BULACAN STATE UNIVERSITY

CITY OF MALOLOS, BULACAN

COLLEGE OF NURSING

OSPITAL NG GUIGUINTO
(MEDICAL WARD)

A CASE STUDY ABOUT

ACUTE CALCULOUS CHOLECYSTITIS

SUDBMITTED BY:
LACAS, JOHN PHILIP
REYES, FIONA NOELLE
(BSN III-D GROUP 3)

SUBMITTED TO:
MR. ROGIE ABALLOS, R.N
(CLINICAL INSTRACTOR)
NURSING ASSESSMENT

A. BIOGRAPHIC DATA

NAME : Wilhelmina Boday

ADDRESS : # 422 Narey Street, Rocka Village, Tabe, Guiguinto, Bulacan

AGE : 48 Years Old

BIRTH DATE : November 02, 1960

GENDER : Female

RELIGION : Roman Catholic

RACE : Asian

STATUS : Married

OCCUPATION : Businesswoman

SOURCE OF HEALTH FINANCING : Herself

DATE OF ADMISSION : September 21, 2009 (12:50pm)

ADMITTING DIAGNOSIS : RUQ Abdominal Pain

FINAL DIAGNOSIS : Acute Calculous Cholecystitis

B. CHIEFT COMPLAINT

The patient complains of RUQ abdominal pain which is happened for almost 2 weeks, according to her.
C. HISTORY OF PRESENT ILLNES

According to her, she often experience RUQ abdominal pain for almost how many years. First, she thought that the pain which she felt is caused by a

hyperacidity attack and try to manage it by taking Aluminum Hydroxide (Kremil S) an antacid drug. As time past by the abdominal pain became

severe and even an antacid drug cannot relieved the symptoms. Then she decided to consult a doctor, which is last January 2009. According to her

the doctor gave her Omeprazole (Prisolec) a Proton Pump Inhibitor which work to stop acid secretion of the stomach. Then it works and it can now

relieve the abdominal pain which she felt. After few months, this September of the same year, the abdominal pain came back and became more sever

with a pain scale of 7/10. Then last Sept. 21, 2009, they decided to bring her in Ospital Ng Guiguinto and seek for some medical explanation. The

doctor said she have gallstone and she will be going to undergo a surgery which is Cholecystectomy.

D. PAST HISTORY OF ILLNESS

According to her, she was complete in different immunization offered at that time. She already has Mumps and Varicella; do not have any known

food or drug allergies: and have not suffered from any minor or major injury when she was a child.

E. FAMILY HISTORY OF ILLNESS

According to her, besides in having Cholecystitis, she also has Hypertension & Diabetes Mellitus Type 1. Her father has Hypertension as well as her

2 siblings: her Mother died with unknown cause; the uncle in her mother side also has Diabetes Mellitus. And there is no family history of

Osteoarthritis, Malignant Neoplasia and Cholecystisis.

 GENOGRAM

N N
N
/A /A /A
N
/A

N N N
/A /A 72 N
/A /A N
/A 69 N
/A

50 48 37
52

N
MALE PATIENT ALIVE AND WELL /A NOT AVAILABLE DIABETES MELLITUS
 FEMALE HYPERTENSION DECEASED CHOLECYSTITIS

F. DEVELOPMENTAL TASK

NAME: WILHELMINA BODAY AGE: 48 YEARS OLD HOSPITAL: OSPITAL NG GUIGUINTO (MEDICAL WARD) DATE: 09-24-09

THEORY ERIK ERIKSON SIGMUND FREUD JEAN PIAGET LAWRENCE JAMES FOWLER
THEORY OF THEORY OF THEORY OF KOHLBERG THEORY THEORY OF FAITH
PSYCHOSOCIAL PSYCHOSEXUAL COGNITIVE OF MORAL DEVELOPMENT
DEVELOPMENT DEVELOPMENT DEVELOPMENT DEVELOPMENT

UNIVERSALIZING
FAITH
STAGE MIDDLE GENITAL STAGE FORMAL POST
ADULTHOOD OPERATIONS CONVENTIONAL
PSYCHOLOGICAL CRISIS:
GENERATIVITY VS
STAGNATION

RELATED ELEMENT IN
SOCIETY: PREPARING,
EDUCATING & GIVING
SOCIAL INVOVEMENT FOR
THE NEXT GENERATION.

Generativity is the True maturity requires the The person at this stage An individual reaches this Unitive view of reality
concern of establishing timing of aggressive and can think abstractive. stage acts out universal and enlightenment.
DEFINITION and guiding the next sexual urges, allowing principles based upon the
 generation. Socially- their to released their equality and worth of all
valued work and repress feeling in a more human beings.
disciplines are social and acceptable
expressions of manner.
generativity. Simply
having or wanting
children does not in and
of itself achieve
generativity

  Our pt. has feeling of She has a healthy sex life Our pt. accepts opinions She can decide accurately The religion of our pt. is
generativity because she and does not suffering from other. She responds and relevant to situation. Roman Catholic; there is
EXPLANATION already have established from any sexual problem. correctly and appropriate And have a good moral no problem in terms of
and guided her children to situation and questions. insight in her life. faith and devotion to God.
by giving a good life and The pt. has relevance of
education. thought and good insight
in organization of vital
event in her life.
 FUNCTIONAL PRIOR HOSPITALIZATION DURING HOSPITALIZATION
HEALTH
PATTERN

HEALTH PERCEPTION She believed in herbal medication like Lagundi Leaves extract in treating cough When I ask her if she can follow what doctor & nurse advices them, she verbalized “
& HEALTH and Guava Leaves extract as an effective anti-microbial agent; she also go to sa abot ng aking makakaya,kailangan kong sundin ang mga gusting ipagawa ng
MANAGEMENT faith healers like Manghihilot as a primary source of health remedies if they doctor, kasi para rin ito sa kabutihan ko”
PATTERN experience unserious medical problems.
The patient also experienced hyperthermia (38.2).

NUTRITIONAL 3 DAYS FOOD RECALL 3 DAYS FOOD RECALL

METABOLIC PATTERN FOOD FLUID FOOD FLUID

DATE BREAKFAST LUNCH DINNER BREAKFAST LUNCH DINNER DATE BREAKFAST LUNCH DINNER BREAKFAST LUNCH DINNER

SEPT. 18, N/A N/A N/A N/A N/A N/A SEPT. 22, 3 Bread Sinigang Chapsuey, 1 Glass of 2-3 2
2009 2009 na 1Cup of Water Glasess Glasess
Baboy, 1 Rice of of
SEPT. 19, N/A N/A N/A N/A N/A N/A Cup of Water Water
2009 Rice, 1
piece of
SEPT. 20, N/A N/A N/A N/A N/A N/A Banana
2009
SEPT. 23, 1 Piece of Ginisang Sinigang 1 Glass of 1-2 1-2
2009 Egg, 1 Cup Gulay, 1 na Isada, Water Glass Glass
of rice Cup of 1 Cup of of of
She’s taking vitamins, specifically Ascorbic Acid continuously, she eats mostly Rice Rice Water Water
fishes & meat, she is fun of eating food rich in seasoning and drinking cola most
of the time, and not experienced weight lost lately. There is no skin problem SEPT.24, 1 Serving of NPO NPO 1 Glass of NPO NPO
noted. There are 3 missing molars and there is no problem in wound healing. 2009 Mami Water
 During hospitalization she cannot eat what her want. And there is sudden decreased in
appetite.

ELIMINATION FECAL-URINARY ELIMINATION PATTERN FECAL-URINARY ELIMINATION PATTERN

PATTERN

CATEGORY FREQUENCY COLOR/CONSISTENC DEVIATION CATEGORY FREQUENCY COLOR/CONSISTENCY DEVIATION

Y
1. URINATON - 5 to 8 as Straw None
estimated 1. URINATON 3 Straw None
- Depends upon
the weather
2. DEFECATIO 2 Brown/Formed None
2. DEFECATION 1 Brown/Hard Constipation
N

ACTIVITY-EXERCISE She considered household chores as a form of exercise.
PATTERN
O Feeding O Bathing O Dressing O Toileting
O Shopping O Home Maintenance O Bed Mobility O General Mobility
There is no form of exercise upon admittance to hospital.
I Feeding N/A Bathing I Dressing I Toileting
N N
/A Shopping /A Home Maintenance I Bed Mobility II General Mobility

Level O - Independent Level O - Independent

Level I - With help from others Level I - With help from others
Level II - With equipment Level II - With equipment
Level III - With help from others & equipment Level III - With help from others & equipment
Level IV - Dependent Level IV – Dependent

SLEEP-REST PATTERN Prior hospitalization, she sleep for approximately 7 hours each night from 10pm
to 5 am, there is no sleep problem noted, she take naps every afternoon, more
often from 2pm to 3pm, all in all the total no. of sleep is 8 hours in every 24
hours, the form of relaxation is thru watching her favorite TV program, chatting
with her family or sometimes her friends & reading news clippings.
During hospitalization, she only sleeps for about 5 hours each night in intermittent
manner, because of environmental factor (sudden changed in environment) &
physiological factor (RUQ Abdominal Pain).

COGNITIVE No hearing and eye problems. According to her, she often experience tip of the Still no change.
PERCEPTUAL tongue phenomenon together with slight confusion.
PATTERN
 SELF PERCEPTION She is satisfied with her physical appearance; lately she felt easily tired. There is Still no change.
SELF CONCEPT no major problem in her self as a whole, according to hers he easily felt angry to
PATTERN those people whose are liars and do not know how to return dept of gratitude’s.

ROLE RELATIONSHIP She is already married, with 3children. They are 5 in the family. She and Her Still no change.
PATTERN husband are responsible for most of the health decision in their family. And
these factors made their family as Nuclear in membership and Egalitarian in
authority.

There is no major family problem encountered lately, and if there is a problem

they handle it by means of having open forums. There is no problem in her
community interaction & there is no feeling of isolation from others.

SEXUALLY She is sexually active; formerly she’s using Oral contraceptive Pills as a form of Still the same.
REPRODUCTIVE family planning method.
PATTERN

COPING STERSS If she has problem, she just kept those problem by herself without saying to Now she is on hospital, she needs the help of other by means of sharing her personal
PATTERN others. problems to lessen the loads which she kept deep inside.

According to her she is very nervous at the same time fearful about the possible
outcome of surgery, if it will be successful or not.

VALUE BELIEF For her religion is very important in her life, although she cannot go to church Now she needs more the help of God, she seek for help by means of praying.
PATTERN regularly.
PATIENT AND HIS DISEASE

A. SCHEMATIC DIAGRAM

MODIFIABLE FACTOR NON MODIFIABLE FACTOR

- LIFESYLE (SEDENTARY) ` - FEMALE, FAIR, AGE (FORTHY)
- DIET (FAT)

HYPERSATURATION OF BILE WITH

CHOLESTEROL & CALCIUM

PRESIPITATION OF SOLUTE FROM

SOLUTION & BECOME CRYSTAL
 CRYSTAL MUST COME TOGETHER
& FUSE TO BECOME CALCULI

GALLSTONE

SHARP PAIN IN THE CHOLELITHIASIS

RIGHT HYPOCHONDRIUM

BILIARY COLLIC DISTENTION OF

 THE GALLBLADDER

VENOUS & LYMPHATIC LOCALIZED CELLULAR

DRAINAGE ARE IMPAIRED OR INFILTRATION

PROLIFERATION OF BACTERIA ISCHEMIA

INFLAMMATION OF GALLBLADDER

CHOLECYSTITIS
B. DEFINITION OF DISEASE

 Cholecystitis is often caused by cholelithiasis (the presence of choleliths, or gallstones, in the gallbladder), with choleliths most commonly blocking

the cystic duct directly. This leads to inspissation (thickening) of bile, bile stasis, and secondary infection by gut organisms, predominantly E. coli

and Bacteroides species.

 The gallbladder's wall becomes inflamed. Extreme cases may result in necrosis and rupture. Inflammation often spreads to its outer covering, thus

irritating surrounding structures such as the diaphragm and bowel.

 Stones in the gallbladder may cause obstruction and the accompanying acute attack. The patient might develop a chronic, low-level inflammation

which leads to a chronic cholecystitis, where the gallbladder is fibrotic and calcified.

C. PREDISPOSING & PRECIPITATING FACTORS

 Female, Fat (Diet), Frothy(Age), Fertile & Fair

D. SIGN & SYMPTOMS WITH RATIONALE

 Cholecystitis usually presents as a pain in the right upper quadrant. This is usually a constant, severe pain. The pain may be felt to 'refer' to the right

flank or right scapular region at first.

 RATIONALE: Gallbladder is located in the RUQ of the Abdominal Cavity along the Left Hypochondriac Region. The pain which the patient felt is
due to Gallbladder distention & this pain is also known as Biliary Collic.

 This is usually accompanied by a fever, vomiting and nausea.

RATIONALE: Fever due to presence of infection; Vomiting is intended to protect a person from harmful ingested substances. However, chronic
nausea and vomiting are typically a pathologic response to any of a variety of conditions.

E. REVIEW OF SYSTEM

SYSTEM DEVIATION
1. GASTROINTESTINAL SYSTEM - Although the upper gastrointestinal tract is relatively bacteria-free,
bacterial overgrowth could potentially occur in the setting of impaired
gallbladder motility.

- Changes in the biliary tract flora, coupled with impairment of the normal
barrier function, allow the gallbladder to serve as a reservoir for pathogens
that can enter the portal and systemic circulations.

- This condition can cause Peritonitis or Septic Schock.

2. INTEGUMENTARY SYSTEM - Accumulation of bile salt under the skin can cause Pruritus or Itching.

- Obstruction of biliary or common bile duct can cause Icterus or Jaundice.

ANATOMY & PHYSIOLOGY

 A. ANATOMY OF GASTROINTESTINAL SYSTEM

Upper gastrointestinal tract

The upper GI tract consists of the mouth, pharynx, esophagus, stomach, and duodenum proximal to the ligament of Treitz.

 The mouth contains the buccal cavity, which contains the openings of the salivary glands; the tongue; and the teeth.

 Behind the mouth lies the pharynx which prevents food from entering the voice box and 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.

Lower gastrointestinal tract

The lower GI tract comprises the most of the intestines and anus.

 Bowel or intestine

o Small intestine, two of the three parts:

 Duodenum

 Jejunum

 Ileum
 o 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

Accessory organs

Accessory organs to the alimentary canal include the liver, gallbladder, and pancreas. The liver secretes bile into the small intestine via the bile duct, 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, which helps neutralize the acidic chyme, 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.

B. PHYSIOLOGY OF GASTROINTESTINAL SYSTEM

Specialization of organs

Four organs are subject to specialization in the kingdom Animalia.

 The first organ is the tongue which is only present in the phylum Chordata.
  The second organ is the esophagus. The crop is an enlargement of the esophagus in birds, insects, and other invertebrates that is used to store food

temporarily.

 The third organ is the stomach . In addition to a glandular stomach (proventriculus), birds have a muscular "stomach" called the ventriculus or "gizzard." The

gizzard is used to mechanically grind up food.

 The fourth organ is the large intestine. An outpouching of the large intestine called the cecum is present in non-ruminant herbivores such as rabbits. It aids in

digestion of plant material such as cellulose

Transit time

The time taken for food or other ingested objects to transit through the gastrointestinal tract varies depending on many factors, but roughly, it takes 2.5 to 3 hours

after meal for 50% of stomach contents to empty into the intestines. Total emptying of the stomach takes 4 to 5 hours. Subsequently, 50% emptying of the small

intestine takes 2.5 to 3 hours. Finally, transit through the colon takes 30 to 40 hours.
The Gallbladder

The gallbladder is a thin, green, saclike structure located on the inferior portion of the liver that stores and modifies bile not immediately needed for digestion. It is

~8 cm long and 4 cm wide and has three layers: the inner mucosa, muscularis, and serosa. The inner mucosa is folded to allow for expansion. The muscularis

contains smooth muscle that allows for contraction. The serosa is the outer covering. The regions of the gallbladder itself include the fundus, body, and neck. It is

connected to the common bile duct via the cystic duct (Figures 5 & 6). Ingesting large amounts of lipids stimulate cholecystokinin (CCK) release into the

bloodstream causing Bile secretion into the duodenum.

 THE PATIENT AND HIS CARE

A. MEDICAL MAGAEMENT

IVF DATE ORDERED GENERAL DESCRIPTION INDICATION CLIENTS RESPONSE

PNSS September 21, 2009 A salt solution (sodium chloride in
water) which has the same salt
content as the normal body fluid,
so that the body will think that it is
just a part of the body fluid.
PNSS can be used to replace fluids Fluid loss was replaced.
in dehydration, go with blood
transfusions, hyponatremia, and
burn victims, it is isotonic,( same
osmolarity as our body fluids)
 B. DIET

TYPE OF DIET DATE STARTED GENERAL INDICATION SPECIFICT FOD CLIENTS RESPONSE
DESCRIPTION TAKEN

DIABETES DIET September 21, 2009 - Limiting sweets. To maintain nornal blood Whole grains Prevent further
- Eating often. glucose level. (oatmeal,cereals), complications due to
- Being careful about when vegetables, fishes. elevated blood glucose
and how many. level.
Carbohydrates you eat.
- Eating lots of whole-grain
foods, fruits and
vegetables.
- Eating less fat.
- Limiting your use of
alcohol.

NOTHING PER OREM September 4, 2009 - No food should be taken - Preparation for abdominal - No ingestion of solid or - Prevent risk for aspiration
P.O. surgery. Liquid foods. during cholecystectomy.
- All P.O medication
should be discontinuing.

C. EXERCISE & ACTIVITY

 CLIENT'S RESPONSE
The pt. was cooperative and
willing to perform the exercise as
he is aware of its importance
The pt is actively participative
and says that he exercises
everyday.
INDICATION
An exercise advised to be
performed by patients expected
and scheduled for surgery
An exercise indicated for patients
with musculoskeletal impairment
GEN. DESCRIPTION DATE EXERCISE
An exercise enhancing the N/A DEEP BREATHING
cardiac muscle and organs to EXERCISE
function, preparing the patient
for surgery and preventing
respiratory arrest.
ACTIVE ROM- this is done by N/A RANGE OF MOTION
the pt, it increases and maintains EXERCISES
muscle tone and joint mobility
PASSIVE ROM- the nurse
assists the pt in performing the
exercise to enhance joint and
muscle function
RESISTIVE ROM- it is the
contraction of the muscle against
an opposing force or weight, it
increases the muscle power
SURGIGAL MANAGEMENT

A. CHOLECYSTECTOMY

 Is the surgical removal of the gallbladder. Despite the development of non-surgical techniques, it is the most common method for treating symptomatic gallstones,

although there are other indications for the procedure, including carcinoma. Surgery options include the standard procedure, called laparoscopic cholecystectomy,

and an older more invasive procedure, called open cholecystectomy. A cholecystectomy is performed when attempts to treat gallstones with ultrasound to shatter

the stones (lithotripsy) or medications to dissolve them have not proved feasible.

B. NURSING RESPONSIBILITY

PRIOR DURING AFTER

- Secure consent. - Assess & monitor patient general condition. - Reassess vital sign.

- Assess vital sign. - Maintain NPO until bowel sound return.

- Maintained NPO. - Diet Progression from clear liquid to full liquid to
soft diet.

- Monitor for complications( Bleeding is the

priority)

- Administer medication correctly.

- Health teaching regarding present condition.

LABORATORY FINDINGS

A. CHEST X-RAY PA

 FINDINGS: HEARTH IS ENLARGED

PULMONARY VASCULARITY IS PROMINENT

DIAPHRAGM IS ELEVATED

 IMPRESSION: SLIGHT CARDIOMEGALLY

MINIMAL PULMONARY HYPERVASELARITY

B. ECG

 IMPRESSION & FINDINGS: REGULAR SINUS RHYTHM & LEFT AXIS DEVIATION
 C. BLOOD CHEMISTRY

DATE: SEPT. 22, 2009

TEST ACTUAL FINDINGS NORMAL FINDINGS

FBS 70-105 mg/dl
BUN 15 mg/dl 8-25 mg/dl
CREATININE 1.0 mg/dl 0.5-1.7 mg/dl
BLOOD URIC ACID 2.5-7.7 mg/dl
CHOLESTEROL <200 mg/dl
TRIGLYCERIDES 44-148 mg/dl
HDL-CHOLE M=26-63 mg/dl

F=33-75 mg/dl
LDL-CHOLE 40-140 mg/dl
VLDL-CHOLE 0-40 mg/dl
Na 142.5 mEq/L 135-155 mEq/L
K 3.9 mEq/L 3.4-5.3 mEq/L
SGPT 5-35 iu/L
SGOT 10-40iu/L
Mg 1.3-2.5 mEq/L
Ca 8.5-10.5 mEq/L

D. HEMATOLOGY

DATE: SEPT.22, 2009

 TEST RESULT NORMAL VALUES
HEMOGLOBIN 139 g/L M=140-175

F=123-135
HEMATOCRIT 0.45 g/L M=0.41-0.50

F=0.35-0.44
WBC 8.9*10 g/L 4.5-10
RBC 4.6810 12/L 3.8-5.8
SEGMENTS 78 43-76
LYMPHOCYTES 22 17-48

E. URINALYSIS

PHYSICAL EXAMINATION: CHEMICAL EXAMINATION:

COLOR- YELLOW pH- 5.0 ALBUMIN- =/-

CHARACTERISTICS- HAZY SGPT- 1.025 SUGAR- NEGATIVE