Introduction/ObjectivesOne of the common gallbladder diseases is calculous cholecystitis. Calculous cholecystitis is the cause of more than 90% of cases of acute cholecystitis. Cholecystitis is inflammation of thegallbladder, a small organ near theliverthat plays a part in digesting food In the Philippines, an extrapolated prevalence of 5, 073, 040 people are affected by the disease. Gallstones that do not cause symptoms do not require treatment. However, if gallstones cause, disruptive, recurring episodes of pain, surgical removal of the gallbladder is recommended.I chose this case because that through this case study, I will be more knowledgeable and aware about such gallbladder disorder and the surgical procedure done for the said disease. I am also interested to know the proper and necessary nursing management that will be given to a patient affected by the disease

Patients ProfileName: Patient D.F.VSex: FemaleAge: 26 y/oBirthdate: May 19, 1987Address: Elias St. Sta. Cruz ManilaReligion: Roman CatholicNationality: FilipinoChief Complaint: Right Upper Quadrant PainDiagnosis: Acute Calculous Cholecystitis

History of Present Illness:3 weeks prior to consultation, patient began to experience intermittent right upper quadrant pain associated with anorexia. No fever, jaundice, nausea, vomiting and change in bowel movement noted and did not seek any medical attention. She just took over the counter drugs such as buscopan which according to her gave her temporary relief.1 week prior to consultation, persistence of intermittent right upper quadrant pain and sought consult to another institution. They prescribed her with omeprazole which according to her gave her no relief at all. She waited for few more days before having another consultation. 1 day prior to consultation, she experienced worsening of pain and opted to seek consult to our institution. She also reported episodes of clay colored stool few days before she seek the consultation.Past medical History:The patient has a history of acute appendicitis and has undergone appendectomy at Novaliches General Hospital last 2004.

Family/Personal history:The patient is a non-smoker and consumes moderate alcohol. She eats little amount of vegetables and fruits and mostly consumes meat on her meal. She does little exercise but spends most of the time doing household chores. She is a plain housewife and lives with her common law husband and her 2 children. The diseases that her family has is diabetes mellitus and gallstones on the maternal side and has no history on the paternal side.

Physical AssessmentName: Patient D.F.VAge: 26 years oldSex: FemaleDepartment: ER-SurgeryDiagnosis: Acute Calculous CholecystitisChief Complaint: Right Upper Quadrant pain

1. General SurveyThe patient is awake and responsive, not in any respiratory distress, ambulatory but with fair activity.1. Vital SignsTechniques: Inspection, Palpation, AuscultationPatient has temperature of 37.3C, axillary with cardiac rate of 110 beats per minute, regular respiratory rate of 23 breaths per minute, and blood pressure of 130/80 mmHg. PARTTECHNIQUENORMAL FINDINGSACTUAL FINDINGSINTERPRETATION

SkinInspection and Palpation1. Color varies from light to deep brown

1. No edema

1. Skin temperature is uniform within normal range

1. Light to deep brown

1. No edema noted

1. Skin temperature is uniform with axillary temperature of 37.C1. Normal

1. Normal

1. Normal

HeadInspection and Palpation1. Configuration is normocephalic1. No lesions or tenderness

1. Anterior and posterior fontanels are flat and closed1. Head is normocephalic in shape1. Absence of lesions and no signs of tenderness

1. Anterior and posterior fontanels appear to be flat and closed1. Normal

1. Normal

1. Normal

HairInspection1. Evenly distributed, thick hair, silky, resilient, no infestation1. Hair is thick, smooth, moist, and with no signs of parasitic infestation1. Normal

Eyes:Sclera

Cornea

Pupils

Eye BallsInspection

Inspection

Inspection

Inspection1. Appears white

1. Transparent, shiny, smooth with corneal details visible

1. Black/brown in color; constricts when illuminated and when looking at near objects; dilates when looking at far objects1. Symmetrically aligned

1. Eyeballs are symmetrical in size1. Not protruding1. Appears white

1. Transparent, shiny, smooth; details apparent

1. Black in color; briskly constricts when illuminated and dilates when not illuminated

1. Aligned

1. Eyeballs are symmetrical in shape and size1. There is no protrusion 1. Normal

1. Normal

1. Normal

1. Normal

Palpebral and Bulbar ConjuctivaInspection1. Smooth, pink or red1. Smooth, pink or red1. Normal

EarsInspectonand Palpation1. Auricles fair in color1. Symmetrical and aligned with outer canthus of eyes1. Auricles are flexible, firm, no tenderness1. Absence of purulent discharge in the external canal1. Patient responds to sound1. Auricles are fair in color, symmetrical in shape, flexible with no tenderness1. There is no discharge from the ear canal1. Responds to the voice of mother and father1. Normal

1. Normal

1. Normal

NoseInspection and Palpation1. Nares are patent1. Septum on the midline1. Mucosa is pinkish in color 1. Patent nares with septum on the midline1. Mucosa is pinkish1. Normal

1. Normal

MouthInspection and Palpation1. Lips are moist and pinkish in color1. Oral mucosa is pinkish with no ulcerations1. Lips are pink in color

1. Oral mucosa is pinkish with no ulcerations e1. No ulcerations in oral mucosa1. Normal

1. Normal

1. Normal

NeckInspection and Palpation1. Neck is symmetrical1. Thyroid glands are not tender and enlarged

1. Neck muscles are equal in size1. Trachea is positioned midline upon palpation1. Neck is symmetrical 1. Thyroid glands are not tender and enlarged

1. Neck muscles are equal in size1. Trachea is positioned midline1. Normal1. Normal

1. Normal

ChestInspection, Palpation, Auscultation1. Full and symmetric and not bulging

1. Breathing is abdominal and posterior mobility and posture of thorax is symmetrical upon respiration

1. Clear breath sounds1. Chest is not bulging and appears symmetrical

1. Abdominal breathing is present (pediatric) with thoracic movement symmetrical

1. No presence of harsh breath sounds; patient was crying and irritable during assessment1. Normal

1. Normal

1. Normal

HeartAuscultation1. S1 usually heard at all sites but louder at apical area1. S2 usually heard at all sites but louder at base of the heart1. S1 and S2 are heard audibly on apical and base areas of the heart1. No murmur or gallops (S3 and S4)1. Normal

BreastInspection1. Symmetrical in size and shape1. Areola is round or oval and color is light pink to dark brown1. Nipples are round, and equal in size1. Symmetrical in size and shape1. Areola is small and brown in color

1. Nipples are round and almost in size1. Normal

1. Normal

1. Normal

Finger and Toe NailsInspection and Palpation1. Vascular and pinkish in color1. Smooth texture1. Intact epidermis1. Capillary refill in 3-5 seconds1. Vascular and pinkish in color1. Smooth texture1. Capillary refill of 3 seconds1. Normal

1. Normal1. Normal

AbdomenInspection, Auscultation, Palpation1. Unblemished skin, uniform in color

1. No tenderness upon palpation

1. no evidence of liver enlargement1. Audible bowel sounds

1. Presence of Scar at right lower quadrant

1. Tenderness noted upon palpation at the right upper to epigastric portion of the abdomen

1. no evidence of liver enlargement1. Audible bowel sounds at 12 per minute; abdomen produces a growling sound

1. The scar noted is a post surgical scar because the patient has undergone appendectomy in the past.1. This is due to the inflammation of the gallbladder which is located at the right upper quadrant of our abdomen1. Normal

1. Normal

MusclesInspection, Palpation1. Equal size on both sides of the body; no contractures1. Good muscle tone, firm with smooth coordinated movements1. Symmetrical in size on both sides of the body

1. Good muscle tone with no signs of uncoordinated motor movement1. Normal

1. Normal

Laboratory ProceduresSerum Creatinine, Total, Sodium, PotassiumTestResultUnitNormal ValueAnalysis and interpretation

Creatinine47.30Mmol/L45-104The result is within the normal range.

Na+136.90Mmol/L135-143The result is within the normal range

K+4.49Mmo/L3.4-4.82The result is within the normal range

Complete blood countTestResultUnitNormal ValueAnalysis and interpretation

Hemoglobin137g/L123-153The result is within the normal range

Hematocrit0.430.359-0.446The result is within the normal range

RBC4.5210^12/L4.1-5.1The result is within the normal range

MCV94fL82-98The result is within the normal range

MCH30.35Pg28-33The result is within the normal range

MCHC32.34g/L33-36The result is within the normal range

WBC10.910^9/L4.8-10.8The result is slightly elevated. A high white blood cell count, calledleukocytosis, may result from a number of conditions and diseases such as infections and inflammatory conditions.

DIFFERENTIAL COUNT

Neutrophils0.690.40-0.70The result is within the normal range

Lymphocytes0.220.19-0.48The result is within the normal range

Basophils0.000.00-0.05The result is within the normal range

Monocytes0.070.00-0.15The result is within the normal range

Eosinophils0.020.02-0.08The result is within the normal range

Platelet Count49010^9/L150-400A high platelet count may be referred to as thrombocytosis. This is usually the result of an existing condition such as inflammatory conditions.

MPV7.807.80The result is within the normal range

RDW12.20%11.4-14.0The result is within the normal range

Sonographic ReportGallbladder:Gallbladder is enlarged, with an approximate measurement of 12.9 x 4.1 cm. Its wall is slightly thickened, measuring around 0.44 cm. There are 2 intraluminal hyperchoic foci, at the gallbladder neck, with strong posterior acoustic shadowing approximately measuring 2.3 x 0.6 cm and 0.6 x 0.5 cm.Impression: Hydrops of the gallbladder with cholecystolithiases and signs of cholecystitis

Modifiable factors-Obesity-Rapid weight loss and diet-Lack of physical activityNon modifiable factors-Gender/sex (female)-Genetic predisposition-EthnicityGallbladder contracts after intake of fat to release bileGallstonesCrystals clump together and form stonesPigment solute precipitate as solid crystalsBile stagnates in the gallbladderPATHOPHYSIOLOGYLumen is obstructed by stonesCHOLELITHIASISBile stasisUpon contraction, a stone is moved and becomes impacted on the cystic duct

Edema Fluids leak into gallbladderInflammation of the gallbladderChemical reaction inside gallbladder triggers the release of inflammatory enzymes(Prostaglandins)Right Upper Quadrant PainIncreased intraluminal pressure and distention of the gallbladder

Drug NameClassificationIndicationsMechanism of ActionAdverse ReactionsContraindicationsNursing Considerations

Metronidazole 500m IVantiinfective; antitrichomonal; amebicide; antibioticAmebic liver abscess

Intestinal amebiasis

Trichomoniasis

Refractory Trichomoniasis

Bacterial infections caused by anaerobic microorganisms To prevent post operative infection in contaminated or potentially contaminated colorectal surgeryDirect acting trichomonacide and amebicide that works inside and outside the intestines. Its thought to enter the cells of microorganisms that contain nitroreductase, forming unstable compounds that bind to DNA and inhibit synthesis, causing cell deathCNS: Headache,seizures, fever, vertigo, syncope, dizziness, insomnia

CV: edema,flushing thrombophlebitis after IV infusion

GI: nausea, abdominal cramping or pain, stomatitis, epigastric distress, vomiting, metallic taste

Contraindicated in patients hypersensitive to the drug and other nitroimidazole derivatives and in patients in first trimester of pregnancy

Use cautiously in patients with history of blood dyscrasia, CNS disorder or retinal or visual field changesMonitor liver function test results carefully in elderly patients

Observe patient for edema,especially if hes receiving corticosteroids. Flagyl IV RTU may cause sodium retention.

Drug NameClassificationIndicationsMechanism of ActionAdverse ReactionsContraindicationsNursing Considerations

Ciprofloxacin 200mg IVInhibition oftopoisomerase(DNA gyrase)enzymes, which inhibits relaxation ofsuper coiled DNA andpromotesbreakage ofdouble stranded DNAComplicated intra abdominal infectionInhibit s bacterial DNA synthesis,mainly by blocking DNA gyrase, bactericidalCNS: seizures, confusion, depression, drowsiness, fatigue, hallucinations, headache, insomnia

CV: edma, thrombophlebitis

GI: pseudomembranosous colitis, diarrhea, nausea, abdominal pain or discomfort, constipation

Contraindicated to patients hypersensitive to fluoroquinolonesMonitor patients intake and output and observe patient for signs of crystalluria

Long term therapy may result in overgrowth of organisms resistant to drug

`Drug NameClassificationIndicationsMechanism of ActionAdverse ReactionsContraindicationsNursing Considerations

Ketorolac 30 mg IVnon steroidal anti inflammatory drugsShort term management of moderately severe, acute pain for single dose treatment

Short term management of moderately severe, acute pain for multiple dose treatmentMay inhibit prostaglandin synthesis to produce anti inflammatory , analgesic and anti pyretic effectsCNS: dizziness, drowsiness, sedation

CV: arrhythmias, edema, hypertension, palpitations

GI: dyspepsia, nausea, constipation, diarrhea,flatulenceContraindicated in patients hypersensitive to drug and in those with active peptic ulcer disease, recent GI bleeding or perforation, advanced renal impairmentBe aware thatpatient may be at risk for CV events, GI bleeding, renal toxicity, and monitoraccordingly.

Do notuse during labor, delivery, orwhile nursing

Keep emergency equipment readily available at time ofinitial dose, in case of severe hypersensitivity reaction.

AssessmentNURSING CARE PLANNursing DiagnosisInferencePlanningNursing interventionRationaleEvaluation

SUBJECTIVE:1. Masakit ang kanang tagiliran ko as verbalized by the patient.1. Pain starting suddenly and usually peaking in 30 minutes.

OBJECTIVE:1. Facial mask of pain1. Pain Scale of 7/101. Muscle guarding or rigidly when right upper abdomen palpated1. Narrow focus1. Vital Signs:1. T = 37.3 C 1. PR = 1101. RR = 23BP = 130/80

Acute pain related to inflammation and distortion of tissues asCholelithiasisIFurther complicationIInflammation of the GallbladderIAcute painSHORT TERM OBJECTIVE:After an hour of nursing interventions, patients pain will be relieved or controlled as patient demonstrates use of relaxation skills and as indicated for individual situation.

INDEPENDENT:

Observe and document location, severity (1-10 scale) and character of pain (steady, intermittent, colicky)(Get a baseline data of pain scale)

Promote bed rest, allowing patient to assume position of comfort.

DEPENDENT:Administer medications per physicians order:*refer to the Drug study section for the medications given with corresponding indicatons

Assist in differentiating of pain and provides information about disease progression/resolution, development of complications, and effectiveness of interventions

Bed rest in low Fowlers position reduces intraabdominal pressures; however, patient will naturally assume least painful position.

Short term: After 1 hour of nursing intervention, the patients pain has been relieved or controlled as patient demonstrates use of relaxation skills and as indicated for individual situation

Goal met

Jose R. Reyes Memorial Medical Center

Case Study on Acute Calculous Cholecystitis

PREPARED BY: RYAN JOSEPH M. MAGPAYO, RN (NURSE I-RNHEALS)