I. INTRODUCTION Cholecystitis is inflammation of the gall bladder.

Cholecystitis is often caused by cholelithiasis (the presence of choleliths, or gallstones, in the gallbladder), with choleliths most commonly blocking the cystic duct directly. This leads to inspissation (thickening) of bile, bile stasis, and secondary infection by gut organisms, predominantly E. coli and Bacteroides species. The gallbladder is a small pear-shaped organ which aids in thedigestive process. Its function is to store and concentrate bile - a digestiveliquid continually secreted by the liver. The bile in turn emulsifies fats andneutralizes acids in partly digested food. Despite its importance in thedigestion of fat, many people are unaware of their gallbladder. Fortunatelyenough, the gallbladder is an organ that people can live without. Perhaps,this fact contributes to the laxity of the majority. The gallbladder tends to betaken for granted ignored of the proper care and conditioning. Lifestyletogether with heredity, sex, race and age are just some factors that leave aroom for gallbladder complications to occur. This study is about cholecystitis. The most common cause ofcholecystitis is gallstones (90% of the cases). The bile becomes concentratedin the gallbladder. This later causes irritation and is probably the leadingcause of inflammation. Cholecystitis affects women more often than men andis more likely to occur after age 40. People who have a history of gallstonesare at increased risk for cholecystitis. In the international level, cholecystitishas an increased prevalence among people of Scandinavian descent, PimaIndians, and Hispanic populations, whereas cholelithiasis is less commonamong individuals from sub-Saharan Africa and Asia. It affected 20.5 millionpeople (1988-1994) with a mortality record of 1,077 deaths in 2002.Hospitalizations total up to 636,000 in the same year and over 500,000 haveundergone cholecystectomies. In the Philippines alone, an extrapolated prevalence of 5,073,040 people are affected by the disease last 2007. (http://digestive.niddk.nih.gov/statistics) II. OBJECTIVES GENERAL OBJECTIVES The case study aims to allow the student nurses and the other allied of healthcare workers to learn the appropriate attitude, knowledge and skills on the causes, diagnosis, treatment, prevention and appropriate nursing care for the client, the patient and the student nurses would be familiarized with the etiology and the proper care management that would benefit our patient regarding with the cholecystitis. SPECIFIC OBJECTIVES Gather significant data from the patients chart which includes the doctors order, lab result and etc. to have complete information about the patients current condition. Identify the signs and symptoms of cholecystitis. Discuss the anatomy and physiology of clients affected system. Research and understand the disease process of the patients illness. Determine and interpret the medical management employed including laboratory and diagnostic procedures. Formulate device and implement the appropriate nursing intervention to enhance self care on patient with cholecystitis. Teach the patient and significant others about the nature of the patients illness.

III. NURSING HISTORY I. Biographical Data

Patients Name: R. Mutuc Age: 39 years old Gender: Female Status: Married Date of Birth: January 12, 1973 Nationality: Filipino Religion: Roman Catholic Date of Admission: January 28, 2012 II. Chief Complaint

Sumasakitangtiyanko, gumagapangangsakithanggangsalikodko as the patient verbalized. III. History of Present Illness

One week prior to admission the patient experienced abdominal pain, no medication or treatment done. Six days prior to admission the patient experienced recurrence of abdominal pain, still no medication, treatment done but personally suspected as a simple LBM. Five days prior to admission the patient experienced recurrence of abdominal pain from mild to moderate, pain reliever was taken to lessen the pain; Four days prior to admission the patient feels the pain from the right side of the abdominal area moderate to severe, pain reliever was taken and rested for few hours which subsided the pain felt by her; Three days prior to admission the condition persisted, pain reliever was taken and still not enough to relieve the pain; Two days prior to admission patient condition worsen sought consultation and was advised to undergone ultrasound at Sacred Heart Hospital. Laboratory result revealed multiple gallstones but the patient refused to seek treatment. One day prior to admission the patient condition worsened, thus, the patient was brought to Bulacan Medical Center. IV. Past History of Illness

According to her, she had childhood illnesses such as measles, chickenpox, and mumps. She had a close fracture when she was in 5th grade, thus, she was hospitalized. V. Family History

According to her, she has a Bronchial Asthma that she inherited with her mother. Her father died because of hypertension when she was a child. VI. Health Perception & Health Management Pattern
Before Admission According to her, being healthy person doesnt mean that you are required to take vitamins for you to be free on different diseases, because she believed that every person has a big chances to become sick, even though he/she takes a lot of vitamins. During Admission According to her, she feels really sick when she was being hospitalized.

VII.

Nutrition and Metabolic Pattern

Before Admission During Admission According to her, she was not allowed to eat unhealthy foods when she was hospitalized. She observed that all foods that was being served to her was bland or matabang so that she was not able to eat more whenever she likes to eat.

According to her, she loves to eat unhealthy foods such as junk foods and street foods. Every time she eats, she always had a patis on her table.

VIII. Elimination Pattern

Before Admission According to her, she defecates once a day every morning when she wakes up. She used laxatives because she said that she has difficulty in defecating. According to her, she urinates normally at morning and she experiencing frequent urination at night. During Admission According to her, she defecates twice a day, morning and night. She has no any difficulty in defecating.

She urinates normally at morning and she experiencing frequent urination at night.

IX.

Activity- Exercise Pattern

Before Admission During Admission When she was hospitalized, watching television was her relaxation. She said that, shes bored and she wants go home.

According to her, reading broadsheets and watching television was her relaxation. Sometimes, she went to the gym once a week and play badminton with her friends.

X.

Sleep Rest Pattern

Before Admission During Admission When she was hospitalized, she cant sleep as much as she can because her environment was really destructive.

According to her, she sleeps at 10:00 in the evening and wakes up at 5:00 in the morning. She use naps in the afternoon.

XI.

Value- Belief Pattern

Before Admission During Admission According to her, she doesnt go to church every Sunday but she always has faith on him.

According to her, she doesnt go to church every Sunday but she always has faith on him.

IV. PHYSICAL ASSESSMENT

AREA ASESSED HEAD TECHNIQUE USED Inspection Palpation Neck Inspection Palpation FINDINGS No Lesion Proportional to the size of the body No Palpable mass noted Proportional to the size of the body & head, symmetrical & straight No palpable masses and areas of tenderness noted In centric sclera - symmetrical eyes - pupils equal, round reactive to light and accommodation - appears slightly yellowish in color In the midline, symmetrical, patent; internal nares are clean, with few cilia No nasal discharges noted Ears are parallel, symmetrical, proportional to the size of the head, beanshaped, ear canal is clean, with scant amount of cerumen& few cilia No loss of hearings Moist buccal mucosa Pinkish dark color Dark lips noted The teeth aligned No palpable mass noted Good skin turgor Slightly yellow discoloration of skin Evenly distribution of fine hair in the skin Poor lung expansion With IVF of D5LR 1 L at left arm regulated 30gtts/min Symmetrical with visible veins, fine hair FINDINGS No Lesion Proportional to the size of the body No Palpable mass noted Proportional to the size of the body & head, symmetrical & straight No palpable masses and areas of tenderness noted In centric sclera - symmetrical eyes - pupils equal, round reactive to light and accommodation appears slightly yellowish in color In the midline, symmetrical, patent; internal nares are clean, with few cilia No nasal discharges noted Ears are parallel, symmetrical, proportional to the size of the head, beanshaped, ear canal is clean, with scant amount of cerumen& few cilia No loss of hearings Moist buccal mucosa Pinkish dark color Dark lips noted The teeth aligned No palpable mass noted Good skin turgor Slightly yellow discoloration of skin Evenly distribution of fine hair in the skin Slightly good lung expansion Without IVF Symmetrical with visible veins, fine hair evenly distributed warm dry and elastic

Eyes

Inspection

Nose

Inspection Palpation

Ears

Inspection Palpation

Mouth

Inspection

Throat Skin

Palpation Inspection

Chest Upper Extremities

Inspection Inspection Palpation

Lower Extremities

Inspection Palpation Inspection

Genito urinary system

evenly distributed warm dry and elastic upon palpation No edema noted No edema noted Skin is smooth, fine hair is evenly distributed With Folley Catheter connected to urine bag with 300 cc Dark amber urine noted

upon palpation No edema noted No edema noted Skin is smooth, fine hair is evenly distributed Without Folley Catheter

V. ANATOMY & PHYSIOLOGY The digestive system prepares food for use by hundreds of millions of body cells. Food when eaten cannot reach cells (because it cannot pass through the intestinal walls to the bloodstream and, if it could not be in a useful chemical state. The gut modifies food physically and chemically and disposes of unusable waste. Physical and chemical modification (digestion) depends on exocrine and endocrine secretions and controlled movement of food through the digestive tract. Stomach contractions send signals to the brain making us aware of our hunger. Glucose level in the blood is maintained. Insulin decreases glucose in blood making us feel hungry. Levels of glucose in the blood are monitored by receptors (neurons) in the stomach, liver, intestines, they send signals to the hypothalamus in the brain.

The human digestive system

odifiable: Diet (For 10 years) High Sodium food Intake The gallbladder tay,isaw,baga,lamangloob" Fish sauce lover High Fat/Cholesterol food intakea pear shaped organ located on the liver that stores bile. It is The gallbladder is "taba, chicharon, dipthe intestinal system by the cystic duct which in turn empties into the common bile connected to fry foods" Moderateduct. When we eat a large or fatty meal, nerve and chemical signals cause our gallbladder to Alcohol drinker

contract thereby adding bile into our digestive system.Bile is a complex fluid composed of bile salts, cholesterol and other molecules (phospholipids and lecithin). The bile salts are the breakdown products of hemoglobin, the oxygen carrying pigment of red blood cells. Bile salts and bile itself are formed in the liver and excreted into bile ducts which converge in the liver to form the main bile ducts. Just as there is a left and right liver lobe, there is a left and a right hepatic (liver) bile duct which join to form a single bile duct, the common hepatic or common bile duct. The common bile duct enters the duodenum, the earliest part of the small intestine where digestion and absorption of food begins. You may recognize the word duodenum since it is the most common site for ulcers. Normally we make 1000 to 1500cc of bile a day. It is constantly produced. As a result, there is always a steady amount of bile entering our intestinal tract. Some of it goes into the gallbladder as it comes down the duct. It is stored there until neurochemical signals cause the gallbladder to contract. This provides additional bile to the intestinal system. These neuro chemical signals usually occur after eating. We absolutely need bile to absorb fats. Our intestinal lining can absorb water but not fats. Since fat is not dissolvable in water (like oil in water) we can not absorb fats unless something makes the water and fats attach. This is the function of bile; it can bind to both water and fat. Therefore, when we absorb water, the fats absorb with it if bile is present to link the water to the fat. If we do not have any bile we will not be able to absorb fats. This will in turn lead to severe deficiencies of essential fats, alter our metabolism, cause significant problems which will impair living and lead to diarrhea.The gallbladder seems to be a vestigial organ. That is, the gallbladder is an organ which was important at some point in our evolution but no longer necessary. Indeed, gallbladders have been removed from people for over one hundred years without any known side effects. The amount of bile that is constantly coming into the intestinal system via the common bile duct is more than adequate, under normal circumstances, for absorption of the fats in our diet. However if one eats a particularly rich and or fatty meal, some degree of diarrhea may result.

VI. PATHOPHYSIOLOGY

Increase in serum cholesterol levels

Non Modifiable: Mothers History of Gallstones

Increase cholesterol synthesis in liver

Increase workload of gallbladder in secreting bile.

Prolonged condition causes decrease in bile acid synthesis.

Super saturation of bile with cholesterol and chloride.

Precipitation of bile with in the surroundings of gallbladder causes obstruction.

rol & Chloride formation with in the gallstones

Obstruction of cystic duct Jaundice

ight upper quadrant radiates pain to the back and right shoulder CHOLECYSTISIS ted

Inflammation of gallbladder

VII. DIAGNOSTIC PROCEDURE AND LABORATORY RESULT BLOOD CHEMISTRY

TEST Serum aspartate aminotransferase (SGOT)

NORMAL VALUES 10-40 IU/L

RESULT 94.3

SIGNIFICANCE Increased levels may be seen with acute myocardial infarction, hepatitis, active cirrhosis, hepatic necrosis, alcoholic hepatitis, pancreatitis, cholecystitis, trauma or gangrene. Decreased levels may be seen with azotemia or chronic renal failure. Moderately to highly elevated levels may be seen with hepatocellular disease. Mildly elevated levels may be seen with active cirrhosis or metastastic liver cancer and pancreatitis. Mildly to moderately elevated levels may be seen with obstructive jaundice or biliary obstruction.

Serum alanine aminotransferase (SGPT)

0-47IU/L

106.0

Serum alkaline phosphate (ALP)

10-35 IU/L

23.7

Increased levels may indicate obstructive jaundice, lesions of the liver, hepatocellular or biliary cirrhosis, or cholestatic hepatitis. Decreased levels may indicate hypothyroidism, malnutrition, or pernicious anemia.

ULTRASOUND REPORT Impression : Calculus cholecystitis and hydrops gallbladder. Unremarkable sonogram of the liver, pancreas, spleen, kidneys, and urinary bladder. Date : January 29, 2012 VIII. OPERATIVE PROCEDURE ANESTHESIA:Spinal anesthesia SIMPLIFIED STEPS:

TYPES OF INCISION: Diagonal Incision EXPOSURE OF THE GALLBLADDER retraction of the liver the dome of the gallbladder is initially scored with electrocautery, and a tonsil clamp is used to establish a plane in the thickened gallbladder in proximity to the gallbladder wall itself. The cautery is then used to incise the peritoneal surface of he entire dome. REMOVAL OF THE GALLBLADDER the fundus of the gallbladder is removed from the liver bed with blunt and sharp dissection. Care should be taken in mobilizing the infundibulum of the gallbladder to be certain that it is not adherent to the common bile duct. The cystic artery and its extension are usually encountered on the medial surface of the gallbladder. The cystic artery can be temporarily controlled with a clip on the surface of the gallbladder prior to its formal ligation. The gallbladder is then completely mobilized from the liver bed until it is attached only by the cystic duct. SUTURING OF INCISION SITE
Suturing operations are thos e in w h i c h tissue is approximated

(brought together) a n d stitched using s uture material (s u c h as silk suture, su rgical g u t su ture, wire suture Post- Operative After recovery, position the patient in the low Fowlersposition. IV fluids may be given. Water and other fluids are given in about 24hours, and soft diet is started when bowelsounds returned. Placing warm blankets on the patient to enhance comfort and serve the patient's body temperature Assessing the patient's vital signs, oxygen saturation level, levelof consciousness, circulation, pain, IV site, fluid rate, and hydration status, as well as the status of the surgical site and dressing and all related monitoring equipment Helps in relieving the pain by instructing the patient regarding proper positioning. Helps in improving the respiratory status by instructing the patient regarding deep breathing exercises. Provides skin care like cleaning the incision part and providing clean dressing following a strict aseptic technique Instructs the patient or relatives about the medications that are prescribed by the physician Discussing recommended follow-up management with the physician and the surgeon.

X. HEALTH TEACHING

Medication Advise the patient to take Ranitidine 50mg every 8 hours 3x a day and
Cefuroxime 750mg every 8 hours 3x a day. Advise the patient to take medication as prescribe by the physician on the right time and dosage. Instruct and explain to the patient that the medication is very important to continue for the total recovery of the patient. Ensure the patient understand the medication regimen.

Environment Advise the patient to stay on quiet, calm and well ventilated environment to
promote rest and relaxation.

Treatment Advise the patient to relax in order to recover in his present condition. Instruct
the patient to minimize the exposure to an open environment such as dusty and smoky area, which airborne microorganism is present that can be a high risk factor that may cause severity of his condition. Instruct the patient to do wound care to prevent infection.

Health Teaching Encourage and explain to the patient that it is important to maintain
proper hygiene to prevent infection. Encourage the patient to observe a healthy lifestyle to avoid re-infection.

OPD Regular consultation to the physician can be factor for recovery and to assess and

monitor the patients condition. Emphasize to the patient the importance of follow-up check-up.

Diet Advise the patient to eat low sodium diet. Instruct the patient not to eat salty foods and
high fatty foods to prevent further complications. Encourage patient to drink plenty of oral fluids.

Spiritual Advise the patient relatives to monitor the patients condition at home while on
the period of recovery and medication. XI. EVALUATION

The student nurseshas identified and understood the causative factors of cholecystitis, its signsand symptoms, clinical manifestations, diagnostic studies, medical,pharmacological and nursing interventions through obtaining cues andhealth history in conjunction to the disease process. They underwentextensive research in order to comprehensively understand his condition.Upon learning his case, it challenged and motivated them to work hard toprovide the appropriate and effective nursing intervention and care.

DR.YANGAS COLLEGES, INC. COLLEGE OF NURSING WAKAS, BOCAUE, BULACAN

CHOLECYSTITIS
A Case about..

Submitted by: Anthonie Angelo S. Palaya NCM 105 Group 2

Submitted to: Mr. Narciso Dexter L. Belvis, RN Clinical Instructor