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OpenCHOLECYSTECTOMY
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Patients ProfileName: Balansag, Nicolas
Age: 46 years old
Sex: Male
Civil Status: MarriedReligion: Roman Catholic
Date of Admission: March 5, 2012
Room No.: 424
Complaints: right upper quadrant pain,general abdominal pain for 1 month
Diagnosis: Acute Calculous Cholecystitis
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Case Abstract
Mr. Balansag is residing at Dona RitaVillage 1C Compound, Muntinlupa
City with her wife and their 2
daughters. Patient is working as amechanic at Don Bosco School.Patient is an occasional alcoholic
drinker, a slight smoker which
consumes around 3 sticks perday.He has no known allergy to food
and drugs. Patient is known to be
hypertensive at the age of 40. His
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Patient complains of general
abdominal pain for 1 month nowand that he hasnt been able tosleep well because of the pain
felt in his right upper quadrant.He seek consult to Dr.
Macadagdag thus advised to be
admitted to Medical Centre ofMuntinlupa.
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Introduction
Cholecystectomy is the surgical removal ofthe gallbladder. Despite the development ofnon-surgical techniques, it is the mostcommon method for treating symptomatic
gallstones, although there are other reasonsfor having this surgery done. Each year morethan 500,000 Americans have gallbladdersurgery. Surgery options include the standardprocedure, called laparoscopiccholecystectomy, and an older moreinvasiveprocedure, called open cholecystectomy. Acholecystectomy is performed whenattempts to treat gallstones with ultrasound
to shatter the stones or medications to
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Gallbladder disease is cured byremoval of the gallbladder in a
procedure referred to as acholecystectomythe most commonsurgical procedure performed on the
biliary tract. A cholecystectomy isperformed to relieve thegastrointestinal distress common inpatients with acute or chroniccholecystitis (with or withoutgallstones); it also removes a sourceof recurrent sepsis. Persistent
infection in the biliary tract may
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Open cholecystectomy is a surgery in whichthe abdomen is opened to permit
cholecystectomy -- removal of the gallbladder.This operation has been employed for over 100years and is a safe and effective method fortreating symptomatic gallstones,ones that arecausing significant symptoms. At surgery,
direct visualization and palpation of thegallbladder, bile duct, cystic duct, and bloodvessels allow safe and accurate dissection andremoval of the gallbladder. Intra-operative
cholangiography has been variably used as anadjunct to this operation. The rate of commonbile duct exploration for choledocholithiasis(gallstones in the bile duct) varies from 3% in
series of patients having elective operations to21% in series that include all atients. Ma or
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Open Cholecystectomy
In open gallbladder surgery(cholecystectomy), the surgeonremoves the gallbladder through a
single, large incision in the abdomen.You will need general anesthesia, andthe surgery lasts 1 to 2 hours. Thesurgeon will make the incision either
under the border of the right rib cage orin the middle of the upper part of theabdomen (between the belly button andthe end of the breastbone).
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Definition of the Disease
Cholelithiasis is a condition in which gallstones,lodge in the neck of the gallbladder or in the
cystic duct, interfering with or totallyobstruction normal bile flow from the
gallbladder to the duodenum. Many factors,some of which aren't well understood,
contribute to the formation of gallstones. Firstis too much cholesterol.Normally, bile contains
enough bile salts and lecithin, a fattycompound to dissolve the cholesterol excretedby your liver. But if bile contains morecholesterol than can be dissolved, thecholesterol may form into crystals and
eventually into stones. Cholesterolin bile has
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If the gallbladder doesn't empty completely oroften enough, bile may become too
concentrated and contribute to the formation
of gallstones. This may occur during pregnancy.No matter what their size, shape or number,
gallstones generally fall into one of twocategories. First is cholesterol gallstones.
These gallstones, often yellow in color, arecomposed mainly of undissolved cholesterol,
although they can also have othercomponents, such as calcium and bilirubin, the
residue from the breakdown of red blood cells.About 80 percent of gallstones are cholesterolstones.Second is pigment gallstones. Thesesmall, dark brown or black stones form whenyour bile contains too much bilirubin. It's not
always clear what causes them. They tend
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Complications
Pain Peritonitis
Pancreatitis
Cholecystitis
Cholangitis
Pancreatitis
Nausea and Vomiting
Cholestasis, extrahepatic
Bile Stricture
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Signs and Symptoms Cholecystitis usually presents as a pain in
the right upper quadrant. This is usually aconstant, severe pain. The pain may befelt to 'refer' to the right flank or rightscapular region at first.
This may also present with the abovementioned pain after eating greasy or
fatty foods such as pastries, pies and friedfoods.
This is usually accompanied by a low
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More severe symptoms such as highfever, shock and jaundice indicate
the development of complicationssuch as abscess formation,perforation or ascending cholangitis.
Another complication, gallstoneileus, occurs if the gallbladderperforates and forms a fistula withthe nearby small bowel, leading to
symptoms of intestinal obstruction.
Chronic cholecystitis manifests withnon-s ecific s m toms such as
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Anatomy of the Main OrganInvolve
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GALL BLADDER
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Functions of GALLBLADDER
v The function of the gallbladder isto store bile and concentrate. Bile is
a digestive liquid continuallysecreted by the liver. The bileemulsifies fats and neutralizes acidsin partly digested food. A muscular
valve in the common bile ductopens, and the bile flows from thegallbladder into the cystic duct,
along the common bile duct, and
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Cholesterol is not very soluble, so in order toremain suspended in fluid it must be transportedwithin clusters of bile salts called micelles. If there
is an imbalance between these bile salts andcholesterol, then the bile fluid turns to sludge.
This thckened fluid consists of a mucus gelcontaining cholesterol and calcium billirubinate
If the imbalance worsens, cholesterol crystal form( a condition called supersaturation), which caneventually form galstones
Supersaturation and cholelithiasis can occur as aresult of various abormalities, although the cause isnot entirely clear. There are many events that maypromote cholelithiasis
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The gallbladder may not be able to emptynormally, so bile becomes stagnant
The cells lining the gallbladder may not be able toefficiently absorb cholesterol and fat from bile
There are high levels of billirubin. Billirubin is asubstance normally absorb cholesterol and fatfrom bile
There are high levels of billirubin. Billirubin is asubstance normally formed by the breakdown ofhemoglobin in the blood. It is removed from thebody in bile. Some experts believe billirubinmayplay an important role in formation of cholesterolgallstones
Pigment stones. Pigment stones are composed ofcalcium billirubinate or calci ied billirubin. Pi ment
Di ti d
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Diagnostic andLaboratory Tests
Ultrasonography-Gallstones are suspected inpatients with biliary colic. Abdominalultrasonography is the method of choice fordetecting gallbladder stones; sensitivity andspecificity are 95%. Ultrasonography alsoaccurately detects sludge.
CT SCAN
MRI (Magnetic Resonance Imaging )
Oral cholecystography
Hepatobiliary Nuclear Scan
Endoscopic ultrasonography accurately detects
small gallstones (< 3 mm) and may be needed if
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IMAGES of GALL STONES
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Diagnostic/ Lab test
Asymptomatic gallstones and biliarysludge are often detected incidentallywhen imaging, usually ultrasonography,is done for other reasons.
About 10 to 15% of gallstones arecalcified and visible on plain x-rays.
Elevated conjugated Bilirubin
Elevated Alkaline Phosphatase
Elevated Serum Amylase
Elevated Lipase
i i b
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Diagnostic/ Lab test
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Pathophysiolo
gy
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Drug Study
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Nursing Care Plan: Ineffective Breathing
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Assessment Nursing Diagnosis Planning Interventions Rationale Evaluation
S:O: The patientmay manifest:>tachypnea
>reluctance tocough>holding breath> DOB
Ineffectivebreathing patternr/t to pain
Short-term:After 1 hour of nursinginterventions, thepatient will
demonstrate improvedbreathing pattern.Long-term:After 4 hours ofnursing interventionthe patient willestablish effectivebreathing pattern
1. administersupplementaloxygen vianasal cannula
as ordered2. administer pain
medications asordered
3. monitor vitalsigns especiallyrespiratory rate
4. encourage/assist with deep-
breathingexercises andpursed-lipbreathing asappropriate
5. check forrestlessnessand changes inmental status
1. Maximizesavailableoxygen,especially
whileventilation isreducedbecause pain
2. to treatunderlyingcause ofrespiratoryproblem
3.
for baselinedata4. promotes
maximalventilationandoxygenation
5. may indicatehypoxia
Short-term:After 1 hour ofnursinginterventions, the
patient shall havedemonstratedimprovedbreathing pattern.Long-term:After 4 hours ofnursinginterventions, thepatient shall have
established aneffectivebreathing pattern
Nursing Care Plan: Ineffective BreathingPattern
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N i C Pl A ti it
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Assessment Nursing Diagnosis Planning Interventions Rationale Evaluation
S: O: The patient
may manifest:>tachypnea>reluctance tocough>holding breath> DOB
Ineffectivebreathing patternr/t to pain
Short-term:After 1 hour of
nursinginterventions, thepatient willdemonstrateimprovedbreathing pattern.
Long-term:
After 4 hours ofnursingintervention thepatient willestablish effectivebreathing pattern
administersupplementaloxygen via nasal
cannula asordered
administer painmedications asordered
monitor vital signsespeciallyrespiratory rateencourage/assistwith deep-
breathingexercises andpursed-lipbreathing asappropriatecheck forrestlessness andchanges in mentalstatus
Maximizesavailable oxygen,especially while
ventilation isreduced becausepainto treatunderlying causeof respiratoryproblem
for baseline data
promotesmaximalventilation andoxygenation
may indicatehypoxia
Short-term:After 1 hour of
nursinginterventions, thepatient shall havedemonstratedimprovedbreathing pattern.Long-term:
After 4 hours ofnursinginterventions, thepatient shall haveestablished aneffectivebreathing pattern
Nursing Care Plan: ActivityIntolerance
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Nursing
Diagnosis
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Acute pain and discomfort related to
surgical incision
Imbalanced nutrition less than bodyrequirements related to inadequate bile
secretionRisk for constipation related to effects
of surgery
Risk for infection related Impaired skin integrity related to
disruption of first line of defense
Activity intolerance
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Nursing
Interventions
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Relieving Pain
The location of the subcostal incision inOpen Cholecystectomy surgery
diseases likely to cause the patient toavoid turning and moving, to splint the
affected site, and to take shallowbreaths to prevent pain. Because full
exacerbation of the lings and gradually
increased activity are necessary toprevent postoperative complications,the nurse should administer analgesic
agents as prescribed to relieve pain and
promote well-being.
Improving respiratory
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Improving respiratorystatus
Patients undergoing biliary tractsurgery are prone to pulmonary
complications, as areall
abdominal incision. Thus, thenurse remind patient to take
deep breaths and coughevery
hour to expand the lungs fullyand prevent atelectasis.
I i N t iti l
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Improving NutritionalStatus
The nurse encourages the patient toeat a diet low in fats and high in
carbohydrates and proteinsespecially after surgery. At the time
of hospital discharge, these areusually no special dietary
instructions other than to maintain a
nutritious diet and avoid excessivefats. Fat restriction usually is lifted in
4-6 weeks when the biliary ducts
dilate to accommodate the volume
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Monitoring and Managing
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Monitoring and ManagingPotential Complications
Bleeding may occur as a result ofinadvertent puncture or nicking
of major bloodvessel. Post-operatively, the nurse closely
monitors vital signs and inspects
the surgicalincision and drains, ifin place, for evidence of
bleeding.