Pamantasan ng Lungsod Pasig COLLEGE OF NURSING

Case Study on

Obstructive Jaundice secondary to Cholelithiasis

Submitted By Princess Celmea S. Aspuria Group A BSN III-Nightingale

Submitted To Mr. David Allan Alcantara, RN

August 2011

Chapter I

INTRODUCTIONObstructive jaundice is caused by a blockage of the bile ducts, which prevents the bile from flowing out of the liver. Obstructive jaundice can also occur if the bile ducts are missing or have been destroyed. As a result, bile cannot pass out of the liver, and bilirubin is forced back into the blood. The manifesting features and clinical signs and symptoms of obstructive jaundice are: yellow discoloration of the skin and the mucous membranes; stools are pasty and whitish; urine becomes dark yellow-brown; nausea; vomiting; pruritus or itching of the skin; fever; pain in the abdomen; loss of appetite; fatigue; confusion; headache. Obstructive jaundice frequently requires a surgical cure. If the original passageways cannot be restored, surgeons have several ways to create alternate routes. A popular technique is to sew an open piece of intestine over a bare patch of liver. Tiny bile ducts in that part of the liver will begin to discharge their bile into the intestine, and pressure from the obstructed ducts elsewhere will find release in that direction. As the flow increases, the ducts grow to accommodate it. Soon all the bile is redirected through the open pathways. Approximately 10 to 15 percent of the people with gallstones have them in the common bile duct. More elderly people have gallstones in the common bile duct, for it is estimated that 25 percent of them have stones in this duct. Most gallstones are formed within the gallbladder, but many leave the gallbladder and migrate to the common bile duct. From there, the stones may continue on to the small intestines or stay in the common bile duct and obstruct the bile flow

Chapter II

PURPOSE AND OBJECTIVE OF THE STUDYGeneral Objective This study focuses on obstructive jaundice, the causative factors of obstructive jaundice and its diseases process, as well as the different medical and nursing management for obstructive jaundice. Specific Objectives Identify factors that caused obstructive jaundice Discuss the disease process of obstructive jaundice and the roots of the signs and symptoms of the disease Discuss briefly the patients health history and identify what caused the disease Discuss the anatomy and physiology of the gallbladder and liver, as well as related organs to the disease Discuss the medical and surgical management for obstructive jaundice Provide a theoretical framework for the study Provide a nursing care plan for the prioritized patient problem/diagnosis

Chapter III

SIGNIFICANCE OF THE STUDYTo the client and family or significant others This study will inform the client as well as his family about his current condition, the causes of his disease and how they could manage his condition. To the health care providers and the nursing practice and nursing education This study will help expound case studies on obstructive jaundice secondary to Cholelithiasis. To the future researchers This study would serve as a reference on the case study of obstructive jaundice secondary to Cholelithiasis.

Chapter IV

PATIENTS PROFILEBiographic DataName: Patient X Address: Pinagbuhatan, Pasig City Age: 45 years old Gender: Male Marital Status: Single Occupation: City Government Employee, BCEO Religious Orientation: Roman Catholic Health Care Financing and Usual Source of Medical Care: Philhealth Chief Complaint: Abdominal pain accompanied by cough, after a day, the abdominal pain started radiating towards the back. The patient went to the emergency room and was given antacids by Dr. Uclaray. After 3 days the started having dyspnea, he went back to the emergency room and was then admitted to the Male Surgery Ward

Nursing Health HistoryA. History of Present Illness Symptoms started one (1) year ago Problem occurred when patient started to drink alcohol often (about at least thrice a week) Patient sought consultation at the hospitals emergency room Doctor gave pain relievers and buscopan

The problem made a huge impact on the patients life. He has to stop from work.

A. Past History Patient had a history of measles during childhood Patient had completed childhood immunizations from the local health center No known allergies No past accidents or injuries Chronic health condition: anemic A. Family History of Illness No family member had an illness similar to the patient Patients mother is also anemic Siblings, and patients father are hypertensive Pain Assessment Patient experienced pain/discomfort for 1 year Patient rated pain with a scale of 10/10 Pain was described as stabbing, radiating from abdominal area towards the back Pain is felt with ascending intensity Patient could not identify what alleviates or aggravates the pain Patient managed pain by seeking help to the emergency room

Gordons Functional Health PatternA. Health Perception and Health Management Pattern Patient had been living having vices Patient seldom had coughs and colds in the past Patient takes vitamins to keep self healthy Substance abuse of tobacco and alcohol: Started at age 25 and consumes 2 packs of cigarettes a day and takes alcohol for about once to thrice a week Patient finds difficulty in following what doctors/nurses suggest in the past Patient perceives that alcoholic drinks and eating much fatty foods caused the disease B. Nutrition and Metabolic Pattern Patient eats five (5) times a day, usually rice

Patient drinks water of approximately two (2) liters per day Patient had a weight loss from 85 kilos to 61 kilos upon admission No change in appetite noted Patient is prescribed with soft diet

C. Elimination Pattern Patients bowel was described as yellowish then turned to gray, with acid-like bubbles; patient defecates every day Urine was described as amber-colored to reddish with a frequency of six (6) times a day, usually at night Excessive perspiration noted D. Activity-Exercise Pattern Patient stated sufficient energy for completing required activities prior admission Patient considers his work as his daily exercise E. Sleep-Rest Pattern Patient sleeps at approximately 6 hours per night Patient experiences dyspnea when sleeping Sleep is intermittent and the client feels tired after waking up Patient take naps during noon time Patient relaxes himself by watching TV, having a conversation with others, smoking, and drinking alcohol F. Cognitive Perceptual Pattern Patient had no previous eye checkups; Patient states he is farsighted Patient verbalizes observation of memory loss Patient had no difficulty on learning G. Self-Perception and Self-Concept Pattern Patients states that he feels good about himself and someone who will start a new lifestyle upon discharge Patient observes weight loss Waiting makes the patient angry Anxiety and depression, caused by the presence of Jackson Pratt and T-Tube to be placed for six weeks H. Role-Relationship Pattern Patient lives with mother, significant other, children, and helper Family is having financial problems

Patient and significant other are both working for the family The family talks things over in handling problems Mother is the patients support system in times of stress The clients illness have caused depression to the family Patient belongs to social groups and has close friends Things go well with the patient at work, however, income is not sufficient for needs Patient is in good terms with his neighbors Neighborhood and community services are available in meeting the clients needs

I. Sexuality-Reproductive Pattern No known changes or problems in sexual relations since illness started Significant other uses contraceptives J. Coping-Stress Tolerance Pattern When the patient is tense, he sometimes drinks alcohol to help him sleep Major stressors are when the patient is handling students at work Mother is most helpful in talking things over No known big changes for the past two years, just the current illness of the patient K. Value-Belief Pattern Religion is important in the patients life Praying helps the patient when difficulties arise Being in the hospital does not interfere with the patients religious practices

Physical AssessmentA. Vital Signs and Anthropometric Measurements Temperature: 36C axilla Pulse Rate: 84 beats per minute regular Respiratory Rate: 20 cycles per minute regular BP: 140/100mmHg lying

B. General Survey Patient is conscious and coherent. Oriented with no signs of distress. Patients body development is mesomorphic, well developed and looks according to age. Patient is well nourished. In a calm emotional state

C. Skin Skin shows jaundice, smooth texture with good skin turgor. Skin is cool to touch and wet/clammy. Presence of T-tube and JP drain are present in the right upper quadrant part of the abdomen D. Head Normocephalic configuration. Fontanelles closed. Fine and evenly distributed hair. Clean scalp E. Eyes Eyelids symmetrical. Pale conjunctiva. Icteric sclera. Smooth cornea and lens. Equal pupil size. Fixed reaction to light on both eyes. Uniform constriction and uniform convergence. Patient is farsighted F. Ears Normoset ears. Symmetrical gross hearing G. Nose Symmetrical nasolabial fold. Midline septum. Pale mucosa and negative discharge. Symmetrical gross smelling. Non-tender sinuses H. Mouth Negative deviation on lips. Tongue midline with white spots present. Patient is using dentures. Pale gums and mucosa. Negative lesions. Speech is intact I. Pharynx Uvula midline. Pinkish mucosa. Tonsils not inflamed J. Neck Midline trachea. Nonpalpable cervical lymph nodes and thyroids. Normal ROM K. Chest and Lungs Eupneic breathing. Patient is barrel chested with APL ratio of 1:1. Chest expansion and tactile fremitus symmetrical. L. Heart Point of maximal impulse found at 5th intercostals space, left midclavicular line. Faint heart sounds

M. Breast and Axilla Symmetrical. Non-tender N. Abdomen Presence of T-tube and Jackson-Pratt drainage at right upper quadrant. Sunken umbilicus. Globular configuration. Normoactive bowel sounds (14 per minute). Negative bruit O. Genito-Urinary System Refused P. Back and Extremities Regular peripheral pulses. Pale nail beds. Full ROM of joints. Equal size and normal tone of muscles. Spine midline. Negative costovertebral angle tenderness

Chapter V

ANATOMY AND PHYSIOLOGYThe hepatobiliary system refers to the liver, gall bladder and bile ducts organs that are involved with the production, storage, transport and release of bile, a secretion that prepared fats for further digestion.

Liver The liver is the largest glandular organ of the body. It weighs about 3 lb (1.36 kg). It is reddish brown in color and is divided into four lobes of unequal size and shape. The liver lies on the right side of the abdominal cavity beneath the diaphragm. Blood is carried to the liver via two large vessels called the hepatic artery and the portal vein. The hepatic artery carries oxygen-rich blood from the aorta (a major vessel in the heart). The portal vein carries blood containing digested food from the small intestine. These blood vessels subdivide in the liver repeatedly, terminating in very small capillaries. Each capillary leads to a lobule. Liver tissue is composed of thousands of lobules, and each lobule is made up of hepatic cells, the basic metabolic cells of the liver. Gallbladder The gallbladder is a small pear-shaped organ that stores and concentrates bile. The gallbladder is connected to the liver by the hepatic duct. It is approximately 3 to 4 inches (7.6 to 10.2 cm) long and about 1 inch (2.5 cm) wide.

The function of the gallbladder is to store bile and concentrate. Bile is a digestive liquid continually secreted by the liver. The bile emulsifies fats and neutralizes acids in partly digested food. A muscular valve in the common bile duct opens, and the bile flows from the gallbladder into the cystic duct, along the common bile duct, and into the duodenum (part of the small intestine). Bile Ducts The common bile duct (ductus choledochus) is a tube-like anatomic structure in the human gastrointestinal tract. It is formed by the union of the common hepatic duct and the cystic duct (from the gall bladder). It is later joined by the pancreatic duct to form the ampulla of Vater. There, the two ducts are surrounded by the muscular sphincter of Oddi. When the sphincter of Oddi is closed, newly synthesized bile from the liver is forced into storage in the gall bladder. When open, the stored and concentrated bile exits into the duodenum. This conduction of bile is the main function of the common bile duct. The hormone cholecystokinin, when stimulated by a fatty meal, promotes bile secretion by increased production of hepatic bile, contraction of the gall bladder, and relaxation of the Sphincter of Oddi. Several problems can arise within the common bile duct. If clogged by a gallstone, a condition called choledocholithiasis can result. In this clogged state, the duct is especially vulnerable to an infection called ascending cholangitis. Very rare deformities of the common bile duct are cystic dilations (4 cm), choledochoceles (cystic dilation of the ampulla of Vater (38 cm)), and biliary atresia. Bile Production Bile is produced by hepatocytes, draining through the many bile ducts that penetrate the liver. During this process, the epithelial cells add a watery solution that is rich in bicarbonates that dilutes and increases alkalinity of the solution. Bile then flows into the common hepatic duct, which joins with the cystic duct from the gallbladder to form the common bile duct. The common bile duct in turn joins with the pancreatic duct to empty into the duodenum. If the sphincter of Oddi is closed, bile is prevented from draining into the intestine and instead flows into the gallbladder, where it is stored and concentrated to up to five times its original potency between meals. This concentration occurs through the absorption of water and small electrolytes, while retaining all the original organic molecules. Cholesterol is also released with the bile, dissolved in the acids and fats found in the concentrated solution. When food is released by the stomach into the duodenum in

the form of chyme, the duodenum releases cholecystokinin, which causes the gallbladder to release the concentrated bile to complete digestion. The human liver can produce close to one liter of bile per day (depending on body size). About 95% of the salts secreted in bile are reabsorbed in the terminal ileum and re-used. Blood from the ileum flows directly to the hepatic portal vein and returns to the liver where the hepatocytes reabsorb the salts and return them to the bile ducts to be re-used, sometimes two to three times with each meal. Pancreas The pancreas lies beneath the stomach and is connected to the small intestine at the duodenum. The pancreas contains enzyme producing cells that secrete two hormones. The two hormones are insulin and glucagon. Insulin and glucagon are secreted directly into the bloodstream, and together, they regulate the level of glucose in the blood. The pancreas produces the body's most important enzymes. The enzymes are designed to digest foods and break down starches. The pancreas also helps neutralize chyme and helps break down proteins, fats and starch. Chyme is a thick semi fluid mass of partly digested food that is passed from the stomach to the duodenum. If the pancreas is not working properly to neutralize chyme and break down proteins, fats and starch, starvation may occur.

Chapter VI

PATHOPHYSIOLOGY

Chapter VII

LABORATORIES AND DIAGNOSTIC TEST

Chest X-Ray (Radiography) The chest x-ray is the most commonly performed diagnostic x-ray examination. A chest x-ray makes images of the heart, lungs, airways, blood vessels and the bones of the spine and chest. An x-ray (radiograph) is a noninvasive medical test that helps physicians diagnose and treat medical conditions. Imaging with x-rays involves exposing a part of the body to a small dose of ionizing radiation to produce pictures of the inside of the body. X-rays are the oldest and most frequently used form of medical imaging. The chest x-ray is performed to evaluate the lungs, heart and chest wall. A chest x-ray is typically the first imaging test used to help diagnose symptoms such as: shortness of breath; a bad or persistent cough; chest pain or injury; fever.

X-RAY RESULTS Chest: Chest PA/AP (Adult) Both lung fields are clear Heart and great vessels are normal size and configuration Other chest structures are unremarkable IMPRESSION: NORMAL CHEST ABDOMEN: Examination show no abnormal finding in the visceral and retroperitoneal soft tissues and bony thorax No abnormal mass nor calcification seen Intestinal gas pattern are within normal No other significant finding IMPRESSION: NORMAL ABDOMEN

Ultrasound Ultrasound uses high-frequency sound waves to look at organs and structures inside the body. Health care professionals use them to view the heart, blood vessels, kidneys, liver and other organs. During pregnancy, doctors use ultrasound tests to examine the fetus. Unlike x-rays, ultrasound does not involve exposure to radiation.

ULTRASOUND RESULTS Ultrasound Proc: HBT/Pancreas The liver is normal in size with increase parenchymal echogenicity. No discrete mass or abnormal calcification. The portal vein and its tributaries are unremarkable The gallbladder is normal in size and echo. A strong echo with distal acoustic shadowing is noted with the gallbladder. It measured 1.34 x 1.14 x 0.89 cm. The wall is of normal thickness. The common bile duct and biliary passages are of normal character with anechoic lumen. The pancreas is of normal size and echo. No discrete mass or calcification is noted. Peripancreatic are unremarkable. IMPRESSION: FATTY LIVER, CHOLECYCTOLITHIASIS, NORMAL PANCREAS Hemoglobin and Hematocrit Hematocrit and hemoglobin measurements are blood tests. They are part of a complete blood count, or CBC. SECTION OF HEMATOLOGY August 10, 2010 Result 131.0 0.42 Normal Value 135.00-180.00 g/L 0.40 0.54 g/L

Hemoglobin: Hematocrit

SECTION OF HEMATOLOGY August 13, 2010 Result 98.0 0.30 Normal Value 135.00-180.00 g/L 0.40 0.54 g/L

Hemoglobin: Hematocrit

Blood Typing SECTION OF HEMATOLOGY ABO Typing: O Rh Typing: Positive

Urea, Sodium, Potassium, AST, ALT, ALK AST (Serum Glutamic-Oxalocetic Transaminase - SGOT) - found primarily in the liver, heart, kidney, pancreas, and muscles. Seen in tissue damage, especially heart and liver. ALT (Serum Glutamic-Pyruvic Transaminase - SGPT) - Decreased SGPT in combination with increased cholesterol levels is seen in cases of a congested liver. We also see increased levels in mononucleosis, alcoholism, liver damage, kidney infection, chemical pollutants or myocardial infarction ALKALINE PHOSPHATASE - Used extensively as a tumor marker it is also present in bone injury, pregnancy, or skeletal growth (elevated readings. Low levels are sometimes found in hypoadrenia, protein deficiency, malnutrition and a number of vitamin deficiencies

Urea Sodium Potassium AST ALT ALK

LO LO LO HI HI HI

Chapter VIII

THEORETICAL FRAMEWORKDorothea Orems Self Care Deficit Theory is most applicable for the patient which is on his post operative state due to obstructive jaundice. The patient is unable to move independently due to the presence of t-tube and Jackson-Pratt drainage attached to his abdomen. The self care deficit theory proposed by Orem is a combination of three theories, i.e. theory of self care, theory of self care deficit and the theory of nursing systems. In the theory of self care, she explains self care as the activities carried out by the individual to maintain their own health. The self care agency is the acquired ability to perform the self care and this will be affected by the basic conditioning factors such as age, gender, health care system, family system etc. Therapeutic self-care demand is the totality of the self care measures required. The self care is carried out to fulfill the self-care requisites. There are mainly 3 types of self care requisites such as universal, developmental and health deviation self care requisites. Whenever there is an inadequacy of any of these self care requisite, the person will be in need of self care or will have a deficit in self care. The deficit is identified by the nurse through the thorough assessment of the patient. Once the need is identified, the nurse has to select required nursing systems to provide care: wholly compensatory, partly compensatory or supportive and educative system. The care will be provided according to the degree of deficit the patient is presenting with. Once the care is provided, the nursing activities and the use of the nursing systems are to be evaluated to get an idea about whether the mutually planned goals are met or not. Thus the theory could be successfully applied into the nursing practice.

Chapter IX

MEDICAL-SURGICAL MANAGEMENTSurgeryOpen Cholecystectomy This operation has been employed for over 100 years and is a safe and effective method for treating symptomatic gallstones, ones that are causing significant symptoms. At surgery, direct visualization and palpation of the gallbladder, bile duct, cystic duct, and blood vessels allow safe and accurate dissection and removal of the gallbladder. Intra-operative cholangiographyhas been variably used as an adjunct to this operation. The rate of common bile duct exploration for choledocholithiasis (gallstones in the bile duct) varies from 3% in series of patients having elective operations to 21% in series that include all patients. Major complications of open cholecystectomy are infrequent and include common duct injury, bleeding, biloma, and infections. Open cholecystectomy is the standard against which other treatments must be compared and remains a safe surgical alternative. T-Tube Insertion During liver-transplant surgery, the surgeon may find it necessary to place a small tube, called a T-tube, into the bile duct. The T-tube allows bile to drain out of the patient's body into a small pouch, known as a bile bag. The amount of bile, which varies in color from deep gold to dark green, can then be measured. If a Ttube is put in place, it may remain attached to a bile bag for a week or possibly longer. When the bile bag is removed the T-tube will be tied or capped. It will remain in place for several months so that it can be used for special testing. The T-tube is attached to the skin with a stitch. The dressing around the tube should be changed at least once daily, and more often if it becomes moist. The transplant nurse will show the patient how to change the dressing without pulling out the T-tube. Other drains may be in the patient's abdomen during the postoperative period. A common name for these drains is Jackson-Pratt (JP). They are used to drain fluid from around the liver. Generally, these drains are removed before the patient goes home.

Drug StudyDrug Classificat ion/ IndicationAntacids, Antireflux Agents & Antiulcerant s/

Dose, Route & Frequen cy50mg OD while on NPO then discontinu e once on DAT

Mechanism of Action

Contrain dication

Side Effects/ Adverse EffectsDiarrhea, nausea, fatigue, constipation, vomiting, flatulence, acid regurgitation, taste perversion, arthralgia, myalgia, urticaria, dry mouth, dizziness, headache, paraesthesia, abdominal pain, skin rashes, weakness, back pain, upper respiratory infection, cough. Potentially

Drug Interaction

Nursing Responsibilit iesGive meals before

Omeprazole

Omeprazole suppresses gastric acid secretion by specific inhibition of the enzyme system hydrogen/potassium adenosine triphosphatase (H+/K+ ATPase) present on the secretory surface of the gastric parietal cell. Onset: Antisecretor y: approx 1 hr; peak effect:0.5-3.5 hr. Duration: 72 hr. Absorption: Rapid but variable (oral); dose-dependent. Bioavailability: Oral: approx 30-40%. Distribution: Protei n-binding: 95%. Metabolism: Exten sively hepatic; converted to

Omeprazol e is contraindic ated in patients hypersensi tive to it. Omeprazol e should be used when the benefits outweigh the risks in patients with hepatic disease or a history of hepatic disease, as the drugs half life may be prolonged and dosage

Decreases absorption of itraconazole, ketocon azole, dasatinib, oral iron salts. Decreases levels of nelfinavir. Increases levels of benzodiazepines (e.g. diazepam, midazol am, triazolam), HMGCoA reductase inhibitor, CYP2C19 substrates (e.g. citalopram, diazepam, methsuximide, phenytoi n, propranolol, and sertraline), and CYP2C9 substrates (e.g. bosentan, dapsone, fluoxetine, glimepiride, glipizide, losartan, montelukast, nateglinide, paclitaxel, phenytoin, warfarin, and zafirlukast). Decreased levels/effects with CYP2C19 inducers (e.g. aminoglutethimide, carb

Do not crush or chew tablets, swallow whole Evaluate for therapeutic response like relief of Gastrointestinal symptoms Question if Gastrointestinal discomfort, nausea, and diarrhea occurs.

hydroxyomeprazole and omeprazole sulfone. Excretion: Via urine (77%) and bile. Elimination half-life: 0.5-3 hr.

adjustment may be necessary.

Fatal: Anaph ylaxis.

amazepine, phenytoin, and rifampin). Decreases excretion of methotrexate. Enhances the adverse/toxic effect of cilostazol. May alter the concentrations/effects of clozapine. Avoid concurrent use with clopidogrel.

Drug

Classifica tion/ Indicatio nLevofloxaci n ; Belongs to the class of fluoroquinol ones. / Used in the systemic treatment of infections.

Dose, Route & Freque ncy750mg TIV OD

Mechanism of Action

Contrai ndicatio nHypersens itivity to levofloxac in or other quinolone s. Child