THE ARAB AMERICAN UNIVERSITR

FACULTY OF ALLIED MEDICAL SCIENCE

DEPARTMENT OF NURSING

CASE STUDY

Student Name: Mona Amal Jbareen

ID: 21410843

Date: 21/12/2015

Hospital: Rafidia Surgical Hospital

Instructor Name: Salah

Introduction:

The patient (A.A) is a 53-year-old man, from Nablus, Muslim, married since 25 years, have four sons and two

daughters, he works in the electricity company .

He Is admitted to the hospital with abdominal pain in the right upper quadrant, center of abdomen just below breastbone, and in the right shoulder.

His pulse rate, Blood pressure and temperature were with in normal range.

The patient had been hospitalized 3 months .

Pathophysiology:

The process of gallstone formation is referred to as cholelithiasis. It is generally a slow process, and usually causes no pain or other symptoms. The majority of gallstones are either the cholesterol or mixed type. Gallstones can range in size from a few millimeters to several centimeters in diameter.

About 70% of gallstones are formed from cholesterol. Pigment stones (black or brown) are also very common and account for the remaining 30% of stones. Patients can have a mixture of the two gallstone types.

Cholesterol Stones

Gallstones may develop when there is too much cholesterol in the bile secreted by your liver. Bile usually dissolves or breaks down cholesterol. However, if the liver makes more cholesterol than bile can dissolve, hard stones may develop.

Bilirubin

Bilirubin is a chemical produced when the liver destroys old red blood cells. Some conditions, such as cirrhosis of

the liver and certain blood disorders, cause the liver to produce more bilirubin than it should. Stones form when the gallbladder cannot break down the excess bilirubin. These hard substances are also called pigmented stones.

Concentrated Bile

The gallbladder needs to empty bile to be healthy and function properly. If it fails to empty its bile content, the bile becomes overly concentrated, which causes stones to form.

Pathophysiology (Clinical picture)

Rationalmedial surgicl treatment

Rational for clinical picture

clinical picture: signs & symptoms

removal of the gallbladder a small pearshaped sac that is located directly beneath the liver in the upper right side of the abdomen. The gallbladder's main function is to store bile, which is produced by the liver, and to release it as needed for digestion. the gallbladder's function is important, but it is not an essential organ.

laparoscopic cholecystectomy

Due process that have undergone

Abdominal Pain

to removal of the gallbladder. It is a common treatment of symptomatic gallstones and other gallbladder conditions.

laparoscopic cholecystectomy

occurs when the extrahepatic ducts-cystic, (hepatic duct or common bile duct) are suddenly blocked by a gallstone.

biliary colic

Assessment:

Demographic Data:

Patient Initials: A.A

Occupation: worker in the electricity company

Religion: Muslim

Age: 53 years old

Gender: Male

Marital status: married

Date of Patient Admission: 05.12.2015

Time: 09:48

History:

Chief complaint: the patient told me she complain of pain in the right upper quadrants of the abdomen.

Past Medical history : the patient told me :

began to suffer from this pain of about 3 months. after this she went to the Rafidia Surgical Hospital , ultrasound examination was done .And knew the cause of the disease.

Past surgical history: No past surgical history.

Allergies:

food: the patient told me that she doesn't have allergies to any type of food.

Medication: the patient told me that she doesn't have allergies to any type of medication.

Smoking: the patient told me : she isn’t smoker.

General Data:

Vital signs

1. Body temperature: Temp: 37 C /Normal / obtained axillary ( the normal average between 36.5-37.4)

2. Respiratory: Respiration: 18 breath/min, the normal average (12-20)16 breath/min.

3. Pulse: 95 beat/min (the normal average (60-100)80 beat/min

4. B/P: 110/70 MMHG, obtained from the left hand, and in normal range, the normal average of systole (110-135), and the normal average of diastole (65- 80).

5. Height: The patient told me that he is 159 cm.

6. Weight: The patient told me that he is 80 kg.

* The BMI IS 31.6 / Normal weight = 18.5–24.9 / Underweight = <18.5/ Overweight = 25–29.9 / Obesity = BMI of 30 or greater

General Appearance :

1. Skin color: light brown/ by inspection.

2. Level of consciousness: completely oriented/ by inspection.

3. Posture & position: able to walk but with help by another person.

4. Physical deformities: he hasn’t any deformities.

5. motility :

Gait: by inspection/ has upright posture and steady gait, and spinal column is straight.

Involuntary movements: by inspection/ he doesn’t has any involuntary movement.

Use of assistive device: by inspection/ he needed help , and need an assistive device.

6. Facial expression: by inspection/ his facial expression was smiley .

7. Mood & affect: by inspection / good mood, respond to us very well.

8. Personal hygiene: by inspection/ its clean, with help from her family.

9. Speech: comprehensive word, clear sound.

Medical Diagnosis:

Etiology, signs, symptoms

DefinitionMedical Diagnosis

signs and symptoms may result, such as: *Sudden and rapidly intensifying pain in the upper right portion of your abdomen * Sudden and rapidly intensifying pain in the center of your abdomen, just below your breastbone * Back pain between your shoulder blades *Pain in your right shoulder.

little pebbles that develop inside the gallbladder-a small, pear-shaped organ located on the right side of your upper abdomen. The gallbladder stores and releases bile, a liquid that helps digest fats. If the bile contains too much cholesterol or waste products, it can harden into gallstones. If the tubes (ducts) carrying bile are blocked by gallstones, the gallbladder may become swollen and painful.

G.B.S gallbladder stone

Systems Include

Neurovasclar system:

1. Reflexes: the patient is relaxed and the joint is flexed appropriately.

2. Level of consciousness: normal.

3. Speech: the patient can express himself.

4. Coordination and general balance: he walks across the room, turns, and walks back.

5. Appearance and behavior: appropriate.

6. Eye-opening response: spontaneously.

7. Motor response: obeys.

8. Verbal response: oriented.

musculoskeletal system:

1. Temporal mandible joint for tenderness: by inspection the joint and palpation each joint for tenderness no swelling , no tendernrss, and joient more smoothly.

2. Upper extremities (ROM & muscle strength): by deep palpation strength muscle.

a. Shoulder: by palpation strength muscle and equal strength on each body side.

b. Elbow: by palpation strength muscle and equal strength on each body side.

c. Wrist and carpals: by palpation strength muscle and equal strength on each body side.

3. Lower extremities:

a. Hip: client raises one leg at a time while I attempt to hold it down/ painful due process that have undergone.

b. Knee: client spreads his legs against my resistance, strength muscle.

c. Ankle & foot: the pt attempt to flex the foot again resists, strength muscle.

Cardiovascular System :

1. Auscultate the carotid artery: no sound hear on auscultate.

2. Palpate the apical impulse: apical pulsation can be felt by palpation.

3. Percussion sound: by percussion dull sounds are, normally heard over dense area such as heart.

4. Auscultation listens for s1 & s2 (rate &rhythm ): by auscultation s1 and s2 can be heard at all anatomic site.

Respiratory system:

1. Shape of chest: by inspection/ anteroposterior to transverse diameter is 1:2 , chest symmetrical.

2. Skin condition: by inspection / light brown, uniform with the color of body.

3. Symmetric expansion of the lung: by inspection / full symmetric expansion during breathing.

4. Auscultation of breath sound: the thorax vesicular and bronchovesicular breath sound very normal.

5. Respiratory rate &rhythm: normal breath and it is silent.

Skin:

1. Color: by inspection / light pink, uniform color.

2. Moisture: the skin is very moisture.

3. Texture: smooth skin and warm.

4. Thickness: by palpation & inspection the pt is normal thickness of skin/ thin skin is 0.5 mm/ thick skin is up to 6 mm in palms and soles.

5. Edema: patient doesn’t has any edema her skin is uniform with no edema.

6. Turgor: when pinched , skin springs back to previous state.

7. Hygiene: by inspection / its clean.

8. Lesions & rashes: by inspection/ patient doesn’t has any lesions & rashes.

Urinary System:

1. urinary habits: the patient told me: he is accustom to urinate when he wake up.

2. color: the patient told me : light yellow color.

3. frequency:

the patient told me: he is voiding more than 3 times per day.

4. urgency: the patient told me : he can control himself to doesn’t go to the bathroom immediately .

5. burning: the patient told me : he doesn’t has any burning.

Gastrointestinal System:

1.Contour: by inspection/ the contour is rounded.

2.Color & skin condition (abdomen): by inspection / light brown color and uniform, no lesion.

3.Umbilicus (hernia, discharge): by inspection he has'nt discharge , after dressing for the site of operation.

4.Bowel sound: the pt didn’t eat for a week so he doesn’t has a bowel sound.

5. rectum:

a. bowl habits: the patient told me: he defecate at least 3 times a weak.

b. sphincter control: the patient told me: he can to control herself .

c. Incontinency: the patient told me he doesn’t has facial incontinency.

d. Hemorrhoid: the patient told me he has no hemorrhoid.

e. Fissures: the patient told me he has no fissures.

Hematology:

There are leukocytosis with a "left" shift, and elevations in the amylase and lipase levels in the pancreatitis. And elevations of hepatic transaminases and alkaline phosphatase.

Endocrine:

1. Rate of growth: normal.

2. Heat or cold intolerance: normal.

3. Changes in glove, shoe, or ring sizes: no change.

4. Sweating or flushing: normal.

5. Weight changes: no changes, in average.

6. Abnormal pigmentations: There is no appearance of pigmentation.

7. Change in skin texture: no change.

8. Impotence: no impotence.

9. Dryness of skin and hair: no dryness, no loss of body hair or hirsutism (people with endocrine problems often have either hirsutism or loss of body hair).

Pain:

The most common symptom of gallstones is pain in the stomach area or in the upper right part  of the belly, under the ribs.

The pain start suddenly in the center of the upper belly (epigastric area) and spread to the right upper back orshoulder blade area. It was hard to the patient to get comfortable. Moving around does not make the pain go away. Continuous pain for 1 to 5 hours.The patient prevent the pain from taking normal or deep breaths.

The pain begin at night and was severe enough to wake he. and occur after meals

Psychological/ social:Sleep: the patient was unable to sleep enough due to her conifinement.The patient is cooperating even in pain he is awae of her current condiotion.And give appropriate solution to problem he encounter in life. She Knows how to manage stress by diverting her attention to others.

Self Care Ability

DependentAssistiveIndependentActivity√Eating/ Drinking

√Bathing√Toileting√Ambulating

Refrences:

1. From Wikipedia.

2. Nursing care plane .

3. Clinical Pharmacology for Nurses – john Trounce

Notes

Medication:

(list all treatment: refer to chart, medication sheet, krdex)

Nursing Implications

Expected Side Efeects

Indication for My Patient

Dosage and Rout

Drugs and Classification

nausea, vomiting, sedation, dizziness, diaphoresis, urinary retention and constipation

for the treatment of moderate to severe pain.

75 mg / IMPethidine

Avoid skipping doses or not completing the full course of therapy.

Swelling, redness, pain, or soreness at the injection site may occur. This medication may also infrequently cause loss of appetite, nausea, vomiting, diarrhea, irritability, or headache.

prevent infections that are proven or strongly suspected to be caused by bacteria.

750 mg / IVZINACEF (cefuroxime)

This medication may be taken with food or a full glass of water or milk to prevent stomach upset.

Diarrhea ,dizziness or lightheadedness, headache loss of appetite, nausea or vomiting.

is an antibiotic effective against anaerobic bacteria and certain parasites.

1500/ Tablet

metronidazole (Flaggy)

Lab Work:

Nursing Interpretation

Current Values

Normal ValuesLab TestDate

Normal9.6 K/UL4.8-10.8WBC05/12/2015

Normal12.1 g/dl12_16HgbNormal36.937_47HctNormal287 k/ul140_450PlateletsNormal91.6 mg/dl60_120GlucoseNormal14 mg/dl4_23BUN

Low0.4 mg/dl0.6_1.3CreatinineNormal140mEq/L135_145NaNormal3.6mEq/L3.5_5K

Low1.29mEq/L4.5-5.5CaNormal4.65 M/ul4.20_5.40RBCNormal79.4 Fl80_97MCV

PIE (Plan, Intervention, Evaluation):EvaluationRationalImplementationPlaning&

GoalNursing

Nursing Interpretation

Current Values

Normal ValuesLab TestDate

Hight14.4 K/UL4.8-10.8WBC06/12/2015Low11.2 g/dl12_16HgbLow34.637_47Hct

Normal270 k/ul140_450PlateletsNormal91.6 mg/dl60_120GlucoseNormal14 mg/dl4_23BUN

Low0.4 mg/dl0.6_1.3CreatinineNormal140mEq/L135_145NaNormal3.6mEq/L3.5_5K

Low1.29mEq/L4.5-5.5CaNormal4.35 M/ul4.20_5.40RBCNormal79.6 Fl80_97MCV

Diagnosis

After 8 hours of nursing interventions, the patient will verbalize relief or control of pain.

Helps evaluate degree of discomfort and may reveal developing complications.• Reduction of anxiety or fear that can promote relaxation and comfort.• Reduces muscle tension, promotes relaxation, and may enhance coping abilities.Requiring prompt Medical intervention.• Relieves pain, Enhances comfort and promotes rest.

INDEPENDENT¨ Assess pain, notinglocation, characteristics, intensity (0-10 scale). ¨ Encourage patient to verbalize concerns. Active listen these concerns and provide support by acceptance, remaining with patient and giving appropriate information. ¨ Provide comfort measure like back rub or deep breathing exercises.

After 8 hours of nursing interventions, the patient will verbalize relief or control of pain.

Acute pain

after 8 hours of nursing interventions the patient was able verbalize understanding of therapeutic needs .

provides knowledge base on which patient can make informed choices. * promotes independence in care and reduces risk of complication. * during initial 6 mounths after surgery, low fat diet limits need for bile and reduces discomfort assosiated with inadequate digestion of fat. * minimizes the risk of pancreatic involvement.* intestines require time to adjust to stimulus of

independent:- * review disease process, surgical procedure or prognosis. * demonstrate care of incisions or dressing or drains. * emphasize importance low fat diet, eating small frequent meals,gradual reintroduction of foods or fluids containing fats over 4 to 6 mounth period. * discuss avoiding or limiting use of alcoholic beverages. * inform patient that loose stools may occur for several mounths. * identify signs and

after 8 hours of interventions the patient will verbalize understanding oh therapeutic needs.

knowledge deficient regarding condition and self care related to information misinterpretation

continuous output of bile. * indicators of obstruction of bile flow or altered digestion, requiring further evaluation and intervention. * resumption of usual activities is normally accomplished within 4-5 weeks.

symptoms requiring notification of healthcare provider like dark urine , jaundiced color of eyes or skin, clay colored stools. * review activity limitations depending on individual situation.

relaxed and report anxiety is reduced to a manageable level * showing problem- solving skills * demonstrate healthy ways to deal with and express anxiety.

assess level of anxiety * assisst client ti identify anxiety and begin to deal with problems .

after 6 hour of nursing intervention the patient will: showing problem -solving skills * demonstrate healthy ways to deal with and express anxiety* appear relaxed and the level of anxiety is reduced to manageable level.

Anxiety

Feeding Tubes:

The patient eat orally, not applied any feeding tubes.

Dates:

Date admission: 5/12/2015, Time- 09:48.

Date of operation: 7/12/2015, Time- 12:48.

Date of discharge: 9/12/2015.