I.

BIOGRAPHIC DATA:

NAME : Mr. Bhuneshwar Singh

AGE : 52 years
SEX : Male
WARD : Male Medical Ward
IP NO : P2190615
MARITAL STATUS : Married
EDUCATION : 10th class pass
OCCUPATION : Watchmen
INCOME : Did not tell
RELIGION : Hindu
LANGUAGE KNOWN : Hindi
ADDRESS : Phase-2, Greater Noida
DIAGNOSIS : Cholelithiasis
DATE OF ADISSION : 02\04\24
DATE OF SURGERY : 05\04\2024
NATURE OF SURGERY: Laparascopic cholecystectomy
POST O.P. DAY : 01
DATE OF CARE STARTED: 02/04/24
DATE OF CARE ENDED : on going

II. INTRODUCTION
Mr Bhuneshwar Singh came to the causalities with the complains of upper quadrant abdominal pain since 1 years,
fever since 2days, after receiving case in the emergency ward . He was immediately admitted to Male medicine
ward for further treatment. He is undergoing treatment and is seems to be responding to the treatment.

III. SOCIO ECONOMIC BACKGROUND

Patient hails from a village in U.P. but moved to Delhi 25 years ago. He has his own house. He lived with his wife
but she 18 years ago. He has 1son and 1 daughter. No. of rooms are 4 with water supply from Delhi Jal Board,
have Indian toilet. His eldest son is married and he only brought him to the hospital. He has no pets.
 IV. FAMILY HEALTH HISTORY LEGEND:

FEMALE

Patient Wife
MALE

PATIENT

Son Daughter Daughter

in law

a) Family composition

S.NO NAME RELATIONSHIP AGE SEX EDUCATION OCCUPATION HEALTH STATUS

TO PATIENT
1. Bhuvanesh Self 52yrs M 10nd class pass Watchman Cholelithiasis
war Singh
2. Kalawati Wife 48yrs F 5th pass Tailar Healthy
3. Sonu Son 30yrs M Postgraduate Pvt. job Healthy
4. Neetu Daughter in law 25yrs F Graduate Housewife Healthy
5. Priya Daughter 26yrs F Graduate Student Healthy
 b) Family Medical History:
There is no family history of any diseases like diabetics mellitus , hypertension, ect
v. PERSONAL HISTORY

a) Personal Habits: Patient have no addiction of any substance and alcohol.

b) Diet: Patient takes a total no. of 2-3 meals a day. He is a vegetarian.

c) Sleep/Rest: 6-7 hrs sleep per day.

d) Activities of daily living: Patient is able to brush his teeth and bathe by himself.

e) Elimination:

➢ Bowel habits: 1-2 times per day

➢ Bladder habits: 2-3 times per day

f) Hobbies: No as such

g) Marital history
1. Duration of marriage:27 years
h) Sexual history: Did not tell
i) Contraceptives: Did not tell
j) Drug history: No history of drug allergy and addiction.
 V. HSITORYOF PRESENT ILLNESS

a) Present medical history

Patient was apprarently asymptomatic 1year ago. When he suddenly develop pain in upper quadrant abdominal
pain . since 3 days, along with fever and weakness since 3days, patient came Sharda Hospital in emergency on
2\04\2024. He was immediately admitted to Male medicine ward for further treatment. He is undergoing treatment
and is seems to be responding to the treatment.
b) Present surgical history
No present surgical history

c) Present obstetrical history:

NA

VI. HISTORY OF PAST ILLNESS

a) Past medical history:

Patient has no medical past medical history of blood pressure, diabetes mellitus, asthma, ect.

b) Past surgical history:

No past or present surgical history.
 VII. HEAD TO TOE EXAMINATION
General appearance
Nourishment : Patient is moderately nourished
Body build : The body built of the patient is moderate.
Hygiene and grooming : Patient’s hygiene was fairly maintained
Activity : Bit dull due to pain in upper quadrant abdominal.
Health : Unhealthy
Posture : Patient has normal posture

Mental status:
Consciousness : Patient is fully conscious
Behavior
Look : Patient looked pleasant when I greeted him and did history collection
Attitude : Patient was co-operative throughout the conversation
Affect/ mood : Patient’s mood was appropriate to the situation
Speech : Speech of the patient was clear
Orientation : Patient was oriented to time, place and person
Vital signs
Temperature : 100.4 F
Pulse : 100 beat per minute
Respiration : 24 breaths per minute
Blood pressure : 130/80 mm of hg

Height and weight

Height : 5’8 feet
Weight : 75 kg

(A) HEAD
Shape : Patient’s shape of the head is Normal cephalic.
Scalp : No pediculosis present.
Face : Patient’s face appeared pale.

(B) HAIR : Patient has Oily and uncombed hair.

Texture : Patient has normal texture of hair.
Colour : Patient’s hair is grey in colour.
Grooming : Not properly groomed.

(C) EYES
Eyebrows : Hair are unevenly distributed around the brows.
Eyelashes : Patient’s eyelashes are equally distributed.
Eyelids : Patient’s skin is intact round the eyelid.
Colour : Patient’s colour of the eye is black.
Size : Diameter of his eye is 3-7mm in diameter.
Shape : Patient’s eyes are round in shape.
Reaction to light : Pupils equally reactive to light and accommodation.
Corneal reflex : Corneal reflex in patient is present.
Conjunctiva : Patient’s conjunctiva is normal in appearance.
Sclera : Sclera is white in colour.
Lens : Lens of the patient is transparent.
Vision : Patient can see near objects clearly but has little difficulty in seeing distant objects but
he does not wear glasses always.
Extra ocular muscle test : Normal.
 (D) EAR
Position : Patient’s ears are normally placed.
Cerumen : Absent.
Otorrhoea : Absent.

Hearing
- Response to normal voice tone : Patient’s response to voice is normal and audible.

- Watch tick test: Patient is able to hear ticking sound of the watch in both ears but with little difficulty.

- Weber’s test: In the Weber test, the stem of a tuning fork is placed gently against a midline structure of the
skull (i.e., the maxillary incisor teeth or vertex of the cranium or forehead) and the patient is asked where he
hears the sound. Sound is transmitted to both ears through the air but particularly through the vibrations of
the bones of the skull. If sound is transmitted to both sides equally, the sound is heard in the midline and it
can be presumed that the conduction and neural apparatus is intact. With neural deafness, the sound
transmits best to the normal side and the patient lateralizes the sound to that side. With conduction deafness,
sound transmits best to the side of the deafness. This is thought to occur because ambient sound is prevented
from getting to the cochlea on the blocked side. This causes the nervous system to amplify sounds on that
side by sensitizing cochlear transduction. This can be demonstrated by plugging an ear with finger, causing
conduction deafness, and then humming. The sound will be heard well on the occluded side. The test was
done on my patient and it was found that the hearing was not clear in both ears which is due to ageing.
 (E) NOSE
External nose : Symmetric.
Nasal septum : Located midline.
Patency of nasal cavity : Air moves freely as client breaths through the nares.
Frontal and maxillary sinus : Normal.
Smell : Normal.

(F) MOUTH AND PHARYNX

Outer lips : Lips are dried and darkish in texture.
Inner lips : Slightly brown lips.
Gums : Pink in colour.
Tongue : Central position.
Movement : Able to move freely.
Palate : Light pink soft palate.
Tonsils : No enlargement of tonsils.
Odour of mouth : Halitosis present.
Pharynx : Normal gag reflex present.
Voice : Patient has clear voice but with slurred speech.
 (G) NECK
Range of motion : Range of motion is normal ie; flexion, extension and rotation.
Thyroid gland : No enlargement of thyroid gland.
Trachea : Midline located.
Lymph nodes : No palpable lymph node was found.

(H) CHEST
Expansion of the chest : Symmetrical expansion of chest.
Palpation
-Tactile fremitus: Place the bony aspects of the hand (ball or ulnar surface) on the patient's chest
Using one or two hands at a time, palpate bilaterally in an L-shaped pattern as outlined:
o Posterior chest: Start at level of T1 (in between scapulae), descend to areas of T4 and T6, then finish
laterally at T8 area.
o Anterior chest: Start at the level of sternal angle, then between the nipple and sternum, and finish
laterally along costal margin.
Ask the patient to repeat the words "ninety-nine" in a sufficiently deep and audible voice for each point on
the chest
Compare symmetry from side-to-side. The test was done on my patient and sound produced was
asymmetrical due to collection of secretions.

-Thoracic excursion: It is performed by asking the patient to exhale and hold it. The examiner
then percusses down their back in the inter-costal margins (bone will be dull), starting below the scapula, until
sounds change from resonant to dull (lungs are resonant, solid organs should be dull). That is where the examiner
marks the spot. Then the patient takes a deep breath in and holds it as the examiner percusses down again, marking
the spot where the sound changes from resonant to dull again. Then the examiner will measure the distance
between the two spots. Repeat on the other side, is usually higher up on the right side. If it is less than 3–5 cm the
patient may have pneumonia or pneumothorax in which a chest x-ray is diagnostic for either. The test was done
on my patient and distance is 5cm.

Breath sounds : Normal breath sound.

Cough : Cough is not present.
Sputum : Not present.
Heart : S1 and S2 are heard.

(I) ABDOMEN
Inspection : surgery scar is present.
Palpation : patient feel pain in right side of abdomen due to cholelithiasis.
Percussion : no sign of edema.
Auscultation : abdominal sound is abnormal
Inguinal lymph nodes : no enlarged.
Appetite : Decreased.
 (K ) SKIN
Colour : Patient has fair complexion.
Texture : skin is little dry and pale.
Lesion : No lesion present.
Turgor : Normal.

(L ) UPPER EXTREMITY
Symmetry : Symmetrical.
Range of motion : Range of motion is normal.
Reflexes : Normal reflexes.
Oedema : Absent.
Cyanosis : Not present.
Joints : Stiffness present.
Deformity : Absent.

(M) LOWER EXTREMITY

Symmetry : Symmetrical.
Toenail : Normal .
Range of motion : Range of motion is restricted due to stiffness in joints.
Reflexes : Did not perform as patient was restless due to pain.
Oedema : Slight oedema is present in both foot.
Cyanosis : Not present.
Joints : Stiffness present in both knee joint.
Deformity : No deformity present.

(N) NAILS
Shape : Normal.
Texture : Little thickness present in the nail of the both toes
Capillary refill : Blanch test performed and it was 20 seconds

(O) GENITAL AND RECTUM

Haemorrhoids : Not present.
IX INVESTIGATIONS
DATE TYPE OF PATIENT NORMAL REMARKS
INVESTIGATION VALUE VALUE
02\01\2024 HEMATOLOGY
Hb 10.20g/dl 13-18g/dl Decreased
TLC 6.08 4-11 10x8micrOL Normal
DLC:
Neutophils 75% 49-79% Increased
Lymphocytes 7.1 20-49% Decreased
Monocytes 4.9 2-10% Normal
Eosinophils 0.5 1-6% Decreased
Basophils 0.3 <1.2% Decreased
RBS count 4.39 4.5-5.5milicumme Normal
Hematocrit 40.3 40-50% Normal
MCV 91.8 83-100fl Normal
MCH 29.4 27-32pg Normal
MCHC 32 32-36g/dl Normal
Platelet Count 162 150-40010x3microL Normal
PCV 49.70 35-44 Increased
02/01/2024
BIOCHEMISTRY

KFT

Blood urea 31 15-45mg/dl Normal

Serum Creatinine 1.07 0.5-1.4mg/dl Normal
Serum Uric Acid 6.3 2.5-7.5mg/dl Normal
 Serum protein total 5 6-8g/dl Decreased
Albumin 2.3 3.4-5g/dl Decreased
Globulin 2.7 1.5-3.0g/dl Normal
Sodium 128 136-149meq/l Decreased
Potassium 3.0 3.5-5.4meq/l Decreased
Chloride 90 98-108meq/l Decreased

04/01/2024 HEMATOLOGY
Hb 13.6 13-18g/dl Normal

TLC 8.4 4-11 10x8micrOL Normal

DLC:
Neutophils 77 49-79% Normal
Lymphocytes 14.2 20-49% Decreased
Monocytes 7.1 2-10% Normal
Eosinophils 1.1 1-6% Normal
Basophils 0.6 <1.2% Decreased
RBS count 4.65 4.5-5.5milicumme Normal
Hematocrit 42 40-50% Normal
MCV 90.3 83-100fl Normal
MCH 29.2 27-32pg Normal
MCHC 32.4 32-36g/dl Normal
Platelet Count 193 150-40010x3microL Normal
RDW 13.5 11.6-14 Normal

BIOCHEMISTRY
KFT
Blood urea 31 15-45mg/dl Normal
Serum Creatinine 1.13 0.5-1.4mg/dl Normal
Serum Uric Acid 4.7 2.5-7.5mg/dl Normal
Serum protein total 5.7 6-8g/dl Normal
Albumin 2.5 3.4-5g/dl Decreased
Globulin 3.2 1.5-3.0g/dl Increased
Sodium 129 136-149meq/l Decreased
Potassium 3.3 3.5-5.4meq/l Decreased
Chloride 88 98-108meq/l Decreased

LFT
S. Bilirubin test
S. Bilirubin Total 1.36mg/dl 0.2-1.30mg/dl Increased
S. Bilirubin Indirect 0.65 0.2-0.8mg/dl Normal
S. Bilirubin Direct 0.19 0.0-0.2mg/dl Normal
SGOT 99.80IU/L 0.00-0.40IU/L Increased
SGPT 41 5-40IU/L Increased
S. Alkaline 184IU/L 45-116IU/L Increased
Phosphate
 X MEDICATION
DRUG AND ROUTE ACTION SIDE EFFECTS NURSES RESPOSIBILITY
DOSE
Inj. Intra Antibiotic
Amikacin venously CNS: Drowsiness, dizziness,
Amikacin is a semi- vertigo, fatigue, headache, Nursing Implications
Chemical synthetic somnolence, restlessness,
name: aminoglycoside euphoria, confusion, anxiety, Assessment & Drug Effects
Amikacin antibiotic derived coordination disturbance, sleep
• Administer dose as needed
from kanamycin A. disturbances, seizures.
Dose Similar to other CV: Palpitations, vasodilatation. but not to exceed the
Intravenous: aminoglycosides, a GI: Nausea, recommended total daily
250mg, mikacin disrupts constipation, vomiting, dose.
• Monitor vital signs and
500mg bacterial protein xerostomia, dyspepsia, diarrhoea,
synthesis by binding abdominal pain, anorexia, assess for orthostatic
to the 30S ribosome flatulence. hypotension or signs of CNS
of susceptible Body as a depression.
• Discontinue drug and notify
organisms. Whole: Sweating, anaphylactic
reaction (even with first dose), physician if S&S of
withdrawal syndrome (anxiety, hypersensitivity occur.
• Use seizure precautions for
sweating, nausea, tremors,
diarrhoea, piloerection, panic patients who have a history
attacks, paresthesia, of seizures or who are
hallucinations) with abrupt concurrently using drugs
discontinuation. that lower the seizure
Skin: Rash, pruritis threshold.

Inj. Route: Mechanism of CNS: Drowsiness, dizziness,
metronidazole I/V action: vertigo, fatigue, headache,
somnolence, restlessness,
Dose : Metronidazole euphoria, confusion, anxiety,
500mg,
interacts with the coordination disturbance, sleep
750mg. microbial DNA to disturbances, seizures.
break its and helical CV: Palpitations, vasodilatation.
structure leading to GI: Nausea,
inhibition of protein constipation, vomiting,
synthesis, xerostomia, dyspepsia, diarrhoea,
degradation, and abdominal pain, anorexia,
cell death. flatulence.
Body as a
Whole: Sweating, anaphylactic
reaction (even with first dose),
withdrawal syndrome (anxiety,
sweating, nausea, tremors,
diarrhoea, piloerection, panic
attacks, paresthesia,
hallucinations) with abrupt
discontinuation.
Skin: Rash, pruritis
• Notify patient signs of
reaction and report them on
experiencing.
Nursing Implications
Assessment & Drug Effects
• Monitor BP for therapeutic
effectiveness. BP reduction
is greatest after peak levels
of amlodipine are achieved
6–9 h following oral doses.
• Monitor for S&S of dose-
related peripheral or facial
edema that may not be
accompanied by weight
gain; rarely, severe edema
may cause discontinuation
of drug.
• Monitor BP with postural
changes. Report postural
hypotension. Monitor more
frequently when additional
 antihypertensives or
diuretics are added.
• Monitor heart rate; dose-
related palpitations (more
common in women) may
occur.

Patient & Family Education

• Report significant swelling

of face or extremities.
• Take care to have support
when standing & walking
due to possible dose-related
light-headedness/dizziness.
• Report shortness of breath,
palpitations, irregular
heartbeat, nausea, or
constipation to physician.
• Do not breast feed while
taking this drug without
consulting physician.
Vancomycin Route : Mechanism of CNS: Drowsiness, dizziness,
hydrochlorid Oral/125mg action: vertigo, fatigue, headache,
Nursing Implication
e Bacteriocidal and somnolence, restlessness,
1. Administering vancomycin
Chemical bacteriostatic in euphoria, confusion, anxiety,
name: action coordination disturbance, sleep include ensuring a patent IV
vancomycin Acts by interfering disturbances, seizures. line.
with cell membranes CV: Palpitations, vasodilatation. 2. Planning for administration
synthesis in GI: Nausea, of the percoperative doses
multiplying constipation, vomiting, as much as two hours
organisms. xerostomia, dyspepsia, diarrhoea, before the initial incision is
abdominal pain, anorexia, made.
flatulence. 3. Including information about
Body as a the doses and timing of
Whole: Sweating, anaphylactic preoperative vancomycin
reaction (even with first dose), administration in the
withdrawal syndrome (anxiety, surgical time out.
sweating, nausea, tremors,
diarrhoea, piloerection, panic
attacks, paresthesia,
hallucinations) with abrupt
discontinuation.
Skin: Rash, pruritis

Inj Rantac Route : Mechanism of Stomach pain

I.V action: Headache
Nursing Implication
Dose: Ranitidine reduce Diarrhoes
150mg the secretion of Nausea
gastric acid in the Constipation • Use this medication exactly
stomach, by Confusion as it was prescribed for you.
blocking the effect Skin rash • Do not use it in larger
of histamine on Dizziness doses or for longer than
histamine H2- Muscle pain recommended by your
receptors located on
doctor.
the parietal cells OTHERWISE NO SERIOUS
lining the stomach SIDE EFFECTS EXIST • Follow the directions on
wall. your prescription label.
• This medication comes with
patient instructions for safe
and effective use.
• Follow these directions
carefully.
• Store Duolin Respules at
room temperature away
from moisture and heat.
Keep the cap tightly closed
when not in use. Do not
allow the medicine to
freeze.
 ANATOMY AND PHYSIOLOGY OF GALL BLADDER
(cholelithiasis)
INTRODUCTION:
Gallstones are hardened, concentrated pieces of bile that form in your gallbladder or bile ducts.
“Gall” means bile, so gallstones are bile stones. Your gall bladder is your bile bladder. It holds and
stores bile for later use. Your liver makes bile, and your bile ducts carry it to the different organs in
your biliary tract. Healthcare providers sometimes use the term “cholelithiasis” to describe the
condition of having gallstones. “Chole” also means bile, and “lithiasis” means stones forming.
Gallstones form when bile sediment collects and crystallizes. Often, the sediment is an excess of one
of the main ingredients in bile.

DEFINITION OF COPD:
Cholelithiasis referes to calculi, or gallstones, usually form in the gallbladder from the solid
constituents of bile; they vary greatly in size, shape, and composition.
If gall stones migrate into ducts of biliary tract it is known as choledocholithiasis.
ANATOMY AND PHYSIOLOGY OF GALLBLADDER:
The gallbladder, a pear-shaped, hollow, sac like organ that is 7.5 to 10cm (3 to 4 in) long, lies in a
shallow depression on the inferior surface of the liver, to which it is attached by loose connective
tissue.
The capacity of the gallbladder is 30 to 50 ml of bile. Its wall is composed largely of smooth muscle.
The gallbladder is connected to the common duct by the cystic duct.
Functions as a storage depot for bile.
TYPES OF GALL STONES:
1. Cholesterol stones: those composed predominantly of cholesterol. If excessive cholesterol is
present and insufficient bile acid is secreted, bile becomes supersaturated with cholesterol and
results in cholesterol stones.
2. Pigment stones: probably form when unconjugated pigments in the bile precipitate to form
stones.
3. Mixed stones: combination of cholesterol and pigment stones.
ETIOLOGY:
• Excessive amounts of cholesterol .
• Increase body weight and older age with increased cholesterol in the bile.
• Bile contains too much bilirubin.
RISK FACTORES:
• Family history
• Obesity
• Women, especially those who have had multiple pregnancies.
• Women of native American or U.S. southwestern Hispanic ethnicity
• Frequent changes in weight
• Rapid weight loss
• Treatment with high estrogen therapy
• Cystic fibrosis
• Diabetes
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 OF CHOLITHIASIS:

Book Picture Patient Picture

• Pain and biliary colic • Present

• Epigastric distress
• Present
• Feeling of fullness • Absent
• Vitamin deficiency • Present
• Present
• Murphy sign
• Present
• jaundice • Present
• change in urine and stool color • Present
• Present
• Fever • Present
• Lack of energy • Present
• Present
• Unintended weight loss (in later stages) • Present

DIAGNOSTIC TESTS:
(BOOK PICTURE):
1. Abdominal X-Ray

2. Ultrasonography

3. Radionuclide imaging/ cholecystography:

a radioactive agent is administered intravenously(I/V). The biliary tract is then scanned, and images of
the gallbladder and biliary tract are obtained.

4. Cholecystography:

An iodide containing contrast is administered 10 to 12hours before the x-ray study.

The normal gallbladder fills with this radiopaque substance. If gallstones are present, they appear as
shadows on the x-ray film.

5. Endoscopic retrograde cholangiopancreatography:

ERCP permits direct visualization of structures

The procedure system via a side viewing flexible fibreoptic endoscope insertion through the
oesophagus to the descending duodenum.

6. Percutaneous transhepatic cholangiography:

 It involves injection of dry directly into biliary tract and x rays are done.

(PATIENT PUCTURE):
In my patient ultrasound was done which identified cholelithiasis of size 45x40x35mm
CBC, LFT,KFT was also done.
MEDICAL MANAGEMENT OF CHOLELITHIASIS:

Nutritional and Supportive Therapy

➢ The diet immediately after an episode is usually low-fat liquids.
➢ These can include powdered supplements high in protein and carbohydrate.
➢ Cooked fruits, rice or tapioca, non gas-forming vegetables, bread, coffee, or tea may be added as tolerated.
➢ The patient should avoid eggs, cream, fried foods, cheese, rich dressings, and alcohol.
Pharmacologic Therapy
➢ Ursodeoxycholic acid and chenodeoxycholic acid have been used to dissolve small gallstones.
➢ It acts by inhibiting the synthesis and secretion of cholesterol, thereby desaturating bile.
➢ Six to 12 months of therapy is required in many patients to dissolve stones, and monitoring of the patient for
recurrence of symptoms or the occurrence of side effects is required during this time.

Nonsurgical Removal of Gallstones

 Dissolving Gallstones:
➢ To dissolve gallstones by infusion of a solvent ( mono- octanoic or methyl tertiary butyl ether ) into the
gallbladder.
➢ The solvent can be infused through the following routes:
➢ through a tube or catheter inserted percutaneously directly into the gall bladder, through a tube or drain
inserted through a T-tube tract to dissolve stones not removed at the time of surgery.
➢ endoscopically with ERCP;
➢ trans nasal biliary catheter.
SURGICAL MANAGEMENT OF CHOLELITHIASIS:
1. Laparoscopic Cholecystectomy:
➢ Laparoscopic cholecystectomy is performed through a small incision or puncture made through the
abdominal wall at the umbilicus.
➢ The fibreoptic scope is inserted through the small umbilical incision.
➢ Several additional punctures or small incisions are made in the abdominal wall to introduce other
surgical instruments into the operative field.
➢ A camera attached to the laparoscope permits the surgeon to view the intra-abdominal field and biliary
system on a television monitor.
2. Cholecystectomy :
Gallbladder is removed through an abdominal incision after the cystic duct and artery are ligated.
A drain is placed close to the gallbladder bed and brought out through a puncture wound if there
is a bile leak.
3. Percutaneous Cholecystostomy:
Under local anaesthesia, a fine needle is inserted through the abdominal wall and live edge into the
gallbladder under the guidance of ultrasound or computed tomography (CT).
 Bile is aspirated to ensure adequate placement of the needle, and a catheter is inserted into the gallbladder
to decompress the biliary tract.
PATIENT PICTURE:
In my patient there is no there is no surgical procedure is performed.

COMPLICATION OF CHOLELITHIASIS:

➢ Chronic cholecystitis
➢ Acute cholecystitis
➢ Choledocholithiasis
➢ Gallstone pancreatitis
➢ Gallstone ileus
➢ Perforation of gall bladder
➢ Gallbladder carcinoma
 NURSING CARE PLAN
ASSESSMENT DIAGNOSIS EXPECTED INTERVENTION RATIONALE IMPLEMENTATION EVALUATION
OUTCOME
Subjective data Assess the To obtain base Assessed the Patient has
Acute pain To reduce condition of the line data[3/10] condition of the slight
1.: Patient says related to the patient pain patient. patient reduction in
that Iam having surgical level. Bed pain as 02/10
stomach pain” incision as Promote bed rest. rest is promoted Bed rest is promoted accordingly to
evidence by by providing calm pain score.
Objective data patient Provide pillows Extra pillow environment to the
I observed that verbalization. around incision to provided for patient.
patient having relieve pain. comfort
sever pain in Extra pillow is
abdominal as Encourage Deep breathing givned to the
evidence by relaxation promoted patient.
assessing patient techniques such as
facial expression. deep breathing. Deep breathing
Patient
exercises teach to
Encourage walking encourage to the patient
and using heat pad walk
to ease discomfort.
Analgesics is Tab ibuprofen is
givend to the patient
Provide analgesics given to the
patient as as per doctor orders.
prescribed by
doctor.
Subjective data: Altered body To reduce Assess the To obtain Assessed the Patient felt
2.Patient temperature temperature condition of the baseline data condition of the better
verbalized that I related to patient patient.
am having fever infection as
evidenced by Check temp. every To monitor Checked temp.
checking hourly temperature every hourly.
Objective data: temperature
Temp- 101f (101f)
Give cold sponge To reduce temp. Given cold sponge.

Give oral fluids to To keep patient Given oral fluids to

drink hydrated drink..

Administer To treat fever Administered

antipyretic as antipyretic as
prescribed prescribed. Eg; Inj.
Paracip Infusion
Subjective data Imbalanced To provide Assess the To take action Assessed the Patient
nutritional optimal condition of the promptly condition of the nutritional
3. Patient pattern less nutritional patient patient status is same.
verbalized that “ than body intake. Patient
mujhe khana requirements promises to
khane ka man related to the Encourage patient Patient was Diet chart is follow the
nahi krta.” bile secretion. to have diet rich in encouraged to provided to the diet.
carbohydrates and eat protein rich patient.
Objective data protein and low in food such as
fats. daal and low fat
I observed that food such as oily
“patient having food.
loss of appetite as
evidence by Encourage patient Patient Health education is
monitoring to follow this diet encourage to provided to the
patient intake even after getting follow the diet. patient.
output chart.” discharge for 4-6
weeks. Elimination
pattern recorded
as patient is
Assess the Maintain daily the
having
intake output chart
elimination pattern. constipation.
of the patient.
Subjective data Knowledge To clear Assess the level of To teach Knowledge level Patient
deficit related doubts and understanding according to assessed as low. knowledge
4.Patient to disease improve patient has been
verbalized that I condition as knowledge understanding enhanced.
don’t have evidenced by
Educate patient To educate the Provide brief about
knowledge about frequent medication
about the patient about
the disease questioning medicine and Time, frequency.
condition medication and
their action. their action

Objective data Educate about the To educate Adverse reaction is

symptoms to report about the explained to the
- Frequent such as jaundice, adverse effect of patient.
questioning dark, urine, medication
prueities.
- Anxious

Educate about care To educate Patient know the

of wound about the wound steps of wound care.
care
BIBLIOGRAPHY
• JOYCE M. BLACK, TEXTBOOK OF MEDICAL SURGICAL NURSING, PUBLISHED BY JAYPEE
BROTHERS, 7TH EDITION, PAGE NO.697-699
• HINKLE JANICE L. AND CHEEVER H. KERRY, BRUNNER AND SUDDHART’S TEXTBOOK OF
MEDICAL SURGICAL NURSING, VOLUME 2, 13TH EDITION, 2014, WOLTERS IKLUWER
PRIVATE ITD. PG NO- 1391-1401.
• ROSS AND WILSON, TEXTBOOK OF ANATOMY AND PHYSIOLOGY, 7TH EDITION, PAGE NO.78-
81
• Patient details from patient file and through data collected on interview basis.
 CASE STUDY
ON A PATIENT WITH [CHOLELITHIASIS]

SUBMITTED TO: SUBMITTED BY:

M.S. ANAM MOHAMED SALEEM SHILPA THAKUR
ASSISTANT PROFESSOR, 2023538791
SHARDA UNIVERSITY. MSC 1ST YEAR
SUBMITTED ON: