I. INTRODUCTION

A. OVERVIEW

Gallstones are collection of one or more stones in the gallbladder, which is the hollow organ under the liver that stores bile. Cholecystolithiasis is the fifth leading cause of hospitalization among adults. The disease may also be occurring in persons who are obese, who have high cholesterol, or who are on cholesterol lowering drugs. In most cases, gallbladder and bile duct diseases occur during middle age. Between ages 20 and 50, they're six times more common in women, but incidence in men and women becomes equal after age 50. Incidence rises with each succeeding decade. Diseases of the gallbladder and biliary tract are common and painful conditions that may be life threatening and mostly require surgery. They are generally associated with deposition of calculi and inflammation.

B. CLIENT CENTERED

Patient R.D. is a 24 year old female, was admitted at Candelaria District Hospital on 17th of August, 2011 with a reported history of recurring right upper quadrant pain for the past 4 months and complaining of severe RUQ abdominal pain that radiates to her back. She nauseated and has had a few episodes of vomiting at home. The pain is less intensed if she walks around bent forward. An ultrasound revealed stones in the gallbladder. She was admitted for the gallbladder stone removal.

C. STUDENT CENTERED

We, group 2, students of Columban College would like to thank Candelaria District Hospital, and also our Clinical Instructor, Ma’am Charmaine Abdon, for her patience in teaching us and making sure we learn the most from our clinical exposure. The purpose of this case study is to be familiar with a patient that undergo Cholecystectomy; How it starts, what are the causes and what are the signs and symptoms; especially how to prevent, treat and manage the patient by giving medication for treatment and providing rapport.

In this case, we had a hard time to evaluate the Laboratory results of the patient because she has a private doctor and all her Lab results were taken, left at the private clinic and did not forward to the hospital . Her private doctor was the same doctor who had her surgery at the hospital.

We have chosen this case not only because it is only the choice but somehow, we observed and noticed that during our ages, 20-50, we can have this disorder. And for further knowledge to control the number of the case, that will start on us even though we are just student nurses. II. PATIENT PROFILE

A. DEMOGRAPHIC DATA:

Name: Patient R.D.

Age: 24 years old

Sex: Female

Address: Babancal, Candelaria. Zambales

Civil Status: Single (with Live in partner and 2 children)

Nationality: Filipino

Religion: Roman Catholic

Birth Place: Valenzuela

Admission Date: August 17, 2011

Admitting Time: 11am at ER

Diagnosis: Cholelcystolithiasis for Cholecystectomy

B. CHIEF COMPLAINT:

“Epigastric Pain, radiating to right flank to back of long duration & scheduled for OR this afternoon” according to chart.

C. HISTORY OF PRESENT ILLNESS:

Four months PTA, the patient consulted a private doctor because of fever and vomiting with abdominal pain; epigastric area radiating to RUQ area and was diagnosed with Ulcer. The doctor gave her Ranitidine for medication.

The patient continued to feel the same pain and said that, she consulted the hospital every time the pain occurs and the doctor will just give her injectable (not mentioned) pain reliever. She said that she came in the hospital like more than 10x for 4 months and the hospital was giving her pain reliever.

Until she decided herself to have an ultrasound because the pain was just keep coming back. The Ultrasound shows that she has a stone (about 1.5cm) in the gallbladder. She was then scheduled for operation (Cholecystectomy) on August 17, 2011 at 11am.

D. HISTORY OF PAST ILLNESS:

The patient has no allergies, past surgeries nor hospitalization. According to her she doesn’t have any illnesses such as Hypertension, Asthma, Diabetes Mellitus and etc. She also doesn’t have her regular consultations.

E. FAMILY HISTORY:

The patient’s Father has a history of Hypertension, Mother has Diabetes Mellitus. They have no history of any gallbladder disorder.

F. LIFESTYLE & SOCIAL HISTORY:

She doesn’t smoke; neither drinks alcohol nor use of drugs. But she’s often eats oily fatty foods such as “binagoongan”.

III. ASSESSMENT

A. HEAD TO TOE ASSESSMENT (POST OPERATIVE)

Skin

Uniform color with fever, fair and smooth. No scars, lesions, rashes and the hair are evenly distributed, (+) surgical incision in the RUQ.

Nails

Pale nail beds, 1 second capillary bed refill

Head and Face

The skull is proportionate to body size, no tenderness and there is no scar. Hair is oily, thick and evenly distributed. Face is symmetrical with symmetrical facial movement, (+) facial grimace

Eyes

The client has straight normal eye condition, pupil is black in color and equal in size, have thin eyebrows.

Nose and Thorax

The nasal septum is in the midline, mucosa is moist, (-) secretions,

(-) nasal congestion, (-) sputum, (-) adventitious sound, (-) retractions

Mouth

(+) dry lips, symmetrical, tongue is in midline, complete teeth, pinkish gums, (-) dysphagia,

Neck

The skin is uniform in color. Neck muscles are equal in size and can function well. No tenderness and masses upon palpation.

Breast and Axilla

No masses and tenderness upon palpation

Abdomen

Uniform in color, (+) surgical incision at RUQ with pain scale of 5-6, dry and intact, no abdominal distention, (+) redness and dressing with slight blood content, (-) pus, (-) ascites, (+) function of peristalsis

Upper Extremities

There is resistance for muscle strength.

Lower Extremities

Limited movements due to pain when walking, (-) edema, (-) varicous vein
I and O Urine = 3 as verbalized by the patient, amber in color Bowel = 1 as verbalized by the patient, golden brown

B. AFFECTED SYSTEM

Urinary system, right upper quadrant (RUQ).

IV. COURSE IN THE WARD

|August 17, 2011 – 6am – 2pm |
|11 am |
|>Admitted a 24 years old female, single, accompanied by relatives with cc taken as epigastric pain radiating to right flank |
|to back of long duration and scheduled for OR this afternoon, PTC. |
|>admission care done: |
|BP: 100/70mmhg RR: 25cpm |
|PR: 97bpm Temp: 37 C |
|>scan and examined by the Dr. Duque with orders made and carried out. |
|>admission consent signed |
|>D5LRS IL hooked well as venoclysis @ Left basilic vein using catheter & G18 this regulated @ 31 gtts/min, |
|>NPO instructed & maintained |
|>OR staff notified |
|>endorsed to hand nurse |
| |
|August 17, 2011 – 2pm-10pm |
|>Inform Or at 5:30 pm |
|>with ongoing D5LRS IL @ 700cc level |
|>with IFC intact |
|>place flat on bed |
|>oxygen inhalation rendered @ 21 pm |
|>NPO maintained |
|>medication started |
|>BP: 100/70 mmhg |
|>afebrile |
|>attended |
|>with same IVF @ oxygen inhalation on |
|>still with IFC intact |
|> endorsed for continuity of care. |
| |
|August 18, 2011 – 6am – 2pm |
|>received pt. on bed |
|>with IVF D5NM 1L at 930cc level |
|>IFC |
|>NPO |
|7:40am |
|>seen on rounds by Dr .Piga with orders made and carried out |
|>due meds given |
|9:30am |
|>seen by Dr. Passi with orders |
|9:35am |
|>IFC removed aseptically |
|>encourage to ambulantory |
|>BP 100/80 |
|>(+) flatus, no BMM |
|>afebrile |
| |
|August 18,2011 – 2pm – 10pm |
|>Received pt. on bed |
|>IVF D5NM 490cc level |
|>NPO |
|>dry and intact dressing |
|>encourage for earl ambulance |
|>due meds given |
|>vomited once |
|>referred to ROD with order meds and carried out |
|> BP 110/80 |
|6:20pm |
|>methodoplamide 1 amp. Given TIVP |
|>afebrile |
|7:50pm |
|>above IVF consumed and ffd. With D5LRS 1L and reg. at 30 |
|>attended |
|>same IVF on |
|>endorsed |
| |
|August 18, 2011 – 10pm – 6am |
|>received pt. awake flat on bed |
|>conscious and coherent |
|>with ongoing IVF of D5LRS 1L at 550cc level |
|>O2 inhalation |
|>IFC |
|>NPO main |
|>still flat |
|11:50pm |
|>BP 110/70 |
|>V/S monitored and recorded on separated sheet |
|>slept with interval |
|>meds given |
|>BP 110/70 |
|>afebrile |
|>no BM noted |
|>(-) flatus |
|>NPO still |
|>attended |
|>with same IV on |
|>IFC |
|>O2 inhalation removed at 354cm |
|>endorsed for continuity of care |
|5:30pm |
|>above IVF consumed |
|August 19, 2011 – 6am – 2pm |
|-received with D5LR |
|10:10am |
|-above IVF dislodge and reinserted after. |
|12:30pm |
|-above IVF consumed and follow up with D5LRS x KVO |
|-BP: 90/80 |
|-afebrile |
| |
|August 19,2011 – 2pm – 10pm |
|>-received with ongoing D5LRS at 990xKVO |
|-on general liquids to soft diet. |
|-BP: 100/70 |
|-afebrile |
|-attended |
|-with same IVF on. |
|-endorsed. |
|August 19, 2011 – 10pm – 6am |
|>received pt. with IVF at 980cc level |
|>meds given |
|>slept with intervals |
|>NPO maintain |
|>BP 90/70 |
|>(+) flatus |
|>afebrile |
|>meds attended |
|August 20, 2011 -10am-6pm |
|>received pt. awake |
|>IVF D5LRS 1L 450cc level |
|>on general liquid to soft diet |
|>meds given |
|>afebrile |
|>BP 100/70 |
|>Attended |
|August 20, 2011 – 6am – 2pm |
|-received with ongoing IVF of D5LRS1 at 200 level. |
|-meds given. |
|-seen on rounds by Dr. Emperial with orders made and carried out. |
|12pm |
|-above IVF of D5MMNL with 800cc level. |
|-due meds given. |
|BP:90/70 |
|-afebrile |
|-attended |
|-with same IVF |
|-endorsed |
| |
|August 21, 2011 – 6am – 2pm |
|>received pt. on bed |
|>with ongoing IVF of D5LRS 1L at 950cc level |
|>due meds given |
|>seen on rounds by Dr. Beltran |
|>with orders made and carried out |
|>wound dressing done |
|>BP 90/70 mmHg |
|>afebrile |
|>attended |
|>with same IVF on |
|>endorsed for continuing of care |
|August 21,2011 – 2pm – 10pm |
|>received on bed awake |
|>D5LR @ 600cc |
|>BP: 120/80 |
|>afebrile |
|>attended |
|>with same IVF on |
|>endorsed |
|August 21, 2011 – 10pm – 6am |
|>received pt. awake in bed |
|>with ongoing IVF of D5NM 1L at 400cc level regulated with intervals |
|>meds given |
|August 22, 2011 – 6am – 2pm |
|BP: 90/70 |
|>afebrile |
|August 22,2011 – 2pm – 10pm |
|>received patient with contraption |
|>seen on record by Dr. Passi |
|>ordered med |
|>meds given |
|BP: 90/70 |
|>afebrile |
|>attended |
|>endorsed |
|August 22, 2011 – 10pm – 6am |
|>meds |
|>slept |
|>above IVF consumed |
|BP: 80/60 |
|>afebrile |
|August 23, 2011 – 6am – 2pm |
|>awake |
|>without contraption |
|>addresses of monitor |
|>BP: 100/70 |
|>afebrile |
|>attended |
| |
|August 23,2011 – 2pm – 10pm |
|10:30am |
|>went home in normal condition |
|>With advised |
| |
| |

V. ANATOMY AND PHYSIOLOGY

In some cases, the gallbladder must be removed. The surgery to remove the gallbladder is called a cholecystectomy (pronounced co-lee-sist-eck-toe-mee). In a cholecystectomy, the gallbladder is removed through a 5-to 8-inch long cut in your abdomen. Once the gallbladder is removed, bile is delivered directly from the liver ducts to the upper part of the intestine.

[pic]

Function of liver The liver has many functions. Some of the functions are: to produce substances that break down fats, convert glucose to glycogen, produce urea (the main substance of urine), make certain amino acids (the building blocks J of proteins), filter harmful substances from the blood (such as alcohol), storage of vitamins and minerals (vitamins A, D, K and B12) and maintain a proper level or glucose in the blood. The liver is also responsible for producing cholesterol. It produces about 80% of the cholesterol in your body.

Function of gall bladder.

The function of the gallbladder is to store bile and concentrate. Bile is a digestive liquid continually secreted by the liver. The bile emulsifies fats and neutralizes acids in partly digested food. A muscular valve in the common bile duct opens, and the bile flows from the gallbladder into the cystic duct, along the common bile duct, and into the duodenum (part of the small intestine).

Function of duodenum

The duodenum is largely responsible for the breakdown of food in the small intestine. Brunner's glands, which secrete mucus, are found in the duodenum. The duodenum wall is composed of a very thin layer of cells that form the muscularis mucosae. The duodenum is almost entirely retroperitoneal. The pH in the duodenum is approximately six. It also regulates the rate of emptying of the stomach via hormonal path ways.

Function of pancreas

The pancreas is a small organ located near the lower part of the stomach and the beginning of the small intestine. This organ has two main functions. It functions as an exocrine organ by producing digestive enzymes and as an endocrine organ by producing hormones, with insulin being the most important hormone produced by the pancreas. The pancreas secretes its digestive enzymes, through a system of ducts into the digestive tract, while it secretes its variety of hormones directly into the blood stream. Abnormal pancreatic function can lead to pancreatitis or diabetes mellitus.

Function of cystic duct Bile can flow in both directions between the gallbladder and the common hepatic duct and the (common) bile duct. In this way, bile is stored in the gallbladder in between meal times and released after a fatty meal.
Function of transverse colon The large intestine comes after the small intestine in the digestive tract and measures approximately 1.5 meters in length. Although there are differences in the large intestine between different organisms, the large intestine is mainly responsible for storing waste, reclaiming water, maintaining the water balance, and absorbing some vitamins, such as vitamin K.

VI. PATHOPHYSIOLOGY

VII. DIAGNOSTIC PROCEDURE & LABORATORY STUDY

Open cholecystectomy (koe-le-sis-TEK-toe-mee) is a surgery perfored to treat gallbladder and bile duct diseases. These diseases include cholecystitis (swelling of the gallbladder) and cholelithiasis (stones in the gallbladder or bile ducts). The gallbladder is a pear-shaped organ found under your liver on the right side of your upper abdomen (stomach). It stores bile that comes from the liver and helps in the digestion of food. Bile is carried by the bile duct to the intestines. If left untreated, gallstones or biliary sludge may block the flow of bile. This can cause more swelling, infection, and abdominal pain.

Before surgery:

• Informed consent: A consent form is a legal document that explains the tests, treatments, or procedures that you may need. Informed consent means you understand what will be done and can make decisions about what you want. You give your permission when you sign the consent form. You can have someone sign this form for you if you are not able to sign it. You have the right to understand your medical care in words you know. Before you sign the consent form, understand the risks and benefits of what will be done. Make sure all your questions are answered.

• Enema: You may need to have an enema before your surgery. This is liquid put into your rectum to help empty your bowel.

• IV: An IV (intravenous) is a small tube placed in your vein that is used to give you medicine or liquids.

• Pre-op care: You may be given medicine right before your procedure or surgery. This medicine may make you feel relaxed and sleepy. You are taken on a stretcher to the room where your procedure or surgery will be done, and then you are moved to a table or bed.

• General anesthesia: Physicians use this medicine to keep you asleep and free from pain during surgery. They give you anesthesia through your IV or as a gas. You may breathe in the gas through a mask or through a breathing tube placed down your throat. The tube may cause you to have a sore throat when you wake up.

• Foley catheter: A Foley catheter is a tube that is put into your bladder to drain your urine into a bag. The bladder is an organ where urine is kept. Keep the bag of urine well below your waist. Lifting the urine bag higher will make the urine flow back into your bladder, which can cause an infection. Avoid pulling on the catheter because this may cause pain and bleeding, and the catheter may come out. Do not allow the catheter tubing to kink because this will block the flow of urine. In most cases, physicians will remove the catheter as soon as possible to help prevent infection.

• Tests:

o Abdominal ultrasound: An abdominal ultrasound is a test to see inside your abdomen. Sound waves are used to show pictures of your gallbladder and abdomen on a TV-like screen. This allows your physician to check for stones and other problems.

o Blood tests: You may need blood taken for tests. The blood can be taken from a blood vessel in your hand, arm, or the bend in your elbow. It is tested to see how your body is doing. It can give your physicians more information about your health condition. You may need to have blood drawn more than once.

o X-rays: Before surgery, physicians may want to have an x-ray (picture) of your abdomen to see any other problems. IMPRESSION: Consider cholelithiasis. Follow-up study and clinical correlation is suggested. Nephrolithiasis, right. Unremarkable liver, pancreas (head and body), spleen, left kidney and urinary bladder.

|Diagnostic/ |Indication or purpose |Results |Normal |Interpretation |
|Lab Procedure | | |Values | |
|Ultrasound |Use to visualize the | | | |
| |structure of the human | | | |
| |body. It is indicated to| | | |
| |examine the abdominal | | | |
| |organs to detect any | | | |
| |abnormalities present. | | | |
|Abdominal | | | |IMPRESSION:Consider |
|& CXR | | | |cholecystolithiasis. Follow-up study |
| | | | |and clinical correlation is suggested.|
| | | | |Nephrolithiasis, right. Unremarkable |
| | | | |liver, pancreas (head and body), |
| | | | |spleen, left kidney and urinary |
| | | | |bladder |
|CBC |Is a routine test to | | | |
| |determine any | | | |
| |abnormalities in the | | | |
| |blood sample | | | |
| | | | | |
|*Hemoglobin | | |120-160g/L | |
|*Hematocrit | | |0.36-0.4 | |
|*Red Blood Cell | | |4.20-5.40x10^12L | |
|*White Blood Cell | | |4.50-10.0x10^9L | |
|*Platelet | | |140-440x10/9L | |

During surgery:

After you go to sleep, your body will be moved into position for your surgery. Your skin is cleaned with soap and water and covered with sheets. An incision (cut) is made in your abdomen to reach the gallbladder. Once it is seen, the blood vessels attached to it are tied off and cut. It is removed carefully, making sure not to damage the liver. Your physician checks for bleeding and the other damage to organs nearby. Your physician may place a drain (small tube) to let fluid flow out from your abdomen. The incision is closed with sutures (stitches) and covered with a bandage.

After surgery:

You may be taken to a recovery room, where you will stay until you are fully awake. Physicians will watch you closely for problems. Do not attempt to get out of bed until your physician says it is OK. When physicians see that you are OK, you will be taken back to your hospital room. The bandages covering your incision keep the area clean and dry to prevent infection. A physician may remove the bandages soon after your surgery to check your incision. • Activity: Physicians may help you get out of bed to walk on the same day of surgery, or the day after. Ask physicians if there are exercises that you may do while in bed. Exercise helps blood move through your body and may help prevent blood clots from forming. Your physician will tell you when it is okay to get out of bed. Call your physician before getting up for the first time. If you feel weak or dizzy while standing up, sit or lie down right away, and call your physician.

• Deep breathing and coughing: This breathing exercise helps to keep you from getting a lung infection after surgery. Deep breathing opens the tubes going to your lungs. Coughing helps to bring up sputum (mucus) from your lungs for you to spit out. You should deep breath and cough every hour while you are awake even if you wake up during the night.

o Hold a pillow tightly against your incision (cut) when you cough to help decrease the pain. Take a deep breath and hold the breath as long as you can. Then push the air out of your lungs with a deep, strong cough. Put any sputum that you have coughed up into a tissue. Take 10 deep breaths in a row every hour while awake. Remember to follow each deep breath with a cough.

o You may be asked to use an incentive spirometer. This helps you take deeper breaths. Put the plastic piece into your mouth and take a very deep breath. Hold your breath as long as you can. Then let out your breath. Use your incentive spirometer 10 times in a row every hour while awake.

• Diet: You may be able to eat when bowel sounds are heard. Your physician will listen to your stomach for bowel sounds using a stethoscope. You may be given ice chips at first, and then liquids such as water, broth, juice, or soda pop. If you do not have problems after drinking liquids, physicians may then give you soft foods. Some examples of soft foods are ice cream, applesauce, or custard. Once you can eat soft food easily, you may begin eating your usual diet.

• Medicines: You may need any of the following:

o Antibiotics: Antibiotics may be given to help treat or prevent an infection caused by germs called bacteria.

o Pain medicine: Physicians may give you medicine to take away or decrease your pain.

▪ Do not wait until the pain is severe to ask for your medicine. Tell physicians if your pain does not decrease. The medicine may not work as well at controlling your pain if you wait too long to take it.

▪ Pain medicine can make you dizzy or sleepy.

-----------------------

-Diet
(High fat diet)

-Age (24y/o)
-Female

Sphincter oddi relaxes then gallbladder contracts

Allows the bile to enter the intestines

If bile contains too much cholesterol that usually remains dissolved in the bile

Bile becomes oversaturated with cholesterol

Cholesterol becomes insoluble and crystallizes

Gallstones in gallbladder which retain the small crystals and allows them to grow

Stones may travel to bile ducts from gallbladder

Can cause narrowing of bile ducts

Obstruction of the bile flow

Icteric sclerae

Nausea

Pain in upper middle or upper right abdomen

Vomiting

Fever
38.1 ºC