chole lithia sis
TRANSCRIPT
Case PresentatiCase Presentation of Cholelithion of Cholelithi
asisasis
Case PresentatiCase Presentation of Cholelithion of Cholelithi
asisasis
INTRODUCTION• DEFINITION• Disorder of the gallbladder and ducts are
extremely common. These includes gallstones, inflammatory conditions, infections, tumors and congenital malformations. The two most common conditions are cholelithiasis(presence of gall stones) and associated cholecystitis (inflammation of the gall bladder)
INCIDENCEStudies show that the incidenc
e of gall stones increases with age, as do the risk associated with cholelithiasis. Women account for 70% of those treated for gall stones, although studies have suggested that the mortality rate is higher in men.
ETIOLOGYThe etiology of gall stone disease is
not well understood. Based on various theories, there are four possible explanations of stone formation.
First, bile may undergo a change in composition. Studies of clients with cholesterol gall stones indicate that their bile is supersaturated with cholesterol but deficient in bile salts. The cholesterol saturation of bile seems to increase with age.
Second, gall bladder stasis may lead to bile stasis. Bile stasis may (1)change bile composition, (2)supersaturate bile with cholesterol and (3)precipitate some bile constituents. Gall bladder stasis may result from decreased contractility of the gall bladder and spasm of the sphincter of Oddi.
Third, infection may predispose a person to stone formation. Finally, genetics also seem to play some role in stone formation.
RISK FACTORSConditions that predispose clients to gall stone formation include:
• Diabetes mellitus• Multiple pregnancies• Vagotomy• Ileal disease or resection
• Long term parenteral nutrition• Cirrhosis of the liver• Chronic hemolytic disorders• Obesity• Exogenous estrogen administration• Pancreatitis• Caloric restriction with some diets• Cholestrymine therapy
CLINICAL MANIFESTATION
• Fewer than half of the clients with gall stones report any distress because gall stones cause no symptoms unless complications develop. The primary symptom is pain or biliary colic. The pain usually follows the temporary obstruction of the gall bladder outlet. Characteristically, the pain starts in the midline area. It may radiate around to the back and right shoulder blade.
The client is often restless, changing positions frequently to relieve the pain’s intensity. Pain may persist for a few hours or several days and the interval between attacks is variable.
Jaundice only appears when common duct obstruction is present. Nausea and vomiting may occur, and occasionally self induced vomiting alleviates the symptoms. Assessment may further reveal a history of flatulence , bloating, dyspepsia, belching, an intolerance to fatty foods and vague upper abdominal sensations.
DIAGNOSTIC ASSESSMENT
• Blood test are unremarkable. Jaundice is not present unless there is common bile duct obstruction. Diagnosis of cholelithiasis may involve abdominal ultrasonography, computerized axial tomography, cholescintography, cholangiography, or biliary drainage examination.
Current trends, point to the use of endoscopic retrograde cholangiopancreatography and endoscopic retrograde catheterization of the gall bladder. Biliary ultrasonography may be the initial study because it is accurate, safe and does not use radiation and can be performed without preparation.
MEDICAL MANAGEMENT
• For clients with symptomatic cholelithiasis, treatment is dictated by the severity of symptoms. An oral analgesic may be prescribed and the client may be instructed to avoid those foods that precipitate the attacks and it may mean hospitalization.
Retrogade endoscopy for stone removal is an important non surgical alternative. Because the gall bladder is left in place in all interventions except cholecystectomy and laparoscopic cholecystectomy, the recurrence of stones is likely.
Another important non surgical intervention is the use of oral administration of dissolution agents for cholesterol gall stones. These drugs act by reducing the amount of cholesterol in the bile.
SURGICAL MANAGEMENT
• Cholecystectomy consists of excising the gall bladder from the posterior liver wall and ligating the cystic duct, vein, and artery. Following cholecystectomy the client should be monitored for the usual post operative complications such as hemorrhage, pneumonia, thrombophebitis, urinary retention and ileus.
• Cholecystectomy is the most common surgical intervention for gall stones. However, changes in the medical care reimbursement have initiated the innovation of laparoscopic cholecystectomy. Risks for this procedure include hemorrhage, bile duct injury and injury to other organs. However the advantage of small scars and short hospital stay have influence the increase use of this procedure.
•Extracorporeal shock wave lithotripsy and percutaneous cholecystolithotomy are procedures which may also be used to some clients.
POST HOSPITAL CARE• The client treated medically may be
sent home with oral analgesics or other medications for comfort as well as an oral dissolution agent. Diet instructions may be necessary if ingestion of food precipitated the attack. The client should be given information on what to do should another attack occur.
PATIENT’S PROFILE• NAME: SW• AGE: 43 years old• ADDRESS: Caloocan• BIRTH DATE: October 18, 1965• SEX: Female• NATIONALITY: Filipino• CIVIL STATUS: Married• RELIGION: Roman Catholic• EDUCATIONAL ATTAINMENT: High School Graduate• OCCUPATION: Sari sari store owner• DATE OF ADMISSION: May 13, 2008• CHIEF COMPLAINT: Abdominal pain• DIAGNOSIS: Cholelithiasis• ATTENDING PHYSICIAN:
Nursing History• Past health history
Patient SW had already experienced childhood illnesses such as chickenpox and mumps. He also said that he had complete immunizations. He has no allergies to drugs and medications.
According to patient SW, he was hospitalized last year due to the same complain. He also said that he was supposedly operated but due to financial problem the operation did not push through.
Present health history
Few days PTA, the patient already experienced abdominal pain but he disregard it because it is within tolerable level.
Few hours PTA, the patient again experienced abdominal pain on his upper quadrant of his abdomen and described it as stabbing pain. Since he can no longer tolerate the pain, this prompted him to seek for medical health and thus was rushed into the ER.
Family health history
According to the patient, he had no family history of G.I disorders. He further said tat he has a family history of hypertension on his father side. There are no further disease noted on his mother side.
Gordon’s 11 Functional Pattern
• Health Perception – Health Management PatternBefore Hospitalization:
According to the S.O, the patient views health as very important to human. One cannot function well without it. Once health is absent, other aspects such as emotional, spiritual and social are affected. They always consult a doctor for any health problems. The S.O. also reported that he also takes over-the-counter drugs for simple illnesses such as fever
During hospitalization• The S.O. said that patient SW
perceived himself as weak and is not able to do his daily activities. He manages his condition by complying with the entire doctor’s order and taking adequate rest. He reported no allergies to any foods and medications.
Nutritional – Metabolic Pattern
Before hospitalization: According to the S.O., the patient eats 3
times a day with snacks in between. He prefers to eat more on meat than vegetables. He drinks at least 7-9 glasses of water approximately 220/glass throughout the day. He usually eats crackers, biscuits and bread for his snacks with coffee. He had no difficulty in swallowing.
During hospitalization: Patient SW is in a DAT diet.
Elimination Pattern
• Before Hospitalization:According to the S.O., patient SW had
no problem with urination and defecation. Patient SW urinates at least 5-6 times a day depending on the urge he feels. The S.O describes the patient urine as light yellow in color. He defecates 1-2 times a day before starting his day in the morning and sometimes in the evening before going to bed. He describes his stool with brown color and is semi formed in consistency.
During hospitalization: •According to the S.O., the
patient urinates smoothly without difficulty. The S.O. describes patient SW’s urine as light yellow and defecates once a day with light brown, semi-formed stool.
Activity – Exercise Pattern
• Before Hospitalization: According to the S.O., patient SW, has no
difficulty doing his ADLs such as gardening. He makes his day busy with their sari-sari store.
• Few days prior to admission, he can no longer do his activities of daily living because of the discomforts brought by his underlying condition..
• During hospitalization: Patient SW can do is ADLs but with
assistance. Pt. is still suffering from discomfort but it is tolerable.
Sleep – Rest Pattern
• Before hospitalization: He sleeps about 6-7 hours at night
and sometimes 5-6 hours. He sleeps at around 10pm and wakes up at 5am or 6 am. After lunch, he takes about an hour or less for his naps.
• During hospitalization: The patient had difficulty getting
asleep due to environmental stimulation. “hindi ako makatulog dhil maingay ang paligid.” as verbalized by the patient.
Cognitive Perceptual
•The patient has no cognitive problem. He is oriented to time, place, and persons. He can see and hear clearly. He is able to understand and follow the instructions given to him by the nurses, doctors and SO.
Role – Relationship Pattern
• According to the S.O., patient SW has no problem with regards to his relationship with his family and the people around him. The S.O. also added that they treat him nicely. He is married and had 4 children, 1 had finished college.
Self- perception/Self-concept Pattern
• According to the patient he never thinks of losing hope about his condition, he always thinks positive that someday he can recover in whatever illness that he feels. He didn’t feel any awkwardness regarding his condition and accepted it wholeheartedly.
Sexual – Reproduction Pattern
• Patient has no sexual dysfunction. He and his wife copulated for quite some time. He can not remember how frequent they’ve done this. After the incident, they never engaged into sexual activities. They have four children. They did not use any form of contraceptive measures.
Coping – Stress Management Pattern
• Before hospitalization: According to the S.O (his son),
patient SW always seek his wife’s pieces of advice whenever problem occurs. The S.O. reported that the patient prays regularly to relieve his worries. He takes a rest to alleviate
whatever stress he feels.
During hospitalization: • With his present condition,
according to the S.O. he copes through adequate rest, following all the doctor’s instructions and adhering with the regiments given. He always asks his SO to position him comfortably. He regularly prays to relieve his worries regarding his condition.
Value – Belief
• The patient is a Roman Catholic. According to the S.O. he believes that the Lord will be the one who will help him to all his problem especially about his condition and the Lord has a purpose why he is experiencing the illness he had. They also believe in superstitious beliefs. They sometimes seek help from “albularyos”.
PHYSICAL ASSESSMENT
DATE: May 13, 2008GENERAL APPEARANCE: Conscious and coherent
VITAL SIGNS: BP: 110/70 mmHg
RR: 24 cpmPR: 66 bpm
Temp.:37.5 C
AREA ASSESSED METHOD USED NORMAL FINDINGS ACTUAL FINDINGS ANALYSIS
SKINColorTurgorMoistureTexture
InspectionPalpationPalpationPalpation
Light to deep brownSnaps back immediatelyMoist Smooth, elastic
Light brownSnaps back immediatelymoistSmooth
Normal
NAILSNail plate shapeNail bed colorTextureCapillary refill
InspectionInspectionPalpation
Palpation/ Blanch test
ConvexPinkSmoothReturns to normal
immediately (2- 3 seconds)
ConvexPinkSmooth2-3 seconds
NormalNormalNormal
HEADScalpTextureCircumference
InspectionPalpationPalpation
SymmetricalSmoothProportional
circumference to the body
SymmetricalSmoothProportional
circumference to the body
NormalNormalNormal
FACEFace symmetryFacial movements
InspectionInspection
SymmetricalEqual facial movements
SymmetricalEqual facial movements
NormalNormal
EYES: EXTERNAL STUCTURESHair distributionSkin qualityEYELIDSAbility to blinkSCLERAColorCONJUNCTIVAColor
InspectionPalpationInspectionInspectionInspection
Evenly distributedIntact, smoothBlinks 15- 20 times per
minute involuntarily and bilaterally
WhiteLight pink
Evenly distributedIntact, smoothBlinks 17 times perminute involuntarily and
bilaterallyYellowishPale
NormalNormalNormalNormalDue to pathologic process
EARS: TextureAURICLESSymmetry and position
InspectionPalpation
Smooth without lesionAuricles are at level with each other
Smooth without lesionAuricles are at level with each other
NormalNormal
NOSESymmetryCilia distributionNasal septumNares
InspectionInspectionInspectionInspection
SymmetricalEvenly distributedMidlineSymmetrical size of opening
SymmetricalEvenly distributedMidlineSymmetrical size of opening
NormalNormalNormalNormal
MOUTHSymmetryColor
InspectionInspection
SymmetricalPink
Symmetricalpink
NormalNormal
NECKSymmetryRange of motionPositionLymph nodes
InspectionInspectionPalpationPalpation
SymmetricalMoves freelyCentrally located at the shoulderNot palpable
SymmetricalMoves freelyCentrally located at the shoulderNot Palpable
NormalNormalNormalNormal
THORAX: PosteriorShape SymmetrySpinal alignmentDiaphragmatic
excursionRespiratory RateRespiratory excursionTrachea Chest
InspectionInspectionInspectionPercussion
ObservationPalpation
AuscultationAuscultation
Rounded, cylindricalChest symmetricSpine vertically aligned,
no tenderness, no bulges
Excursion is 3- 5 cm16-20 cpmFull symmetric excursionBronchial and tubular bre
ath soundsBronchovesicular and ve
sicular breath sounds
Rounded, cylindricalChest SymmetricSpine vertically aligned
no tenderness, no bulges
Excursion is 3-5 cm Full symmetric excursio
nBronchial and tubular br
eath soundsBronchovesicular and ve
sicular breath sounds
NormalNormalNormalNormalNormalNormalNormal
ABDOMEN
ColorAbdominal Contour Bowel soundsTenderness
InspectionInspectionAuscultation
Uniform with the rest of the body
Present and activeNot tender
Uniform with rest of the body
Present: 8 times/minTender
NirmalNormalNormalDue to pathologic process
UPPER EXTREMITIES
Symmetry Color Texture ROM
InspectionInspectionPalpationInspection
SymmetricalUniform with skin colorSmooth, (-)lesions,
(-)swellingMoves freely and
without pain
SymmetricalUniform with skin colorSmooth, (-) lesion,
(-)swellingMoves freely and
without pain
NormalNormalNormalNormal
LOWER EXTREMITIES
Symmetry Color TextureROM
InspectionInspectionPalpationInspection
SymmetricalUniform with skin colorSmooth, (-)Swelling, (-)
lesionsMoves freely and
without pain
symmetricalUniform with skinSmooth, (-)Swelling,
(-)LesionMoves freely and
without pain
NormalNormalNormalNormal
NEUROLOGIC SYSTEM
Level of Consciousness Mental Status
InterviewInterview
ConsciousOriented to person
ConsciousOriented to person
NormalNormal
Anatomy and Physiology of the
Gastrointestinal tract• The digestive tract (also known as the alimentar
y canal) is the system of organs within multicellular animals that takes in food, digests it to extract energy and nutrients, and expels the remaining waste. The major functions of the GI tract are ingestion, digestion, absorption, and defecation.
•The GI tract differs substantially from animal to animal. Some animals have multi-chambered stomachs, while some animals' stomachs contain a single chamber. In a normal human adult male, the GI tract is approximately 6.5 meters (20 feet) long and consists of the upper and lower GI tracts. The tract may also be divided into foregut, midgut, and hindgut, reflecting the embryological origin of each segment of the tract
Upper gastrointestinal tract
• Upper gastrointestinal tract
The upper GI tract consists of the mouth, pharynx, esophagus, and stomach.
• The mouth contains the buccal mucosa, which contains the openings of the salivary glands; the tongue; and the tooth.
• Behind the mouth lies the pharynx, which leads to a hollow muscular tube, the esophagus.
• Peristalsis takes place, which is the contraction of muscles to propel the food down the esophagus which extends through the chest and pierces the diaphragm to reach the stomach.
Lower gastrointestinal tractThe lower GI tract comprises the intestines and anus.
Bowel or intestine Small intestine, which has three parts:
Duodenum Jejunum
Ileum Large intestine, which has three parts:
Cecum (the vermiform appendix is attached to the cecum).
Colon (ascending colon, transverse colon, descending colon and sigmoid flexure)
RectumAnus
Accessory organs• Accessory organs to the alimentary canal in
clude the liver, gallbladder, and pancreas. The liver secretes bile into the small intestine via the biliary system, employing the gallbladder as a reservoir. Apart from storing and concentrating bile, the gallbladder has no other specific function. The pancreas secretes an isosmotic fluid containing bicarbonate and several enzymes, including trypsin, chymotrypsin, lipase, and pancreatic amylase, as well as nucleolytic enzymes (deoxyribonuclease and ribonuclease), into the small intestine. Both of these secretory organs aid in digestion.
GallbladderAnatomy
• The cystic duct connects the gallbladder to the common hepatic duct to form the common bile duct.
• The common bile duct then joins the pancreatic duct, and enters through the hepatopancreatic ampulla at the major duodenal papilla.[2][3]
• The fundus of the gallbladder is the part farthest from the duct, located by the lower border of the liver [4]. It is at the same level as the transpyloric plane.
Microscopic anatomyThe different layers of the gallbladder are as follows:
• The gallbladder has a simple columnar epithelial lining characterized by recesses called Aschoff's recesses, which are pouches inside the lining.
• Under the epithelium there is a layer of connective tissue (lamina propria).
• Beneath the connective tissue is a wall of smooth muscle (muscularis externa) that contracts in response to cholecystokinin, a peptide hormone secreted by the duodenum.
• There is essentially no submucosa separating the connective tissue from serosa and adventitia.
Function• The gallbladder stores about 50 ml (1.7 US flui
d ounces / 1.8 Imperial fluid ounces) of bile, which is released when food containing fat enters the digestive tract, stimulating the secretion of cholecystokinin (CCK). The bile, produced in the liver, emulsifies fats and neutralizes acids in partly digested food.
• After being stored in the gallbladder the bile becomes more concentrated than when it left the liver, increasing its potency and intensifying its effect on fats. Most digestion occurs in the duodenum.
•
LABORATORY LABORATORY EXAMEXAMLABORATORY LABORATORY EXAMEXAM
43y/o Male 05/13/08HEMATOLUGY REPORT
TEST RESULT UNIT REFERENCE ANALYSIS
HGB 160 g/l 135-180 normal
HCT 0.46 g/l 0.40-0.54 normal
RBC 5.43 X 10^12L 4.6-6.2
MCV 85 L 80-96 normal
MCH 29 g/l 27-31 normal
MCHC 34 g/dl 33-36 normal
RDW-CV 13.8 % 11.6-14 normal
WBC 11.43 X 10^9L 5-10 Due to inflammation
Neutrophils 69.5 % 55 Due to inflammation
Lymphocytes 34 % 34 normal
Basophils 0.1 % 1 normal
Monocytes 3 % 3 normal
Elosunophils 3 % 3 normal
Platelef 215 X 10^9L 150-450 normal
HEMATOLOGY REPORT
TEST RESULT UNIT REFERENCE ANALYSIS
PROTHROMBIN 12.9 SEC 11.3-15.3 normal
PT Control 13.2 SEC
PT I&R 0.97 SEC
PT% Activity 100 % 70-100 normal
APTT 28.6 SEC 28-37 normal
APTT Control 31.2 SEC
URINE EXAM RESULT TEST RESULT REFERENCE ANALYSIS
COLOR Amber Amber Normal
CHAR Slightly Turbid Clear Due to infection
PH 6 5-6 normal
Spe. Cerav. 1.030 1.010-0.30 normal
MICROSCOPIC TEST RESULT UNIT REFERENCE ANALYSIS
RBC 4-5 /hpf 0-2 Due to infection
WBC 3-4 /hpf 0-5 normal
CRYSTALS Amorphous urates few
EPITHELIAL CELL
BACTERIA FEW few normal
NCPASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
Subjective data: “hindi ako makatulog”, as verbalized by the patientObjective data:-frequent yawning-Noisy environment-irritability
Disturbed sleep pattern r/t
At the end of 10 mins. The patient will verbalize ways on how to improve sleeping pattern
> provided comfort measures such as back rub> instructed patient to avoid caffeinated drinks such as coffee> instructed pt. to position himself on his most comfortable position when sleeping> instructed pt. to do any activities that induces sleep (imaginary counting)
> prepares client for sleep>increases mental alertness, do not induce sleep
>provides comfort inducing sleep
> this induces sleep disregarding the environmental stimulant
Goal met… The pt. verbalized understanding on ways to improved his sleep pattern
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
Subjective data:“ medyo maskit ang
tiyan ko” as verbalized by the patient.
Objective data: - Pain scale of 5/10- sleep disturba
nce- Grimace face- Irritability- Guarding behavi
or- RR of 24
Alteration in comfort: pain r/t obstruction on the bile duct.
At the end of the shift, The pt. will report lessen pain with a pain scale of 2/10
> provided comfort measures such as rubbing the affected part
> instructed to do focus breathing
> encourage adequate rest period
> to provide non-pharmacological pain management
>to alleviate pain
> prevent fatigue
Goal partially met…
The pt. reported relief of pain with the pain scale of 4/10.
He said pain is already tolerable.