St Anne College Lucena Inc.

Diversion rd. Bry Gulang Gulang, Lucena city

College of Nursing

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IN

RELATED LEARNING EXPERIENCE (105)

A CASE STUDY ABOUT CHOLECYSTITIS

Presented to:

Presented by:

DOLLY JOY SALOMES

BSN IV A

I Patient profile
 Biographical Data
Name: Mr XXX

Age: 46 years old

Sex: Male

Nationality: Filipino

Date of Birth: August 28, 1962

Place of Birth: General Santos City

Civil Status: Married

Address: Lucban Quezon

Religion: Christianity (Roman Catholic)

Educational attainment: high School Graduate

Occupation:

II History
A, Nursing history
I chief complain: Right upper quadrant pain
II admitting diagnoses: Cholecystitis T/C Cholelithiasis
III physical Examination
IV final dx
B, Present Health history
I Symptom (PTA)

Pt prior to admission, Mr X experienced right upper quadrant pain associated

with a sense of bloatedness, without nausea and vomiting. The pain was tolerable so he
did not seek medical attention yet. He said he also had an increased level of pain
tolerance so he also didn’t mind to take any pain relievers. Until three days prior to
admission, patient had severe right upper quadrant pain, which was said to be intolerable.
Moreover, when pressure is applied on the RUQ of the abdomen, pain is elicited. He had
also lost his appetite because of the pain. His scleras were also slightly icteric during
admission and he was positive with Murphy’s sign. So he sought consultation at Out-
Patient Department- Emergency Room at Tayabas Community Hospital. Ultrasound
revealed cholecystitis, so patient was advised admission and operation.

C, Past Health History

I Hospitalization
 Mr. x experienced common illness such as colds, cough, and fever during his
childhood. He also had chicken pox during his childhood. However, he could not recall at
what age he got the disease and as well as the management of his chicken pox.

Two years ago (2007), he was admitted to Davao Medical Center due to loss of
consciousness. Prior to that, he was experiencing palpitations, and pain on the
suboccipital area (nape) associated with headache. He had blood pressure of 180/100 as
he could remember during the VS taking at the emergency room. And his diagnosed with
hypertension.

II Surgical management
None
III allergies
None
D family Health History

Grandfather Grandmothe Grandfather Grandmother

Hypertension
r

Father Mother

Step-brod died at the age of 18 because of

Patient X . Hypertension and cholo

Younger sister Anna died of car accident at age of six years

Mr. X is the eldest among Mr. Dad‘s and Mrs. Mom‘s two children. But his younger
sister Anna died of car accident at the age of six years old,. He grew up at General Santos City
where the relatives of his mother live. When Mr. X was a first year high school, his parents got
separated because of third party. He lived with his mother and Mrs. Mom’s live-in partner at
Davao City, while his father returned to Leyte where his other relatives live. With his mother’s
second family, he had another two siblings, Step-brod and Step-sis. Step-brod died at the age of
18 because of suicide. He had suicide because of altered mental status due to shabu use. Today,
Step-sis has her own family at Leyte.

Because Mr.X had been away from the relatives of his father, he does not know any significant
disease they have or had. He doesn’t also know the causes of deaths of his grandmother and
grandfather on the paternal side. On the other hand, what he only knows is that the eldest sister
of her mother has hypertension, and that his grandfather on the maternal side died of
hypertension.
IV Nutrition
A 24 hrs food result
B Regular Routine of diet
C habits

V Disease Entity
A Definition
Cholecystitis is an inflammation of the gallbladder wall and nearby abdominal lining.
Cholecystitis is usually caused by a gallstone in the cystic duct, the duct that connects the
gallbladder to the hepatic duct. The presence of gallstones in the gallbladder is called
cholelithiasis. Cholelithiasis is the pathologic state of stones or calculi within the gallbladder
lumen. A common digestive disorder worldwide, the annual overall cost of cholelithiasis is
approximately $5 billion in the United States, where 75-80% of gallstones are of the cholesterol
type, and approximately 10-25% of gallstones are bilirubinate of either black or brown pigment.
In Asia, pigmented stones predominate, although recent studies have shown an increase in
cholesterol stones in the Far East.

Gallstones are crystalline structures formed by concretion (hardening) or accretion

(adherence of particles, accumulation) of normal or abnormal bile constituents. According to
various theories, there are four possible explanations for stone formation. First, bile may
undergo a change in composition. Second, gallbladder stasis may lead to bile stasis. Third,
infection may predispose a person to stone formation. Fourth, genetics and demography can
affect stone formation.

B Etiology
C epidemiology

D Anatomy of Origin
 HEPATOBILLARY TREE

LIVER

A. Location and size of the liver- largest gland in the body, weighs approximately 1.5 kg;
lies under the diaphragm; occupies most of the right hypochondrium and part of the
epigastrium.
B. Liver lobes and lobules- two lobes separated by the falciform ligament
1. Left lobe- forms about one sixth of the liver
2. Right lobe- forms about five sixths of the liver; divides into right lobe proper,
caudate lobe, and quadrate lobe
3. Hepatic lobules- anatomical units of the liver; small branch of hepatic vein
extends through the center of each lobule
C. Bile ducts
1. Small bile ducts form right and left hepatic ducts
2. Right and left hepatic ducts immediately join to form one hepatic duct
3. Hepatic duct merges with cystic duct to form the common bile duct, which opens
into the duodenum
D. Functions of the liver
1. Glucose Metabolism
-after a meal, glucose is taken up from the portal venous blood by the liver and
converted into glycogen (glycogenesis), which is stored in the hepatocytes.
Glycogen is converted back to glucose (glycogenolysis) and release as needed into
the blood stream to maintain normal level of the blood glucose.

-glucose can be synthesized by the liver through the process gluconeogenesis

2. Ammonia Conversion
-use of amino acids from protein for gluconeogenesis result in the formation of
ammonia as a by product. Liver converts ammonia to urea

3. Protein Metabolism
-Liver synthesizes almost all of the plasma protein including albumin, alpha and
beta globulins, blood clotting factors plasma lipoproteins

4. Fat Metabolism
-Fatty acid can be broken down for the production of energy and production of
ketone bodies
 5. Vitamin and Iron Storage
-stores vitamin A, D, E, K

6. Drug Metabolism
7. Bile Formation
-bile is formed by the hepatocytes

-composed of water, electrolytes such as sodium, potassium, calcium, chloride,

bicarbonate, lecithin, fatty acids, cholesterol, bile salts

-collected and stored in the gallbladder and emptied in the intestine when needed
for digestion

a. Lecithin and bile salts emulsify fats by encasing them in shells to form tiny
spheres called micelles
b. Sodium bicarbonate increases pH for optimum enzyme function
c. Cholesterol, products of detoxification, and bile pigments (e.g. bilirubin) are
wastes products excreted by the liver and eventually eliminated in the feces
GALLBLADDER

The gallbladder (or cholecyst, sometimes gall bladder) is a small organ whose function in
the body is to harbor bile and aid in the digestive process.

Anatomy
• The cystic duct connects the gall bladder to the common hepatic duct to form the
common bile duct.
• The common bile romero duct then joins the pancreatic duct, and enters through the
hepatopancreatic ampulla at the major duodenal papilla.
• The fundus of the gallbladder is the part farthest from the duct, located by the lower
border of the liver. It is at the same level as the transpyloric plane.

Microscopic anatomy

The different layers of the gallbladder are as follows:

• The gallbladder has a simple columnar epithelial lining characterized by recesses called
Aschoff's recesses, which are pouches inside the lining.
• Under the epithelium there is a layer of connective tissue (lamina propria).
• Beneath the connective tissue is a wall of smooth muscle (muscularis externa) that
contracts in response to cholecystokinin, a peptide hormone secreted by the duodenum.
• There is essentially no submucosa separating the connective tissue from serosa and
adventitia.
Size and Location of the Gallbladder

The gallbladder is a hollow, pear-shaped sac from 7 to 10 cm (3-4 inches) long and 3 cm
broad at its widest point. It consists of a fundus, body and neck. It can hold 30 to 50 ml of bile. It
lies on the undersurface of the liver’s right lobe and is attached there by areolar connective
tissue.

Structure of the Gallbladder

Serous, muscular, and mucous layers compose the wall of the gallbladder. The mucosal
lining is arranged in folds called rugae, similar in structure to those of the stomach.

Function of the Gallbladder

 The gallbladder stores bile that enters it by way of the hepatic and cystic ducts. During
this time the gallbladder concentrates bile fivefold to tenfold. Then later, when digestion occurs
in the stomach and intestines, the gallbladder contracts, ejecting the concentrated bile into the
duodenum. Jaundice a yellow discoloration of the skin and mucosa, results when obstruction of
bile flow into the duodenum occurs. Bile is thereby denied its normal exit from the body in the
feces. Instead, it is absorbed into the blood, and an excess of bile pigments with a yellow hue
enters the blood and is deposited in the tissues.

The gallbladder stores about 50 mL (1.7 US fluid ounces / 1.8 Imperial fluid ounces) of
bile, which is released when food containing fat enters the digestive tract, stimulating the
secretion of cholecystokinin (CCK). The bile, produced in the liver, emulsifies fats and
neutralizes acids in partly digested food.
After being stored in the gallbladder the bile becomes more concentrated than when it left
the liver, increasing its potency and intensifying its effect on fats. Most digestion occurs in the
duodenum.
BILIRUBIN PRODUCTION AND ELIMINATION

Bilirubin is the substance that gives bile its color. It is

formed from senescent red blood cells. In the process of
degradation, the hemoglobin from the red blood cell is broken down
from biliverdin, which is rapidly converted to free bilirubin thru
biliverdin reductase. Free bilirubin, which is not soluble in plasma,
is transported in the blood attached to plasma albumin. Even when
it is bound to albumin, this bilirubin is still called free bilirubin. As
it passes through the liver, free bilirubin is released from its albumin carrier molecule and moved
into the hepatocytes. Inside the hepatocytes, free bilirubin is converted to conjugated bilrubin
thru glucoronyl transferase, making it soluble to bile. Conjugated bilirubin is secreted as a
constituents of bile, and in this form, it passes through the bile ducts into the small intestine. In
the intestine, approximately one half of the bilirubin is converted into a higly soluble substance
called urobilinogen by the intestinal flora. Urobilinogen is either absorbed into the portal
circulation or excreted in the feces. Most of the urobilinogen that is absorbed is returned to the
liver to be re-excreted into the bile. A small amount of urobilinogen, approximately 5% is
absorbed into the general circulation and then excreted by the kidneys.

VI pathophysilogy

Risk factor
• Heredity
• Obesity
• Rapid Weight Loss, through diet or surgery
• Age Over 60
• Female Gender
• Diet-Very low calorie diets, prolonged fasting, and
low-fiber/high-cholesterol/high-starch diets.
 Thecholesterol
e must become supersaturated with solute precipitate from solution
and calcium as solid
Crystals crystals
must come together and fuse to form sto

Gallstones

Obstruction of the cystic duct and common bile duct

Sharp pain in the right part of abdomen Jaundice

Distention of the gall bladder

Venous and lymphatic drainage is impaired

ProliferationLocalized Areas
of bacteriacellular irritation or infiltration or bothof ischemia
take place may occur

Inflammation of gall bladder

CHOLECYSTITI

tion during which the gallbladder is opened, gallstones are removed, and excess bile is drained. The gallbladder is not re
VII management
A Medical Management
1. Chest X-ray- this is used to rule out respiratory causes of referred pain.
2. Intake and Output- I&O measurement provide an other means of assessing fluid
balance. This data provide insight into the cause of imbalance such as decrease
fluid intake or increase fluid loss. These measurement are not that accurate as
body weight, however, because of relative risk of errors in recording.

3. ultrasound (Also called sonography.) - a diagnostic imaging technique which

uses high-frequency sound waves to create an image of the internal organs.
Ultrasounds are used to view internal organs of the abdomen such as the liver
spleen, and kidneys and to assess blood flow through various vessels.

4. endoscopic retrograde cholangiopancreatography (ERCP) - a procedure that

allows the physician to diagnose and treat problems in the liver, gallbladder,
bile ducts, and pancreas. The procedure combines x-ray and the use of an
endoscope. A long, flexible, lighted tube. The scope is guided through the
patient's mouth and throat, then through the esophagus, stomach, and
duodenum. The physician can examine the inside of these organs and detect any
abnormalities. A tube is then passed through the scope, and a dye is injected
which will allow the internal organs to appear on an x-ray.

5. Cholecystotomy- the establishment of an opening into the gallbladder to allow

drainage of the organ and removal of stones. A tube is then placed in the
gallbladder to established external drainage. This is performed when the patient
cannot tolerate cholecystectomy.
B Nursing Management
C Pharmacology
VIII laboratory/ diagnoses procedure
A Blood Analysis
B urinalysis
C fecalysis
D x-ray
E ultrasound
F CT scan
IX ncp
X discharge plan .

M - Instructed the patient to continue medication as ordered

1. Cephalexin 500 mg cap 3 x day (8am-1pm-8pm) for 1 week

2. Mefenamic Acid 500 mg cap 3 x day (am-1pm-8pm) for 1 week

E - Instructed the patient to do exercise as tolerated such as walking

T - Instructed the patient to continue the medication

H - 1. Encouraged patient to increase fluid intake

2. Encouraged patient to eat foods rich in Vitamin and Nutritious foods

3. Encourage patient to avoid salty and fatty foods

4. Encourage patient to have enough rest

O - Instructed to come back for follow-up check-up on February 23, 2006,

Thursday.

D - Advised the patient to a diet as tolerated but preferably avoiding salty and

fatty foods.