cholecystectomy final

8/13/2019 Cholecystectomy Final

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CHAPTER I INTRODUCTION

Cholecystitis is an inflammation of the gallbladder wall and nearby abdominal lining. Cholecystitis is

usually caused by a gallstone in the cystic duct, the duct that connects the gallbladder to the hepatic

duct. The presence of gallstones in the gallbladder is called cholelithiasis. Cholelithiasis is the pathologic

state of stones or calculi within the gallbladder lumen. A common digestive disorder worldwide, the

annual overall cost of cholelithiasis is approximately $5 billion in the United States, where 75-80% of

gallstones are of the cholesterol type, and approximately 10-25% of gallstones are bilirubinate of either

black or brown pigment. In Asia, pigmented stones predominate, although recent studies have shown an

increase in cholesterol stones in the Far East .Gallstones are crystalline structures formed by concretion

(hardening) or accretion(adherence of particles, accumulation) of normal or abnormal bile constituents

.According to various theories, there are four possible explanations for stone formation. First, bile may

undergo a change in composition. Second, gallbladder stasis may lead to bile stasis. Third, infection may

predispose a person to stone formation. Fourth, genetics and demography can affect stone formation.

Risk factors associated with development of gallstones include heredity, Obesity, rapid weight loss,

through diet or surgery, age over 60, Native American or Mexican American racial makeup, female

gender-gallbladder disease is more common in women than in men. Women with high estrogen levels,

as a result of pregnancy, hormone replacement therapy, or the use of birth control pills, are at

particularly high risk for gallstone formation, Diet-Very low calorie diets, prolonged fasting, and low-

fiber /high-cholesterol/high-starch diets all may contribute to gallstone formation. Sometimes, persons

with gallbladder disease have few or no symptoms. Others, however, will eventually develop one or

more of the following symptoms; (1) Frequent bouts of indigestion, especially after eating fatty or

greasy foods, or certain vegetables such as cabbage, radishes, or pickles, (2) Nausea and bloating (3)

Attacks of sharp pains in the upper right part of the abdomen. This pain occurs when a gallstone causesa blockage that prevents the gallbladder from emptying (usually by obstructing the cystic duct). (4)

Jaundice (yellowing of the skin) may occur if a gallstone becomes stuck in the common bile duct, which

leads into the intestine blocking the flow of bile from both the gallbladder and the liver. This is a serious

complication and usually requires immediate treatment. The only treatment that cures gallbladder

disease is surgical removal of the gallbladder, called cholecystectomy. Generally, when stones are

present and causing symptoms, or when the gallbladder is infected and inflamed, removal of the organ

is usually necessary. When the gallbladder is removed, the surgeon may examine the bileducts,

sometimes with X rays, and remove any stones that may be lodged there. The ducts are not removed so

that the liver can continue to secrete bile into the intestine. Most patients experience no further

symptoms after cholecystectomy. However, mild residual symptoms can occur, which can usually becontrolled with a special diet and medication.


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CHAPTER II ASSESSMENT

A. Nursing Health History

Personal Data

Name: Mrs. Dina Natuto

Age: 70 years old

Gender: Female

Status: Married

Address: Pob. San Manuel, Tarlac

Date of Birth: Nov. 23, 1943

Place of Birth: Nueve Ecija

Religion: Roman Catholic

Date of Admission: Nov. 30, 2013

Time of Admission: 3:10pm

Chief Compliants: chills and abdominal plain

Final diagnosis: Hydrops of gallbladder secondary to cholecystolithiasis multiple

Opreation: E RUQ exploration,adhesiolysis, cholecystectomy with IOC( Intra-operative Cholangiogram), Common Bile Duct - exploration, T- tube

choledochostomy.

Past Medical History

Present Medical History

3 days prior to admission (+) fever on and off. 1 day prior to admission (+) abdominal pain at the hypogastric area to epigastric area associated

with chills.

Family Health History


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B. Physical Assessments

Physical Assessment done by the attending physician reveals that patient is;

Febrile pale anicteric sclera pinkish palpebral conjunctiva symmetrical chest expression fair pulse (-) cyanosis (+) NABS non tender abdomen

Vital Signs upon admission (Nov. 30, 2013)

o BP- 130/80 mmHgo RR-20 cpmo PR-89 bpmo Temp-38 C

Physical Assessment done by the student reveals that patient is;

Febrile Warm to touch pale and weak looking (+) dry lips (+) dry skin decreased skin turgor

Vital Signs taken and recorded as of (Nov. 30, 2013) are as follows;

o BP- 130/80 mmHgo RR-20 cpmo PR-89 bpmo Temp-38 C

C. Laboratory Exams

1. Complete Blood Count (CBC)

This is to determine blood components and the response to inflammatory process and streptococcal

infection.


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Date Ordered: Nov. 30, 201

Date Result In: Nov. 30, 2013

Results:

WBC - 14.5 g/l

RBC - 3.73 g/l

Lymphocytes - 0.15 g/l

Monocytes - 0.08 g/l

Granulocytes - 0.77 g/l

Hemoglobin126 g/l

Hematocrit - 0.34 g/l

Platelet count357 g/l

Repeat CBC

Date Ordered: Dec. 1, 2013

Date Result In: Dec. 1, 2013

Results:

WBC - 18 g/l

RBC - 3.71 g/l

Lymphocytes - 0.04 g/l

Monocytes - 0.06 g/l

Granulocytes - 0.90 g/l

Hemoglobin106 g/l

Hematocrit - 0.29 g/l

Conclusion: WBC is slightly elevated based on the normal value of 5.0-10 g/l which confirms the

presence of infection.


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2. Serum Electrolytes

Date Ordered: Nov.30, 2013

Date Result in: Nov.30,2013

Results:

Serum Sodium - 135.7 mmol/L

Potassium - 3.25 mmol/L

Chloride - 98.1 mmol/L

Repeat Serum Electrolytes

Date Ordered: Dec.1 ,2013


Results:

Potassium - 3.24 mmol/L


Date Result in: Dec. 6, 2013

Results:

Serum Sodium138.1 mmol/L

Potassium2.83 mmol/L

Conclusion: The potassium level is below the normal value of 3.40-5.60 mmol/L. While the sodium level

is within nomal range based on the normal value of 134.0-148.0 mmol/L.

3. Creatinine

This is the indicator of the renal function.



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Result In: Dec. 4, 2013

Results: 0.8mg/dl

Conclusions: The result is within normal range based on the normal value of 0.5 - 1.7mg/dl.

4. BUN

This is an indicator of renal function and perfusion, dietary intake of CHON and the level of

protein metabolism.



Results: 5.3 mg/dl

Conclusions: The result is within normal range based on the normal value of mg/dl.

5. Urinalysis

Urinalysis yields a large amount of information about possible disorders of the kidney and lower

urinary tract, and systematic disorders that alter urine composition. Urinalysis data include color,

specific gravity, pH, and the presence of protein, RBCs, WBCs, bacteria, Leukocyte, esterase, bilirubin,

glucose, ketones, casts and crystals.

Date Ordered: February 10, 2006

Date Result In: February 10, 2006

Results: Color- yellow Specific Gravity- 0.010

Sugar/ Albumin- negative Pus cells- 0.1 hpf

Conclusions: The results are normal but there is a presence of pus cells in the urine which means that

there is also the presence of infection.


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D. Anatomy and Physiology

Gallbladder, muscular organ that serves as a reservoir for bile, present in most vertebrates.

In humans, it is a pear-shaped membranous sac on the undersurface of the right lobe of the liver just

below the lower ribs. It is generally about 7.5 cm (about 3 in)long and 2.5 cm (1 in) in diameter at its

thickest part; it has a capacity varying from 1 to1.5 fluid ounces. The body (corpus) and neck (collum) ofthe gallbladder extend backward, upward, and to the left. The wide end (fundus) points downward and

forward, sometimes extending slightly beyond the edge of the liver. Structurally, the gallbladder consists

of an outer peritoneal coat (tunica serosa); a middle coat of fibrous tissue and unstriped muscle (tunica

muscularis); and an inner mucous membrane coat (tunica mucosa).The function of the gallbladder is to

store bile, secreted by the liver and transmitted from that organ via the cystic and hepatic ducts, until it

is needed in the digestive process. The gallbladder, when functioning normally, empties through the

biliary ducts into the duodenum to aid digestion by promoting peristalsis and absorption, preventing

putrefaction, and emulsifying fat. Digestion of fat occurs mainly in the small intestine, by pancreatic

enzymes called lipases. The purpose of bile is to; help the Lipases to Work, by emulsifying fat into

smaller droplets to increase access for the enzymes, Enable intake of fat, including fat-soluble vitamins:

Vitamin A, D, E, and K, rid the body of surpluses and metabolic wastes Cholesterol and Bilirubin.


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E. Pathophysiology


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Risk factor

Heredity Obesity Rapid Weight Loss, through diet or surgery Age Over 60

Bile must become supersaturated with cholesterol and calcium The solute precipitate from solution as

solid crystals Crystals must come together and fuse to form stones Gallstones Obstruction of the cystic

duct and common bile duct Sharp pain in the right part of abdomen Jaundice Distention of the gall

bladder Venous and lymphatic drainage is impaired Proliferation of bacteria Localized cellular irritation

or infiltration or both take place Areas of ischemia may occur Inflammation of gall bladder

CHOLECYSTITIS

CHAPTER III PLANNING

A. List of Prioritized Nursing Diagnosis

Pre-operative nursing diagnosis: Acute pain

Knowledge Deficit

Disturbed sleeping pattern

Intra-operative nursing diagnosis Deficient Fluid Volume

Post-operative nursing diagnosis: Risk for infection

Ineffective Coping

B. Nursing Care Plan

1. Acute Pain

Cues Nursing

Diagnosis

Scientific

Explanation

Objective Nursing

Intervention

Rationale Evaluation

S- ang

sakit ng

tyan ko

as

claimed

by thepatient.

O-(+)

guarding

behavior

, pain

scale of

Acute pain

related to

inflammati

on and

distortion

of thegallbladder

as

evidenced

by verbal

reports of

pain.

Due to the

presence of

stones in

the

gallbladder

it causessome

obstruction

in the cystic

duct which

in turn

causes a

sharp acute

After 4

hours of

nursing

intervent

ion the

patientwill

report

relieve of

pain.

1. Observe

and document

location,

severity (0

10scale), and

character ofpain (e.g.,

steady,

intermittent,

colicky). 2.

Promote bed

rest, allowing

patient to

- Assists in

differentiating

cause of pain,

and provides

information

about diseaseprogression/r

esolution,

development

of

complications,

and

effectiveness

Is there a change

on the patients;

a. Pain scale

b. RR

c. BP

d. Reports ofpain.

e. Facial

expressions.


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7/10,

difficulty

in

moving

as

manifest

ed by

facial

grimaces

-(+)

pallor,

V/S as

follows:

BP -

130/80

mmHg,

PR- 89

bpm,RR-

20cpm,

T- 38C

pain on the

right part of

the

abdomen.

assume

position of

comfort. 3.

Control

environmental

temperature.

4. Encourage

use of

relaxation

techniques,

e.g., guided

imagery,

visualization,

deep-

breathing

exercises.

Provide

diversionalactivities. 5.

Make time to

listen to and

maintain

frequent

contact with

patient. 6.

Administer

analgesics as

indicated.

of

interventions.

- Bed rest in

low-Fowlers

position

reduces intra-

abdominal

pressure;

however,

patient will

naturally

assume least

painful

position.

- Cool

surroundings

aid in

minimizingdermal

discomfort.-

Promotes

rest, redirects

attention,

may enhance

coping.-

Helpful in

alleviating

anxiety and

refocusingattention,

which can

relieve pain.-

Relief of pain

facilitates

cooperation

with other

therapeutic

interventions.

2. Fluid Volume Deficit

Cues Nursing

Diagnosis

Scientific

Explanation

Objective Nursing

Intervention

Rationale Evaluation

S - Deficient There is this After an 1. Provide - Information -Does the patient


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pwede

bang

maulit

ang sakit

ko as

verbaliz

ed by

the

patient

O-

Frequen

tly

asking

question

about

his

conditio

n,treatme

nt and

diet

-With

worried

gaze dry

mouth

knowledge

related to

condition,

prognosis,

treatment,

self - care,

and

discharge

needs

presence of

knowledge

deficit due

to some

unfamiliar

information

that causes

some

confusion to

the client

that needs

to be

discussed.

hour of

nurse-

patient

interacti

on the

patient

will

verbalize

understa

nding of

disease

process,

prognosi

s, and

potential

complica

tions

explanations

of reasons for

test

procedures

and

preparation

needed.

2. Review

disease

process/

prognosis.

Discuss

hospitalization

and

prospective

treatment as

indicated.

Encouragequestions,

expression of

concern.

3. Review

drug regimen,

possible side

effects

4. Instruct

patient to

avoid

food/fluidshigh in fats

(e.g., whole

milk, ice

cream, butter,

fried foods,

nuts, gravies,

pork), gas

producers

(e.g., cabbage,

beans, onions,

carbonated

beverages), or

gastric

irritants(e.g.,

spicy foods,

caffeine,

citrus).

5. Suggest

patient limit

can decrease

anxiety,

thereby

reducing

sympathetic

stimulation.

- Provides

knowledge

base from

which

patient can

make

informed

choices. - -----

- Effective

communicati

on and

support atthis time can

diminish

anxiety and

promote

healing.

- Gallstones

often recur,

necessitating

long-term

therapy.

- Prevents/limits

recurrence of

gallbladder

attacks.

-

Promotes gas

formation,

which can

increase

gastric

distension/

discomfort.

understands and

could recall all the

teachings given?

-Is there a

significant changes

that occur on the

patients

knowledge

regarding;

a.disease

condition b.diet

c.treatment

d.medication

e.self-care needs


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gum chewing,

sucking on

straw/hard

candy, or

smoking

C. Drug Study

Name of Drug Route/

Dosage

andFrequency

Action Indication Adverse

Reaction

Nursing

Consideration

GN:Cefuroxime

BN: Zinacef

750 mg IV

Q8hrs

ANST(-)

-

Anti-infectives

-Second-

generation

cephalosphorin

that inhibits cell-

wall synthesis,

promoting

osmotic

instability;

usually

bactericidal

Perioperative

prevention

Phlebitis,

nausea,

anorexia,vomiti

ng,

maculopapular

and

erythematous

rashes,

urticarial, pain,

induration

1.Check the

doctors order.

2. Inform the

patient about

the adverse

reaction.

3. Before giving

drug, ask

patient if he is

allergic to

penicillins or

cephalosphorin

s.

4. Intsruct

patient to

notify

prescriber

about rash,

loose stools,

diarrhea, or

evidence of

superinfection.5. Advise

patient

discomfort

receiving drug

IV to report

discomfort at

IV insertion


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site.

GN: Cefoxitin

Sodium

BN: Mefoxitin

1gm IV

Q8hrs

ANST(-)

-

Anti-infectives

-Second-

generation

cephalosphorin

that inhibits cell-

wall synthesis,

promoting

osmotic

instability;

usually

bactericidal

Serious

infection of the

respiratory and

GU tracts; skin;

soft-tissue,

bone, or joint

infection;

blood-stream

or intra-

abdominal

infection

caused by

susceptible

organisms(

such as E. coli

and other

coliformbacteria.

Fever, phlebitis,

diarrhea,

nausea,

vomiting,

anemia, acute

renal failure,

pain, induration.

1. Before givig

ng drug, ask

patient if he is

allergic to

penicillins or

other

cephalosphorin

s. 2. After

reconstitution,

drug may be

stored for

24hrs at room

temperature or

1 week under

refrigeration.

3. Intsruct

patient tonotify

prescriber

about rash,

loose stools,

diarrhea, or

evidence of

superinfection.

4. Advise

patient

discomfort

receiving drugIV to report

discomfort at

IV insertion

site.

GN:

Metronidazole

BN: Flagyl

500 mg IV

Q8hrs

ANST(-)

- BacterialInfectio

ns

caused

by

anaerob

ic

microor

ganisms.

- Toprevent

postope

rative

infectio

n in

Direct- acting

trichomonocid

e and

amoebicide

that works

inside and

outside the

intestines. Its

thought to

enter the cells

of

microorganism

s that contain

nitroreductase,

forming

Headache,

seizures, fever,

constipation,

nausea, pain,

edema,

peripheral

neuropathy

1. Monitor liver

function test

results

carefully in

elderly

patients. 2. Use

cautiously in

patients who

take

hepatotoxic

drug or have

hepatic disease

or alcoholism.

3. Use

cautiously in


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contami

nate or

potencia

lly

contami

nate

colorect

al

surgery.

unstable

compounds

that bind to

DNA and

inhibit

synthesis,

causing cell

death.

patients with

history of

blood

dyscrasia, CNS

disorder, or

retinal or visual

retinal

changes.

4. Record

number and

character of

stool when

drug is used to

treat

amoebiasis.

5. Observe

patient for

edema,especially if

hes receiving

corticosteroids;

Flagyl IV RTU

may cause

sodium

retention.

GN: Ketorolac

Tromethamine

BN: Toradol

15 mg/ml

IV Q6hrs

PRN

Short-term

management of

moderately

severe, acutepain for multiple

dose

treatment.

May inhibit

prostaglandin

synthesis, to

produce anti-inflammatory,

analgesics, and

antipyretic

effects.

Headache,

dizziness,

drowsiness,

hypertension,palpitation,

sedation, peptic

ulceration,

prolonged

bleeding time

1. Correct

hypovolemia

before giving.

2. Carefullyobserve

patients with

coagulopathies

and those

taking anti-

coagulants.

3. Teach

patient signs

and symptoms

of GI bleeding,

including blood

in vomit; and

black tarry

stool. Tell

patient to

notify

prescriber

immediately if

any of these


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occurs.

4. Serious GI

toxicity,

including

peptic ulcers

and bleeding,

can occur in

patient taking

NSAIDs,

despite lack of

symptoms.

CHAPTER IV - IMPLEMENTATION

Medical/ Surgical Management

1. Chest X-ray- this is used to rule out respiratory causes of referred pain.

2. Intake and Output- I&O measurement provide an other means of assessing fluid balance. This data

provide insight into the cause of imbalance such as decrease fluid intake or increase fluid loss. These

measurement are not that accurate as body weight, however, because of relative risk of errors in

recording.

3. Electrocardiogram - The ECG is an essential tool in evaluating cardiac rhythm. Electrocardiography

detects and amplifies the very small electrical potential changes between different points on the surface

of the body as a myocardial cell depolarize and repolarize, causing the heart to contract.

4. O2 Inhalation - Oxygen therapies are used to provide more oxygen to the body into order to promote

healing and health.

5. Intravenous Rehydration - when the fluid loss is severe or life - threatening, intravenous (IV) fluids are

used for replacement.

6. Ultrasound (Also called sonography.) - a diagnostic imaging technique which uses high-frequency

sound waves to create an image of the internal organs. Ultrasounds are used to view internal organs of

the abdomen such as the liver spleen, and kidneys and to assess blood flow through various vessels.

7. Hepatobiliary scintigraphy - an imaging technique of the liver, bile ducts, gallbladder, and upper part

of the small intestine.

8. Cholangiography - x-ray examination of the bile ducts using an intravenous (IV) dye (contrast).


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9. Percutaneous transhepatic cholangiography (PTC) - a needle is introduced through the skin and into

the liver where the dye (contrast) is deposited and the bile duct structures can be viewed by x-ray. 10.

10. Endoscopic retrograde cholangiopancreatography (ERCP) - a procedure that allows the physician to

diagnose and treat problems in the liver, gallbladder, bile ducts, and pancreas. The procedure combines

x-ray and the use of an endoscope. A long flexible, lighted tube. The scope is guided through the

patient's mouth and throat, then through the esophagus, stomach, and duodenum. The physician can

examine the inside of these organs and detect any abnormalities. A tube is then passed through the

scope, and a dye is injected which will allow the internal organs to appear on an x-ray.

11. Computed tomography scan (CT or CAT scan) - a diagnostic imaging procedure using a combination

of x-rays and computer technology to produce cross-sectional images (often called slices), both

horizontally and vertically, of the body. A CT scan shows detailed images of any part of the body,

including the bones, muscles, fat, and organs. CT scans are more detailed than general x-rays.

12. Cholecystectomy- removal of the gallbladder. This procedure may be performed to treat chronic or

acute cholecystitis, with or without cholelithiasis, to remove a malignancy or to remove polyps.

13. Cholecystotomy - the establishment of an opening into the gallbladder to allow drainage of the

organ and removal of stones. A tube is then placed in the gallbladder to established external drainage.

This is performed when the patient cannot tolerate cholecystectomy.

14. Choledochoscopy- the insertion of a choledoscope into the common bileduct in order to directly

visualize stones and facilitate their extraction.

CHAPTER V DISCHARGED PLANNING

Instructed the patient and S.O to continue medication at home as ordered.1) Tergecef ( Cefixime ) 400mg/ cap, 1 capsule once a day for 7 days. (8am)2) Ciprofloxacin ( Ciprobay ) 1 gm/tab, 1 tablet once a day for 7 days. (8am)3) Omeprazole 400mg/cap, 1 capsule twice a day (7am-7pm)4) Vestar MR 35mg/tab, 1 tablet twice a day (8am-8pm)5) Clopidogrel 75mg/tab, 1 tablet once a day (8am)6) Erdostiene 300mg/tab, 1 tablet three times a day (8am-1pm-7pm)7) Levociterizine/Montelukast 10/5, 1 tablet daily at bedtime. (9pm)8) Kalium Durule tab, 1 tablet three times a day for 6 doses. (8am-1pm-7pm)9) Celecoxib 200mg/cap, 1 capsule twice a day. (8am-8pm)

Instructed patient to do deep breathing exercise, coughing technique while puttingpressure/splinting at the operative site, and walking as tolerated.

Emphasized the importance of completing the drug regimen, especially the antibiotics.


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Encouraged patient to increase oral fluid intake. Advised patient to eat nutritious foods rich inVit.C. Advised patient avoid eating salty and fatty foods.

Advised to return for the follow-up check-up on Monday, Dec.16,2013.

VI Conclusion

Cholecystitis is the inflammation of the gall bladder which is usually accompanied by gallstones

or cholelithiasis these gallstones may block the way of toxic substances that really needs to go out, but

due to this blockage this toxic substances are not then being expelled and are just being stored in the

bladder for a period of time. This then causes inflammation of the gallbladder. The treatment usually

done is the cholecystectomy. In order to lower the risk of having this kind of condition each and every

one of us must be conscious in our diet. We should try to avoid foods which are rich in salt and fats,

especially those foods which contains many seasonings. Though there is a saying that

Mas masarap pag bawal

which always pertains to the food were eating we should still be conscious on our health especially if we

want to live longer and also to avoid those life-threatening diseases which not only shorten our life but

causes us some financial problem. Remember also the saying

Mahal ang magkasakit. Just like on what our patient had experience she still has to collect money for

the operation she had underwent causing them to have debt with different persons. Let us not enjoy

ourselves with the delicious food were eating that is rich in salts and fats but we should enjoy living

because we have a healthy condition.


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VII - BIBLIOGRAPHY

Books

Joyce M. Black,PhD, RN, CPSN, CWCN & Jane Hokanson Hawks, DNSc, RN, BC,Medical- Surgical Nursing

7thedition, pg.1302-1314.

Nursing 2004 Drug Handbook, 24thEdition

Doenges, Moorhouse, & Murr, Nurses pocket guide 9thedition.

Online Resources

www.facs.orghttp://tjsamson.client.web-health.com/web-

health/topics/GeneralHealth/generalhealthsub/generalhealth/liver&gallbladder/what_gall

bladder.htmlhttp://www.emedicine.com/emerg/topic97.htmhttp://www.emedicine.com/radio/topic163.htmhttp://www.healthsystem.virginia.edu/uvahealth/adult_liver/chole.cfmhttp://www.emedicine.co

m/EMERG/topic98.htmMicrosoft Encarta 2004 Nursing Care Plan Content CD-ROM

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