Case Presentation of Cholelithiasis

INTRODUCTION
DEFINITION Disorder of the gallbladder and ducts are extremely common. These includes gallstones, inflammatory conditions, infections, tumors and congenital malformations. The two most common conditions are cholelithiasis(presence of gall stones) and associated cholecystitis (inflammation of the gall bladder)

INCIDENCE Studies show that the incidence of gall stones increases with age, as do the risk associated with cholelithiasis. Women account for 70% of those treated for gall stones, although studies have suggested that the mortality rate is higher in men.

ETIOLOGY The etiology of gall stone disease is not well understood. Based on various theories, there are four possible explanations of stone formation. First, bile may undergo a change in composition. Studies of clients with cholesterol gall stones indicate that their bile is supersaturated with cholesterol but deficient in bile salts. The cholesterol saturation of bile seems to increase with age.

Second, gall bladder stasis may lead to bile stasis. Bile stasis may (1)change bile composition, (2)supersaturate bile with cholesterol and (3)precipitate some bile constituents. Gall bladder stasis may result from decreased contractility of the gall bladder and spasm of the sphincter of Oddi. Third, infection may predispose a person to stone formation. Finally, genetics also seem to play some role in stone formation.

RISK FACTORS

Conditions that predispose clients to gall stone formation include: Diabetes mellitus Multiple pregnancies Vagotomy Ileal disease or resection

Long term parenteral nutrition Cirrhosis of the liver Chronic hemolytic disorders Obesity Exogenous estrogen administration Pancreatitis Caloric restriction with some diets Cholestrymine therapy

CLINICAL MANIFESTATION
Fewer than half of the clients with gall stones report any distress because gall stones cause no symptoms unless complications develop. The primary symptom is pain or biliary colic. The pain usually follows the temporary obstruction of the gall bladder outlet. Characteristically, the pain starts in the midline area. It may radiate around to the back and right shoulder blade.

The client is often restless, changing positions frequently to relieve the pains intensity. Pain may persist for a few hours or several days and the interval between attacks is variable. Jaundice only appears when common duct obstruction is present. Nausea and vomiting may occur, and occasionally self induced vomiting alleviates the symptoms. Assessment may further reveal a history of flatulence , bloating, dyspepsia, belching, an intolerance to fatty foods and vague upper abdominal sensations.

DIAGNOSTIC ASSESSMENT
Blood test are unremarkable. Jaundice is not present unless there is common bile duct obstruction. Diagnosis of cholelithiasis may involve abdominal ultrasonography, computerized axial tomography, cholescintography, cholangiography, or biliary drainage examination.

Current trends, point to the use of endoscopic retrograde cholangiopancreatography and endoscopic retrograde catheterization of the gall bladder. Biliary ultrasonography may be the initial study because it is accurate, safe and does not use radiation and can be performed without preparation.

MEDICAL MANAGEMENT
For clients with symptomatic cholelithiasis, treatment is dictated by the severity of symptoms. An oral analgesic may be prescribed and the client may be instructed to avoid those foods that precipitate the attacks and it may mean hospitalization.

Retrogade endoscopy for stone removal is an important non surgical alternative. Because the gall bladder is left in place in all interventions except cholecystectomy and laparoscopic cholecystectomy, the recurrence of stones is likely. Another important non surgical intervention is the use of oral administration of dissolution agents for cholesterol gall stones. These drugs act by reducing the amount of cholesterol in the bile.

SURGICAL MANAGEMENT
Cholecystectomy consists of excising the gall bladder from the posterior liver wall and ligating the cystic duct, vein, and artery. Following cholecystectomy the client should be monitored for the usual post operative complications such as hemorrhage, pneumonia, thrombophebitis, urinary retention and ileus.

 Cholecystectomy is the most common surgical intervention for gall stones. However, changes in the medical care reimbursement have initiated the innovation of laparoscopic cholecystectomy. Risks for this procedure include hemorrhage, bile duct injury and injury to other organs. However the advantage of small scars and short hospital stay have influence the increase use of this procedure.

 Extracorporeal shock wave lithotripsy and percutaneous cholecystolithotomy are procedures which may also be used to some clients.

POST HOSPITAL CARE

The client treated medically may be sent home with oral analgesics or other medications for comfort as well as an oral dissolution agent. Diet instructions may be necessary if ingestion of food precipitated the attack. The client should be given information on what to do should another attack occur.

PATIENTS PROFILE
NAME: SW AGE: 43 years old ADDRESS: Caloocan BIRTH DATE: October 18, 1965 SEX: Female NATIONALITY: Filipino CIVIL STATUS: Married RELIGION: Roman Catholic EDUCATIONAL ATTAINMENT: High School Graduate OCCUPATION: Sari sari store owner DATE OF ADMISSION: May 13, 2008 CHIEF COMPLAINT: Abdominal pain DIAGNOSIS: Cholelithiasis ATTENDING PHYSICIAN:

Nursing History
Past health history

Patient SW had already experienced childhood illnesses such as chickenpox and mumps. He also said that he had complete immunizations. He has no allergies to drugs and medications.
According to patient SW, he was hospitalized last year due to the same complain. He also said that he was supposedly operated but due to financial problem the operation did not push through.

Few days PTA, the patient already experienced abdominal pain but he disregard it because it is within tolerable level. Few hours PTA, the patient again experienced abdominal pain on his upper quadrant of his abdomen and described it as stabbing pain. Since he can no longer tolerate the pain, this prompted him to seek for medical health and thus was rushed into the ER.

Present health history

Family health history

According to the patient, he had no family history of G.I disorders. He further said tat he has a family history of hypertension on his father side. There are no further disease noted on his mother side.

Gordons 11 Functional Pattern

Health Perception Health Management Pattern Before Hospitalization: According to the S.O, the patient views health as very important to human. One cannot function well without it. Once health is absent, other aspects such as emotional, spiritual and social are affected. They always consult a doctor for any health problems. The S.O. also reported that he also takes over-the-counter drugs for simple illnesses such as fever

During hospitalization
The S.O. said that patient SW perceived himself as weak and is not able to do his daily activities. He manages his condition by complying with the entire doctors order and taking adequate rest. He reported no allergies to any foods and medications.

Before hospitalization: According to the S.O., the patient eats 3 times a day with snacks in between. He prefers to eat more on meat than vegetables. He drinks at least 7-9 glasses of water approximately 220/glass throughout the day. He usually eats crackers, biscuits and bread for his snacks with coffee. He had no difficulty in swallowing. During hospitalization: Patient SW is in a DAT diet.

Nutritional Metabolic Pattern

Elimination Pattern
Before Hospitalization: According to the S.O., patient SW had no problem with urination and defecation. Patient SW urinates at least 5-6 times a day depending on the urge he feels. The S.O describes the patient urine as light yellow in color. He defecates 1-2 times a day before starting his day in the morning and sometimes in the evening before going to bed. He describes his stool with brown color and is semi formed in consistency.

During hospitalization:
According to the S.O., the patient urinates smoothly without difficulty. The S.O. describes patient SWs urine as light yellow and defecates once a day with light brown, semi-formed stool.

Activity Exercise Pattern

Before Hospitalization: According to the S.O., patient SW, has no difficulty doing his ADLs such as gardening. He makes his day busy with their sari-sari store. Few days prior to admission, he can no longer do his activities of daily living because of the discomforts brought by his underlying condition.. During hospitalization: Patient SW can do is ADLs but with assistance. Pt. is still suffering from discomfort but it is tolerable.

Sleep Rest Pattern

Before hospitalization: He sleeps about 6-7 hours at night and sometimes 5-6 hours. He sleeps at around 10pm and wakes up at 5am or 6 am. After lunch, he takes about an hour or less for his naps. During hospitalization: The patient had difficulty getting asleep due to environmental stimulation. hindi ako makatulog dhil maingay ang paligid. as verbalized by the patient.

Cognitive Perceptual
The patient has no cognitive problem. He is oriented to time, place, and persons. He can see and hear clearly. He is able to understand and follow the instructions given to him by the nurses, doctors and SO.

Role Relationship Pattern

According to the S.O., patient SW has no problem with regards to his relationship with his family and the people around him. The S.O. also added that they treat him nicely. He is married and had 4 children, 1 had finished college.

Self- perception/Selfconcept Pattern

According to the patient he never thinks of losing hope about his condition, he always thinks positive that someday he can recover in whatever illness that he feels. He didnt feel any awkwardness regarding his condition and accepted it wholeheartedly.

Sexual Reproduction Pattern

Patient has no sexual dysfunction. He and his wife copulated for quite some time. He can not remember how frequent theyve done this. After the incident, they never engaged into sexual activities. They have four children. They did not use any form of contraceptive measures.

Coping Stress Management Pattern

Before hospitalization: According to the S.O (his son), patient SW always seek his wifes pieces of advice whenever problem occurs. The S.O. reported that the patient prays regularly to relieve his worries. He takes a rest to alleviate whatever stress he feels.

During hospitalization:
With his present condition, according to the S.O. he copes through adequate rest, following all the doctors instructions and adhering with the regiments given. He always asks his SO to position him comfortably. He regularly prays to relieve his worries regarding his condition.

Value Belief
The patient is a Roman Catholic. According to the S.O. he believes that the Lord will be the one who will help him to all his problem especially about his condition and the Lord has a purpose why he is experiencing the illness he had. They also believe in superstitious beliefs. They sometimes seek help from albularyos.

PHYSICAL ASSESSMENT
DATE: May 13, 2008 GENERAL APPEARANCE: Conscious and coherent VITAL SIGNS: BP: 110/70 mmHg RR: 24 cpm PR: 66 bpm Temp.:37.5 C

AREA ASSESSED SKIN Color Turgor Moisture Texture NAILS Nail plate shape Nail bed color Texture Capillary refill HEAD Scalp Texture Circumference FACE Face symmetry Facial movements EYES: EXTERNAL STUCTURES Hair distribution Skin quality EYELIDS Ability to blink SCLERA Color CONJUNCTIVA Color

METHOD USED Inspection Palpation Palpation Palpation Inspection Inspection Palpation Palpation/ Blanch test Inspection Palpation Palpation

NORMAL FINDINGS Light to deep brown Snaps back immediately Moist Smooth, elastic Convex Pink Smooth Returns to normal immediately (2- 3 seconds) Symmetrical Smooth Proportional circumference to the body Symmetrical Equal facial movements Evenly distributed Intact, smooth Blinks 15- 20 times per minute involuntarily and bilaterally White Light pink

ACTUAL FINDINGS Light brown Snaps back immediately moist Smooth Convex Pink Smooth 2-3 seconds Normal

ANALYSIS

Normal Normal Normal

Symmetrical Smooth Proportional circumference to the body Symmetrical Equal facial movements Evenly distributed Intact, smooth Blinks 17 times per minute involuntarily and bilaterally Yellowish Pale

Normal Normal Normal

Inspection Inspection Inspection Palpation Inspection Inspection Inspection

Normal Normal

Normal Normal Normal Normal Due to pathologic process

EARS: Texture AURICLES Symmetry and position

Inspection Palpation

Smooth without lesion Auricles are at level with each other

Smooth without lesion Auricles are at level with each other

Normal Normal

NOSE Symmetry Cilia distribution Nasal septum Nares

Inspection Inspection Inspection Inspection

Symmetrical Evenly distributed Midline Symmetrical size of opening

Symmetrical Evenly distributed Midline Symmetrical size of opening

Normal Normal Normal Normal

MOUTH Symmetry Color

Inspection Inspection

Symmetrical Pink

Symmetrical pink

Normal Normal

NECK Symmetry Range of motion Position Lymph nodes

Inspection Inspection Palpation Palpation

Symmetrical Moves freely Centrally located at the shoulder Not palpable

Symmetrical Moves freely Centrally located at the shoulder Not Palpable

Normal Normal Normal Normal

THORAX: Posterior Shape Symmetry Spinal alignment Diaphragmatic excursion Respiratory Rate Respiratory excursion Trachea Chest

Inspection Inspection Inspection Percussion Observation Palpation Auscultation Auscultation

Rounded, cylindrical Chest symmetric Spine vertically aligned, no tenderness, no bulges Excursion is 3- 5 cm 16-20 cpm Full symmetric excursion Bronchial and tubular breath sounds Bronchovesicular and vesicular breath sounds

Rounded, cylindrical Chest Symmetric Spine vertically aligned no tenderness, no bulges Excursion is 3-5 cm Full symmetric excursion Bronchial and tubular breath sounds Bronchovesicular and vesicular breath sounds

Normal Normal Normal Normal Normal Normal Normal

ABDOMEN

Color Abdominal Contour Bowel sounds Tenderness

Inspection Inspection Auscultation

Uniform with the rest of the body Present and active Not tender

Uniform with rest of the body Present: 8 times/min Tender

Nirmal Normal Normal Due to pathologic process

UPPER EXTREMITIE S

Symmetry Color Texture ROM

Inspection Inspection Palpation Inspection

Symmetrical Uniform with skin color Smooth, (-)lesions, (-)swelling Moves freely and without pain

Symmetrical Uniform with skin color Smooth, (-) lesion, ()swelling Moves freely and without pain

Normal Normal Normal Normal

LOWER EXTREMITIE S Symmetry Color Texture ROM Inspection Inspection Palpation Inspection Symmetrical Uniform with skin color Smooth, (-)Swelling, (-) lesions Moves freely and without pain symmetrical Uniform with skin Smooth, (-)Swelling, ()Lesion Moves freely and without pain Normal Normal Normal Normal

NEUROLOGIC SYSTEM

Level of Consciousness
Mental Status

Interview Interview

Conscious Oriented to person

Conscious Oriented to person

Normal Normal

Anatomy and Physiology of the Gastrointestinal tract

The digestive tract (also known as the alimentary canal) is the system of organs within multicellular animals that takes in food, digests it to extract energy and nutrients, and expels the remaining waste. The major functions of the GI tract are ingestion, digestion, absorption, and defecation. The GI tract differs substantially from animal to animal. Some animals have multi-chambered stomachs, while some animals' stomachs contain a single chamber. In a normal human adult male, the GI tract is approximately 6.5 meters (20 feet) long and consists of the upper and lower GI tracts. The tract may also be divided into foregut, midgut, and hindgut, reflecting the embryological origin of each segment of the tract

 Upper gastrointestinal tract The upper GI tract consists of the mouth, pharynx, esophagus, and stomach. The mouth contains the buccal mucosa, which contains the openings of the salivary glands; the tongue; and the tooth. Behind the mouth lies the pharynx, which leads to a hollow muscular tube, the esophagus. Peristalsis takes place, which is the contraction of muscles to propel the food down the esophagus which extends through the chest and pierces the diaphragm to reach the stomach.

The lower GI tract comprises the intestines and anus. Bowel or intestine Small intestine, which has three parts: Duodenum Jejunum Ileum Large intestine, which has three parts: Cecum (the vermiform appendix is attached to the cecum). Colon (ascending colon, transverse colon, descending colon and sigmoid flexure) Rectum Anus

Lower gastrointestinal tract

Accessory organs Accessory organs to the alimentary canal include the liver, gallbladder, and pancreas. The liver secretes bile into the small intestine via the biliary system, employing the gallbladder as a reservoir. Apart from storing and concentrating bile, the gallbladder has no other specific function. The pancreas secretes an isosmotic fluid containing bicarbonate and several enzymes, including trypsin, chymotrypsin, lipase, and pancreatic amylase, as well as nucleolytic enzymes (deoxyribonuclease and ribonuclease), into the small intestine. Both of these secretory organs aid in digestion.

Gallbladder
Anatomy The cystic duct connects the gallbladder to the common hepatic duct to form the common bile duct. The common bile duct then joins the pancreatic duct, and enters through the hepatopancreatic ampulla at the major duodenal papilla.[2][3] The fundus of the gallbladder is the part farthest from the duct, located by the lower border of the liver [4]. 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.

Function 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.

LABORATORY EXAM

43y/o Male 05/13/08 HEMATOLUGY REPORT RESULT TEST UNIT REFERENCE ANALYSIS

HGB
HCT RBC

160
0.46 5.43

g/l
g/l X 10^12L

135-180
0.40-0.54 4.6-6.2

normal
normal

MCV MCH MCHC RDW-CV WBC

85 29 34 13.8 11.43

L g/l g/dl % X 10^9L

80-96 27-31 33-36 11.6-14 5-10

normal normal normal normal Due to inflammation

Neutrophils

69.5

55

Due to inflammation

Lymphocytes Basophils Monocytes Elosunophils Platelef

34 0.1 3 3 215

% % % % X 10^9L

34 1 3 3 150-450

normal normal normal normal normal

HEMATOLOGY REPORT
TEST RESULT UNIT REFERENCE ANALYSIS PROTHROMBIN 12.9 SEC 11.3-15.3 normal

PT Control

13.2

SEC

PT I&R

0.97

SEC

PT% Activity

100

70-100

normal

APTT

28.6

SEC

28-37

normal

APTT Control

31.2

SEC

URINE EXAM RESULT

TEST RESULT REFERENCE ANALYSIS COLOR Amber Amber Normal

CHAR

Slightly Turbid

Clear

Due to infection

PH

5-6

normal

Spe. Cerav.

1.030

1.010-0.30

normal

MICROSCOPIC
TEST RESULT UNIT REFERENCE ANALYSIS RBC 4-5 /hpf 0-2 Due to infection

WBC

3-4

/hpf

0-5

normal

CRYSTALS

Amorphous urates

few

EPITHELIAL CELL

BACTERIA

FEW

few

normal

NCP
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION Subjective data: hindi ako makatulog, as verbalized by the patient Objective data: -frequent yawning -Noisy environment
-irritability

Disturbed sleep pattern r/t

At the end of 10 mins. The patient will verbalize ways on how to improve sleeping pattern

> provided comfort measures such as back rub > instructed patient to avoid caffeinated drinks such as coffee > instructed pt. to position himself on his most comfortable position when sleeping > instructed pt. to do any activities that induces sleep (imaginary counting)

> prepares client for sleep >increases mental alertness, do not induce sleep

Goal met The pt. verbalized understanding on ways to improved his sleep pattern

>provides comfort inducing sleep

> this induces sleep disregarding the environmental stimulant

ASSESSMENT

DIAGNOSIS

PLANNING

INTERVENTION

RATIONALE

EVALUATION

Subjective data: medyo maskit ang tiyan ko as verbalized by the patient. Objective data: - Pain scale of 5/10 sleep disturbance
Grimace face Irritability Guarding behavior RR of 24

Alteration in comfort: pain r/t obstruction on the bile duct.

At the end of the shift, The pt. will report lessen pain with a pain scale of 2/10

> provided comfort measures such as rubbing the affected part > instructed to do focus breathing > encourage adequate rest period

> to provide nonpharmacologi cal pain management >to alleviate pain

> prevent fatigue

Goal partially met The pt. reported relief of pain with the pain scale of 4/10. He said pain is already tolerable.