RAMA COLLEGE OF NURSING

CASE STUDY
ON
CHOLELITHIASIS

SUBMITTED TO:

MRS. SHIPRA SACHAN

ASSISTANT PROFESSOR

RAMA COLLEGE OF NURSING

SUBMITTED BY:

REBINA MOIRANGTHEM

I YEAR M.Sc. (N)

RAMA COLLEGE OF NURSING

DATE OF SUBMISSION: 25/02/2022

 BIOGRAPHIC INFORMATION

Name: Mr. Samar Singh

Age: 49 years
Sex: Male
Father’s name: Mr. Dindayal
Occupation: School teacher
Income: 1,50,000/ annum
Marital status: Married
Religion: Hindu
Nationality: Indian
I. P. D no: 279992
REG no: 1605152
Ward: General Medical Ward
Bed number: 1
Name of the consultant: Dr. Mahesh Gupta
Diagnosis: Cholelithiasis
Date of admission: 08/02/2022
Time of admission: 04:36pm
Local address: - Qutbuddin Bartal, Farrukhabad

CHIEF COMPLAINTS
My client, Mr. Samar Singh came to Rama Hospital on 8/2/2022 at 4:36 pm with chief
complaints of severe abdominal pain, vomiting, indigestion, diarrhea and fever.

HISTORY OF PRSENT ILNESS

Mr. Samar Singh had abdominal pain from the past 1 month. He also had fever, indigestion and
vomiting since past two days of hospitalization. On 8/2/2022, when his pain was severe, he came to
Rama hospital for treatment where he was advised to undergo several investigations like hematology,
liver profile, kidney profile, and ultrasound. He was then hospitalized when he was diagnosed
cholelithiasis with cholecystitis. Now, he is in general medical ward at bed number 1 and is under
treatment.

PAST MEDICAL HISTORY

There is no significant past medical history.
PRESENT AND PAST SURGICAL HISTORY
Mr. Samar had not undergone any surgery in the past. He also had not undergone any surgery at
present.

PAST HEALTH HISTORY

Childhood illness: Nothing significant
Allergies: He is not allergic to any food or drug
Immunization: Primary immunization completed

PERSONAL HISTORY
Habit: He is having habit of smoking since the age of 30 years.
Diet: He takes mixed type of diet, 3 meals/ day
Social Interaction: He is quite social with his neighbors and co- operative.

FAMILY HISTORY
Mr. Samar is residing with his mother, wife, 1 son and 1 daughter. His father passed away. He has an
elder brother. And there is no family history of diabetes mellitus, hypertension.

Family tree:

Key words
-Male

-Female

-Deceased
-Patient
Family composition:

Sl.no Name Age Sex Relationship Educational Occupation Marital Health status
with patient status status
1 Samar 49 M Patient Graduate Teacher Married Cholelithiasis
Singh years
2 Kamala 68 F Mother Nil Housewife Widowed Healthy
years
3 Sunita 34 F Wife 8th passed Tailor Married Healthy
years
4 Amar 13 M Son 7th std. Student Unmarried Healthy
years
5 Jyoti 8 F Daughter 2nd std. Student Unmarried Healthy
years

SOCIO- ECONOMIC HISTORY

The patient’s monthly income is 12,500/- per month. He is the bread-winner of the family. They
belong to a middle-class family. Their income is sufficient for their family.

ENVIRONMENTAL HISTORY
The patient is residing in his own semi-pucca house with proper lightings, corporation water supply,
proper disposal of waste and good toilet facility. The patient and his family keep their environment
clean.

NUTRITIONAL HISTORY
The client is taking 3 meals a day in small quantity. He is a non- vegetarian and takes adequate
nutrition. He complaints of loss of appetite since 1 month.

ELIMINATION PATTERN
His bowel and bladder functions were normal. But from the past few days, he had diarrhea and
indigestion.
ACTIVITY AND REST
The client’s activity is limited due to pain and weakness. He used to sleep 7 hours a day. But, his
sleeping pattern is disturbed recently due to pain. He has difficulty falling asleep.

PHYSICAL EXAMINATION
GENERAL OBSERVATIONS
Constitution: Endomorphic
Stature: Normal stature
Body build: Moderate built
Posture: No deformity, normal posture while sitting, standing or walking
Personal appearance: Hygienic, neat and tidy
Emotional state: Anxious
Sensorium: Conscious and alert
Cooperativeness Respond clearly to questions

VITAL SIGNS
Temperature: 99°F
Pulse: 84 beats/ min
Respiration: 24 breaths/ min
Blood pressure: 110/70 mm of Hg
O2 saturation: 99%

HEIGHT AND WEIGHT

Height: 182 cm
Weight: 75 kg
BMI: 22.4

SKIN AND MUCOUS MEMBRANE

Color of skin: No cyanosis, lesions, crackles
Edema: No edema
Moisture/ turgor: Warm and normal

HEAD
Normocephalic, no lesions or tenderness, hair distribution is normal, normal range of motion

EYES
There is no blephritis, no watery discharge
Expressions: Normal
Eye lids: Symmetrical
Eye balls: Globes clear and firm
Conjunctiva: Pink and clear
Sclera: Creamy white and clear
Iris: Black colour
Visual acuity: Normal
Pupils perrla: Round symmetrical, constrict to light
Eye movements: Moves in conjugate fashion

EARS
Normal shape, no discharges, tinnitus vertigo or infection
Appearance: Auricles are symmetric & wax present
Hearing: Normal

NOSE
There are no deformities, running nose, nasal stiffness and swelling
Appearance: No nasal flaring, mucous membranes are pink and moist
Sense of smell: Normal

MOUTH AND THROAT

No glossitis, stomatitis, it is moisturized
Lips: Symmetric, moist, no lesion, cyanosis
Tongue: Moist, pink, no glossitis, coated tongue
Teeth: Stained teeth, missing teeth- 2, no dental carries
Gums: No gingivitis, no abscess, pink color
Buccal mucosa: No lesion/ inflammation, no stomatitis
Palate: Intact, symmetry, pink, no deformity
Taste: Normal

NECK
Appearance: No deformity, spondylosis, tenderness, stiffness, swelling
Trachea: No deviation, tenderness and swelling
Lymph nodes: Not palpable
Thyroid gland: Symmetric, no enlargement

CHEST AND RESPIRATORY SYSTEM

INSPECTION
Symmetry: Bilaterally asymmetric
Expansion: Thoracic expansion equal
Equality of movement: Normal
Type of respiration: Abdominothoracic
Rate: 24 breaths/ min
Rhythm: Regular
PALPATION No tenderness, no lump or depression along the rib
PERCUSSION Deep resonant sound
AUSCULTATION Breath sounds are heard in all areas of lungs, no wheezing sound

CARDIO VASCULAR SYSTEM

INSPECTION No enlargement
PALPATION No tenderness, no thrill
AUSCULTATION Clear and regular heart rate, 84beats per minute, no murmur sound

ABDOMEN
INSPECTION
Shape: Scaphoid shape of umbilicus is inverted
Movements: Abdomen bulges in inspiration and falls during expiration
Skin texture: No discoloration, cyanosis and distension is seen
Contour: Normal flat, no mass, normal bowel, no scars of lesions
PALPATION
Mass: Tenderness and palpable mass on the upper right quadrant
PERCUSSION
Organ borders: Normal, bladder dullness not found, no gaseous distension
AUSCULTATION Normal gurgling sound heard, No bruits
BACK
Spinal curvature: No deformity
Concavity in the cervical- lumbar regions
Convexity in the thorax
Symmetry: Normal
Movements of mobility: Normal ROM
Tenderness: No tenderness
GENITALIA
Nothing significant
UPPER AND LOWER EXTREMITIES
Nothing significant, Normal ROM, equal strength, muscle masses are smooth non- tender
NERVOUS SYSTEM
Nothing significant
Higher function: Normal
Speech: Fluent or clear words
Cranial nerves: Normal
Motor function: Normal muscle tone, normal gait
Sensory function: Respond to pain, position of light touch
Reflexes: Normal superficial, deep visceral reflexes
NEUROLOGICAL ASSESSMENT
GCS (0-15) Maximum score- 15, Minimum score- 3

RESPONSE SCALE SCORE PATIENT SCORE

Eye opening None 1

To pain 2

To speech 3

Spontaneous 4 4

Motor response None 1

Extension 2

Flexion response 3

Withdrawal 4

Localizes pain 5 5

Obeys command 6

Verbal response None 1

Incomprehensible 2

Inappropriate 3

Confused 4

Oriented 5 5

Total score 15 14

➢ Higher mental function: orientation, insight, judgment, intelligence, behavior changes, speech
 INVESTIGATION

Sl.no Investigation Patient value Reference range Unit Remarks

1 CBC
TLC 8600 4000-11000 cell/cubmm Normal
TRBC 2.6 4.50-5.00 mill/cubmm Decreased
HB 9.3 12-16 g/dl Decreased
PCV 22 41.50-50.40 % Decreased
MCV 86 80.00-96.00 fl Normal
MCH 29 27.00-33.00 pg Normal
MCHC 34 33.40-35.50 g/dl Normal
PLATELET COUNT 1.60 1.50-4.50 lacs/cub Normal
RDW 14 10.00-15.00 % Normal
POLYMORPHS 76 45.00-74.00 % Increased
LYMPHOCYTES 20 20.00-40.00 % Normal
MONOCYTES 01 2.00-8.00 % Decreased
EOSINOPHILS 03 1.00-6.00 % Normal
BASOPHILS 00 Up to 0.00 % Normal
IMMATURE 00 0.00-0.10 % Normal
2 Kidney profile
Serum blood urea 24 15-45 mg/dl Normal
Serum creatinine 0.6 0.4-1.5 mg/dl Normal
Serum uric acid 4.2 3.5-7.2 mg/dl Normal
Serum sodium 135 135-145 mmol/l Normal
Serum potassium 3.9 3.5-5.5 mmol/l Normal
3 Liver profile
Bilirubin total 0.6 0.3-1.10 mg/dl Normal
Bilirubin direct 0.3 0.0-0.3 mg/dl Normal
Serum protein 6.6 6.4-8.3 gm/dl Normal
 Serum albumin 3.1 3.5-5.0 gm/dl Decreased
S. G. O. T 32 Up to 40 u/l Normal
S. G. P. T 23 Up to 40 u/l Normal
ALP 76 40-130 u/l Normal
4 Serum lipase 32 13.00-60.00 u/l Normal
5 Serum amylase 15 Up to 80 u/l Normal

Ultrasound report:
➢ Liver- mild hepatomegaly
➢ Gall bladder- cholelithiasis with mild chronic cholecystitis
PRESENT MEDICATION HISTORY
Sl. Name of Route Dose Freq Action Side effects
No Medication
1 Inj. Prezone- S IM 1.5gm BD Antibiotic Allergic reactions,
reversible
neutropenia,
transient rise in
SGOT-SGPT,
anemia
2 Inj. Rablet I/V 20mg OD Antacid Nausea, vomiting,
headache, diarrhea
3 Inj. Emeset I/V 2ml TDS Anti-emetic Constipation,
diarrhea, fatigue
4 Dynapar Aq I/V 1ml TDS Analgesic Nausea, headache,
vomiting, itching,
indigestion
5 Inj. lasix I/V 40mg OD Diuretics Vertigo, nausea,
vomiting, thirst,
weakness, dizziness
6 Tab. Ultracet Oral 1mg BD Analgesic Drowsiness,
weakness,
constipation,
stomach pain, loss of
appetite
7 Tab. Telekast L 1mg OD Anti-histamine Nausea, dry mouth,
fatigue, headache,
skin rash, sleepiness
8 Inj. Deriphyllin I/V 1mg BD Muscle relaxant Irregular heart rate,
convulsions,
stomach-pain,
headache, sleepiness,
 diarrhea
9 Inj. Primacort I/V 100mg BD Corticosteroid Mood changes, pain
and swelling in
injection site
10 Inj.Human I/V 100ml OD Replaces blood Itching, fever, skin
Albumin 20% or body fluids rash, nausea,
vomiting,
tachycardia
 ANATOMY AND PHYSIOLOGY OF GALLBLADDER

The gall bladder is a pear-shaped sac attached to the posterior surface of the liver by connective tissue. It
has a fundus or expanded end, a body or main part and a neck, which is continuous with the cystic duct.

Structure

The wall of the gall bladder has the same layers of tissue as those described in the basic structure of the
alimentary canal, with some modifications.

Peritoneum

This covers only the inferior surface because the upper surface of the gall bladder is in direct contact
with the liver and held in place by the visceral peritoneum that covers the liver.
Muscle layer

There is an additional layer of oblique muscle fibres.

Mucous membrane

This displays small rugae when the gall bladder is empty that disappear when it is distended with bile.

Blood supply

The cystic artery, a branch of the hepatic artery, supplies blood to the gall bladder. Blood is drained
away by the cystic vein that joins the portal vein.

Functions of the gall bladder

These include:

• reservoir for bile

• concentration of the bile by up to 10- or 15-fold, by absorption of water through the walls of the gall
bladder

• release of stored bile.

When the muscle wall of the gall bladder contracts, bile passes through the bile ducts to the duodenum.
Contraction is stimulated by:

• the hormone cholecystokinin (CCK), secreted by the duodenum

• the presence of fat and acid chyme in the duodenum.

Relaxation of the hepatopancreatic sphincter (of Oddi) is caused by CCK and is a reflex response to
contraction of the gall bladder.
 DISEASE CONDITION
Introduction
Cholelithiasis is the medical term for gallstones. Gallstones are concretions that form in the
biliary tract, usually in the gall bladder. Calculi, or gallstones, usually form in the gall bladder from the
solid constituents of bile; they vary greatly in size, shape, and composition. Cystic duct obstruction, if
persist for more than a few hours, may lead to acute gall bladder inflammation (acute cholecyctitis).

Etiology and Risk factors

Book picture Patient picture
Obesity Not present
Women, especially those who have had Not present
multiple pregnancies
Frequent changes in weight Present
Rapid weight loss Present
Treatment with high dose estrogen Not present
Cystic fibrosis Not present
Diabetes mellitus Not present

Pathophysiology

Decreased bile acid synthesis

Increased cholesterol synthesis in the liver

Super saturation of bile with cholesterol

Formation of precipitates

Gall stones ( Cholelithiasis )

Inflammatory changes ( Cholecystitis )

Clinical manifestations
Book picture Patient picture
Severe pain Present
Tachycardia Present
Diaphoresis Absent
Prostration Absent
Dark amber to brown urine Absent
Indigestion Present
Fever Present
Chills Present
Jaundice Absent
Tenderness in the right upper quadrant Present
Nausea and vomiting Present
Restlessness Present
Fat intolerance Absent
Dyspepsia Absent
Heartburn Present
Flatulence Absent

Diagnostic evaluation
Book picture Patient picture
History collection Done
Physical examination Done
Blood studies Done
Ultrasonography Done
Abdominal radiography Not done
Computed tomography Not done
Magnetic resonance imaging Not done
Endoscopic retrograde Not done
cholangiopancreatography (My client had also done Liver
profile, kidney profile)
Medical management
Book picture Patient picture
Analgesics Given
Antibiotics Given
Antiemetics Given
Anticholinergics Given
Fat soluble vitamin Not given
Bile salts Not given
Transhepatic biliary catheter Not provided
ERCP with sphincterotomy Not done
Extracorporeal shock- wave lithotripsy Not done
Ursodeoxycholic acid Not given
IV fluid Given

Surgical treatment
Book picture Patient picture
Laparoscopic cholecystectomy Not done
Incisional cholecystectomy Not done
 APPLICATION OF THEORY

• Mr. Samar Singh was admitted for the first time in hospital. So, he was anxious about the
outcome of the disease as well as adjusting to new environment.
• So, I applied Peplau’s Theory: Interpersonal relationship with the mutual understanding of
patient and family members while caring her.
• According to Peplau, Nursing is therapeutic in that is a healing art, assisting in individual who is
sick or in need of health care.
• Nursing can be viewed as an interpersonal process because it involves interaction between two
or more individuals with a common goal.
• In nursing, this common goal provides the incentive for the therapeutic process in which the
nurse and patient respect each other as individuals, both of them learning and growing as a result
of the interaction.
• Peplau identifies four sequential phase in interpersonal relationship:
❖ Orientation phase.
❖ Identification phase
❖ Exploitation phase
❖ Resolution phase

Orientation phase- Nurse and patient come together as strangers; meeting initiated by patient
who express felt need work together to recognize, clarify and define facts related to need. It is
also called problem defining phase.

Identification phase- Interdependent goal setting, patient has feeling of belonging and
selectively responds to those who can meet needs. Each patient responds differently in his phase.
Selection of appropriate professional assistance.

Exploitation phase- Patient actively seeking and drawing on knowledge and expertise of those
who can help, use of professional assistance for problem solving alternatives.

Resolution phase- Occurs after other phases are successfully completed and have been met,
leads to termination.
Nursing diagnosis
1. Acute pain, and discomfort related to biliary obstruction and inflammation of biliary tract as
evidence by verbal complain.
2. Alteration in body temperature related to inflammation of biliary tract and pain as evidenced by
hyperthermia.
3. Imbalanced nutrition, less than body requirements, related to inadequate bile secretion as
evidence by weight loss.
4. Disturbed sleeping pattern related to pain as evidenced by red and drowsy eyes.
5. Impaired gas exchange related to pain, anxiety as evidence by ABG analysis.
6. Anxiety related to hospitalization as evidenced by facial expression.
7. Deficient knowledge regarding disease condition as evidenced by frequent questioning.
8. Risk for fluid volume deficient related to vomiting.
9. Risk for impaired skin integrity related to pruritus secondary to biliary obstruction.
 Nursing care plan

1
Nursing theory Subjective and Nursing Goal Planning Implementation Evaluation
applied Objective data Diagnosis
Peplau’s Subjective Acute pain, and To relief Assess the pain Pain level assessed Patient’s pain
Theory: data: discomfort from pain. level of the client. with pain scale. level is reduced
Interpersonal The client says, related to biliary to some extent.
Relationship “I am having obstruction and Provide Positioned the patient
with the mutual severe inflammation of comfortable in side lying position.
understanding of abdominal biliary tract as position.
patient and pain” evidence by
family members verbal complain. Provide comfort Provided pillows.
while caring him. device.

Provide calm Calm and quite

Objective data: environment. environment
Facial provided to the
expression, pain patient.
scale score-7

Administer Provided inj.

analgesics as per Dynapar and tab.
physician’s order. Ultracet as per
physician’s order.
 2
Nursing theory Subjective and Nursing Goal Planning Implementation Evaluation
applied Objective data Diagnosis
Peplau’s Subjective Alteration in To maintain Assess the body Assed body Patient’s
Theory: data: body temperature normal temperature. temperature with temperature is
Interpersonal The client says, related to body thermometer. (temp- maintained to
Relationship “I am having inflammation of temperature. 99℉) some extent.
with the mutual fever” biliary tract and
understanding of pain as Provide light cotton Provided light cotton
patient and evidenced by clothing. clothing.
family members hyperthermia.
while caring Provide cold Provided cold
him. sponging. sponging.

Objective Advice the client to Advised the client to

data: take more fluid. take more fluid.
Hyperthermia
Advice the client to Advised the client to
remove excess remove excess
clothing or blanket. clothing or blanket.

Administer Administered tab.

antipyretics as per Dolo as per doctor’s
doctor’s order. advice.
 3
Nursing theory Subjective and Nursing Goal Planning Implementation Evaluation
applied Objective data Diagnosis
Peplau’s Subjective Imbalanced To Assess the Assessed nutritional Patient can
Theory: data: nutrition, less improve nutritional status of status of the client. breath without
Interpersonal The client says, than body the the client. difficulty.
Relationship “I am unable to requirements, nutritional
with the mutual eat well” related to status of Provide nutritious Provided nutritious
understanding of inadequate bile the client. diet. diet.
patient and secretion as
family members evidence by Provide balanced Provided balanced
while caring him. weight loss. diet to the client. diet.

Advice the client to Advised the client to

avoid fat rich diet. avoid fat rich diet
Objective data: e.g, Ghee, Milk &
Loss of mik-products
appetite,
Weight loss Avice family Advised family
members to give members to give
small & frequent small & frequent diet
diet
 4

Nursing theory Subjective and Nursing Goal Planning Implementation Evaluation

applied Objective data Diagnosis
Peplau’s Subjective Disturb sleeping To Assess the sleeping Assessed the sleeping Sleeping
Theory: data: pattern related o improve pattern of the client. pattern of the client. pattern is
Interpersonal The client says, pain as evidence the maintained to
Relationship “I am unable to by red and sleeping Provide quiet and Provided quiet and some extent.
with the mutual sleep properly” drowsy eyes pattern. calm environment. calm environment.
understanding of
patient and Advice family Advised family
family members members not to members not to
while caring him. provide lots of provide lots of water
water at night. at night

Advice the client Advised the client not

Objective data: not to take nap in to take nap in
Red & drowsy daytime. daytime.
eyes
Provide Provided comfortable
comfortable position to the client.
position to the i.e. side lying
client. position.
 5
Nursing theory Subjective and Nursing Goal Planning Implementation Evaluation
applied Objective data Diagnosis
Peplau’s Subjective Anxiety related To reduce Assess the Assessed the Anxiety level
Theory: data: to hospitalization anxiety. condition of the conditionof the of the client is
Interpersonal The patient as evidenced by patient. patient. reduced to
Relationship says, “I don’t facial expression. some extent.
with the mutual know what will Teach the client Taught the client
understanding of happen to me” about the disease about the disease
patient and condition. condition.
family members
while caring him. Instruct about the Instructed about the
available available
Objective data: management of the management of the
Facial disease. disease.
expression
Provide emotional Provided emotional
support to the support to the client.
client.

Answer every Answered every

questions the client questions the client
ask. ask.
 HEALTH EDUCATION

MEDICATION
- Advised client to take the prescribed drugs on time, without skipping or doubling any dose.
- Instructed client to use OTC drugs.
FOLLOW- UP
- Educated the patient regarding the importance of regular follow- up.
- Advised him to come for regular follow- up.
PERSONAL HYGIENE
- Advised client to maintain a good personal hygiene.
- Maintain daily bath, cleaning and rubbing.
DIET
- Advised client to have a balanced diet with high fat and cholesterol intake restriction.
GENERAL
- Explained the client about the importance of avoiding strenuous activity or excise.
- Explained about importance of fowler’s position.
- Taught the patient adaptive breathing technique to maximize lung expansion and prevent complications.