cholecystitis with cholelithiasis
TRANSCRIPT
INTRODUCTION
Cholelithiasis is the presence of one or more calculi (gallstones) in the gallbladder and is the fifth
leading cause of hospitalization among adults. The disease may also be occurring in persons who are
obese and who have high cholesterol. In most cases, gallbladder and bile duct diseases occur during
middle age. Between ages 20 and 50, they're six times more common in women, but incidence in men
and women becomes equal after age 50. Incidence rises with each succeeding decade. More serious
complications include cholecystitis; biliary tract obstruction (from stones in the bile ducts or
choledocholithiasis), sometimes with infection (cholangitis); and gallstone pancreatitis. Diagnosis is
usually by ultrasonography. If cholelithiasis causes symptoms or complications, cholecystectomy is
necessary.
Cholecystitis, acute or chronic inflammation of the gallbladder is usually associated with a
gallstone impacted in the cystic duct that may cause painful distention of the gallbladder.
Postcholecystectomy syndrome commonly results from residual gallstones or stricture of the common
bile duct. It may be occurs in 1 % to 5 % of all patients whose gallbladders have been surgically removed
and may produce right upper quadrant abdominal pain, biliary colic, dyspepsia and indigestion.
Gallstones develop in many people without causing symptoms. The chance of symptoms or
complications resulting from cholelithiasis is about 20%. With current surgical approaches, the outcome
is excellent with no recurrence of symptoms in over 99% of individuals.
DEMOGRAPHIC DATA
Name: Patient X
Sex: Male
Religion: Iglesia ni Cristo
Address: Tarlac
Age: 50 years old
Date of Birth: February 5, 1960
Date of Admission: January 7, 2011 at 8:45 pm
Chief Complaints: Right upper quadrant pain
Admitting Diagnosis: Acute Cholecystitis with Cholelithiases
Final Diagnosis: Acute Cholecystitis with Cholelithiases
ANATOMY AND PHYSIOLOGY
LIVER
A. Location and size of the liver- largest gland in the body, weighs approximately 1.5 kg;
lies under the diaphragm; occupies most of the right hypochondrium and part of the
epigastrium.
B. Liver lobes and lobules- two lobes separated by the falciform ligament
1. Left lobe- forms about one sixth of the liver
2. Right lobe- forms about five sixths of the liver; divides into right lobe proper,
caudate lobe, and quadrate lobe
3. Hepatic lobules- anatomical units of the liver; small branch of hepatic vein
extends through the center of each lobule
C. Bile ducts
1. Small bile ducts form right and left hepatic ducts
2. Right and left hepatic ducts immediately join to form one hepatic duct
3. Hepatic duct merges with cystic duct to form the common bile duct, which
opens into the duodenum
D. Functions of the liver
1. Glucose Metabolism
-after a meal, glucose is taken up from the portal venous blood by the liver and
converted into glycogen (glycogenesis), which is stored in the hepatocytes. Glycogen
is converted back to glucose (glycogenolysis) and release as needed into the blood
stream to maintain normal level of the blood glucose.
-glucose can be synthesized by the liver through the process gluconeogenesis
2. Ammonia Conversion
-use of amino acids from protein for gluconeogenesis result in the formation of
ammonia as a by product. Liver converts ammonia to urea
3. Protein Metabolism
-Liver synthesizes almost all of the plasma protein including albumin, alpha and
beta globulins, blood clotting factors plasma lipoproteins
4. Fat Metabolism
-Fatty acid can be broken down for the production of energy and production of
ketone bodies
5. Vitamin and Iron Storage
-stores vitamin A, D, E, K
6. Drug Metabolism
7. Bile Formation
-bile is formed by the hepatocytes
-composed of water, electrolytes such as sodium, potassium, calcium, chloride,
bicarbonate, lecithin, fatty acids, cholesterol, bile salts
-collected and stored in the gallbladder and emptied in the intestine when
needed for digestion
a. Lecithin and bile salts emulsify fats by encasing them in shells to form tiny
spheres called micelles
b. Sodium bicarbonate increases pH for optimum enzyme function
c. Cholesterol, products of detoxification, and bile pigments (e.g. bilirubin) are
wastes products excreted by the liver and eventually eliminated in the feces
GALLBLADDER
The gallbladder (or cholecyst, sometimes gall bladder) is a small organ whose
function in the body is to harbor bile and aid in the digestive process.
Anatomy
The cystic duct connects the gall bladder to the common hepatic duct to form the
common bile duct.
The common bile romero duct then joins the pancreatic duct, and enters through
the hepatopancreatic ampulla at the major duodenal papilla.
The fundus of the gallbladder is the part farthest from the duct, located by the
lower border of the liver. It is at the same level as the transpyloric plane.
Microscopic anatomy
The 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.
Size and Location of the Gallbladder
The gallbladder is a hollow, pear-shaped sac from 7 to 10 cm (3-4 inches) long
and 3 cm broad at its widest point. It consists of a fundus, body and neck. It can hold 30
to 50 ml of bile. It lies on the undersurface of the liver’s right lobe and is attached there
by areolar connective tissue.
Structure of the Gallbladder
Serous, muscular, and mucous layers compose the wall of the gallbladder. The
mucosal lining is arranged in folds called rugae, similar in structure to those of the
stomach.
Function of the Gallbladder
The gallbladder stores bile that enters it by way of the hepatic and cystic ducts.
During this time the gallbladder concentrates bile fivefold to tenfold. Then later, when
digestion occurs in the stomach and intestines, the gallbladder contracts, ejecting the
concentrated bile into the duodenum. Jaundice a yellow discoloration of the skin and
mucosa, results when obstruction of bile flow into the duodenum occurs. Bile is thereby
denied its normal exit from the body in the feces. Instead, it is absorbed into the blood,
and an excess of bile pigments with a yellow hue enters the blood and is deposited in
the tissues.
The gallbladder stores about 50 mL (1.7 US fluid 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.
PATHOPHYSIOLOGY
Modifiable Factorso Obesityo High intake of fatty
foodso High Cholesterol levelo Hormonal
replacement therapy
Non Modifiable Factorso Femaleo 40 years old
and above
imbalance on the component of bile
supersaturation of bile with cholesterol
crystal formation
causing obstruction on the cystic duct
inflammation of gallbladder
fever ↑ WBC
gallbladder contracts as it tries to release bile and expel
the stone
Biliary Colic characterized as right upper quadrant pain that may radiate to sternum, right shoulder and right scapula
nausea and vomiting
decrease production of bile in the GI tract
disruption in normal digestion process
indigestion flatulence pain after eating
fatty meal
infection
decreased emulsification
of fats
Increased concentrationof fats in blood
↑ Total Cholesterol
↑Triglycerides
gallstones in the gallbladder
LABORATORY DATA
Laboratory Procedure Date Ordered Results Normal Values
Analysis and Interpretation of
Results
HEMATOLOGY REPORT
Hemoglobin
Hematocrit
WBC Count
Differential Count:
Neutrophils
Lymphocytes
January 7, 2011
15.7
0.47
13.4 x 10 g/L
0.82
0.20
12.5-17.5 g/dL
.40-52
5-10 x 10 g/L
.45-.65
.20-.35
> Normal
> Normal
> Elevated. It indicates inflammation and possible infection.
> Elevated. It indicates an acute infection.
> Normal
Laboratory Procedure Date Ordered Results Normal Values
Analysis and Interpretation of
ResultsBlood Chemistry
Glucose (FBS)
Blood Urea Nitrogen
Creatinine
Cholesterol
Triglycerides
HDL
LDL
SGOT
SGPT
January 3, 2011
120.2
14.4
0.6
210
205.7
22.0
135.0
30.1
88.1
70-105 mg/dL
7-18 mg/dL
0.40-1.40 mg/dL
150-200 mg/dL
44-148 mg/dL
30-75 mg/dL
66-178 mg/dL
5-34 U/L
4-36 U/L
> Elevated. It indicates hyperglycemia
> Normal
> Normal
> Elevated. There is decreased production of bile in the GIT due to obstruction causing decreased emulsification of fats.
> Elevated. There is decreased production of bile in the GIT due to obstruction causing decreased emulsification of fats.
> Decreased. “Good cholesterol” is decreased in amount.
> Normal
> Normal
> Elevated. Suggest possible liver disease
Diagnostic Test Date Ordered Result
Abdominal Ultrasound January 5, 2011Abdominal sonography reveals a liver, within normal in size with no solid mass or cyst noted.There are focal fatty infiltration seen in the liver.The intrahepatic and common ducts are not dilated with common duct measuring 0.5 cm in diameter.There are multiple calculi in the gall bladder one measuring 0.9 cm. The gall bladder wall is thickened measuring 0.4 cm with tenderness elicited on pressure of the gall bladder.The pancreas is normal in size and echogenicity with the head and the body seen with no mass or cyst demonstrated.The proximal abdominal aorta is seen and not dilated.The spleen is homogeneous and not enlarged with no mass or cyst outlined.The kidneys are within normal in sizes and echogenicity with no solid mass, cyst, calculus or hydronephrosis demonstrated.There is minimal ascites in the Morrison’s pouch.There is pleural effusion seen bilaterally.
DRUG STUDY
Drug Name Action Dosage Indication Contraindication Side Effects Nursing ResponsibilitiesGeneric Name:Cefuroxime
Classification:Cephalosporin
Therapeutic Classification:Antibacterial
Cefuroxime binds to one or more of the penicillin-binding proteins (PBPs) which inhibits the final transpeptidation step of peptidoglycan synthesis in bacterial cell wall, thus inhibiting biosynthesis and arresting cell wall assembly resulting in bacterial cell death.
750 mg IVP q 8
Prophylaxis of surgical infections
Hypersensitivity to cephalosporin
GI: nausea, vomiting, diarrhea
GU: nephrotoxicity
Others: Steven-Johnsons syndrome, anaphylaxis, pseudomembranous colitis
> Explain to the client the purpose and action of the drug.> Administer slowly> Monitor for kidney and liver function test> Advise patient to immediately report rash or bleeding tendency.
Drug Name Action Dosage Indication Contraindication Side Effects Nursing Responsibilities
Generic Name:Ranitidine
Therapeutic classification:Antiulcer drug
Ranitidine blocks histamine H2-receptors in the stomach and prevents histamine-mediated gastric acid secretion. It does not affect pepsin secretion, pentagastrin-stimulated factor secretion or serum gastrin.
50 mg IVP q 8 Gastric acid reduction
Porphyria CNS: headache, dizziness, confusion
Hematology: thrombocytopenia, leukopenia
Others: hypersensitivity, gynaecomastia, impotence, somnolence, vertigo, hallucinations
> Explain to the client the purpose and action of the drug.> Administer slowly> Monitor CBC and liver function tests.
Drug Name Action Dosage Indication Contraindication Side Effects Nursing
ResponsibilitiesGeneric Name:Ketorolac
Classification:NSAIDS
Therapeutic classification:Analgesic, Anti inflammatory
Ketorolac inhibits prostaglandin synthesis by decreasing the activity of the cyclooxygenase enzyme.
30 mg IVP q 8
Moderate to severe pain
>Hypersensitivity to aspirin>hypovolemia or dehydration> history of peptic ulcer or coagulation disorders> moderate to severerenal impairment> GI bleeding> Cerebrovascular bleeding
GI: dry mouth, GI ulcer, nausea, bleeding and perforation
CNS: drowsiness, hypotension, headache
Cardio: bradycardia, chest pain
Skin: fever, sweating , rash, pallor, edema
Others: liver function changes
> Explain to the client the purpose and action of the drug.> Administer slowly> Instruct patient to avoid aspirin products and herbs during therapy.> Monitor patient for CNS changes> Provide safety
Drug Name Action Dosage Indication Contraindication Side Effects Nursing
ResponsibilitiesGeneric Name:Hyoscine N butyl bromide
Therapeutic classification:Antispasmodic
Hyoscine competitively blocks muscarinic receptors and has central and peripheral actions. It relaxes smooth muscle and reduces gastric and intestinal motility.
1 ampule IVP now
Gastrointestinal tract spasm
Narrow-angle glaucoma, acute haemorrhage, paralytic ileus, tachycardia due to cardiac insufficiency, myasthenia gravis
CNS: postural hypotension, drowsiness, dizziness, headache, memory loss
Skin: flushing, dry skin, erythema, increased sensitivity to light, rash
Cardio: tachycardia, fibrillation
GIT: constipation, dry throat, dysphagia, nausea, vomiting
GUT: dysuria, urinary retention
Musculoskeletal: tremor, weakness
EENT: Impaired accommodation, blurred vision, cycloplegia, dryness, narrow-angle glaucoma, increased intraocular pain, itching, photophobia, pupil dilation. Dry nose.
> Explain to the client the purpose and action of the drug.> Administer slowly> Check for mental status changes> Provide safety> Evaluate fluid intake and output.
NURSING CARE PLAN
ASSESSMENT DIAGNOSIS PLANNING NURSING INTERVENTION
RATIONAL E EXPECTED OUTCOME
S – “Masakit ang tiyan ko”, as claimed With pain scale of 7/10
O > grimace noted > muscle guarding behavior on the right upper quadrant > pain is aggravated by abrupt movements > pain is referred to the right shoulder and right scapula > use of abdominal muscles in breathing > diaphoretic > slightly exaggerated depth of respiration > tachypneic (25 cpm) > irritable at times
Acute pain r/t inflammation of the gall bladder
Scientific Explanation:As the gallbladder is inflamed and tries to contract to release bile and expel the obstructed stone it produces spasm.
Within 1 hour of proper nursing intervention the patients’ pain scale of 7/10 will decrease to 5/10.
> Assist and place on the preferred position > Assist when changing position > Encourage deep breathing exercise > Provide comfort measure such as back rub > Encourage verbalization of feelings > Eliminate additional stressors or sources of discomfort whenever possible > Administer analgesics and antispasmodic for as ordered
> promote comfort
> to conserve energy > to relieve muscle tension > to promote comfort
> decreases anxiety
> to divert the attention of the patient and to relieve muscle tension
> Decreases spasm and relieve the patient from pain
After one hour of proper nursing intervention the patients’ pain scale of 7/10 will be decreased to 5/10 as manifested by:
a. lessen grimaceb. lessen muscle
guarding behavior
c. lesser use of accessory muscles in breathing
d. RR will decrease within the normal range of 12-20 cpm
e. more comfortable
ASSESSMENT DIAGNOSIS PLANNING NURSING INTERVENTION
RATIONAL E EXPECTED OUTCOME
S – “Mainit ang pakiramdam ko”, as claimed
O > weak in appearance> flushed skin> irritable > febrile: body temperature of 38.1 degree Celsius > tachycardic: 103 > tachypneic: 24 cpm
Altered thermoregulation related to inflammation and presence of infection of the gallbladder
Scientific Explanation:The presence of inflammation and infection can activate immune response resulting to increased body temperature.
Within 30 minutes of proper nursing intervention the patients’ pain scale of 38.1 will decrease to 37.5 degree Celsius
> Remove excessive clothing
> Provide tepid sponge bath
> Maintain patient in bed rest
> Increase fluid intake.
> Encourage patient to eat fruits rich in Vitamin C
> Encourage patient to eat foods rich in carbohydrates and protein
> Administer medication as ordered
> promote cooling effect
> To help lowered body temperature and promote cooling effect. > To decrease metabolic demands > To replace loss fluids.
> To boost immune system
> To meet metabolic needs of the body.
> Antipyretic drugs help in lowering body temperature.
After 30 minutes of proper nursing intervention the patients’ pain scale of 38.1 will be decreased to 37.5 degree Celsius as evidenced by:
a. moist skin b. afebrile
EVALUATION
The patient undergoes cholecystectomy last January 8, 2011. The patient was given take home medications for management of pain and antibiotics as prophylaxis from surgical infection. Daily wound care was taught to the patient. Avoidance of strenuous activities was also advised. The patient was also encouraged to eat foods rich in protein and Vitamin C for wound healing and collagen formation. The prescribed diet is low fat and law salt since the gallbladder is removed. The client was also advised to comply with the follow up check-up for the removal of sutures.
After the surgical treatment done and postoperative management, patient condition is now stable.