the grand case study-choledocholithiasis-group a4

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INTRODUCTION

Choledocholithiasis (stones in common bile duct) is one of the complications of

cholelithiasis (gallstones), so the initial step is to confirm the diagnosis of cholelithiasis.

Typically patients with cholelithiasis present with pain in the right upper quadrant of the

abdomen with the associated symptoms of nausea and vomiting, especially after a fatty meal.

The physician can confirm the diagnosis of cholelithiasis with an abdominal ultrasound that

shows the ultrasonic shadows of the stones in the gallbladder.

The incidence rate for gallstones is 10-20%. Approximately 600,000 cholecystectomies are

performed in the United States every year, and choledocholithiasis complicates 10-15% of these

cases. In Asian populations, infestation with a lumbricoides and C sinensis may promote stasis

by either blocking the biliary ducts or by damaging the duct walls, resulting in stricture

formation. Bactibilia is also common in these instances, probably secondary to episodic portal

bacteremia. Some authors have suggested that the stones are formed because of the bactibilia

alone and that the parasites' presence is just a coincidence. Choledocholithiasis occurs more

frequently in females than in males. Patients with choledocholithiasis may be completely

asymptomatic; in approximately 7% of cases, the stones are found incidentally during

cholecystectomy. Stones are seen in 1% of autopsies performed on individuals older than 60

years who died of unrelated causes. Approximately 25-50% of asymptomatic CBD stones

eventually cause symptoms and require treatment. Symptoms occur when the stones obstruct the

CBD. The clinical presentation varies depending on the degree and level of obstruction and on

the presence or absence of biliary infection.The management of choledocholithiasis remains in

evolution since the introduction of laparoscopic cholecystectomy. If the local surgical group is

adept at laparoscopic cholecystectomy and intraoperative cholecystectomy, then a laparoscopic

cholecystectomy with cholangiography may be the best approach. However, if CBD stones are

present, laparoscopic CBD exploration and stone removal is technically challenging and only the

most proficient and skilled laparoscopist can readily accomplish this operation. Note that an

endoscopic association loaded with skilled laparoscopists performed 1 of the above-mentioned

studies. On the other hand, if you have a well-trained endoscopist, then endoscopic stone

extraction is successful 90% of the time. Alternatively, preoperative magnetic resonance

cholangiopancreatography has been recommended to look for CBD stones.

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The group chose this case because more clinical skills will be developed by experiencing the

clinical management of this disease-condition and it will enhance one’s knowledge in

implementing proper nursing intervention to the patient towards recovery.

Objectives

Nurse Centered:

General:

To enhance skills, comprehension and approach in the practice of nursing and be able to

establish knowledge on the risk factors, prognosis nursing management, current trends and

incidence of the disease condition that was chosen.

Specific:

To come up with a comprehensive presentation of the disease condition by means of

correct presentation of the data gathered through the use of nursing process.

To present the current trends about the disease condition; the reason for choosing

such case for presentation; and the importance of the case study.

Patient Centered:

General:

To be able for the client to fully understand and recognize the disease condition,

emphasize the importance of making appropriate action and to guide the patient towards

recovery.

Specific:

To impart knowledge about the importance of healthy lifestyle.

To render proper nursing management and medical regimen needed by the patient.

To identify predisposing factors that aggregate the present condition of the patient.

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II.NURSING PROCESS

A. ASSESSMENT

1. Personal Data

A. Demographic Data

Name: Patient X

Sex: Male

Age: 45 y/o

Civil Status: Married

Occupation: Farmer

Religious Affiliation: Roman Catholic

Position in the Family: Father

Address: Tarlac City

Date of Birth: January, 1964

Place of Birth: Tarlac City

Nationality: Filipino

Date of Admission: September 29, 2010

Health Care Financing: Phil health

Usual Source of Medical: Health center, Clinics, Hospital Care

Admitting Diagnosis: Choledocholithiasis

B. Environmental Status

Patient X lives at a barangay in Tarlac City.. According to him, their house is made up of

wood and cement with 2 windows and 2 doors: one in front of the house and one at the back.

Their water source is a Cartesian well located outside their house with a distance of 4 meters

from their kitchen. Their toilet is located 3 yards away from their kitchen. Their house has 2

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rooms, one room is used as a store room while the other one is their bedroom.. Their front yard

has irregular elevations with a muddy and slippery pathway leading to the kitchen.

Lifestyle

The patient wakes up at around 5:00 am and drinks a cup of coffee. After that he will

immediately proceed to his owned rice field to start his daily work consisting of plowing the

field and pulling out the weeds around. He usually eats fried eggs and tinapa and drinks coffee

for breakfast. His diet is usually composed of instant noodles, fried foods, and sometimes, if their

budget enough, he stated that he also likes to eat fatty foods. He goes to sleep at 9:00 and does

not observe evening hygiene.. He spends his leisure time by taking a nap.

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3. History of Past Illness:

The patient had chicken pox and measles in her childhood. She also claimed that she

completed her immunizations. Patient X stated that she does not have any allergic reaction to

drugs, animals, or any other substances.

4. History of Present Illness:

Patient X stated that one month before the admission, she started experiencing abdominal

pain located at the right upper quadrant and radiates at the back. She described the pain as

"parang dinudurog ang tiyan ko”. The pain occurred twice a week during the month, but became

intolerable and occurred almost everyday during the last week before her admission. During

these days, the pain was accompanied by occasional fever, anorexia, and nausea and vomiting.

According to the patient, the pain usually occurs during the afternoon up to the evening. During

the assessment, she graded the pain intensity as 8/10 prior to her operation. Patient X tried to

alleviate the pain by applying hot compress and splinting pillows at the site where the pain

originated, yet the pain did not subside. Patient X stated that the pain occur regardless of her

activity. She stated that she had several check-ups prior to her hospital admission. She was then

prescribed medications such as ibuprofen for pain. She was then admitted at Tarlac Provincial

Hospital because of her continuous pain in her abdomen, anorexia, fever, nausea, and vomiting

and advised by the physician to undergo operation.

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3. Physical Assessment

THE THIRTEEN AREAS OF ASSESSMENT

1. SOCIAL STATUS

The patient is 45 years old and currently living at Tarlac City. He has a good relationship

with his family members. They help each other whenever they are in need and work in order to

support each family member. In his age, he still continues to work to provide the needs of his

family. Each of the members of their family performed their specific roles. If one of them got

problems, members are always there to support.

Norms:

Family members should perform their roles. Good communication within the family must

be maintained to obtain a healthy relationship with one another. Social support is a perception

that one has emotional and tangible resource to call on when needed, perceived social support is

being followed by the family to express the love and care to the family. Financial aspect is one of

the normal constraints in the family. (Kozier , copyright 2004).

Analysis

The patient has a good social relationship with his family. If some problem arises, they

can still manage to handle it properly.

2. MENTAL STATUS

Client is oriented to time, place and person. He can identify things or names

being asked. He can recall recent and remote memories he experienced.

He can speak in Tagalog and Kapampangan .He is responsive and answers to the questions being

asked.

Norms: The patient should be oriented to time and place, can identify past and recent memories

and should be able to verbalize concrete messages. The patient’s ability to read and write should

match his educational level. The patient should be able to respond to questions and identify all

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the objects presented to him. (Estez, Health Assessment and Physical Examination, Third

Edition.)

Analysis: Being responsive and being able to answer questions accordingly are the

major determinants which indicate patient’s mental capabilities are still

functioning well.

3. EMOTIONAL SUPPORT

Prior to the procedure, client was first hesitant to communicate with the interviewer.

Although he stayed looking calm, he seemed to be anxious. When asked how he feels, he

admitted that he is quite nervous but he believed that the operation would be successful. Couple

of days after the operation, the patient talked and smiled every time he was interviewed.

Norms:

A person’s emotional status depends much on his ability to cope up with the happening in

his/her life. He or she may not be in the right mood if some unnecessary things had happened.

(Nursing CEU.com, the process of human being).

Analysis

The patient has a strong confidence on himself and was able to cope up with his

condition. His emotional status was stable before and after the surgery. He had a strong belief to

survive, which made him not to worry too much during the operation.

4. SENSORY PERCEPTION

Sense of taste

The patient is fond of eating foods. After the surgery, client’s taste seems to be bitter.

However, as days passed by, he was able to taste the foods presented to him without any taste

abnormalities.

Norms

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Normal sensation would be accurate perceptions of sweet, salty, and bitter taste. (Estes,

Third Edition, Copyright 2006)

Analysis

After the operation, the patient remained NPO to prevent occurrence of aspiration. Bitter

taste he experienced after the operation is maybe mainly because of the effect of anesthesia given

to him at the time of operation.

Auditory Activity

Before the operation started, questions were repeatedly asked before the client was able

to answer. Loud voice was being introduced for him to be able to answer. Nevertheless, he was

able to answer the questions asked correctly.

Norms:

Patient should hear clearly and accurately. Ear must be free from lesions and masses.

Although there are many people that reach old age with acceptable hearing, the common

thing is for this ability to decline through time. In some old people this decline, called

presbycusis, is very strong and can originate in various physiological problems.

(http://en.latinsalud.com)

Hearing loss can start at 40 years of age in some people with hereditary preconditions. In

general, it advances slowly but progressively, until clearly manifesting at the age of 60.

(http://en.latinsalud.com)

Analysis

The client’s auditory sense shows that he experiences hearing difficulty mainly because

of his age affecting his communication and social skills.

Sense of smell

The patient’s nostrils were symmetrically aligned. No lesions, swellings and redness were

noted.

http://en.latinsalud.com/

http://en.latinsalud.com/

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Norms

Patient must be able to identify different smell. Nose should be at the midline position of

the face, free from lesions, and intact nostrils.

Analysis

The patient has a normal sense of smell.

Sense of sight

Prior to the surgery, client claimed to experience blurring of vision. He admitted of using

an eyeglass. However, he couldn’t remember what he’s visual acuity was. No lesions, redness,

swelling and discharges were noted from her eyes.

Norms:

The normal patient has a visual acuity of 20/20 in a Snellen chart test is considered to

have normal vision acuity. (Estes, Third Edition, Copyright 2006).

Vision loss among the elderly is a major health care problem. Approximately one person

in three has some form of vision-reducing eye disease by the age of 65. The most common

causes of vision loss among the elderly are age-related macular degeneration, glaucoma, cataract

and diabetic retinopathy. (http://www.aafp.org)

Analysis

The client’s blurring of vision is associated with his age. During old age, age-related

macular degeneration may happen, thus, impairing the vision of an individual which may

decrease one’s ability to perform activities of daily living.

5. MOTOR STABILITY

Prior to the operation, the patient was in bed. He can move but in minimal circumstances

only because of the pain he felt on his right abdomen. After the operation, he was in complete

bed rest, but was able to progress through more complex movements as day passed by.

http://www.aafp.org/

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Norms

Normal motor stability includes the ability to perform the different steps in doing range

of motion. It should be firm with smooth and coordinated movements. (Estes, Third Edition

2006)

Analysis

The patient’s motor stability prior to the surgery was abnormal due to the presence of

pain. Pain was associated with the said disease condition. After the procedure, the patient’s

motor stability corresponded to his condition postoperatively.

6. BODY TEMPERATURE

The following body temperatures were obtained:

Date Time Assessed Findings

September 29, 2010 4:10 PM 37.3 C

September 29, 2010 5:00 PM 38.4 C

5:15 PM 38.1 C

5:30 PM 37.6 C

6:00 PM 37.4 C

10:00 PM 37. 1 C

September 30, 2010 2:00 AM 37.0 C

6:00 AM 37.0 C

The client presented with fever during her admission until after the surgery. Her temperature

stabilized during the last 3 days of the assessment.

Norms:

36.5 to 37.5˚C is the normal body temperature (Kozier, Seventh edition, Copyright 2004)

Analysis

The client was febrile postoperatively because of the his body’s adaptation

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7. RESPIRATORY STATUS

The table below shows the respiratory rate of the patient.


September 29, 2010 4:10 PM 19 cpm

5:00 PM 26 cpm

5:15 PM 25 cpm

5:30 PM 23 cpm

6:00 PM 22 cpm

10:00 PM 23 cpm

September 30, 2010 2:00 AM 21 cpm

6:00 AM 20 cpm

No cyanosis, chest indrawing and use of accessory muscles was noted. The patient’s lung

sounds were clear upon auscultation.

Norms:

Normal respiratory rate for adults is 12-20 cpm. Average is 18. In terms of pattern,

normal respiration must be regular and even in rhythm. The normal depth of respiration is none

exaggerated and effortless (Health Assessment and Physical Examination 3rd edition Mary Ellen

Zator Estes)

Analysis

The patient’s respiratory rate was elevated as a compensation for his fever.

8. CIRCULATORY SYSTEM

Date Time Pulse Rate Blood Pressure

September 29, 2010 4:10 PM 101 bpm 120/100

5:00 PM 98 bpm 100/70

5:15 PM 92 bpm 100/80

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5:30 PM 87 bpm 110/90

6:00 PM 89 bpm 100/90

10:00 PM 99 bpm 120/90

September 30, 2010 2:00 AM 97 bpm 120/98

6:00 AM 98 bpm 110/80

During the blanch test, the patient’s capillary refill was able to return in less than 2 seconds.

Norms:

The normal pulse rate rages from 60-100 bpm, and the normal blood pressure is 120/80.

Capillary refill in 2 seconds or less is expected in a healthy adult, which denotes proper

oxygenation of the blood.

Analysis

The client’s pulse rate was elevated during the preoperative period due to the presence of

fever and pain. After the surgery, however, his pulse rate returned to the normal range. His blood

pressure and capillary refill was normal.

9. NUTRITIONAL STATUS

The patient claimed that his weight was 46 kilogram before the occurrence of his present

condition. His weight after the operation was 42 kilograms. he usually eats fried eggs and tinapa

and drinks coffee for breakfast and usually eats pinakbet, dinengdeng and fried fish at lunch. He

stated that he eats three (3) times a day. He claimed that he is also fond of eating junk foods such

as “tokneneng and fishball” and high fat foods such as “sisig, chicharon and crispy pata”. He has

no known allergies to foods and allergies. His computed BMI was 17.

Computation of the client’s BMI:

Weight: 42 kg

Height: 5’ (60 inches)

Formula: wt (kg) / ht (m2)

Solution:

42 kg / (1.52 m2)

BMI: 18.2 kg/m2

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Norms:

BMI is a measurement that indicated body composition. The degree of overweight or

obesity as well as the degree of underweight can be determined. (Estes, Third edition, Copyright

2006)

Standard Body Mass Index for Adults:

Underweight = <18.5

Normal weight = 18.5-24.9

Overweight = 25-29.9

Obesity = BMI of 30 or greater

Analysis:

The above data shows that the patient’s food preference is not healthy. His nutritional status was

altered due to her present condition. She is underweight.

10. ELIMINATION

The patient usually defecates 3 times a week. After the operation, he didn’t defecate until

his second day postoperatively. His urination pattern prior to the surgery was 5 times a day. After

the operation, he had a catheter. His urine measured as follows:


September 29, 2010 4:20 PM 1000 milliliters

September 30, 2010 7:30 PM 1100 milliliters

Norms:

Normal bowel movement is usually 2-3 times a day which help in elimination of

unnecessary waste material in the body in the GI tract. It should be soft but formed and brown in

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color. Urine output of an adult is usually 1200-1500mL per day. (Kozier Seventh edition,

Copyright 2004)

Analysis:

The patient has a normal defecation pattern prior to and after the operation. His urinary

status was below the normal range after her operation, but was normal prior to it.

11. REPRODUCTIVE STATUS

**PATIENT REFUSED TO THIS AREA OF ASSESSMENT

12. STATE OF PHYSICAL REST AND COMFORT

Prior to admission, the patient slept for 8 hours a day. During his stay in the hospital, he

was unable to sleep and had his rest for only 3 hours prior to his operation due to anxiousness

and pain. After the operation, the pain on his incision site limited his to 6 hours of rest until his

third day postoperatively when he was able to sleep for 12 hours.

Norms:

A normal sleep hours of an adult per day is 6 - 8 hours without being disturbed (Kozier,

Seventh edition, Copyright 2004)

Analysis:

The patient’s rest and comfort status was altered prior to the surgery due to his condition

13. STATE OF SKIN AND SKIN APPENDIGES

The hair of the patient was properly distributed, black and free from infestations. The

scalp has no flakes and free from lesions. Before the operation, the patient’s skin was slightly

dry. There were noted bruises and scars on his lower right leg. After the operation, his IV line

had infiltration and had to be removed. He also had his incision at the right side of her abdomen.

There were no discharges, swelling, redness and bleeding noted at her incision site.

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Norms:

Skin varies from light to brown from ruddy pink to light pink. Generally, uniform except

in areas exposed to the sun, areas of lighter pigmentation in palms, nail beds, and lips. The hair

should be evenly distributed, thick, shiny and free from infestation. The nails should be 160◦ and

smooth in texture. (Kozie, Seventh edition, Copyright 2004)

Analysis:

The patient’s skin was abnormal due to the presence of scars and bruises. The infiltration

and the presence of the incision site were also observed as an abnormal finding because it

disrupts the integrity of the skin.

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4. DIAGNOSTIC AND LABORATORY PROCEDURES

Diagnostic/ Laboratory Procedures

Date Ordered and date Result/s In

Indication/s or Purposes

Result/s Normal Values (Units used in the Hospital)

Analysis and Interpretation of results

CBC

>WBC

>LYM

>MID

>GRAN

>RBC

September

29, 2010

Result:

September

29, 2010

CBC is used as abroad screening test to determine the values of formed elements of the blood.

10.1

2.8

0.5

6.9

2.49

4.1 – 10.9 g/dL

0.6 – 4.1

0.0 – 1.8

2.0– 7.8

4.20 – 6.30 T/L

Normal>No indicative abnormalities noted.

Normal> No indicative abnormalities noted



Decreased>There is a marked decreased in RBC that may indicate hypoxia.

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>HGB

>HCT

>MCV

>MCH

>MCHC

>PLT

69

0.209

83

32.0

355

258

120 – 180 g/dL

0.370 – 0.510 L/L

80.0 – 97.0 fl

26.0 – 32.0 pg

310 – 360 g/dL

140 -440 g/L

Decreased>There is a marked decreased in HGB that indicates hypoxia.

Decreased>There is a marked decrease in HCT that indicates hypoxia





NURSING RESPONSIBILITIES:

Before:

Determine the clients understanding of the procedure Determine the clients response to previous testing

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During:

Ensure client’s comfort until the procedure will be done

After:

Document the method of testing and results on the clients record Immediately reached the blood sample on the laboratory. Follow-up result from laboratory

Diagnostic/ Laboratory Procedures

Date Ordered and date Result/s In

Indication/s or Purposes

Result/s Normal Values (Units used in the Hospital)

Analysis and Interpretation of results

BLOOD CHEMISTRY September,

29, 2010

Result:

September,

29, 2010

Blood tests are used to determine physiological and biochemical states such as disease, mineral content, drug effectiveness, and organ function

FBS:5.34

BUN:9.0

Creatinine:41

Uric acid:None

Cholesterol:6.25

Triglyceride:.92

HDL:44.6

LDL:

FBS:3.9-6.1 mmol/L

BUN:2.9-8.2 mmol/L

Creatinine:53-106 mmol/ l

Uric acid:None

Cholesterol:3.88-6.47 mmol/L

Triglyceride:.11-

Normal

Not normalincreasedlevels of BUN may be due the presence of infection

Not normal decreased level of creatinine may be due to decreased muscle mass

Normal

Normal

Normal

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180.62

Electrolytes

Na150

K5.1

Cl106.5

2.15mmol/L

HDL:30-75mmol/L

LDL:66-178mmol/L

Na135-145mEq/L

K3.5-5.0mEq/L

Cl98-106 mEq/L

Normal

Not normalElevated LDL may be due to the client’s nutritional preference

Not normalelevated levels of NA may be due to the presence of infection

Not normalelevated levels of K

Not normalelevated levels of Cl

Nursing responsibility:Before:

Explain the purpose of the test and the procedure for collection of blood. Client mat experience anxiety about the procedure, especially if it is perceived as being intrusive or if they fear unknown to the result. A clear explanation will facilitate cooperation on the part of the client.

Inform the client of the time period before the results will be available.

During: Use the correct procedure for obtaining the blood. Aseptic technique should be use in collection to prevent contamination that can cause inaccurate

results. Ensure correct labeling, storage and transportation of the specimen to avoid invalid test results.

After: Report results to the appropriate health team members. Compare the previous and current test results and modifies nursing interventions as needed

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5. ANATOMY AND PHYSIOLOGY

The anatomy of the biliary tree is a little complicated, but it is important to understand. The liver's cells (hepatocytes) excrete bile into canaliculi, which are intercellular spaces between the liver cells. These drain into the right and left hepatic ducts, after which bile travels via the common hepatic and cystic ducts to the gallbladder. The gallbladder, which has a capacity of 50 milliliters (about 5 tablespoons), concentrates the bile 10 fold by removing water and stores it until a person eats. At this time, bile is discharged from the gallbladder via the cystic duct into the common bile duct and then into the duodenum (the first part of the small intestine), where it begins to dissolve the fat in ingested food.The liver excretes approximately 500 to 1000 milliliters (50 to 100 tablespoons) of bile each day. Most (95%) of the bile that has entered the intestines is resorbed in the last part of the small intestine (known as the terminal ileum), and returned to the liver for reuse.The many functions of bile are best understood by knowing the composition of bile:Bile Salts (cholates, chenodeoxycholate, deoxycholate): these are produced by the liver's breakdown of cholesterol. They function in bile as detergents that dissolve dietary fat and allow it to be absorbed. Hence, disruption of bile excretion disrupts the normal absorption of fat, a process called malabsorption. Patients develop diarrhea because the fat is not absorbed (steatorrhea) , and develop deficiencies of the fat-soluble vitamins (A, D, E, and K).Cholesterol and phospholipids-while only 4% of bile is cholesterol, the secretion of cholesterol and its metabolites (bile salts) into bile is the body's major route of elimination of cholesterol. Phospholipids, which are components of cell membranes, enhance the cholesterol solubilizing properties of bile salts. Inefficient excretion of cholesterol can cause an increased serum cholesterol. This predisposes to vascular disease (heart attacks, strokes, etc.)Bilirubin-while this comprises only 0.3% of bile, it is responsible for bile's yellow color. Bilirubin is a product of the body's metabolism of hemoglobin, the carrier of oxygen in red blood cells. Disruption of the excretion of this component of bile leads to a yellow discoloration of the eyes and skin (jaundice).

Bile production and recirculation is the main excretory function of the liver. Tumors that obstruct the flow of bile from the liver can also impair other liver functions. Therefore, it is necessary to understand these other functions to understand the symptoms that these tumors can cause. These include:

Metabolic functions, such as the maintenance of glucose (blood sugar) levelsSynthetic functions, such as the synthesis of serum proteins such as albumin, blood clotting (coagulation) factors, and complement (a mediator of inflammatory responses)Storage functions, such as the storage of sugar (glycogen), fat (triglycerides), iron, copper, and fat soluble vitamins (A, D, E, and K)Catabolic functions, such as the detoxification of drugs

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PATHOPHYSIOLOGY (Book-Based)

RISK AND PREDISPOSING FACTORS

Obstruction of bile outflow alteration

MODIFIABLEObesity, Cigarette smoking,

Alcoholism, Hypercholesterolemia/ ↑ fats intake, pregnancy

NON - MODIFIABLEAge, Gender, Race, Diseases like

Diabetes Mellitus

Bile Stasis

Chemical Reaction

INFLAMMATION

- Epigastric pain

- Tenderness and rigidity of Upper Right Quadrant

Decreased blood supply and decreased lymphatic

drainage

Distension of bile duct

Proliferation of bacteria

Elevated temperature

Nausea and vomiting

Edema

- Tachycardia- Pallor- Diaphoresis

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PATHOPHYSIOLOGY (Patient-Based)

RISK AND PREDISPOSING FACTORS

Obstruction of bile outflow alteration

MODIFIABLEObesity, Cigarette smoking,

Alcoholism, Hypercholesterolemia/ ↑ fats intake, pregnancy

NON - MODIFIABLEAge, Gender, Race, Diseases like

Diabetes Mellitus

Bile Stasis

Chemical Reaction

INFLAMMATION

- Epigastric pain

- Tenderness and rigidity of Upper Right Quadrant

Decreased blood supply and decreased lymphatic

drainage

Distension of bile duct

Proliferation of bacteria

Elevated temperature

Nausea and vomiting

Edema

- Tachycardia- Pallor- Diaphoresis

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Assessment Diagnosis Scientific Explanation

Planning Implementation Rationale Evaluation

S: Ø

O: Presence

of incision grimace Pale and

Weak in appearance

Reduced body movements

Mild erythema in the operated site

Risk for infection related to surgical incision

Due to increased risk for being invaded by pathogenic organisms therefore possible infection can occur. Contributing factors such as altered peristalsis, tissue destruction, increased environmental exposure, trauma and invasive procedure.

Within 1 hour of proper nursing interventions, the client will know ways on how to prevent complication of infection

Encouraged to practice good hand washing and aseptic wound care.

Inspected incision and dressings. Noted characteristics of drainage from wound

Assess and document for any signs and symptoms of infection.

Ensure proper hand hygiene by all caregivers during touching and making of procedure.

To prevent and minimize the spread of microorganism.

Prevents access or limits spread of infecting organisms/cross-contamination.

To identify the cause of infection and determine the appropriate nursing intervention to be applied.

First line defense against health care associated infection.

After 1 hour of proper nursing interventions, the client was able to know ways on how to prevent complication of infection

B. PLANNING- NURSING CARE PLANS

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Instruct the client and the family about the need for good nutrition, especially protein and proper rest.

Optimal nutritional status contributes to health maintenance and prevention of infection.

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S: Ø

O: dry mouth chapped

lips with

surgical incision at right upper quadrant

Pale and Weak in appearance

Restless and irritable

RBC – HGB – Na – K –

Risk for fluid volume deficit related to blood loss

Surgery predisposes the client to lose massive amounts of blood which predisposes the client to shock, and hypovolemia

Within 8 hours of proper nursing interventions, the client will be able to display adequate fluid balance AEB stable vital signs, capillary refill and appropriate urine output.

Maintained accurate record of input and output.

Assessed skin / mucous membrane, peripheral pulses and capillary refill.

Observe for signs of bleeding (e.g hematemesis, melena, petecchiae, ecchymossis)

Provides information about a needs and organ function.

Indicators of adequacy of circulating volume/perfusion.

Prothrombin is reduced and coagulation time prolonged when bile flow is obstructed, increased risk of bleeding/hemorrhage

Within 8 hours of proper nursing interventions, the client will be able to display adequate fluid balance AEB stable vital signs, capillary refill and appropriate urine output.

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Provide fresh water and oral fluids, prescribed diet;offer snacks (e.g. frequent drinks, fresh fruits and fruit juice).

Administer IV blood products, electrolytes as indicated.

The oral route is preferred for maintaining fluid balance.

Maintains adequate circulating volume and aids in imbalances from wound losses.

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S: “Masakit yung suagt ko” with pain scale of 8/10

O: Facial

grimace Guarding

at incision site

Restless and irritable

Observed self-focusing or narrowed focus

Self-protective behavior

Limited movement noted

Slightly diaphoretic

RR – 28 cpm

Acute pain related to obstruction / ductal spasm

It is accompanied by acute localized pain because of potential tissue damage which casue inflammation, swelling and redness at the site.

Within 30 minutes of proper nursing interventions, the client’s pain scale will decrease from 8/10 to 5/10

Promote adequate rest and sleep.

Assist patient in use of distraction techniques.

Assist patient in comfortable position.

Provide diversional techniques such as talking to the family members.

Encourage patient to do deep breathing exercise.

Support patient in use of

To restore body strength.

To control pain.

\ To facilitate

comfort.

To maximize relaxation and comfort.

To promote relaxation.

Cognitive behavioral strategies can

After 30 minutes of proper nursing interventions, the client’s pain scale was decreased from 8/10 to 5/10

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nonpharmaco-logical methods to help contro pain such as imagery, relaxation and application of heat and cold.

Administer pain medication as prescribed.

restore the client’s sense f self-control.

To minimize pain.

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S: “Nanghihina ako”.

O:>Pale and weak in appearance

>Reduced body movement

>Reported dysfunctional eating patterns

Imbalanced nutrition: less than body requirements related to

impaired fat digestion due to obstruction of bile flow

Due to insufficient intake of nutrients it causes the body not to meet metabolic demands because of biological, psychological or economic factors.

Within 8 hours of proper nursing interventions, the client will demonstrate behaviours / lifestyle changes to regain and maintain appropriate weight.

Work with the client to develop a plan for increased activity and energy.

Teach strategies for energy conservation such as limiting of talking to others, increased number of rest periods.

Provide companionship at mealtime.

Emphasize importance of adequate rest and sleep.

To increase patient’s appetite.

To prevent and minimize the spread of microorganism.

To maximize patient’s strength.

To encourage nutritional intake.

For energy conservation.

After 8 hours of proper nursing interventions, the client was able to demonstrate behaviours / lifestyle changes to regain and maintain appropriate weight.

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Encourage patient to eat a well balanced diet.

Encourage patient to drink atleast 8 glasses of water a day.

Offer frequent and small quantities of food.

To restore patient’s energy.

It is important for clients to maintain intake as much as possible.

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Assessment Diagnosis Scientific Explanatio

n


S: “Mainit ang pakiramdam ko”

O: flushed skin warm to touch

movements with minimal

body movements

weak in appearance

T – 38.4°C

Altered thermoregulation related to tissue trauma

Due to tissue trauma it causes the body to compensate such as increasing the temperature.

Within 1 hour of proper nursing interventions, the client’s temperature will decrease from 38.4°C to 37.8°C

Monitored client’s temperature (degree and pattern).

Promoted surface cooling be means of tepid sponge bath.

Encouraged to increase fluid intake.

Provided high caloric diet such as rich in carbohydrates and protein.

Maintained bed rest.

Administe

To be able to know what interventions to be applied.

To help maintain a normal body temperature.

To help replace fluid loss.

To help the body to restore strength and body temperature.

To help patient to conserve energy.

To help replace

After 1 hour of proper nursing interventions, the client’s temperature was decreased from 38.4°C to 37.8°C

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red replacement fluids and electrolytes as indicated.

Administered medications as prescribed by the physician.

fluid loss

To help maintain a normal body temperature .

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C. Implementation1. Medical Management

i. IVF’s, BT, NGT feeding, Nebulization, TPN, Oxygen Therapy etc.

Prior: Understand why the therapy is needed. determine potential outcomes for the client understand the fluid and electrolyte and acid base status of the client provide an explanation to the client and gain cooperation select the appropriate IV set

During:

Medical Management/Treatment

Date Ordered/ Date Taken/Given

Date Changed/ Date Discontinued

General Description Indication/s, Purpose/s Client's reaction to the treatment

IV Therapy

1L LRS (isotonic) with oxytocin regulated at 15 gtts/min

1L D5 NM (hypertonic) regulated at 30 gtts/min

1L D5 LRS (hypertonic) regulated at 30 gtts/min

Started on September 29, discontinued on the same date

September 29-September 30

Started on September 30 discontinued on the same date

IV Therapy is the giving of liquid directly into a vein.

IV Therapy is usually performed for fluid volume maintenance, fluid volume replacement, medication administration, blood administration, total parenteral nutrition and serves as an emergency line

The patient did not reported pain in the IV site

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assess the following:o right intravenous fluids infusingo right intravenous fluids for the cliento date on the tubingo right rate according to the rate prescribed and the clients condition o absence of kinks in the tubing that could result in occlusion of the fluid flowo date on the intravenous access deviceo insertion site and vein access for evidence of pain, redness, warmth, or coolness, and swelling

After: Discard the administration set accordingly Document relevant data.





Oxygen Therapy

2 L/min for 3 hoursvia nasal prong

September 29-30 Oxygen therapy is any procedure in which oxygen is administered to a patient to relieve hypoxia.

Clients who have difficulty ventilating all areas of their lungs, those whose gas exchange is impaired, or people who have heart failure may require oxygen therapy to prevent hypoxia.

The patient tolerated the administered oxygen and verbalized relief from DOB

Prior: Determine the need for oxygen therapy, and verify the order for the therapy. Perform a respiratory assessment to develop baseline data if not already available. inform the client and support people about the safety precautions connected with oxygen use such as:

Avoiding materials that generate static electricity, such as woolen blankets and synthetic fabrics. Avoiding the use of volatile, flammable materials, such as oils, greases, alcohol, ether, and acetone. Provide an explanation to the client and gain cooperation.

Assist the client to a semi-Fowler’s position. set up the oxygen equipment and the humidifier

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During: Check that the oxygen is flowing freely from the tubing. There should be no kinks in the tubing, and the connections should be

airtight. There should be bubbles in the humidifier as the oxygen flows through. Feel the oxygen at the outlets of the cannula. Monitor the level of water in the humidifier. Set the oxygen at the flow rate ordered. if the cannula will not stay in place, tape it at the sides of the face

After: report significant deviation such as tracheal irritation and coughing, dyspnea, and decreased pulmonary ventilation





Urinary Catheterization

September 29-30 Urinary Catheterization is the introduction of a catheter through the urethra into the urinary bladder

Indications of urinary catheterization includes relief from discomfort due to bladder distention or to provide gradual decompression of a distended bladder, to empty the bladder completely prior to surgery, to facilitate accurate measurement of urinary output for critically ill clients whose outputs need to be monitored hourly, to prevent urine from contacting an incision after perineal surgery.

The client didn’t verbalize any discomfort and have adequate (>30cc/hr), amber colored urine output.

Prior:

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Determine the most appropriate method of catheterization based on the purpose and any criteria specified in the order such as total amount of urine to be removed and size of catheter to be used.

Use an indwelling catheter if the bladder must remain empty or continuous urine measurements/collection is needed. Assess the client’s overall condition. Determine if the client is able to cooperate and hold still during the procedure and if the

client can be positioned supine with head relatively flat. Determine when the client last voided or was last catheterized. Percuss the bladder to check for fullness or distention.

During: Ensure that there are no obstructions in the drainage. Check that there are no kinks in the tubing, the client is not lying on the

tubing, and the tubing is not clogged with mucus or blood. Check that there is no tension on the catheter or tubing, that the catheter is securely taped to the thigh, and that the tubing is

fastened appropriately to the bedclothes. Ensure that gravity drainage is maintained. Make sure that there are no loops in the tubing below its entry to the drainage

receptacle and that the drainage receptacle is below the level of the client’s bladder. Ensure that the drainage system is well-sealed or closed. Check that there are no leaks at the connection sites in open systems.

Apply water proof tape around the connection site of the catheter and tubing. Observe the flow of the urine every 2-3 hours, and note color, odor and any abnormal constituents. If sediments are present,

check the catheter more frequently to ascertain whether it is plugged.After:

Conduct appropriate follow-up such as notifying the primary care provider the catheterization results. Performed a detailed follow-up based on findings that deviated from normal for the client. Relate findings to previous assessment data if available

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ii. Drugs

Name/s of drugs (generic and brand

name)

Date ordered/

Date taken/

Date changed

Route of administration &

dosage & frequency of

administration

Mechanism of action

Indication/s

Purpose/s

Client’s response to medication with actual side effect

Generic Name:

Cefuroxime Sodium

September 29, 2010 750 mg, IVF q 8 hours

It is a anti- infective drug and its main action is combat the preset bacteria and inhibit increased growth.

Low respiratory infections, Pharyngitis or tonsillitis

The client did not exhibit any adverse reactions from the drug

Before: Check the expiration date of the drug Check the doctor's order Assess the client's understanding about the drug Assess for skin allergies

During: Reconstitute the drug with 8 ml of sterile water. Slowly inject the drug over 3 to 5 mins.

After: Evaluate the client for adverse effect. Report lack of response, persistent diarrhea or signs ad symptoms of Anemia.

Name/s of drugs Date ordered/ Route of Mechanism of Indication/s Client’s response

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(generic and brand name)

Date taken/

Date changed

administration & dosage &

frequency of administration

action

Purpose/s

to medication with actual side effect

Generic Name:

Ketorolac Tromethamine

September 29, 2010 30 mg, IVF q 6 hours X 6 doses

Possesses anti-inflammatory, analgesics ad antipyretic. Completely absorbed following IM use.

Use for management of moderate ad severe acute pain.


Before: Check the expiration date of the drug Check the doctor's order Assess the client's understanding about the drug

During: Do not mix IV ketorolac in a small volume with morphine sulfate. The IV bolus must be given over o less than 15 sec.

After: Monitor for adverse effect. Report any unusual bruising or bleeding, weight gain, swelling of feet/ ankles, increased joint pain, change in urine patterns.

Name/s of drugs Date ordered/ Route of Mechanism of Indication/s Client’s response

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(generic and brand name)

Date taken/

Date changed

administration & dosage &

frequency of administration

action

Purpose/s

to medication with actual side effect

Generic Name:

Omeprazole

September 29, 2010 Q 12 hours X 2 doses

Hough to be a gastric pump inhibitor and that it blocks the final step of acid production. By inhibiting the Hydrogen/ Potassium ATP-ase system at te secretory surface of the gastric parietal cell.

Use for management of active duodenal ulcer, gastric ulcer, erosive esophagitis and heartburn


Before: Check the expiration date of the drug Check the doctor's order Assess the client's understanding about the drug

During: The capsule should be taken 30 minutes before eating and is to be swallowed whole. Antacid can be administered with Omeprazole.

After: Monitor for adverse effect. Report to the physician if chest pain, abdominal pain and fecal discoloration occurred

iii. Diet

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Type of Diet

Date ordered/

Date taken/

Date changed

General Description

Indication/s

Purpose/s

Specific foods Taken

Client’s response to medication with actual side effect

NPO (nothing by mouth)

September 29 A patient care instruction advising that the patient is prohibited from ingesting food, beverages, or medicine.

It is usually ordered whenever the patient wills undergoes surgery or other diagnostic procedure requiring that the digestive tract be empty.

Foods, beverages and medicine are prohibited.

The client complied with the prescribed diet.

Before:

Explain to the client and significant others the purpose, indication and the duration of the diet. Assist the client’s compliance ability to the diet.

During:

Advise the client to avoid foods. Provide frequent oral hygiene Monitor the compliance of the patient to the diet.

After:

Evaluate the effect of the diet to the client. Report excessive weight loss. Assess any nutritional disturbances and notify the physician.

Type of Diet Date ordered, General Indication/s Specific Foods Client’ s response

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Date started, Date changed

description

Purpose/s

Taken and/or response to the diet

Clear liquid diet September 30, 2010 This client provides the client with fluid and carbohydrate but does not supply adequate protein, vitamins, minerals, or calories

This diet is indicated for post operative patient’s first feeding when it is necessary to fully ascertain return of gastrointestinal function

Crackers

Sips of water and tea


Prior: Assess ability to feed self and prepare meals Determine need for special drinking cups, plates, or feeding utensils Explain the purpose of the diet Discussed allowed and prohibited foods

During: Assist the client to a comfortable position in bed or in a chair, whichever is appropriate Provide assistance of the client is unable to handle eating utensils or to open containers and packages Always allow ample time for the client to chew and swallow the food before offering more

After: After the client has completed the meal, observe how much the client has eaten and the amount of fluid taken, record the fluid

intake and calorie count as required Provide hygiene measures after feeding Record any pain, fatigue or nausea experienced by client

Date ordered/ General Description Indication/s Specific foods Client’s response

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Type of Diet Date taken/

Date changed

Purpose/s Taken to medication with actual side effect

Soft Diet October 1, 2010 A diet that is soft in texture, low in residue, easily digested and well tolerated.

It provides nutrition to the client who has just undergone surgery and client who cannot tolerate hard foods.

Sips of water, tea, crackers


Before: Explain to the client and significant others the purpose, indication and the duration of the diet. Assist the client’s compliance ability to the diet.

During: Position the client in a sitting or high or fowler position. Advise the client to consume foods that are easily digested. Monitor the compliance of the patient to the diet.

After: Evaluate the effect of the diet to the client. Assess any nutritional disturbances and notify the physician.

Type of Diet Date ordered, Date started, Date

General Indication/s Specific Foods Client’ s response and/or response to

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changed description Purpose/s Taken the diet

Diet as tolerated

(DAT)

October 2, 2010 The patient can eat any food as long as tolerated

To increase rate of healing

RiceVegetablesCrackersEggsChicken


Prior

Caution patient to avoid food such as eggs, nuts, milk, sulfites, fish and chocolate that can trigger asthma attack.

During:

Advise client to properly chew the food.

After:

Advise patient to report any allergic reaction to the food taken.

iv. Activity / Exercise

Type of exercise

Date Ordered

Date Started

Date Changed

General Description Indications or Purposes

Specific exercise/activit

y

Client’s response and/or reaction to

the diet

P a g e | 46

Flat on bed

September 29

It is type of exercise done after the surgical procedure; the client must be in a supine position without using a pillow. After 8 hours the client must be able to use pillow already.

To prevent spinal headache.

Complete bed rest within 8 hours.

The client complied to the ordered exercise

Turn from side to side

September 29

Patient will turn on the right side then rotate to the opposite side after 2 hours

To increase blood circulation and prevent pressure ulcer

Turn from side to side every 2 hours

Patient was able to tolerate the exercise but with a little discomfort due to surgical incision

Sitting on bed

October 01, 2010

It is a type of exercise done after the client able to turn side to side, and the back of the client is unsupported and legs hanging freely

To increase blood circulation

Sitting on the bed without assistance


Standing beside the bed

October 02, 2010

It is a type of exercise when the client is able to stand by her own and no significant others assisted to her.

To increase blood circulation

Standing in the side of the bed without assistance


Ambulation Patient will walk unaided on the side of

To increase blood

Walking on the side of the bed

Patient was able to tolerate the exercise but with a little

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October 03, 2010

the bed and on the hallway

circulation without assistance

discomfort due to surgical incision

ROM (Range of Motion) October 01,

2010

A body action involving the muscles, joints, and natural movements such as abduction, adduction, flexion, extension, pronation, supination, and rotation.

These exercises reduce stiffness and help keep your joints flexible.

The client participated in the activity.


Prior:

Learn passive ROM exercises from the person's caregiver. Practice the exercises with the caregiver first. The caregiver can make sure you are doing the exercises right.

Raise the person's bed to a height that is comfortable for you. This will help keep you from hurting your back or other muscles. Make sure the wheels of the bed or wheelchair are locked before you start the exercises.

During Do all ROM exercises smoothly and gently. Never force, jerk, or over-stretch a muscle. This can hurt the muscle or joint

instead of helping. Move the joint slowly. This is especially important if the person has muscle spasms (tightening). Move the joint only to the

point of resistance. This is the point where you cannot bend the joint any further. Put slow, steady pressure on the joint until the muscle relaxes.

Stop ROM exercises if the person feels pain. Ask the person to tell you right away if he feels any pain. Watch for signs of pain if the person is unable to talk. The exercises should never cause pain or go beyond the normal movement of that joint

After: Make ROM exercises a part of the person's daily routine. Follow the caregiver's orders. The person's caregiver will tell you how many times per day you should do ROM exercises. The

caregiver will tell you how many repetitions (number of times) you should do exercises on each joint.

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2. Surgical Management

Name of Procedure

Date Performed Brief Description Indication/Purpose Client’s response to the operation

Cholecystectomy, IOC, CBDE, T-tube Choledochostomy

September 29, 2010

Cholecystectomy is the surgical removal of the gallbladder. Despite the development of non-surgical techniques, it is the most common method for treating symptomatic gallstones.Intraoperative cholangiography (IOC) - The doctor places a small tube called a catheter into the cystic duct, which drains bile from the gallbladder into the common bile duct. A dye that blocks X-rays is injected into the common bile duct, and then X-rays will be taken.A common bile duct exploration is a procedure used to see if a stone is blocking the flow of bile from the liver and

A cholecystectomy is performed to treat cholelithiasis and cholecystitis.Intraoperative cholangiography (IOC) may decrease the risk of common bile duct (CBD) injury during cholecystectomy by helping to avoid misidentification of the CBD. Common Bile Duct Exploration is used to remove large stones during or after some gallbladder operations when stones are detected.Choledochostomy is the creation of an opening into the common bile duct for drainage.

The patient complained of difficulty of breathing and reported little sensation on the lower extremities upon discharge from the PACU. It was observed that the patient was also drowsy.

http://www.revolutionhealth.com/articles?id=stc123726

http://en.wikipedia.org/wiki/Gallstone

http://en.wikipedia.org/wiki/Gallbladder

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gallbladder to the intestine. Choledochostomy: Surgical formation of an opening (stoma) into the COMMON BILE DUCT for drainage or for direct communication with a site in the small intestine, primarily the DUODENUM or JEJUNUM.

Prior: Always check to see if the informed consent has been given and that a signed form documents it. Ask the woman when she last had anything to eat or drink. Frequently, an antacid is given before surgery to reduce the risk of aspiration while the woman is under the effects of

anesthesia. Ensure that an intravenous fluid is in place with a large bore catheter Ensure that an abdominal shave preparation is done immediately before surgery Ensure that a Foley catheter is in place Ensure that laboratory studies ordered are completed

During The nurse supports the woman so that her back remains in a c-shaped curve during placement or a regional anesthesia by the

anesthesiologist The nurse assists the woman to the supine position on the O.R table The nurse places a wedge under one hip, and then places a warm blanket and safety strap on the woman’s legs Ensure that a sterile abdominal preparation with alcohol or Betadine is performed and a sterile drape is provided The nurse performs the second O.R count

http://www.wrongdiagnosis.com/medical/jejunum.htm

http://www.wrongdiagnosis.com/medical/duodenum.htm

http://www.wrongdiagnosis.com/medical/common_bile_duct.htm

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After: The nurse transfers the woman from the operative suite to the PACU Ensures connection of monitoring devices that will record the electrocardiogram, blood pressure, pulse, and oxygen saturation

of the blood Monitor vital signs and pulse oximetry reading every 5 minutes until the readings are stable, and then 15 to 30 minutes until

the patient has met predetermined criteria Monitor the patient’s urinary output to make certain it is at least 30 cc/hour

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D. Evaluation

Discharge Planning

a. General condition of the client upon discharge

Upon client’s discharge (October 04, 2010), the client appeared neatly dressed with no

apparent body odor. He was afebrile. He was able tolerate minimal levels of activity such as

walking, moving from place to place and transferring from sitting to standing position without

dizziness. He was able to take any food tolerated. He also does not perspire excessively or show

signs of emotional distress such as nail biting or avoidance of eye contact.

III. Conclusion

This case served as a realization for the group. It required thorough investigation about client’s

condition against both theory and the large comparative environment. In this study, objectives

are important. Formulating objectives before conducting the study of Choledocholithiasis was

very challenging because it was very unfamiliar.

After doing this case study, the group attained the formulated nurse-centered objectives. They

were able to come up with a comprehensive presentation of the disease condition by means of

correct presentation of the data gathered through the use of nursing process. They were also able

to present the current trends about the disease condition, the reason for choosing such case for

presentation, and the importance of the case study.

By means of proper education rendered during the period of assessment and care, the client was

able to fully understand and recognize the disease condition. The client learned the importance of

healthy lifestyle and identified the predisposing factors that aggravated her condition.

IV. Recommendation

The group would like to convey the following recommendations that would enable to

facilitate the greater accumulation of knowledge and would improve the greater understanding of

the disease condition.

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To the Tarlac Province Health Divisions: Improve the awareness of disease in its towns and barangays, the common causes of it,

the clinical manifestations.

To the Nurses and Student - Nurses:

Complete assessment of the disease. Improve the knowledge of the client regarding disease condition

To the next researchers:

Continue establishing useful and latest trends about CHOLEDOCHOLITHIASIS. Validate the data found here with the latest studies

V. Bibliography

http://health.nytimes.com/health/guides/disease/gallstones/open-or-laparoscopic-common-bile-duct-exploration-(choledocholithotomy).html

http://en.wikipedia.org/wiki/Cholecystectomy http://jama.ama-assn.org/cgi/content/abstract/289/13/1639 http://www.med.umich.edu/1libr/aha/aha_commbd_crs.htm Kozier & Erb’s Fundamentals of Nursing Michelle Zator Estez Health Assessment and Physical Examination Mosby’s Drug Guide for Nurses 2009 Edition Mosby’s Nurse’s Pocket Guide 11th Edition Mosby’s Pocket Dictionary of Medicine, Nursing and Health Professions 5th edition Hole’s Essentials of Human Anatomy and Physiology

http://www.med.umich.edu/1libr/aha/aha_commbd_crs.htm



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REPUBLIC OF THE PHILIPPINES

TARLAC STATE UNIVERSITYCOLLEGE OF NURSING

Lucinda CampusTarlac City

GRAND CASE STUDY

ON CHOLEDOCHOLITHIASIS

In Partial Fulfillment of the Requirements

Of the Course Nursing Care Management 104

Presented by:

Group A4

Abraham, Aliana CristelBulatao, MarivicCapian, Jeiel Ann

Consul, Maria EloisaDelos Reyes, Arvin Christian

Guevarra, VanesaLaureano, Kristine JoyMolina, Dwain Mark

Molina, Victor Sandino Suba, Mary Joy

October 12, 2010

the grand case study-choledocholithiasis-group a4

Documents