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Case Study Cholelithiasis
Case Study Cholelithiasis
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TABLE OF CONTENTS
CHAPTER II – ASSESSMENT
A. Nursing Health History
Personal Data
Past Medical History
Present Medical History
Family Health History
B. Physical Assessment
C. Laboratory Exams
D. Anatomy and Physiology
E. Pathophysiology
CHAPTER IV – IMPLEMENTATION
A. Discharge Planning
CHAPTER I
OBJECTIVES
INTRODUCTION
CHAPTER II – ASSESSMENT
A. NURSING HEALTH HISTORY
PERSONAL DATA
Name: L. M.
Age: 24 years old
Sex: Male
Address: Mandaluyong City
Civil Status: Married
Nationality: Filipino
Religion: Roman Catholic
Birth Place: Pampanga
Admission:
Date: December 31, 2007
Time: 3pm at ER
Admitting Diagnosis:
- T/C Ascending Cholangitis
Choledolithiasis cystic duct stones
- S/P Papillotomy with stone extraction
Attending Physician: Dr. Buelva
The patient is a smoker and alcohol drinker but stopped 2 years ago.
The patient stated that he was confined at Mandaluyong City Medical
Center because of jaundice and stomachache. Then after 4 hours in the
operating room, he was transferred to UERM.
- The patient was admitted December 31, 2007 at 3pm with a chief
complaint of abdominal pain.
- 1 day PTA, the patient developed fever and vomiting with abdominal
pain; epigastric area radiating to RUQ area.
- Patient consulted at the Emergency Room, Patient was managed at ER
and subsequently admitted.
B. PHYSICAL ASSESSMENT
VITAL SIGNS
Pulse Rate (80) 60-100 bpm 103 bpm Increased pulse rate
indicates Tachycardia
Skin
Uniform color with slightly warmer than normal temperature, dry and
smooth. No scars and hairs are evenly distributed.
Nails
Pale and Clean
Head and Face
The skull is proportionate to body size, no tenderness and there is a scar.
Hair is oily, thick and evenly distributed. Face is symmetrical with
symmetrical facial movement.
Eyes
The client has straight normal eye condition; with yellowish sclera. Pupil is
black in color and equal in size. Have thin eyebrows.
Nose
The nasal septum is in the midline, mucosa is moist.
Mouth
The lips are pale and dry, symmetrical, pale mucosa, tongue is in midline.
Neck
The skin is uniform in color. Neck muscles are equal in size. No
tenderness and masses upon palpation.
Breast and Axilla
No masses and tenderness upon palpation
Abdomen
Uniform in color. There is a wound dressing at RUQ, dry and intact.
Upper Extremities
There is resistance for muscle strength.
Lower Extremities
*Not done because of present condition*
C. LABORATORY EXAMINATIONS
HEMATOCRIT 0.37 – 0.54 0.18 Decreased because the patient have a bile infection
RED BLOOD CELL 4.0 – 6.0 x 1012L 1.96 Decreased oxygen production due to bile infection
that cause anemia
WHITE BLOOD CELL 4.5 – 10 x 109L 33.2 Increase because infection started
DIFFERENTIAL
COUNT
NEUTROPHILS 0.38 – 0.68 0.70 Slightly increase because of WBC elevation
(segmenters)
LYMPHOCYTES 0.22 – 0.53 0.30 Normal range
A complete blood count (CBC), also known as full blood count (FBC) or full
blood exam (FBE) or blood panel, is a test requested by a doctor or other
medical professional that gives information about the cells in a patient's
blood. A Medical technologist performs the requested testing and provides
the requesting Medical Professional with the results of the CBC. A CBC is also
known as a "hemogram".
The cells that circulate in the bloodstream are generally divided into three
types: white blood cells (leukocytes), red blood cells (erythrocytes), and
platelets or thrombocytes. Abnormally high or low counts may indicate the
presence of many forms of disease, and hence blood counts are amongst the
most commonly performed blood tests in medicine.
HEMOGLOBIN:
Is a protein that is carried by the red cells. It picks up oxygen in the lungs
and delivers it to the peripheral tissues to maintain the viabilty of the cells.
The amount of hemoglobin in the blood, expressed in grams per litre. (Low
hemoglobin is called anemia.)
NEUTROPHILS:
This is the main defender of the body against infection and antigens. High
levels may indicate an active infection.
May indicate bacterial infection. May also be raised in acute viral infections.
LYMPHOCYTES:
Is a type of blood cell in the vertebrate immune system.
Elevated levels may indicate an active viral infections.
Higher with some viral infections such as glandular fever and. Also raised in
lymphocytic leukaemia CLL.
MONOCYTES:
May be raised in bacterial infection
Is a leukocyte, part of the immune system that protects against bloodborne
pathogens and moves quickly to sites of infections in the tissue.
Elevated levels may indicate an allergic reactions or parasites.
EOSINOPHILS:
Are white blood cells of the immune system that are responsible for
combating infection by parasites in vertebrates. They are granulocytes that
develop in the bone marrow before migrating into blood.
Increased in parasitic infections.
High levels are found in allergic reactions.
BASOPHILS:
Circulates vhite blood cells.
Basophils degranulate to release histamine, proteoglycans (e.g. heparin and
chondroitin), and proteolytic enzymes (e.g. elastase and lysophospholipase).
They also secrete lipid mediators like leukotrienes, and several cytokines.
PLATELET COUNT:
Platelets or thrombocytes are the cell fragments circulating in the blood that
are involved in the cellular mechanisms of primary hemostasis leading to the
formation of blood clots. Dysfunction or low levels of platelets predisposes to
bleeding, while high levels, although usually asymptomatic, may increase the
risk of thrombosis.
Functions of Platelets can be generalised into a number of categories:
Adhesion, Aggregation, Clot retraction, Pro-Coagulation, Cytokine signalling,
Phagocytosis.
A normal platelet count in a healthy person is between 150,000 and 400,000
per mm³ of blood (150–400 x 109/L). 95% of healthy people will have
platelet counts in this range. Some will have statistically abnormal platelet
counts while having no abnormality, although the likelihood increases if the
platelet count is either very low or very high.
Low platelet counts are generally not corrected by transfusion unless the
patient is bleeding or the count has fallen below 5 x 109/L; it is
contraindicated in thrombotic thrombocytopenic purpura (TTP) as it fuels the
coagulopathy. In patients having surgery, a level below 50 x 109/L) is
associated with abnormal surgical bleeding, and regional anaesthetic
procedures such as epidurals are avoided for levels below 80-100.
PERIPHERAL SMEAR:
- A Peripheral smear is a blood test that gives information about the number
and shape of blood cells.
URINALYSIS REPORT
PHYSICAL EXAMINATION:
Color- amber
Transparency- turbid
PH- 6.0
sp.gr- 1.020
CHEMICAL EXAMINATION:
Leukocytes-
Albumin- negative
Ketons-
Billirubin- positive (+++)
Nitnte-
Sugar- negative
Urobilinogen-
Blood-
MICROSCOPIC EXAMINATION:
Epithelial cells- occasional
Mucus thread-
Amorphous urates-
PUS or WBC- 0-1/hpf
RBC-
Casts-
Crystals-
Bacteria- moderate
LABORATORY MEDICINE (CLINICAL CHEMISTRY I)
ELECTROLYTES
X-RAY
Plain film is unremarkable. ERCP shows good filling of the common, right &
left hepatic ducts. The common bile duct & common hepatic duct are slightly
dilated. No evidence of lithiasis & filling defects are noted.
ULTRA SOUND
The liver is normal in size and outline. The hepatorenal interface is intact.
Parenchumal echogenicity is increased w/ no focal mass or calcifications
seen. Intrahepatic duct are dilated. The common bile duct has diameter of
1.2cm.
The gallbladder is normal in size & configuration, the wall is smooth & not
thickened. There are two shadowing hypere chor foci seen in the area of
gallbladder neck/cystic duct measuring about 1.1cm & 0.9cm.
The pancreas is not well visualized in this study due to abundant bowel gas
obscuring it.
IMPRESSION:
1) Fatty infiltrative changes of the liver considered.
2) Biliary tract obstruction most likely secondary to lithiasis formation. Exact
location not well determined.
3) Lithiase formation in the gallbladder neck/cystic duct.
BLOOD TRANSFUSION
ELECTROCARDIOGRAM (ECG)
Done & recorded
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
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 fore
producing cholesterol. It produces about 80% of the cholesterol in your body.
Function of duodenum
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 bloodstream.
Abnormal pancreatic function can lead to pancreatitis or diabetes
mellitus.
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.
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.
C. DRUG STUDY
CHAPTER IV – IMPLEMENTATION
DISCHARGE PLANNING
M – MEDICINE
- Advice patient to continue taking his prescribed medicines like
Ceftriaxone and Tramadol.
T – TREATMENT
- Continue home medications.
- Teach patient about wound care
- Encourage patient to take multivitamins for immunity
H – HEALTH TEACHING
- Provide written and oral instructions about wound care, activity,
diet recommendations, medications, and follow-up visits.
- Instruct patient to limit his activity for 24 to 48 hrs after discharge.
D – DIET
- Encourage patient to increase protein intake for tissue repair
- Advice patient to eat smaller-than-normal amounts of food at
mealtime.
S – SPIRITUALITY
- Encourage patient to communicate with God.
- Encourage patient to communicate with other people.
CHAPTER III - PLANNING
Subjective: Pain discomfort, > After 3hrs. of > Monitor v/s of > To obtain > After 3hrs. of
related to Nursing the patient baseline data Nursing
“Samasakit ang surgical incision. Intervention the Intervention the
tahi ko sa pain will be pain will be
tiyan”as lessen. > Encourage > To lessen the lessen.
verbalized by the verbalization of pain of the
patient. Pain scale feelings about patient. Pain Scale
> 5/10 to 3/10 pain. > 5/10 to 3/10
Objective:
> Provide non- > To relax &
>Temp. 37.7°c pharmacological provide comfort
>RR: 36 cpm Therapies ex.: to the patient.
>PR: 103 bpm Radio, Books,
>BP: 120/80 Socialization w/
others.
>(+)Facial
Grimace > Provide calm > To lessen the
activities. pain of the
>Irritable patient.
Subjective: Anxiety related to Short term: > Assess > To establish Short term:
“Nahihirapan ako change in health At the end of patient’s level of baseline data. At the end of
ngayon sa sakit status, as 5Hrs. of nursing anxiety. 5Hrs. of nursing
ko”. As evidence by fear intervention intervention
verbalized by the of specified patient will be > Place patient in > To help the patient was able
patient. consequence. able to reduce comfortable patient have to reduce feeling
anxiety. position. adequate period of anxiety.
Objective: of rest and sleep.
Vital signs taken
and recorded: > Provide non- > To relax &
Long term: pharmacological provide comfort Long term:
BP: 120/80 After two weeks Therapies such to the patient. After two weeks
PR: 103 BPM of nursing care, as: of nursing care,
RR: 36 CPM patient will be T.V, Radio, patient was able
Temp: 37.7°C able to accept Books, to accept
changes in health Socialization w/ /understand his
status. others. health status.
Cholelithiasis
Refers to the formation of calculi
(e.g. gallstones in the gallbladder)
There is inflammation
Removal of the Increase
due to infection
gallbladder after Bile stasis Gastric irritation bilirubin
ligation of the
cystic duct
Biliary Cholecystitis
cirrhosis Rupture of if If not treated
gallbladder
Peritonitis Death