridine calcium to severe hypertension
Brand Name: channel antagonist that
Cardipine channelthe antagonist that where immediate
inhibits
Cardipine inhibits the correction of blood
Classification: transmembrane influx of
Classification: transmembrane pressure is required; pre-
Antihypertensive calcium ions intoinflux of
cardiac
calciumandionsvascular
into cardiac and post-operative
Antihypertensive
Therapeutic Class: muscle
muscle and vascular hypertension.
Therapeutic Class:
Cardiovascular Agent smooth muscle without
Cardiovascular Class:
Agent smooth muscle
changing serumwithout
calcium
Pharmacologic changing serum calcium
Pharmacologic Class: ion concentrations.
Calcium Channel Blocker ion concentrations.
Calcium Channel Blocker

Dosage: IV
Dosage: IV
infusion Dilute to 10-20
infusion Dilute to 10-20
mg/100 mL
mg/100 mL
1
DRUG STUDY
SIDE EFFECTS
CNS: Headache, dizziness, hot flashes,
vertigo, hyperkinesia, impotence, mental
depression
CARDIO: Hypotension, pericarditis,
peripheral vascular disorder
GI: Abdominal pain, nausea, vomiting,
dyspepsia, constipation, diarrhea, dry
mouth, anorexia, heartburn.
*** No side effects seen on the patient
NURSING
CONSIDERATION
Carefully monitor patient's BP and
heart rate since nicardipine decreases
peripheral vascular resistance and
occasionally causes excessive and
poorly tolerated hypotension or
tachycardia.
2
 NURSING CARE PLAN: ANXIETY
NURSING BACKGROUND
ASSESSMENT DIAGNOSIS KNOWLEDGE
SUBJECTIVE Anxiety (mild) related to Psychological factor
upcoming surgery as (fear)
Kinakabahan ako as evidenced by
verbalized by the patient. restlessness and
increased vital signs. Unknown environment

Anxiety
OBJECTIVE

BP: 198/82
Restlessness
RR: 22
Increase in BP
And Respiratory rate

1
 NURSING
PLANNING
After 5-10
CARE INTERVENTION
1. Established rapport 1.
RATIONALE
Introducing self lessen the
anxiety of the patient and
PLAN
minutes
nursing
of 2 and introduced self.
2. Talked to the patient
establishing rapport can
develop patients trust.
and explained the 2. Explaining the procedure
intervention, procedure further. to the patient can give
patient will be 3. Prevented further understanding.
3. Patients are concerned
able to lessen unnecessary
about loss of dignity and
her anxiety exposure of body
inability to exercise
parts.
and vital signs control.
4. Control external 4. Extraneous noises and
will return to stimuli. commotion can
normal. accelerate anxiety.

2
 EVALUATION

After 5-10 minutes of nursing

intervention, patient was be able to
lessen her anxiety and vital signs
returned to normal.

2
RECOMMENDATIONS
Medications
Antibiotic and analgesic as prescribed

Environment
Safe and clean environment.

Treatments
Daily wound care
RECOMMENDATIONS
HEALTH TEACHING:
Teach the importance of sleep and rest.
Encourage the patient to use breathing techniques specially
during times of increased pain.
Avoid lifting or carrying any heavy objects 6 weeks after surgery.
Avoid fatty foods.
Eat small frequent meals.
Avoid eating a very large dinner after fasting all day.
Do not soak in a bathtub or hot tub, or go swimming, until your
doctor tells you it is ok.
RECOMMENDATIONS
OBSERVATION:
Observe for increased pain.
Observe for signs of infection: fever. Foul odor, pain
abnormal bleeding.
DIET:
increase fluid intake.
low fat diet
SPIRITUAL:
Encourage patient to pray.