Introduction/Objectives

One 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 the gallbladder, a small organ near
the liver that 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 Profile
Name: Patient D.F.V
Sex: Female
Age: 26 y/o
Birthdate: May 19, 1987
Address: Elias St. Sta. Cruz Manila
Religion: Roman Catholic
Nationality: Filipino
Chief Complaint: Right Upper Quadrant Pain
Diagnosis: 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 Assessment
Name: Patient D.F.V
Age: 26 years old
Sex: Female
Department: ER-Surgery
Diagnosis: Acute Calculous Cholecystitis
Chief Complaint: Right Upper Quadrant pain

General Survey
The patient is awake and responsive, not in any respiratory distress, ambulatory but with fair
activity.

II

Vital Signs
Techniques: Inspection, Palpation, Auscultation
Patient 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.

PART
Skin

Head

TECHNIQ
UE
Inspection
and
Palpation

Inspection
and
Palpation

NORMAL FINDINGS

ACTUAL FINDINGS

INTERPRETATION

Color varies from

light to deep brown

Light to deep brown

No edema

No edema noted

Normal

Skin temperature is
uniform within
normal range

Skin temperature is
uniform with axillary
temperature of 37.C

Normal

Configuration is
normocephalic
No lesions or
tenderness

Head is
normocephalic in
shape
Absence of lesions
and no signs of
tenderness

Normal

Normal

Normal

Normal

Normal

Anterior and
posterior fontanels
are flat and closed

Hair

Inspection

Evenly distributed,
thick hair, silky,
resilient, no
infestation

Anterior and posterior

fontanels appear to
be flat and closed
Hair is thick, smooth,
moist, and with no
signs of parasitic
infestation

Eyes:
Sclera

Inspection

Appears white

Appears white

Normal

Cornea

Inspection

Transparent, shiny,
smooth with corneal
details visible

Pupils

Inspection

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

Eye Balls

Inspection

Palpebral
and
Bulbar
Conjuctiv
a
Ears

Eyeballs are
symmetrical in size
Not protruding

Inspection

Smooth, pink or red

Inspecton
and
Palpation

Auricles fair in color

Symmetrical and
aligned with outer
canthus of eyes
Auricles are flexible,
firm, no tenderness
Absence of purulent
discharge in the

Transparent, shiny,
smooth; details
apparent

Black in color; briskly

constricts when
illuminated and
dilates when not
illuminated

Aligned

Normal

Normal

Normal

Normal

Auricles are fair in

color, symmetrical in
shape, flexible with
no tenderness

There is no discharge
from the ear canal

Responds to the voice

of mother and father

Normal

Eyeballs are
symmetrical in shape
and size
There is no protrusion
Smooth, pink or red

Normal
Normal


Nose

Inspection
and
Palpation

Mouth

Inspection
and
Palpation

external canal
Patient responds to
sound
Nares are patent
Septum on the
midline
Mucosa is pinkish in
color
Lips are moist and
pinkish in color
Oral mucosa is
pinkish with no
ulcerations

Normal

Normal

Patent nares with

septum on the
midline
Mucosa is pinkish

Lips are pink in color

Normal

Oral mucosa is
pinkish with no
ulcerations e
No ulcerations in oral
mucosa

Normal

Normal

Neck is symmetrical
Thyroid glands are
not tender and
enlarged

Normal
Normal

Neck muscles are

equal in size
Trachea is positioned
midline

Normal

Chest is not bulging

and appears
symmetrical

Normal

Normal

Neck

Inspection
and
Palpation

Neck is symmetrical
Thyroid glands are
not tender and
enlarged

Chest

Inspection
,
Palpation,
Auscultati
on

Neck muscles are

equal in size
Trachea is positioned
midline upon
palpation
Full and symmetric
and not bulging
Breathing is
abdominal and
posterior mobility

Abdominal breathing
is present (pediatric)

and posture of
thorax is
symmetrical upon
respiration

Heart

Auscultati
on

Clear breath sounds

S1 usually heard at
all sites but louder at
apical area
S2 usually heard at
all sites but louder at
base of the heart
Symmetrical in size
and shape
Areola is round or
oval and color is light
pink to dark brown
Nipples are round,
and equal in size

Vascular and pinkish

in color
Smooth texture
Intact epidermis
Capillary refill in 3-5

Breast

Inspection

Finger
and Toe
Nails

Inspection
and
Palpation

with thoracic
movement
symmetrical

Normal

Normal

Normal

Normal

Nipples are round and

almost in size

Normal

No presence of harsh
breath sounds;
patient was crying
and irritable during
assessment
S1 and S2 are heard
audibly on apical and
base areas of the
heart
No murmur or gallops
(S3 and S4)
Symmetrical in size
and shape
Areola is small and
brown in color

Vascular and pinkish

in color
Smooth texture
Capillary refill of 3
seconds

Normal

Normal
Normal

Abdomen

Inspection
,
Auscultati
on,
Palpation

seconds
Unblemished skin,
uniform in color

No tenderness upon
palpation

no evidence of liver
enlargement
Audible bowel
sounds

Presence of Scar at
right lower quadrant

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

Muscles

Inspection
, Palpation

Equal size on both

sides of the body; no
contractures
Good muscle tone,
firm with smooth
coordinated
movements

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

The scar noted is a

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

Normal

Symmetrical in size
on both sides of the
body

Normal

Normal

Good muscle tone

with no signs of
uncoordinated motor
movement

Laboratory Procedures
Serum Creatinine, Total, Sodium, Potassium
Test
Result
Unit
Normal
Value
Creatinine
47.30
Mmol/L
45-104

Na+

136.90

Mmol/L

135-143

K+

4.49

Mmo/L

3.4-4.82

Normal
Value
123-153

Analysis and
interpretation
The result is
within the normal
range.
The result is
within the normal
range
The result is
within the normal
range

Complete blood count

Test

Result

Unit

Hemoglobin

137

g/L

Hematocrit

0.43

RBC

4.52

10^12/L

4.1-5.1

MCV

94

fL

82-98

MCH

30.35

Pg

28-33

MCHC

32.34

g/L

33-36

WBC

10.9

10^9/L

4.8-10.8

0.359-0.446

Analysis and
interpretation
The result is
within the normal
range
The result is
within the normal
range
The result is
within the normal
range
The result is
within the normal
range
The result is
within the normal
range
The result is
within the normal
range
The result is
slightly elevated.
A high white
blood cell count,

called leukocytosi
s, may result
from a number of
conditions and
diseases such as
infections and
inflammatory
conditions.
DIFFERENTIAL COUNT
Neutrophils
0.69

0.40-0.70

Lymphocytes

0.22

0.19-0.48

Basophils

0.00

0.00-0.05

Monocytes

0.07

0.00-0.15

Eosinophils

0.02

0.02-0.08

Platelet
Count

490

MPV

7.80

RDW

12.20

10^9/L

150-400

7.80

11.4-14.0

The result is
within the normal
range
The result is
within the normal
range
The result is
within the normal
range
The result is
within the normal
range
The result is
within the normal
range
A high platelet
count may be
referred to as
thrombocytosis.
This is usually the
result of an
existing condition
such as
inflammatory
conditions.
The result is
within the normal
range
The result is
within the normal
range

Sonographic Report
Gallbladder:
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

PATHOPHYSIOLOGY
Modifiable factors

Non modifiable factors

-Obesity

-Gender/sex (female)

-Rapid weight loss and diet

-Genetic predisposition

-Lack of physical activity

-Ethnicity

Bile stagnates in the

gallbladder

Pigment solute
precipitate as solid
crystals
Crystals clump
together and form
stones
Gallstones

Gallbladder contracts
after intake of fat to
release bile
Upon contraction, a stone is moved
and becomes impacted on the
cystic duct

CHOLELITHIASIS
Lumen is obstructed
by stones
Bile stasis

Chemical reaction inside

gallbladder triggers the release
of inflammatory enzymes
(Prostaglandins)

Fluids leak into

gallbladder

Inflammation of the
gallbladder

Edema

Increased
intraluminal
pressure and
distention of the

Right Upper Quadrant

Pain

Drug Name

Classification

Indications

Mechanism
of Action

Adverse
Reactions

Metronidaz
ole 500m
IV

antiinfective;
antitrichomon
al;
amebicide;
antibiotic

Amebic liver
abscess

Direct acting
trichomonac
ide and
amebicide
that works
inside and
outside the
intestines.
Its thought
to enter the
cells of
microorgani
sms that
contain
nitroreducta
se, forming
unstable
compounds
that bind to
DNA and
inhibit
synthesis,
causing cell
death

CNS:
Headache,seiz
ures, fever,
vertigo,
syncope,
dizziness,
insomnia

Intestinal
amebiasis
Trichomonia
sis
Refractory
Trichomonia
sis
Bacterial
infections
caused by
anaerobic
microorgani
sms
To prevent
post
operative
infection in
contaminate
d or
potentially
contaminate
d colorectal
surgery

Contraindicat
ns

Contraindicat
d in patients
hypersensitiv
to the drug
and other
nitroimidazole
derivatives
and in patient
CV:
in first
edema,flushing trimester of
thrombophlebit pregnancy
is after IV
infusion
Use cautiousl
in patients
GI: nausea,
with history o
abdominal
blood
cramping or
dyscrasia, CN
pain,
disorder or
stomatitis,
retinal or
epigastric
visual field
distress,
changes
vomiting,
metallic taste

Drug
Name

Classification

Indication
s

Mechanism
of Action

Adverse
Reactions

Contraindi
ons

Ciprofloxa
cin
200mg IV

Inhibition
of topoisomerase(
DNA
gyrase)enzymes,
which inhibits
relaxation of super
coiled DNA
and promotes bre
akage of double
stranded DNA

Complica
ted intra
abdomina
l infection

Inhibit s
bacterial
DNA
synthesis,m
ainly by
blocking
DNA gyrase,
bactericidal

CNS: seizures,
confusion,
depression,
drowsiness,
fatigue,
hallucinations,
headache,
insomnia

Contraindi
ed to patie
hypersens
e to
fluoroquin
nes

CV: edma,
thrombophlebitis
GI:
pseudomembrano
sous colitis,
diarrhea, nausea,
abdominal pain or
discomfort,
constipation

`
Drug
Name
Ketorol
ac 30
mg IV

Classification
non steroidal
anti
inflammatory
drugs

Indication
s
Short term
managem
ent of
moderatel
y severe,
acute pain
for single
dose
treatment

Mechanism
of Action
May inhibit
prostagland
in synthesis
to produce
anti
inflammato
ry ,
analgesic
and anti
pyretic
Short term effects
managem
ent of
moderatel
y severe,
acute pain
for
multiple
dose
treatment

Adverse
Reactions
CNS: dizziness,
drowsiness,
sedation
CV:
arrhythmias,
edema,
hypertension,
palpitations
GI: dyspepsia,
nausea,
constipation,
diarrhea,flatule
nce

Contraindications
Contraindicated in
patients
hypersensitive to
drug and in those
with active peptic
ulcer disease,
recent GI bleeding
or perforation,
advanced renal
impairment

NURSING CARE PLAN

Assessment

Nursing
Diagnosis
SUBJECTIVE: Acute pain
related to
Masakit
inflammatio
ang
n and
kanang
distortion of
tagiliran
tissues as
ko as
verbalized
by the
patient.
Pain starting
suddenly
and
usually
peaking in
30
minutes.
OBJECTIVE:
Facial mask
of pain
Pain Scale
of 7/10
Muscle
guarding
or rigidly
when right
upper
abdomen
palpated
Narrow
focus
Vital Signs:
- T = 37.3
C
- PR =
110
- RR = 23
BP = 130/80

Inference

Planning

Cholelithiasi
s
I
Further
complicatio
n
I
Inflammatio
n of the
Gallbladder
I
Acute pain

SHORT
TERM
OBJECTIVE:
After an
hour of
nursing
intervention
s, patients
pain will be
relieved or
controlled as
patient
demonstrate
s use of
relaxation
skills and as
indicated for
individual
situation.

Nursing
intervention
INDEPENDEN
T:
Observe and
document
location,
severity (110 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

Rationale

Assist in
differentiating o
pain and provide
information abou
disease
progression/reso
tion, developme
of complications
and effectivenes
of interventions

Bed rest in low

Fowlers position
reduces
intraabdominal
pressures;
however, patien
will naturally
assume least
painful position.

section for
the
medications
given with
correspondin
g indicatons

Jose R. Reyes Memorial Medical Center

Case Study
on Acute
Calculous
Cholecystit
is
PREPARED BY: RYAN JOSEPH M. MAGPAYO, RN

(NURSE I-RNHEALS)