A Nursing Case Analysis on

CHOLECYSTOLITHIASIS

In Partial Fulfillment of the

Requirements in NCM 209-RLE
PEDIATRIC NURSING ROTATION

Submitted to:
Monaliza Lee, RN, MN
Clinical Instructor

Submitted by:
Pama, Jeofy F., St. N.
BSN 2P Group 4

February 19, 2023

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 I. INTRODUCTION 2

II. OBJECTIVES 3
a. General Objectives 3
b. Specific Objectives 4

III. DATA BASE 5

a. Biographical Data 5
b. Clinical Data 5
c. Family Health History 5
d. Past Health History 6
e. History of Present Illness 7
f. Developmental Tasks 7

IV. PHYSICAL ASSESSMENT 8

V. DEFINITION OF DIAGNOSIS 10

VI. ANATOMY & PHYSIOLOGY 11

VII. PATHOPHYSIOLOGY 14
a. Etiology 14
b. Symptomatology 16
c. Disease Process 19

VIII. MEDICAL MANAGEMENT 22

a. Diagnostic Exams and Laboratory Tests 22
b. Pharmacological Management 25
c. Non-pharmacological Management 35

IX. NURSING MANAGEMENT 35

a. Nursing Care Plan 36
b. Nursing Theory 43
c. Discharge Planning 49
d. Review of Related Literature 55

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X. PROGNOSIS 56

XI. REFERENCES
A 57

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 I. INTRODUCTION AND OBJECTIVES

Introduction

Children from birth to age 18 are the primary focus of pediatric nursing, which
is a subspecialty of the nursing profession (NurseJournal, 2022). Most kids don't know
much about hospitals and doctors since they rarely get sick enough to require medical
attention. Supporting the kid and their family through the process of getting ready for
or adjusting to the experience is central to the nurse's role. More than just telling people
what they might go through throughout their illness, this responsibility involves a wide
range of activities. Providing emotional support is also a part of this (Maternal and
Child Health Nursing Practice-LWW, 2019).

According to Mayo Clinic (2021), gallstones form when bile becomes solidified
in the gallbladder. Gallstones are referred to as cholecystolithiasis. Bile is stored in the
gallbladder and released into the small intestine when needed. Gallstones can be as
tiny as a grain of sand (also known as "sludge") or as large as a golf ball. Gallstones
can affect anyone at any time, and while some individuals only have one, others get
dozens. It is possible that gallstones will not cause any discomfort. However, if a
gallstone blocks a duct, symptoms like severe, sudden pain in the upper right
abdomen, pain in the right shoulder, and sometimes even nausea and vomiting might
develop. Until they cause discomfort, gallstones are mostly benign. Gallbladder illness
symptoms. Disease of the gallbladder encompasses all conditions affecting the organ.

Cholecystolithiasis and cholecystitis are two common names for this condition.
Cholelithiasis is what the Cleveland Clinic terms the process of making gallstones,
while cholecystitis is the inflammation of the gallbladder (2020). Inadequate drainage
from the gallbladder can lead to cholelithiasis, or gallstones, when bilirubin levels are
too high. Cholesterol in the liver is mainly dissolved by bile. Cholesterol can crystallize
if the liver creates more of it than the bile can carry away. Gallbladder mucus contains
crystals, which contribute to the buildup of gunk. When these crystals harden into
stones and block the bile ducts, a condition known as gallstone disease results.
Cholecystitis occurs when gallstones obstruct the cystic duct. There is a possibility of
gallbladder enlargement and infection. Inflammation of the gallbladder can also be

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caused by factors that are less prevalent, such as viruses, scarring of the bile ducts,
decreased blood flow to the organ, tumors that obstruct bile flow, and so on.

As mentioned by Zakko (2022), over a million Americans suffer gallstones,

joining almost 38 million worldwide. Cholelithiasis rarely causes symptoms or requires
treatment. Most US gallstone sufferers are ignorant. Europeans, Hispanics, Native
Americans, Asians, and African Americans have less cholelithiasis (Terrie, 2020). The
National Organization for Rare Disorders reports 120,000 cases of acute cholecystitis
annually (2023). Gallstones affect 12% of men and 25% of women by 65. 60% of
women have acute cholecystitis, while 10% have gallstones. BS Biology students at
De La Salle University in Manila report no national publications on gallstone
occurrence, risk factors, or awareness. As stated in Ecological Profile Olongapo City,
according to the 2013 Philippine Health Statistics (2021), 723 people, 352 men and
371 females, died from cholelithiasis and associated gallbladder and biliary system
disorders per 100,000 inhabitants . In 2019 and 2020, Olongapo city expected 169
and 64 deaths from cholecystitis.

This case study highlights acute cholecystolithiasis and its symptoms and
therapies. This case study shows nursing and client well-being. Nursing improves
disease prevention, diagnosis, and monitoring. This case study educates patients,
nurses, and healthcare professionals. This research can improve acute
cholecystolithiasis treatment, pharmaceutical production, and other medical
emergencies. Patients, nursing students, healthcare workers, and unrelated scholars
will benefit from this case study. This case study also compiles the many observations
and notes taken by the student nurse over his three days of clinical rotation. Also
included are the nursing care plans that the student put into action for the client in an
effort to provide the patient with the best possible medical attention as a health care
provider.

II. Objectives
a) General Objective

Within the first three weeks of the student nurse’s primary nursing
rotation, he will have used the concepts and teachings presented in the
RLE skills lab and nursing lectures to create a comprehensive case

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 study about Acute Cholecystolithiasis. This will allow the student nurse
to provide the patient with the comprehensive care they need in a similar
situation.

b) Specific Objectives

The student nurse's specific goals, within the context of the larger
goal, are to:

a. Develop an in-depth introductory section that discusses

Acute Cholecystolithiasis, includes pertinent statistics from
international, national, and local elements, and discusses
the study's significance for nursing education, practice,
and research;
b. Create objectives that are SMART (specific, measurable,
achievable, relevant, and timely);
c. Share the patient's background information, medical
history, family medical history, medical history, and
developmental tasks;
d. Display the outcomes of the patient's physical and
neurological evaluations;
e. Provide a brief overview on how the diagnosis is often
defined;
f. Recognize which body parts are being affected by the
illness;
g. The etiology, symptoms, and course of the disease should
all be covered in a discussion of the pathophysiology of the
condition.
h. The etiology, symptoms, and course of the disease should
all be covered in a discussion of the pathophysiology of the
condition.
i. Find the best methods and tests for diagnosing the
disease;
j. Develop disease-specific medicines and drug studies;
k. Generate one nursing care plan, which is actual diagnoses

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 l. Discuss the discharge planning of the patient;
m. Connect the disease to at least two nursing theories;
n. Review at least three pieces of relevant literature and
studies that were published within the past five years and
are relevant to the case in question;
o. Cite all materials that is used for this study.

III. DATA BASE

a.) Biographical Data

The patient’s name is J,C,R. He is a 23 year old male currently residing

at Brgy. 23-C Isla Verde Boulevard, Davao City. He was born on June 21, 1999.
He is the daughter of Mr. F.R. and Mrs. A.R.. he is a Roman Catholic and has
a blood type “B” Rh Positive. She currently works as a marine engineer.

b.) Clinical Data

Lab tests were done to the patient in order to help in the diagnosis of her
condition.he had an electrolyte test, CBC test,. These are the findings of her
electrolyte test: The CBC results were hemoglobin withy the results of 135 g/L,
RBC with the results of 4.57 10^12/L, MCH 29.6 pg, MCV 90 fl, MCHC 32.7
g/L, WBC 16.8 10^9/L, neutrophil 82%, lymphocyte 12%, monocyte 5%,
eosinophil 1%, basophil 0%, hematocrit 0.41%, platelet count of 289 10^9/L.
Total Bilirubin of 6.70 umol/L, direct bilirubin 2.25 umol/L, indirect bilirubin 4.45
umol/L, and alkaline phosphatase of 120 U/L.

c.) Family Health History

Genogram

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 The patient’s family health history is presented in the genogram above. The
genogram shows the father, mother, grandmother, grandfather, son, and wife. The
father of the patient had an Anal Fistula two to three years ago. The mother of the
patient has no sickness. The grandmother and grandfather’s sickness is unknown.
The patient’s son has no sickness as well.

d.) Past Health History

J.R., a 23-year-old male patient, was rarely ill, had never been hospitalized, and
stated that this was his first procedure. He reported receiving the COVID-19
vaccination manufactured by Pfizer three times, including once as a booster. In
addition to his current health, there was no evidence of any serious or chronic diseases
or ailments. According to the data gathered, he does not have any known food or
medicine allergies. The patient has been absent for the previous many weeks. The
patient had a job interview in Malate City, Manila, on January 23, 2023. Once the
interview phase is passed, the company will typically require a medical checkup before
you can begin working. After obtaining the findings of his medical examination, he
returned to Davao, where he was advised that he required gallstone removal surgery
before he could return to work. The patient then proceeded to Davao City on January
30, 2023, to check into San Pedro Hospital for surgery. J.R.

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 e.) History of Present illness

Two weeks before to admission, the patient had completed a routine marine
medical exam in their company; unintentional discoveries included gallstones
measuring 1.8 cm with Cholecystolithiasis impression; no related symptoms were
identified; however, surgery was advised.

f.) Developmental Task

The term "developmental tasks" refers to the unique and important

experiences and developmental milestones that all people go through as they
get mature and grow older. These are considered to be universal and
necessary for a normal, healthy process of human growth.

Erik Erikson was a German-American psychologist and psychoanalyst

best known for his theory of the eight stages of psychosocial development.
Erikson’s eight stages of psychosocial development are eight successive
stages of personal human development, with each stage being influenced by
biological, psychological, and social variables throughout the course of a
lifetime. Gerontology, personality development, identity formation, life cycle
development, and other disciplines of research have all been influenced by this
bio-psychosocial approach (Orenstein & Lewis, 2021).

Developmental Task Justification Achieved or Not

Achieved

Erik Erikson’s 8 stages Early adulthood stage

Intimacy: Achieved
of Psychosocial 20-25 years old
Development (intimacy vs isolation) Isolation: Not Achieved

Erikson felt that The client is a 23-year-

developing close, old male, therefore he

dedicated relationships belongs to the early

with others was adulthood stage of

essential. These

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emotionally intimate psychosocial
interactions are crucial development.
to a person's emotional
The patient belongs to
health as they enter
the sixth stage which
adulthood.
identifies intimacy vs.
isolation. This stage
Romantic and sexual
establishes intimate
connections can play a
bonds of love &
significant role in this
friendship. Intimate love
period of life, but
and friendship
intimacy is primarily
relationships are formed
defined by intimate,
during this time. Since
caring relationships. It
he has a close
involves romantic
relationship with his
partners, but can also
family, his wife, and
include intimate,
those who consistently
durable friendships with
support him, I can
others beyond the
conclude that he
family.
belongs to intimacy. His
relationships with his
Although many people
friends have weakened
equate closeness with
over years since they
sexuality, it covers
are now more focused
much more than that.
on living their own lives
Intimate relationships,
and achieving success
according to Erikson,
in the future than they
are defined by
were when he was in
closeness, honesty,
high school, where they
and love.
just focus on the things
that always makes them
happy. Though they
don't bond as well as

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 they did in high school,
he is still there for her
buddies when they need
him.

Robert Havighurst is another individual who is best known for his theory of
development. Havighurst’s developmental tasks have six stages, and his theory states
that all through life, from conception to death, there is constant change and progress.
And according to Robert Havghurst, People continue to learn throughout their lives
since learning is fundamental to life (Bialowas & Boyd, 2022).

Developmental Task Justification Achieved or Not

Achieved

Finding a partner (and Robert Havighurst stated Finding a partner:

learning to cohabitate with in his developmental Achieved
them) tasks that in early Learning to cohabitate wih
adulthood will have to partner:
select a mate, until it is Not Achieved
accomplished, the task of
finding a marriage partner
is at once the most
interesting and the most
disturbing of the tasks of
early adulthood. And learn
to live with a marriage
partner, After the wedding
there comes a period of
learning how to fit two
lives together. In the main
this consists of learning to
express and control one’s
feeling that is anger, joy,

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 disgust, so that one can
live intimately and happily
with one’s spouse.
Patient claims to have a
deep and meaningful
relationship with his wife
of three years. The
patient's admission that
he still lives with his
parents and siblings
indicates that he is unable
to provide a stable living
environment for his wife
and child.

Achieving a preferred Marriage often involves Achieved

masculine or feminine breaking of social ties for
social role one or both young people,
and the forming of new
friendships. Either the
man or the woman is apt
to move away from former
friends. In any case,
whether old friendships
are interrupted by
distance or not, the young
couple faces something of
a new task in forming a
leisure time pattern and
finding others to share it
with. The young man
loses interest in some of
his former bachelor

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 activities, and his wife
drops out of some of her
purely feminine
associations.
The patient chose to
become a marine
engineer, a provider and
the father figure in their
household

Managing a home and Family life is built around Not Achieved

starting a family a physical center, the
home, and depends for its
success greatly upon how
well-managed this home
is. Good home
management is only partly
a matter of keeping the
house clean, the furniture
and plumbing and lighting
fixtures in repair, having
meals well cooked, and
the like. The patient is still
living at home with his
parents and siblings, so
he was unable to set one
up.

Beginning a career This task takes an Not Achieved

enormous amount of the
young person’s time and
energy during young
adulthood. Often, he
becomes so engrossed in

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 this particular task that he
neglects others. He may
put off finding a spouse
altogether too long for
own happiness. His
professional life is
currently underway
because he has submitted
an application and is
undergoing the necessary
procedures to be hired.

Taking on civic To assume responsibility Not Achieved

responsibility for the welfare of a group
outside of the family such
as a neighbourhood or
community group or
church or a political
organisation. The client
expressed regret that he
was unable to participate
in environmental
initiatives like tree planting
and recycling drives.

IV. PHYSICAL ASSESSMENT

GENERAL SURVEY

All over, the skin tone is a consistent tan. The client has clearly taken the time
to groom himself. Eye contact was maintained; he showed emotion; he was
cooperative; and he answered questions. He has a medium bone structure and he
weighs 60 kilograms and stands 5 feet, six inches tall. To put it another way, your body
mass index is too low at 17.89.

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HEAD

The client has a normal, symmetrical head shape. There is no dandruff, lice,
and tumors on the scalp.The client's hair is silky and fine, and it grows in a healthy,
uniform pattern all over the head. The jaw is strong enough, and the face can turn and
tilt in a typical way.

EYES

There is a balance between the two eyebrows, and their movements are both
smooth and even.The client's pupils are reactive and accommodating, seeming round.
There is no abnormality in the structure of the eyes, and the alignment and movement
of the eyebrows are both normal. Wide eyelashes that extend outward are
symmetrically placed on both eyelids. Her brown irises contrast with her pinkish
conjunctiva. Overt bleeding is not present. He responds quickly to the light, his eyes
responding.

NOSE

The client has a fairly standard nose. Both nostrils are open, and the nasolabial
folds on either side are similar in size and placement. No nasal lesions or soreness
have been noted.

MOUTH

The clients lips are symmetrical, pink and moist, with no visible abnormalities.
Pinkness also can be seen in the mucosa, palate, and gums. A typical position for the
tongue is in the middle of the mouth. The client has a full set of teeth.The client’s upper
and lower lips are symmetrical and pinkish.

EARS

The client's ears seem to be of normal size and shape, and there are no signs
of tumors, pus, or bleeding. The hearing in both ears is noral. No lesions of re-folding
of the ears into their original positions occurred.

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SKIN AND NAILS

The client has a uniformly fair complexion and skin tone. Skin turgor is excellent,
and the skin is smooth, warm, clammy, and dry. The natural color of human skin is a
pale brown. Lack of cuts, scrapes, rashes, and bruising Its skin showed no signs of
edema or ulceration. Her fingernails and toenails are both neatly cut, and you can see
through and feel how strong they are. Fingernails and nail beds are brown.

PHARYNX

His uvula rests in the middle of his throat, and his oral mucosa is pink with no
signs of edema. There is no sign of tonsillitis.

ABDOMEN

The client's abdomen has a globular form and appears to be intact. There was
no tenderness or muscle guarding felt when the area was palpated. Normal bowel
sounds were detected upon auscultation.

UPPER EXTREMITIES

In addition to sharing the same colors, the two arms are also proportionally
balanced. His fingers are completely complete, and his palms are fair. There were no
abnormalities, no swellings, sores, or scabs found during the checkup.

LOWER EXTREMITIES

The client's lower extremities look healthy, normal, and proportional. There
doesn't appear to be any noticeable difference between the length or width of his legs.
A slight pigmentation was seen on the client's knees and ankles.There are n
abnormalities throughout the examination.

V. DEFINITION OF DIAGNOSIS

The final diagnosis of the patient would be Acute Cholecystitis secondary to

Cholelithiasis. According to Tokyo Guidelines diagnostic criteria for acute
cholecystitis that there are 3 categories: (A) Local signs of inflammation etc. which
includes Murphy’s sign, or RUQ mass/pain/tenderness; (B) Systemic signs of

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inflammation etc. which includes fever, elevated CRP, or elevated WBC count; and
(C) Imaging findings which has characteristic of acute cholecystitis. A definite
diagnosis of acute cholecystitis would be 1 item in A (RUQ pain) + 1 item in B (elevated
WBC count) + C (positive findings characteristics of acute cholecystitis due to
gallbladder stone/cholelithiasis) (Takada, 2018).

As much as 90% to 95% of the cases of acute cholecystitis is responsible for

gallstone-associated cystic duct obstruction (Gallaher and Charles, 2022). Acute
cholecystitis is usually caused by obstruction of gallbladder neck or cystic duct by
stone impacted on the cystic duct. A possible need for cholecystectomy for
cholelithiasis which is a common disease of the biliary tract which can result in
cholecystitis (Anderson et al., 2019).

Moreover, cholelithiasis is linked to patients' age, gender, body mass index,

and other fundamental physical parameters, as shown by clinical research (Hao Sun
et al, 2022). Additionally, clinical evidence suggests that obesity, diabetes, and non-
alcoholic fatty liver disease are risk factors for cholelithiasis. Genetic factors, increased
hepatic cholesterol output, rapid formation of liquid and solid cholesterol crystals,
decreased gallbladder motility, and cardiovascular risks were studied as a result.

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VI. ANATOMY AND PHYSIOLOGY

Anatomy

The gallbladder is a sac with a pear-like shape that ranges in size from 7 to 10
cm long with a 30 to 50 mL capacity on average. It can distend markedly and contain
up to 300mL when obstructed. It is located in an anatomic fossa on the liver's inferior
surface. Cantle's line which is a vertical plane running from the gallbladder fossa
anteriorly to the inferior vena cava (IVC) posteriorly divides the lover into right and left
lobes, The gallbladder is divided into 4 anatomical areas: fundus, body, infundibulum,
and neck. The left lobes. The gallbladder is separated anatomically into four parts. The
body mainly stores the bile, its body tapers towards the neck of the gallbladder and
the cystic duct (infundibulum or Hartmann’s pouch).

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 The same peritoneal lining that surrounds the liver extends to cover the fundus
and the inferior surface of the gallbladder. The mucosal lining is composed of smooth
muscle and fibrous tissue, its lumen is high columnar epithelium containing cholesterol
and fat globules. Its blood supply comes from cystic artery that supplies the gallbladder
is usually a branch of the right hepatic artery, and venous drainage comes from the
cystic vein and small vein coming from the gallbladder toward the liver. Lymph node
from gallbladder to the liver then to nodes along surface of portal vein. The nerve
supply arise from celiac plexus that lie along hepatic artery.

The extrahepatic biliary system starts from the right and left hepatic ducts which
are coming from the right lobe and the left lobe of the liver, respectively. Once they
converge together, they become the common hepatic duct. Then once this common
hepatic duct is joined by the cystic duct coming from the gallbladder, this now become
the common bile duct. The common bile duct extends distally towards the duodenum
where it drains the bile. This segment is typically about 7 to 11 cm in length and 5 to
10 mm in diameter. There are 3 portions of common bile duct namely: upper third
(supraduodenal portion), middle third (retroduodenal portion), and lower third
(pancreatic portion). The duct then runs obliquely downward within the wall of the
duodenum before opening on a papilla of mucous membrane (ampulla of Vater). The
sphincter of Oddi controls the flow of bile, and in some cases pancreatic juice, into the
duodenum. The extrahepatic bile ducts are lined by a columnar epithelium with many
mucous glands that are concentrated in the common bile duct. Its arterial supply is
derived from the gastroduodenal and the right hepatic arteries. The nerve supply is
the same as for the gallbladder (Anderson et al., 2019).

Physiology

The physiology of the gallbladder, biliary tree, and sphincter of Oddi are
regulated by a complex interplay of hormones and neuronal inputs designed to
coordinate bile release with food consumption. It is the liver that produces bile
continuously and excretes it into the bile canaliculi. The bile leaves the liver thru the
right and left hepatic ducts, into the common hepatic duct and then the common bile
duct. The sphincter of Oddi which contracts and diverts the flow of the bile into the
gallbladder for storage. The normal adult consuming an average diet produces 500 to
1000 mL of bile a day. The secretion of bile is responsive to neurogenic, hormonal,

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and chemical stimuli. After a meal, the hydrochloric acid, partly digested proteins, and
fatty acids entering the duodenum from the stomach will stimulate the release of
secretin, and increase production of bile and flow. Bile is mainly composed of water,
mixed with bile salts and acids, cholesterol, phospholipids (lecithin), proteins, and
bilirubin. The cholate and chenodeoxycholate which are primary bile salts, are
synthesized in the liver from cholesterol metabolism and are then excreted into the
bile by hepatocytes and helps in digestion and absorption of fats in the intestines.

The gallbladder, bile ducts, and the sphincter of Oddi act together to store and
regulate the flow of bile. The main function of the gallbladder is to concentrate and
store hepatic bile in order to deliver it in a coordinated fashion to the duodenum in
response to a meal. It rapidly absorbs sodium, chloride, and water which then
concentrates the bile as much as 10-fold and will result to a marked change in bile
composition. The gallbladder’s mucosal glands secrete at least two important products
into the gallbladder lumen: glycoproteins and hydrogen ions. These mucosal glands
are believed to protect the mucosa from the harmul action of bile and to facilitate the
passage of bile through the cystic duct. It is the transport of hydrogen ions that
decreases the pH of stored bile. This may cause acidification which helps to prevent
the precipitation of calcium salts, which can act as a nidus for stone formation.

Bile passage to duodenum involves gallbladder contraction & Sphincter of Oddi

relaxation. When you ingest food, there is a release of cholecystokinin (CKK) which
then contracts gallbladder wall, relaxes terminal bile duct, Sphincter of Oddi and
duodenum. Vagys nerve also stimulates the gallbladder contraction. Splanchnic
sympathetic stimulation inhibits motor activity of gallbladder. Gallbladder emptying
takes place 30 minutes after fatty meals and gallbladder filling occurs when bile duct
pressure is greater than that within the gallbladder which is correlated with low CCK
levels, vasoactive intestinal peptide, pancreatic peptide, and peptide YY. Gallstones
form as a result of solids settling out of solution and the major organic solutes in bile
are bilirubin, bile salts, phospholipids, and cholesterol (Anderson et al., 2019).

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VII. PATHOPHYSIOLOGY

A. Etiology

Table 1.1: Predisposing Factors of Acute Cholecystitis secondary to cholelithiasis

PREDISPOSING PRESEN RATIONALE

FACTORS T

Age x There is an increased risk if the patient is 40 and

above years old (Antonio et al., 2018).

Sex x Women are 3x more likely to develop gallstones

than men (Anderson et al., 2019).

Fertile x

(Multiparity) Fertile women has higher risk (Antonio et al.,

2018).

Ethnicity x Increased prevalence in patients of Native

American and Latin American descent
(Anderson et al., 2019).

Family history x First-degree relatives of patients with gallstones

have a twofold greater prevalence, possibly
indicating a genetic predisposition (Anderson et
al., 2019).

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 Certain conditions x Some conditions predispose to the development
of gallstones including pregnancy, non-HDL
hyperlipidemia, Crohn’s disease, and certain
blood disorders such as hereditary
spherocytosis, sickle cell disease, and
thalassemia (Anderson et al., 2019).

Table 1.2: Precipitating Factors of Acute Cholecystitis secondary Cholelithiasis

PRECIPITATING PRESEN RATIONALE

FACTORS T

Fat (obesity) x When there is presence of cholesterol

hypersecretion, either through increased intake
or dysfunctional processing, there is
supersaturation of the secreted bile forming a
cholesterol stone (Anderson et al., 2019).

Rapid weight loss x Due to bariatric surgery or lifestyle changes

can also precipitate gallstone formation by
creating an imbalance in bile composition
(Anderson et al., 2019).

Surgery x This can alter the normal neural or hormonal

regulation of the biliary tree including terminal
ileal resection and gastric or duodenal surgery

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 increase the risk of cholelithiasis (Anderson et
al., 2019).

Medications x Somatostatin analogues and estrogen-

containing oral contraceptives are also
associated with an increased risk of developing
gallstones (Anderson et al., 2019).

B. Symptomatology

Table 2: Symptomatology

SYMPTOMS PRESENT RATIONALE

Presence of / Ultrasound has a high specificity as well sensitivity

Stones in the for cholelithiasis. The density of gallstone in
Gallbladder ultrasound shows an echogenic focus with a
characteristic shadowing behind the stone. There
gallbladder wall thickening and prericholecystic
fluid seen in cholecystitis (Townsend et al., 2022).

Right Upper / The pain develops due to a stone obstruction on

Quadrant the cystic duct which results in the distension of
Abdominal Pain the gallbladder wall as it contracts in response to
(Biliary Colic) a meal. In addition to pain, gallstones may
progress to cause complications such as acute
cholecystitis (Anderson et al., 2019).

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Elevated White / An elevated white blood cell (WBC) count may
Blood Cell Count indicate an infection within the gallbladder (acute
cholecystitis) (Anderson et al., 2019). Infection in
the absence of obstruction is rare through low
bacteria load and flow of bile but with gallstones
or obstruction, there is a higher chance of
increased bacterial infection (Townsend et al.,
2022).

Nausea and x The pain usually occur at night or after a fatty meal
Vomiting and it is severe and abrupt. This biliary colic is
associated with nausea and sometimes vomiting,
and these patients generally suffer discrete,
recurrent attacks of pain, between which they feel
well (Anderson et al., 2019).

Increased / High concentrations of cholesterol and lipid in bile

Cholesterol secretion from the liver may contribute to
Production gallbladder stone. These stones in the gallbladder
are formed due to supersaturation of secreted
bile, concentration of bile in the gallbladder,
crystal nucleation, and gallbladder dysmotility
(Townsend et al., 2022).

Fever / There is an infection of the biliary tree

(cholecystitis) (Townsend et al., 2022).

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Jaundice x This suggests and obstruction of the duct due to
the stones. Hyperbilirubinemia may be secondary
increased direct bilirubin possibly due to
obstruction (Townsend et al., 2022).

Increased / Cholestasis which is an obstruction to bile flow is

Alkaline characterized by elevation in alkaline
Phosphatase phosphatase, but it may have no transaminitis
(Anderson et al., 2019).

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 C. Disease Process

Predisposing Factors Precipitating Factors

• Age over 23 years old • Metabolic Syndrome
• Male • Excessive weight loss
• Ethnicity • Certain Medications
• Family History
• Certain Conditions

Super Saturation of Bile Increased nucleation points Decreased mixing of gallbladder

(Increased Cholesterol relative to bile acid
solubilizing agent)
Physically facilitating gallstone
crystallization
Presence of gallstones
contents, increased residence time for
stone growth within the gallbladder
Physically facilitating gallstone
crystallization

Blocked cystic duct

Acute
Cholelithiasis
Cholecystitis
s
Bile Stasis
ACUTE
CHOLECYSTOLITHIASIS

Inflammatory Enzymes
Signs and Symptoms

• Presence of Stones in the

Gallbladder Lecithin Lysolecithin

• Right Upper Quadrant

Abdominal Pain (Biliary Colic) Inflammation generate

• Elevated White Blood Cell

Ischemia, necrosis, perforation
Count Gallbladder
• Increased Cholesterol
Production Mucosa
• Fever
• Increased Alkaline Fluid secreted
Phosphatase into lumen

Diagnostic Exams and Lab Tests Distention

➢ Complete Blood Count (CBC)
➢ Bilirubin Blood Test
➢ Coagulation Release of pros
taglandin

With Treatment Without Treatment

25
If managed with: If left untreated:
➢ Rupture Gallbladder
Non-pharmacological Treatment ➢ Gangrene
➢ Surgery to remove the gallbladder ➢ Gallbladder Cancer

(cholecystectomy)
Medications
Poor Prognosis
➢ Sultamicillin
➢ Dexketoprofen Trometamol

DEATH

Good Prognosis

RECOVERY

D. Narrative Pathophysiology

Gallstones obstruct the cystic duct. Bile sludge—a viscous mixture of

glycoproteins, calcium deposits, and cholesterol crystals in the gallbladder or bile
ducts—often precedes gallstones. Gallstones in the US are mostly cholesterol-rich
bile. Hypersecretion of cholesterol due to faulty hepatic cholesterol metabolism causes
hypersaturation, when cholesterol concentration exceeds water solubility. An uneven
ratio of pronucleating and antinucleating proteins in bile speeds up cholesterol
crystallization. Mucin, a glycoprotein mixture produced by biliary epithelial cells, is a
pronucleating protein. Cholesterol crystals may result from diminished mucin
degradation by lysosomal enzymes.

The inability to fully contract the sphincter and the decreased mobility of the
gallbladder wall muscles are additional factors in gallstone formation. Reduced
reservoir function and prolonged biliary stasis are results of this hypomotility (delayed
gallbladder emptying). When bile accumulates for an extended period of time, stones
may form. Inefficient filling and a higher percentage of hepatic bile being diverted from
the gallbladder to the small bile duct are both possible outcomes of hypomotility.

Gallstones sometimes contain bilirubin, a byproduct of normal red blood cell

breakdown. Increased enterohepatic bilirubin cycling and biliary tract infection have
both been connected to the formation of bilirubin stones. Pigment stones (bilirubin
stones) are more common in people who have chronic biliary tract infections or

26
hemolytic diseases (or damaged RBCs). Colored stones with pigments are more
common in Asia and Africa.

Cholecystitis is caused by gallstones becoming impaction in the bladder neck,

Hartmann's pouch, or the cystic duct, however gallstones themselves are rarely
present in this illness. Pressure, growth, wall thickening, decreased blood flow, and
the possibility for exudate production all occur in the gallbladder. Acute cholecystitis
can progress to chronic cholecystitis if the inflammation of the gallbladder is not
treated, and vice versa. The gallbladder is susceptible to infection from numerous
microorganisms, including those that produce gas. Ignoring a gallbladder infection can
lead to complications such as necrosis, gangrene, and clinical sepsis. Perforation of
the gallbladder is a rare but potentially dangerous consequence of cholecystitis if it is
not addressed. Cholecystitis can potentially lead to gallstone pancreatitis if the
gallstones migrate to the sphincter of Oddi and are not removed.

Few things are as fixed and unchangeable as age and genetic make-up, but
they both play a role in gallstone development along with environmental influences.
Some intrinsic and extrinsic risk factors for the development of gallstones include
heredity, age, gender, parity, ethnicity, rapid weight loss, medications (estrogen
replacement therapy, oral contraceptives), a westernized diet, obesity, Type 2
diabetes mellitus, metabolic syndrome, dyslipidemia, hyperinsulinemia, increased
enterohepatic circulation of bilirubin, and defective gallbladder motility.

Cholelithiasis therapy depends on symptoms and complications. Lifestyle,

nutritional, and medication adjustments are usually part of the treatment.
Pharmacological therapy alone may help those with occasional right upper quadrant
pain and mild symptoms. Recurrent right upper quadrant pain or inflammation
warrants surgical consideration, especially in acute cholecystitis. Pharmacologic
treatment includes NSAIDs, antiemetics, and dissolving agents. Symptomatic
cholelithiasis requires laparoscopic cholecystectomy. Early diagnosis improves
prognosis and recovery. Untreated, the condition can develop and kill.

27
VIII. MEDICAL MANAGEMENT
A. Diagnostic Exam and Lab Tests

The patient had his extraction for Bilirubin Blood Test last last January 30, 2023
at 8:39PM; Coagulation last January 30, 2023 at 11:38PM; and Complete Blood
Count (CBC) last February 02, 2023 at 9:30AM. The results were then released at
January 30, 2023 at 9:10PM; January 31, 2023 at 12:15AM; and February 02, 2023
at 9:55AM, respectively.

1. Complete Blood Count (CBC)

DEFINITION NURSING RESPONSIBILITIES

a. Explain test technique.

Complete blood count (CBC) is a test that
Rationale: Explain that minor discomfort
measures the number of red blood cells,
may be experienced when the skin is
white blood cells, and platelets in the
penetrated.
blood. The CBC provides essential
diagnostic information regarding the
b. Encourage to avoid stress if possible
patient's hematologic and other body
Rationale: Normal hematologic levels are
systems, prognosis, therapy response,
influenced and altered by altered
and recovery.
physiologic condition.

• H:135 g/L
● RBC: 4.57 10^12/L c. Clarify that fasting is not required.

● MCH :29.6 pg Rationale: Fasting is not required;

● MCV: 90 fl however, fatty meals may affect certain

● MCHC: 32.7 g/L test findings due to lipidemia.

● WBC: 16.8 10^9/L

Normal: d. Observe the puncture site for leaking
or the formation of a hematoma.
● H:140-180 g/L Rationale: The symptoms of a bruise or
● RBC: 4.5- 5.0 10^12/L haematoma are pain, touch sensitivity,
● MCH :28-33 pg swelling, and discolouration. The blood in
● MCV: 82 - 98 fl a bruise or hematoma is eventually

28
 ● MCHC: 33 - 36 g/L broken down and reabsorbed by the
● WBC: 4.8 - 10.8 10^9/L body.

2. Bilirubin Blood Test

DEFINITION NURSING RESPONSIBILITIES

The purpose of a bilirubin blood test is to a. Before the test, instruct the patient not
measure the amounts of bilirubin in the to eat or drink and not to take any drugs.
blood. This test is used to determine the Rationale: Some foods, beverages, and
health of the liver; a healthy liver will drugs can change bilirubin levels, hence
eliminate the majority of bilirubin from the altering the results.
body. If the liver is injured, bilirubin can
flow into the bloodstream. b. Inform the patient of the procedure.
● Bilirubin: 6.70 umol/L, Rationale: To obtain the client's consent
● direct bilirubin: 2.25 umol/L, and to prepare them for the insertion of
● indirect bilirubin: 4.45 umol/L the needle for the blood sample.
● alkaline phosphatase: 120 u/L
c. Wipe the puncture site with an alcohol
Normal: swab to disinfect it.
● Bilirubin: 5.1 - 20.5 umol/L, Rationale: For infection prevention
● direct bilirubin: 0.0 - 5.1 umol/L, purposes.
● indirect bilirubin: 0.0 - 19.0 umol/L
● alkaline phosphatase: 43 - 115 d.Assess the puncture site for the
u/L formation of a hematoma; if a hematoma
develops, apply direct pressure.
Rationale: To prevent pain and distress.

3.3. Coagulation

DEFINITION NURSING RESPONSIBILITIES

29
Thrombosis is what stops bleeding a. Inform the patient of the process.
following a cut or wound. However,
Rationale: To induce cooperation from
blood should not clot as it travels through
the client.
your veins and arteries. If blood clots
form, they may travel through the
circulatory system and lodge in crucial
organs such as the brain, heart, or lungs. b. Clean the puncture site, do a
This could result in a heart attack, a venipuncture, and place the blood
stroke, and even death. Coagulation sample in a 3 to 4 cc clot activator tube.
tests assess both your blood's clotting
Rationale: To prevent disease
capacity and its clotting time. The results
of testing can assist your physician in
predicting whether you will bleed
c. Examine the puncture site for the
excessively or develop a blood clot
formation of a hematoma; if a hematoma
(thrombosis) in one of your blood
develops, apply direct pressure.
vessels.
Rationale: to prevent pain and distress.
• Protime 12.2 seconds
• INR 1.03
• APTT Control 31.7 seconds

Normal:

• Protime 11-13.5 seconds

• INR 0.8-1.1
• APTT Control 21-35 seconds

B. Pharmacological Management

GENERIC NAME SULTAMICILLIN

30
BRAND NAME SILGRAM

CLASSIFICATION ANTIBIOTICS

ORDERED DOSE 750g for 5 days, 1 tab 2x a day

SUGGESTED DOSE (By Adult: 375-750 mg bid for 5-14 days; treatment
Manufacturer) duration may be extended if necessary. For
group A β-haemolytic streptococcal infections,
duration of treatment for at least 10 days is
recommended.

Child: Dosage is individualised depending on the

severity of the infection and clinical judgement.
<30 kg: 25-50 mg/kg daily in 2 divided doses;
≥30 kg: Same as adult dose.

31
MODE OF ACTION Sultamicillin interrupts bacterial cell wall
synthesis, which is the protective covering of
bacteria. This leads to death of bacterial cells,
thereby offering effective infection control

INDICATION upper respiratory tract infections including

sinusitis, otitis media and tonsillitis; lower
respiratory tract infections including bacterial
pneumonias and bronchitis; urinary tract
infections and pyelonephritis; skin and soft
tissue infections and gonococcal infections.

CONTRAINDICATION individuals with a history of an allergic reaction

to any of the penicillins. Serious and
occasionally fatal hypersensitivity reactions
(including anaphylactoid and severe cutaneous
adverse reactions) have been reported in
patients receiving therapy with beta- lactams.

SIDE EFFECTS The only significant side effect of sultamicillin is

diarrhea/loose stools, which, although a frequent
complaint in some studies, is of mild to moderate
severity and results in a low discontinuation rate.

32
ADVERSE EFFECTS CNS: lethargy, hallucinations, anxiety,
confusion, agitation, depression, fatigue,
dizziness, seizures

CV: vein irritation, thrombophlebitis, heart failure

EENT: blurred vision, itchy eyes

GI: nausea, vomiting, diarrhea, abdominal pain,

enterocolitis, gastritis, stomatitis, glossitis, black
“hairy” tongue, furry tongue, oral and rectal
candidiasis, pseudomembranous colitis

GU: hematuria, hyaline casts in urine, vaginitis,

nephropathy, interstitial nephritis

Hematologic: anemia, eosinophilia,

agranulocytosis, hemolytic anemia, leukopenia,
thrombocytopenic pur- pura, thrombocytopenia,
neutropenia Hepatic: nonspecific hepatitis
Musculoskeletal: arthritis exacerbation
Respiratory: wheezing, dyspnea, hypoxia,
apnea

Skin: rash, urticaria, diaphoresis Other: pain at

injection site, fever,
hyperthermia,superinfections,hyper- sensitivity
reactions, anaphylaxis, serum sickness

33
DRUG INTERACTION Allopurinol: increased risk of rash
Chloramphenicol:synergisticorantag- onistic
effects

Hormonal contraceptives: decreased

contraceptive efficacy, increased risk of
breakthrough bleeding

Probenecid: decreased renal excretion and

increased blood level of ampicillin
Tetracyclines:reduced bactericidal effect

NURSING RESPONSIBILITIES ● Monitor for signs and symptoms of

hypersensitivity reaction.

R: Erythematous maculopapular rash, urticaria,

and anaphylaxis are all examples of adverse
immune system reactions such allergies and
autoimmunity.

● Check for signs and symptoms of infection at

the injection site. Monitor for seizures when
giving high doses.

R: include wound characteristics, sputum

characteristics, urine characteristics, stool
characteristics, white blood cell characteristics,
earache characteristics, and fever
characteristics; obtain baseline information and
during treatment; finish C&S prior to beginning
product therapy to determine if correct treatment
has been initiated.

34
● Watch for bleeding tendency and hemorrhage.

R: In patients receiving medicine for an

extended period, various side effects may occur:
Guaiac for daily use in cases of ecchymosis,
bleeding gums, hematuria, and blood in the
stool.

● Instruct patient to immediately report signs and

symptoms of hypersensitivity reaction, such as
rash, fever, or chills.

R: Re-exposure to penicillin or other related

drugs can result in the potentially fatal condition
known as anaphylaxis in patients who have
shown symptoms of a real allergic reaction. If
given penicillin again, up to 60% of people with
penicillin allergies are expected to have another
allergic reaction.

● Tell patient to report signs and symptoms of

infection or other problems at the injection site.

R: include wound characteristics, sputum

characteristics, urine characteristics, stool
characteristics, white blood cell characteristics,
earache characteristics, and fever
characteristics; obtain baseline information and
during treatment; finish C&S prior to beginning
product therapy to determine if correct treatment
has been initiated.

● Advise patient to minimize GI upset by eating

small, frequent servings of food and drinking
plenty of fluids.

35
R: Small, frequent meals (SFMs) are a dietary
regimen characterized by multiple small eating
episodes throughout the day.

● Inform patient that the drug lowers resistance

to certain infections. Instruct him to report new
signs or symptoms of infection, especially in the
mouth or rectum.

R: Sultamicillin may cause any of the following

side effects: diarrhoea, nausea, vomiting,
abdominal pain, sore mouth, fatigue, and itching.
Some side effects may need immediate medical
help. Alert your doctor quickly if you experience
any of the following: rashes, breathlessness,
swelling of the face, eyes or mouth, rashes with
peeling of the skin or blistering of the lips, mouth
or eyes accompanied by fever, yellowing of the
skin or eyes, severe diarrhoea, severe stomach
cramps, bloody stool, Inform your doctor if any
of these side effects do not go away or are
severe, or if you experience other side effects.
Inform patient taking hormonal contraceptives
that the drug may reduce contraceptive efficacy.
Advise her to use an alternative birth control
method.

36
GENERIC NAME Dexketoprofen Trometamol

BRAND NAME Ketesse

CLASSIFICATION NSAIDs

ORDERED DOSE 25 mg/tab x 6 tab. 1 tab 3x a day x 2 days

SUGGESTED DOSE (By ● Adult: 12.5 mg 4-6 hourly or 25 mg 8

Manufacturer) hourly. Max: 75 mg daily.
● Elderly: Initiate at the lower end of the
dosage range with total dose not
exceeding 50 mg daily. Dose may be
increased to that recommended for
general population only if well tolerated.

37
MODE OF ACTION Adult: 12.5 mg 4-6 hourly or 25 mg 8 hourly.
Max: 75 mg daily.

Elderly: Initiate at the lower end of the dosage

range with total dose not exceeding 50 mg daily.
Dose may be increased to that recommended
for general population only if well tolerated.

INDICATION Tab: Treatment of pain of mild to moderate

intensity like musculo-skeletal pain,
dysmenorrhea & dental pain.

Inj: Symptomatic treatment of acute pain of

moderate to severe intensity, when oral
administration is not appropriate such as post-
operative pain, relic colic, and low back pain.

38
CONTRAINDICATION Hypersensitivity or to eg, aspirin and other
NSAIDs. History of stroke (CVA), heart attack
(MI), CABG, uncontrolled HTN, CHF NYHA II-
IV; precipitate attacks of asthma,
bronchospasm, acute rhinitis, or cause nasal
polyps, urticaria or angioneurotic edema; active
or suspected peptic ulcer/ hemorrhage or
history of recurrent peptic ulcer/hemorrhage (22
distinct episodes of proven ulceration or
bleeding) or chronic dyspepsia; NSAID-related
GI bleeding or perforation; GI or other active
bleedings or bleeding disorders; Crohn's
disease or ulcerative colitis; history of bronchial
asthma; severe heart failure; moderate to
severe renal dysfunction (CrCl < 50mL / m * in)
severe hepatic dysfunction (Child-Pugh score
10-15); haemorrhagic diathesis & other
coagulation disorders. Pregnancy (3rd
trimester) & lactation. Child & adolescent.

Inj: Neuraxial (intrathecal or epidural)

administration.

39
SIDE EFFECTS CNS: headache, dizziness, CNS excitation
(insomnia, nervousness, and dreams) or CNS
depression (somnolence and malaise).

CV: peripheral edema.

EENT: visual disturbances, tinnitus.

GI: dyspepsia, abdominal pain, anorexia,

constipation, diarrhea, flatulence, nausea,
stomatitis, vomiting.

GU: UTI signs and symptoms.

Skin: rash.

ADVERSE EFFECTS GU: nephrotoxicity

DRUG INTERACTION ACE inhibitors, ARBs: May significantly

decrease glomerular filtration and renal

function. Monitor therapy.

40
NURSING RESPONSIBILITIES • Don't use extended-release form for
patients in acute pain.

Rationale: Extended-release medications enter

the body gradually over a period of time,
typically 12 or 24 hours. For patients suffering
from acute pain, using extended-release
formulations may have a slower onset of action.

• Check the patient’s allergy status.

Rationale: Previous allergic reactions to

NSAIDs may render the patient unable to take
them. Alternatives to NSAIDS should therefore
be considered in case of allergy.

• Check renal and hepatic function every 6

months or as indicated.

Rationale: Performing tests to determine how

well the kidneys function plays a vital role in
order to know how well they respond to the
treatment as well as to determine the
progression of renal disease

• Assess the patient’s mucous

membranes and his ability to swallow.

Rationale: To check for any potential problems

with administration, hydration, and absorption.
To ensure that the right form of NSAIDs is
given through the right route.
• Administer with or after meals as
prescribed.

41
Rationale. This is best taken on a full stomach
to reduce the occurrence of stomach upset.
• Administer on time as prescribed.
Rationale. This should always be taken on
time to prevent any delays and errors during
treatment.
• Monitor input and output.
Rationale. NSAIDs may cause impaired
urinary elimination.
• Routinely check for blood glucose level
of the patient. Especially if the patient is
diabetic.
Rationale. NSAIDs may reduce serum glucose
level.
• Monitor the patient’s response to
NSAIDs.
Rationale: To check if the NSAIDs are effective
or if the dose needs to be adjusted.
• Educate the patient about the action of
the action, indication, common side
effects, and adverse reaction.
Rationale. To inform the patient on the basics
of NSAIDs, as well as to empower her to safely
self-administer the medication.
• Ask the patient to repeat information
about NSAIDs.
Rationale. To evaluate the effectiveness of
health teaching on NSAIDs.

• Check renal and hepatic function every 6

months or as indicated.

Rationale: Performing tests to determine how

well the kidneys function plays a vital role in
order to know how well they respond to the

42
treatment as well as to determine the
progression of renal disease

• Monitor BP at start of and throughout

therapy.

Rationale: As blood pressure rises, it can

constrict and can narrow the blood vessels
which can damage and weaken them to the
point that they may no longer work properly

43
C. Non-pharmacological Management

● Surgery to remove the gallbladder (cholecystectomy).

Given that gallstones usually recur, the doctor may recommend getting
your gallbladder surgically removed. After your gallbladder is removed, bile no
longer needs to be stored in the gallbladder and instead flows directly from the
liver into the small intestine. Gallbladder removal doesn't damage the ability to

44
 digest food and doesn't affect the ability to survive, although it can induce
diarrhea, which is typically only temporary.

IX. NURSING MANAGEMENT

45
Name of the Client: M.G.C Age/Sex: 23/M Ward: St. Lorenzo Room#: 309 Bed #: 1
Chief Complaint: Right upper quadrant pain Attending Physician: Dr. Encarnacion
Admitting Diagnosis or Impression: Acute Cholecystolithiasis

DAT CUES NE NURSING PATIENT NURSING INTERVENTIONS IMPLE EVALUATION

E ED DIAGNOSIS OUTCOME MENT
/ ATION
TIM
E

F Subjective: N Acute Pain Within 8 1. Establish rapport and provide FEBRUARY 5, 2023
1
related to hours of client’s privacy
E · “sakit U @ 7am
inflammation of nursing
kaayo R: Creates a trusting relationship
B T the gallbladder intervention, “GOAL MET”
akong that promotes cooperation and
as evidenced by the patient
U tagiliran R comfort After 8 hours of nursing
abdominal pain will be able to
sir” as intervention, the patient
with a pain report 2. Monitor vital signs every 4
A verbalized I
scale of 6/10. reduction of hours. reported a reduction of
by the 2
R T pain from a pain from a pain scale
patient of 6/10 to 3/10.
pain scale of R: To assess general well-being,
Y I

46
 · Pain O Rationale: 6/10 to 3/10. detect signs of medical
Scale of disorders, and provide
4 N Gallstones,
6/10 appropriate health care.
which are made
A
Objective: of cholesterol,
3. Keep the client in a semi-
2 L calcium salts,
VS @ 12mn: Fowler’s position. 3
and bile
R: To lessen the pain. Gravity
0 / pigments,
· Temp: localizes inflammatory exudate
39.5°C develop as a
2 M into the lower abdomen or pelvis, PAMA, JEOFY F, St. N.
result of
relieving abdominal tension,
3 · PR: 69 E cholelithiasis.
which is accentuated by the
bpm Gallstones that
@ T supine position.
obstruct bile
· CR:72
A flow cause the
bpm
gallbladder to 4. Encourage patient to have a
11 B 4
· RR: 23 swell, which general liquid diet to soft diet.
cpm increases the
P O
R: To give time of the gallbladder
chance of pain,
· to rest thus results in healing.
M L inflammation, or
BP:11
infection. Often,
0/60 I
cholelithiasis 5. Administer prescribed

47
 mmHg C symptoms and medications (analgesics). 5
indicators do
VS @ 4AM: R: To alleviate the symptoms of
not appear until
abdominal pain.
· Temp: P the gallstone

36.5°C has blocked the 6. Administer antibiotics as

A biliary system. ordered.
· PR: 68 Jaundice, fever, 6
T
bpm and stomach R: To prevent infection

T pain—usually in
· CR: 71 7. Administer IV as ordered by
the upper right
bpm E the Doctor.
quadrant of the
· RR: 21 R abdomen—may R: To maintain an appropriate 7
cpm be among them. hydration level.
N
Thereby causes
· BP: 8. Encourage adequate bed rest
acute pain.
110/60
R: To reduce gastrointestinal
mmHg References:
simulations thus decreasing GI 8
Laborato Romero, B. W., activity.
ry: RN, & MSN.
9. Provide diversional activities
(n.d.). Nursing
CBC: and relaxation techniques.
Care Plan –

48
● H:135 Cholelithiasis. R: Refocuses attention, 9
g/L Nursing Crib. promotes relaxation, and may
● RBC: https://nursingc enhance coping abilities.
4.57 rib.com/nursing
10. Apply warm compress on the
10^12/ -care-
abdomen
L plan/nursing-
● MCH care-plan- R: To calm spasms and relieve 10
:29.6 cholelithiasis/ pressure from bile buildup
pg
● MCV: 11. Educate patients on bladder

90 fl training.

● MCHC
R: To increase the amount of
: 32.7 11
time in between emptying and
g/L
intaking of fluids in your bladder.
● WBC:
16.8 12. Monitor intake and output.
10^9/L
R: To monitor patient’s fluid
,
volume accurately and
● neutro 12
effectiveness of actions.
phil:
82%,

49
● lymph
ocyte:
References:
12%,
● monoc Doenges, M.(2021). Nursing
yte: Care Plans | Guidelines for
5%, Individualizing Client Care
● eosino Across the Life Span. F.A. Davis
phil: Company.
1%,
● basop
hil:
0%,
● hemat
ocrit:
0.41%
,
● Platele
t: 289
10^9/L
● Bilirubi
n: 6.70

50
 umol/L
,
● direct
bilirubi
n: 2.25
umol/L
,
● indirec
t
bilirubi
n: 4.45
umol/L
● alkalin
e
phosp
hatase
: 120
U/L.

· (+)

51
rebound
tendernes
s on the
RUQ

·
Anicte
ric sclera

·
Slightl
y pale
conjunctiv
a

· (-)
murphy
sign

·
Restle

52
ssness

· On a
NPO diet
then
shifted to
Low Fat
Diet and
General
Liquids

·
Administe
red
D5LR1L
@
120cc/hr

Silgram
750 g for 5
days

53
54
NURSING THEORY

NURSING NEED THEORY

VIRGINIA HENDERSON

American nurse Virginia Henderson,

who came up with the Nursing Need Theory, is
widely regarded as a pioneer in the field. The
philosophy emphasizes maximizing patient
autonomy to speed up recuperation after
hospitalization. Her insistence on patients'
most basic needs as the primary focus of
nursing practice has stimulated new lines of thought about how the profession might
best meet those demands. The individual, the environment, health, and nursing are
the four key tenets of the nursing need theory. Henderson argues that all people have
basic health requirements. They may require assistance in either regaining health and
independence or passing away with dignity. This concept shifts focus away from the
patient as a singular consumer or client and toward the patient as a generic
physiological requirement. A person's environment consists of the conditions in which
they develop their unique set of behavioural patterns. the sum of all external causes
and impacts on growth and existence. People are a part of nature just as much as
families are. Basic nursing care includes helping the patient to: breathe normally; eat
and drink adequately; eliminate body wastes; move and maintain desirable postures;
sleep and rest; choose appropriate clothing; dress and undress appropriately; maintain
normal body temperature by adjusting clothing and modifying the environment; keep
the body clean and well groomed; protect the integument; avoid dangers.

Patients with acute cholecystolithiasis can benefit from Virginia Henderson's

idea by learning how to self-manage their disease. Through her recovery from acute
cholecystolithiasis, the nurse acts as a mentor and caregiver for the patient. The nurse
combines health education into patient care in order to empower the patient to take
charge of his or her own recovery. Acute cholecystolithiasis is an inflammation and
gallstone formation in the gallbladder. The accumulation of cholesterol in the form of

55
stones is the primary culprit in the development of gallstones. The nurse can aid the
patient by imparting health teachings that the patient can apply independently, such
as the fourteen tasks of the nursing need theory: eating a low-fat diet, drinking plenty
of fluids (unless contraindicated), taking pain medications as prescribed by the doctor,
avoiding strenuous activity for two weeks, and keeping the surgical area clean and
dry.

SELF-CARE NURSING THEORY

DOROTHEA E. OREM

Dorothea Orem developed the concept of

self-care, which emphasizes the individual's ability
to look out for their own needs. Taking care of one's
health and maintaining a balanced lifestyle may fall
under this heading. To determine if a patient has
fully recovered or if more therapy is necessary, this
concept could be applied. The primary idea behind
this approach is that patients who need help taking
care of themselves typically require continued nursing care, whereas patients who are
able to take care of themselves may no longer need a nurse's services. After
undergoing surgery for acute cholecystolithiasis, the patient may require nursing care
in all areas. Taking this into account, nurses must play a pivotal role in determining
what aspects of patient care to prioritize under given conditions. If nurses had this
information, they could better assist patients in making a full recovery while allowing
them to maintain some kind of autonomy over their self-care. According to proponents
of the self-care hypothesis, looking after oneself is a basic human need. While this
may be true, it creates tricky situations for the nurse who has to intervene when a
patient is unwilling to exercise full autonomy. Whenever a disease process impacts
one's sense of self-worth, some patients may opt to switch roles and become the ones
receiving treatment. This may give them a false sense of security, at least momentarily.
Thus, when nursing intervention is focused at giving the patient back control of the
circumstance, the patient can begin the process of self-care and healing. By receiving

56
health education, patients in the post-operative period may learn how to take
responsibility for their own health and recovery. Because of this, it may suggest that
they are cognizant of their predicament and are prepared to resort to self-defense in
order to achieve their health potential.

The philosophy of self-care, the self-care deficit, and nursing systems are the
three facets of the larger Self-Care framework. As previously said, self-care
philosophy places an emphasis on the individual's initiative to maintain his or her
own health, wellbeing, and quality of life. Self-care deficit hypothesis, on the other
hand, specifies when assistance from nurses is warranted. A valid patient and a
legitimate nurse have multiple relationships that contribute to the nursing systems
theory. The patient in this case study is recovering from surgery, and her mobility
restrictions make it difficult for her to deliver consistent, high-quality self-care. The
nursing system is activated and nursing care is required when the client's therapeutic
self-care needs exceed the individual's ability to meet those needs. Orem outlined
five approaches nurses should take when providing care: performing what needs to
be done for the patient, guiding them through the process, offering emotional
support, creating an atmosphere where they can learn new skills to meet future
needs, and teaching them to others.

57
DISCHARGE PLANNING (METHOD)

METHOD HEALTH TEACHINGS RATIONALE

Medication ● Instruct the patients

to take following
prescribed
medications:
○ Analgesics ● As this patient recently
(Dexketopro underwent
fen) laparoscopic
cholecystectomy,
which can cause pain
after surgery and
throughout recovery,
analgesics are needed
to relieve his pain.
● Antibiotics
(Sultamicillin ● Antibiotics are
) medications used to
destroy or inhibit
bacterial growth and
are prescribed in order
to avoid further
infections.

Exercise ● After a week of ● Walking keeps the

being discharged, patient's body lively
go through with the while they are
patient the recovering, helps to
usefulness of strengthen the muscle,
walking exercises and enables faster
for recovering wound healing.
condition.

58
 ● Avoid strenuous ● Exercises that require a
activity for 4-6 large amount of effort
weeks. might delay the healing
of surgical wounds and
increase the risk of
infection.

● Avoid lifting heavy ● Carrying heavy objects

objects for 2-4 after the surgery puts
weeks one's body under
physical exertion that
can increase blood
pressure and lead to
the surgical incision
rupturing and bleeding.

● Advise the patient ● Resting will help the

to give the patient patient to recover
adequate rest. easily.

Treatment ● Provide to the ● Pharmacological

patient any drugs or therapy refers to the
antibiotics that are use of drugs to address
appropriate for their typical side effects of
pharmacological laparoscopic
therapy. cholecystectomy and to
lessen postoperative
pain.

Hygiene ● Inform the patient ● Water should not be

59
 to wait a few days applied to surgical
to take a bath until wounds until they have
the wound has healed because doing
healed. so could weaken the
skin and cause the
wound to resurface.

● Once the wound ● Washing gently will

has healed, advise prevent damaging the
the patient to take surgery wound area.
gentle washes.

Outpatient ● Instruct the patient ● In order for the doctor

of the importance of to monitor the patient's
following checkups. recovery process,
follow-up exams are
necessary.

● Encourage the
patient to inform the ● Any unexpected
doctor of any symptoms should be
unusual symptoms reported to the doctor
or a discomfort that right away so they can
gets worse over be treated and further
time. complications can be
avoided.

Diet ● Inform the patient ● A healthy diet is

of the worth of a essential for a quick
balanced diet for recovery from a
maintaining good laparoscopic
health. cholecystectomy. A
nutritious diet can aid in

60
 our body's optimal
healing during the
healing process and
provide it with the
energy it requires to
complete the remaining
stages of the healing
process.

● Give the patient ● After cholecystectomy,

guidance to eat avoiding nausea,
clear liquids, soups, vomiting, and
and gelatine as part constipation by
of their diet. maintaining a soft,
liquid diet.
● Instruct the patient
to have a low salt ● Fast food and
low fat diet. processed foods that
are high in saturated
and trans fats should
be especially avoided.
Consuming foods high
in fiber helps promote
regular bowel
movements.
● Inform the patient
to avoid food that ● Consuming foods that
cause constipation can lead to diarrhea
or diarrhea such as and constipation might
spicy foods. make patients
uncomfortable and
slow the recovery from

61
 cholecystectomy.

REVIEW OF RELATED LITERATURE

Title: Concept of the pathogenesis and treatment of cholelithiasis

Bibliography: Reshetnyak, V. I. (2019). Concept of the pathogenesis and treatment of

cholelithiasis. World Journal of Hepatology, 4(2), 18.
https://doi.org/10.4254/wjh.v4.i2.18

Gallstone disease (GD), which results in the production of gallstones in the

hepatic bile duct, common bile duct, or gallbladder, is a chronic, recurrent hepatobiliary
illness. Its cause is the poor metabolism of cholesterol, bilirubin, and bile acids. One of
the most common gastrointestinal conditions, GD places a heavy load on healthcare
systems. Serious consequences of GD can include gallbladder cancer and severe
pancreatitis from gallstones. In this overview, the epidemiology, etiology, and
management of GD are covered. Regional differences in GD prevalence are significant.
In recent years, gallstone disease has become more common. This is related to a
change in lifestyle, including lessening physical load, motor activity, and food.
Ultrasonography's ability to identify asymptomatic cases of gallstone disease, which
enables early treatment and the avoidance of disastrous outcomes, is one of the key
advantages of gallstone disease early screening. It is thought that the development of
GD is multifaceted, with complicated interactions between genetic and environmental
variables. It implies that the development of cholelithiasis in men may be modelled after
the effects of corticosteroids and oral contraceptives, which contain hormones linked to
steroid hormones. Expanding indications for therapeutic treatment of GD have been
made possible by advances in the study of the physiology of bile production and the
pathogenesis of GD.

62
Title: Cholelithiasis: Presentation and Management

Bibliography: Littlefield, A., & Lenahan, C. (2019). Cholelithiasis: Presentation and

Management. Journal of Midwifery & Women’s Health, 64(3), 289–297.
https://doi.org/10.1111/jmwh.12959

Approximately 15% of Americans have cholelithiasis. An rise in cholelithiasis

diagnoses has been attributed to rising trends in obesity and the metabolic syndrome.
Cholelithiasis has a number of controllable and non-modifiable risk factors.
Cholelithiasis is more prevalent in women than in males. An additional risk factor for
cholelithiasis in women is pregnancy, increased parity, and obesity during pregnancy.
The right upper quadrant pain of the abdomen, which is frequently elicited upon touch
during physical examination and documented as a positive Murphy's sign, is the
characteristic presentation of those suffering from cholelithiasis, specifically when
gallstones obstruct the common bile duct. Those with cholelithiasis frequently
additionally have referred pain to the right supraclavicular area and/or shoulder, nausea,
and vomiting. Cholecystitis (gallbladder inflammation) and cholangitis are two
consequences of cholelithiasis (inflammation of the bile duct). It is nevertheless possible
to be diagnosed with cholelithiasis despite the lack of physical examination evidence.
Nevertheless, ultrasonography is the gold standard for diagnosis. Laboratory tests such
as white blood cell count, liver enzymes, amylase, and lipase may help the clinician in
making a cholelithiasis diagnosis. The severity and frequency of symptoms determine
how they should be managed. For people who experience a single symptomatic
episode, lifestyle and dietary changes along with pharmaceutical treatment, such as the
use of gallstone dissolving agents, may be advised. It is advised to have a laparoscopic
cholecystectomy if the symptoms worsen or return. Regardless of the severity or
regularity of symptoms, people with cholelithiasis should be referred to a surgeon and/or
gastroenterologist within two weeks of their initial presentation.

Title: Independent Risk Factors for Gallstone Formation in a Region with High
Cholelithiasis Prevalence

63
Bibliography: Völzke, H., Baumeister, S. E., Alte, D., Hoffmann, W., Schwahn, C.,
Simon, P., John, U., & Lerch, M. M. (2020). Independent Risk Factors for Gallstone
Formation in a Region with High Cholelithiasis Prevalence. Digestion, 71(2), 97–105.
https://doi.org/10.1159/000084525

North-eastern Germany has a high prevalence of the condition cholelithiasis.

Analysis of this population's gallstone risk factors may have a strong explanatory power.
Using data from the population-based Study of Health in Pomerania, it was possible to
analyze the relationships between gender-specific risk variables for gallstone formation
(SHIP). Data on 4,202 people between the ages of 20 and 79 were available. A history
of cholecystectomy or the detection of gallstones on an abdominal ultrasonography were
used to characterize cholelithiasis. In order to find independent risk factors for gallstone
formation, multivariable analyses were carried out. There were 468 individuals (11.1%)
having a history of cholecystectomy, and 423 individuals (10.1%) had gallstones
detected by sonography. Compared to men, women had a twofold increased chance of
developing cholelithiasis. In both men and women, cholelithiasis was independently
correlated with age, body mass index, and low blood HDL cholesterol levels. Gallstone
formation was additionally independently correlated with low alcohol and high coffee
consumption in the male group and poor physical activity in the female population. There
were also discovered sex-specific relationships between risk variables. In this location
where cholelithiasis is a common illness, female sex, age, and being overweight are
significant risk factors for gallstone production. A gender-specific risk of gallstones is
influenced by additional variables and interactions.

Title: Clinical diagnosis of cholecystitis in emergency department patients with

cholelithiasis is indication for urgent cholecystectomy: A comparison of clinical,
ultrasound, and pathologic diagnosis

Bibliography: Martin, W. T., Stewart, K., Sarwar, Z., Kennedy, R., Quang, C.,
Albrecht, R., & Cross, A. (2022). Clinical diagnosis of cholecystitis in emergency
department patients with cholelithiasis is indication for urgent cholecystectomy: A
comparison of clinical, ultrasound, and pathologic diagnosis. The American Journal of
Surgery, 224(1), 80–84. https://doi.org/10.1016/j.amjsurg.2022.02.051

64
 If a sonographic evaluation does not find indications of cholecystitis, biliary
pathology is a typical cause for visits to the emergency room with discharge and
outpatient follow-up. This retrospective assessment was done to compare the clinical
evaluation's sensitivity to sonographic evaluation's sensitivity in identifying patients who
needed urgent cholecystectomy. Retrospective chart evaluation of 308 patients who
underwent cholecystectomy and cholelithiasis surgery and 308 patients who underwent
cholecystectomy and cholelithiasis surgery. The accuracy of the clinical and pathologic
diagnosis was assessed using the history and physical examination, laboratory results,
ultrasonography (US), and final surgical pathology. For pathologic cholecystitis, RUQ
discomfort with known cholelithiasis lasting more than 4 hours is sensitive. Even though
there is no sonographic evidence of cholecystitis, the discovery calls for an immediate
cholecystectomy in the index encounter.

Title: The Laparoscopic Cholecystectomy and Common Bile Duct Exploration: A Single-
Step Treatment of Pediatric Cholelithiasis and Choledocholithiasis

Bibliography: Pogorelić, Z., Lovrić, M., Jukić, M., & Perko, Z. (2022). The Laparoscopic
Cholecystectomy and Common Bile Duct Exploration: A Single-Step Treatment of
Pediatric Cholelithiasis and Choledocholithiasis. Children, 9(10), 1583.
https://doi.org/10.3390/children9101583

The diagnosis of complex biliary tract illnesses in children is rising. Children are
increasingly undergoing laparoscopic cholecystectomy procedures after common bile
duct exploration. This study's objective was examined the results of LCBDE in kids and
compare them to those of an once popular procedure called endoscopic retrograde
cholangiopancreatography. A total of 84 kids (78.5%) underwent laparoscopic
cholecystectomy from January 2000 to January 2022. Of these, 14 children underwent
LCBDE for choledochiothiasis and 6 children underwent laparoscopic cholecystectomy
(LC) With ERCP. The study's main goal was to determine whether the treatment was
successful based on the frequency of side effects, the likelihood of recurrence, and the
frequency of operations. Stone features, symptoms upon presentation, length of
operation, and length of hospital stay were secondary objectives. Pediatric patients for
the treatment of choledocholithiasis may undergo exploration of the common bile duct
and removal of stones via LCBDE. This method allows for the simultaneous treatment

65
of choledocholithiasis and cholelithiasis without the need for papillotomy or fluoroscopy.
The hospital stay is shorter with LCBDE compared to LC + ERCP. Although problems
were rare, they were not statistically significant.

X. Prognosis
According to Tokyo Guidelines 2018, the severity grading of acute cholecystitis
is categorized by 3. Grade III (severe) acute cholecystitis is associated with
dysfunction of any one of the following organs/systems: (1) Cardiovascular dysfunction:
hypotension requiring treatment with dopamine ≥5 μg/kg per min, or any dose of
norepinephrine; (2) Neurological dysfunction: decreased level of consciousness; (3)
Respiratory dysfunction: PaO2/FiO2 ratio <300; (4) Renal dysfunction: oliguria,
creatinine >2.0 mg/dl; (5) Hepatic dysfunction: PT-INR >1.5; and (6) Hematological
dysfunction: platelet count <100,000/mm3 . Grade II (moderate) acute cholecystitis is
associated with any one of the following conditions: (1) Elevated WBC count
(>18,000/mm3); (2) Palpable tender mass in the right upper abdominal quadrant; (3)
Duration of complaints >72 hours; and (4) Marked local inflammation (gangrenous
cholecystitis, pericholecystic abscess, hepatic abscess, biliary peritonitis,
emphysematous cholecystitis). Grade I (mild) acute cholecystitis does not meet the
criteria of “Grade III” nor “Grade II” acute cholecystitis and can be defined as acute
cholecystitis in a healthy patient with no organ dysfunction and mild inflammatory
changes in the gallbladder. Thus, have an excellent prognosis because of safe and low-
risk procedure after a cholecystectomy has performed.

In our case, the patient has Grade II Acute Cholecystitis due to increased WBC
count, RUQ abdominal pain, and duration of the complaint is already 2 weeks which is
already more than 72 hours (Takada, 2018). The definitive treatment for this is
cholecystectomy. Early cholecystectomy which is performed within 72 hours of onset is
preferred versus delayed cholecystectomy which is performed 6-10 weeks after initial
medical treatment and recuperation. Thus, early cholecystectomy is more
recommended as soon as possible to attain quicker recovery times. Laporoscopic
cholecytectomy is now accepted as being safe for acyte cholecystitis and found to be
superior over open cholecystecomy due to lower incidence of complications, shorter
length of postoperative hospital stay, quicker, and earlier return to work. Failure to
improve after surgery may be due to gangrene or perforation of the gallbladder. Patients

66
present with acute cholecystitis should receive initial IV fluids, broad-spectrum
antibiotics for infection (increased WBC count), and analgesia before surgery is
performed (Anderson et al., 2019).

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