CHAPTER I Introduction Cholelithiasis is another name for gallstones.

Gallstones are hard, solid lumps that form from bile in the gallbladder. Bile is a special liquid chemical made by the liver that helps the body break down and digest fats. The gallbladder is a storage sack for bile. One may have just one or many gallstones that can be as small as a piece of sand or as large as golf balls.

There are different kinds of gallstones. The most common stone is made of cholesterol (a fatlike material). A pigment stone is made up from bilirubin, which is a part of old, dead blood cells. Other kinds of stones may be a mixture of

cholesterol and bilirubin. Gallstones in the gallbladder or in the bile ducts can cause problems. Stones can block bile ducts flexible tubes). Bile ducts go from the liver to the gallbladder or from the gallbladder to the small intestine. Gallstones are more common in woman than in men between 20 and 50 years of age. But, as one gets older, anyone can get gallstones. Most gallstones result from supersaturating of cholesterol in the bile, which acts as an irritant, producing inflammation in the gallbladder, and which precipitates out of bile, causing stones. Risk factors include gender (women four

times as like to develop cholesterol stones as men), age (older than age 40), multiple parity, obesity, use of estrogen and cholesterol-lowering drugs, bile acid malabsorption with GI disease, genetic predisposition, rapid weight loss. Pigment

stones occur when free bilirubin combines with calcium. These stones occur primarily in patients with cirrhosis, hemolysis, and biliary infections. Cholelithiasis is the pathologic state of stones or calculi within the gallbladder lumen. A common digestive disorder worldwide, the annual overall cost of Cholelithiasis is approximately $5 billion, where 75-80% of gallstones are of the cholesterol type, and approximately 10-25% of gallstones are bilirubinate of either black or brown pigment. In Asia, pigmented stones predominate, although recent studies have shown an increase in cholesterol stones in the Far East. Gallstones are crystalline structures formed by concretion (hardening) or accretion (adherence of particles, accumulation) of normal or abnormal bile 1

constituents. According to various theories, there are four possible explanations for stone formation. First, bile may undergo a change in composition. Second, gallbladder stasis may lead to bile stasis. Third, infection may predispose a person to stone formation. Fourth, genetics and demography can affect stone

formation. Risk factors associated with development of gallstones include heredity, Obesity, rapid weight loss, through diet or surgery, age over 60, Native American or Mexican American racial makeup, female gender-gallbladder disease is more common in women than in men. . Sometimes, persons with gallbladder disease have few or no symptoms. Others, however, will eventually develop one or more of the following symptoms;

(1) Frequent bouts of indigestion, especially after eating fatty or greasy foods, or certain vegetables such as cabbage, radishes, or pickles. (2) Nausea and bloating.(3) Attacks of sharp pains in the upper right part of the abdomen. This pain occurs when a gallstone causes a blockage that prevents the gallbladder from emptying (usually by obstructing the cystic duct). (4) Jaundice (yellowing of the skin) may occur if a gallstone becomes stuck in the common bile duct, which leads into the intestine blocking the flow of bile from both the gallbladder and the liver. This is a serious complication and usually requires immediate treatment. The only treatment that cures gallbladder disease is surgical removal of the gallbladder, called cholecystectomy. Generally, when stones are present and causing symptoms, or when the gallbladder is infected and inflamed, removal of the organ is usually necessary. When the gallbladder is removed, the surgeon may examine the bile ducts, sometimes with X rays, and remove any stones that may be lodged there. The ducts are not removed so that the liver can continue to secrete bile into the intestine. Most patients experience no further symptoms after cholecystectomy. However, mild residual symptoms can occur, which can usually be controlled with a special diet and medication.

Goals: To provide the proper nursing care as needed by the patient. Objectives: a.)To have a deeper understanding of this condition, the course of the illness and the rationale behind the nursing measures to meet the patient s needs. b.)To be able to give appropriate nursing care based in the presenting symptoms of the condition. C.)To be able to educate the patient about his condition to gain his trust and cooperation to the medical regimen.

Nurse-Centered Objectives Upon completion of this case study, the student nurse should be able to: y y Identify the risk factor contributing to the disease. Formulate significant nursing diagnosis, with the significantly related nursing care plan. y Identify the different medications administered for this disease their indications, contraindications, side effect, and specific responsibility. y Identify the laboratory and diagnostic procedure done with the patient, their indication and purposes, and specific nursing responsibilities. Client-Centered Objectives Upon completion of this case study, the client should be able to: y y y Understand awareness of her disease. Know the possible causes of the disease. Learn and understand why such laboratory examinations are being done.

The group NQD 3 was assigned at Pozorrubio Community Hospital last June 7-9, 2010, 11-7 shift under the supervision of Mr. Jesus Aniban. The group chooses

Cholelithiasis as a case study because of the uniqueness of it in the ward. We want to further know about Cholelithiasis; its causes and risk factors, complications, signs and symptoms, treatment and interventions.

CHAPTER II

Patient Profile A. Biographical data Name: Ward: Gender: Age: Patient X PHIC Female Ward) Female 48 years old

Birth Date: July 28, 1963 Birth Place: Rosario La union Civil Status: Married Occupation: Housekeeper Nationality: Filipino Address: Pozurrobio, Pangasinan

Admission Date: June 21, 2011 Time: 11:05 p.m

C/C: Pain on Right Upper Quadrant that radiates at the Lower Back this started in the morning. She vomited six times in the morning. Diagnosis: To consider Cholelithiasis To rule out urinary tract infection

B. Clinical History This is the case of Patient X, a 48 years old,Female, a Filipino citizen. She was born on July 28, 1963 in She was admitted at Pozurrobio Community Hospital last July 22, 2011 at 11:05 pm accompanied by his husband, and with a chief complaint Pain on Right Upper Quadrant that radiates at the Lower Back this started in the morning. She vomited six times in the morning. It was started 1 day prior to admission when the patient started vomiting. She had no idea about it. So she went to PCH to have a check- up. The physician examined. The result revealed that he has a cholelithiasis. She needs to stay in the hospital in order for her to be examined well and to be treated and be observed for any possible complications. The patient is aware of her current condition and is very cooperative to all the medical procedures done to her.

B.1 History of Present Illness During the past years the patient has been experiencing pain on her right upper side part of the abdomen that radiates to her lower back which she ignored. And she verbalized that it was a tolerable pain and when she sleeps the pain is alleviated. Before the hospitalization, she had experienced an intense pain but instead of going to the hospital for check up she just took pain relievers. She had experienced nausea and vomiting. Two days prior to admission the patient again experienced intense pain while at home accompanied by vomiting.

B.2 History of Past Illness Mrs. Patient X44 was hospitalized before for six times already. She had a severe headache and flu in the past years.She was also diagnose with cardiomegaly and gastritis atLepanto Consolidated Mining Corporation Hospital but aside from that she was never brought to hospital for conditions which are related to her condition now.

B.3 Family history Patient X has family history of hypertension and has negative family history for cancer, diabetes and asthma.

B.4 Socio-Economic Mrs. Patient X is a housekeeper. Her hospitalization expenses are covered by her husband and her needs are adequately compensated. She is born a Roman Catholic. She is considered a modern woman; she works at home and at the same time she is also a mother. She is barely the one cooks foods which are easily done for example fried foods.

CHAPTER III 13 Areas of assessment A. Psychosocial Status According to Erik Erikson s Psychosocial Tasks, Patient X is under the Generatively vs. Stagnation Stage. Her primary concern is establishing and guiding the next generation through the means of socially-valued work and disciplines. In addition, she contributes to the society by raising a family and working toward the betterment of the people.

Patient X is a 47 year old Filipino and an active member of the Pentecostal Church. She is married and lives with her husband and four children. As a housewife, she usually spends most of her time at home. She enjoys interacting with her family and opts to stay at home and tend to her garden. In addition, the most important aspect of her life is being with her family, especially on Sundays, when they go to church together.

B. Mental Status Patient X is able to state correctly the place and time during her assessment. She is also able to answer basic questions and is able to converse properly. It will take the patient a few seconds to answer questions regarding her present condition. She is a bit hesitant to share her feelings because she fined it awkward to open up to a complete stranger. During her hospitalization, she is able to comply with nursing routines like taking vital signs and medication.

C. Environmental Status Patient X is confined in the PHIC Female Surgery Ward together with other patients. The ward is well lighted and consists of 8 beds. Her bed is approximately 1 x 2 meter, 2-3 feet above the floor and located at the left corner. The Patient s bed has no side rails to prevent her from falling. A bed side table is also available. A wooden chair was provided beside the client s bed for the significant others. Nurse station is approximately 10-15 steps away from her bed. The comfort room is located

approximately 5-8 steps from the patient s bed, on the right corner of the ward. In addition, a garbage can outside the ward is also provided for their trash and it is usually collected during the janitor s round.

D. Sensory Status D.1 Visual Status With the use of penlight, the patient s sense of sight was evaluated. Her pupils constricted when struck by light, indicating a normal vision. Eyes have normal color (white sclera), with no signs of redness, jaundice and irritation, Round and reactive to light and accommodation. The conjunctiva is pale upon assessment. He has no abnormalities of the eye that implies no visual defects.

D.2 Auditory Status Patient has no auditory deficits and impaired verbal communication. The voice whisper test was used. Words were whispered into the patient s ear and the patient was then instructed to repeat the words that were whispered to her. The procedure was then repeated to the other ear. Based on the given data, the patient s auditory status is normal since she was able to repeat the word whispered to her from a distance of 2 inches. Both ears show no signs of abnormal discharge and there were no noted deviation in size and location of ears. She does not wear any hearing aids.

D.3 Olfactory Status Patient is able to distinguish pleasant and unpleasant odors like 70% Isopropyl alcohol, perfume and medicines. This indicates that the patient has a normal sense of smell. There were no noted deformities, lesions or deviation on patient s nose.

D.4 Gustatory Status Patient is able to distinguish the taste of coffee, salt, and sugar while being blindfolded. Based on her description of the food s taste, her gustatory sense is normal.

D.5 Tactile Status During assessment, patient has the ability to perceive hot and cold surfaces on her body. She can distinguish textures like rough and smooth surfaces and can compare light and firm touch.

E. Motor Status The patient was not able to stand on her own and balance herself during assessment due to pain felt in right upper quadrant. She is also able to go to the comfort room with minimal assistance from significant others. Upon assessment of motor stability, we were able to conclude that the patient has a weak motor gait and posture, affected mainly by her present condition.

4/5

4/5

4/5

4/5

This implies that both the upper and lower extremities have weakness. Legend: 0/5- No muscular contraction detected 1/5- Barely detectable flicker or trace of contraction 2/5- Active Movement of the body part with gravity eliminated 3/5- Active movements against gravity 4/5- Active movement against gravity and some resistance 5/5- Active movement against full resistance fatigue.

F. Nutritional Status The patient is able to eat well and prefers fruits and vegetables mostly beans and pork mostly the fatty part. She is also fond of drinking herbal tea and fruit juice. Patient X is eats well and is in a good state of nutritional health.

G. Elimination Status The patient urinates about 2-3 times of approximately 200-300 ml in the toilet prior to admission. Her urine is yellow and clear in appearance. She defecates at least once a day.

H. Fluid and Electrolytes Patient is hydrated with an IVF of D5LRS 1000 ml x 12hours regulated at 20-21 utts/min. She has no observable signs of edema and dehydration. She drinks at least 2 glasses of water a day. I. Circulatory Status Patient s cardiac rate ranges from 80-91 beats per minute. Her pulse rate was strong with regular rate and rhythm. J. Temperature Status The patient s temperature ranges from 36.3 thermometer. C up to 37.2 C through digital

K. Respiratory Status Patient s respiratory rate ranges from 16-20 breaths per minute. There were signs of difficulty of breathing like using accessory muscle for breathing, no chest pain; no cough and clear sound were heard on both lungs upon auscultation. The airway is patent with normal breath sound and pattern upon inhalation and exhalation. There was symmetrical expansion of the chest wall upon exhalation.

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L. Integumentary Status Patient X had an intact IV site on her left hand. Skin has good skin turger. Patient s hair is dry and coarse while her nails are yellowish with a capillary refill of 1-2 seconds.

M. Comfort and Rest Status According to the patient, she usually sleeps for at least 8 hours a day prior to admission. Upon hospitalization, she finds it hard to get a good night s sleep due to pain on right upper quadrant. Her hour of sleep usually lasts for only 6 hours but she takes a nap in the afternoon.

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CHAPTER IV Laboratory Findings A. URINALYSIS Urinalysis yields a large amount of information about possible disorders of the kidney and lower urinary tract, and systematic disorders that alter urine composition.Urinalysis data include color, specific gravity, pH, and the presence of protein, RBC s,WBC s, bacteria, Leukocyte, esterase, bilirubin,glucose, ketones, casts and crystals.

Results: Color- yellow Transparency- turbid Specific Gravity- 0.010 Sugar/ Albumin- negative Pus cells- 0.1 hpf Conclusions: The results are normal but there is a presence of pus cells in the urine which means that there is also the presence of infection.

B. ULTRASOUND Ultrasounds diagnose a variety of heart conditions and to assess damage after a heart attack or diagnose for valvular heart disease. Result: Liver: The liver is unenlarge. Parenchyma echotexture and medium. The intra and extra hepatic ducts are not dilated. The portal venous radicels and inferior vena cava are not dilated. GALLBLADDER:the gallbladder is dilated measuring about 105x41 mm. Its wall is slightly thickened about 2 shadowing echogenic foci is noted intraluminally the larger one measuring about 2.2cm is located on the gallbladder fundus and the smaller on the measuring about 1.3cm is noted lodged on the gallbladder neck. Conclusion:

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The result shows the presence of gallstones, a thickened gallbladder wall, and pericholecystic fluid. In those patients with symptomatic gallstones and a negative ultrasound examination, endoscopic ultrasound may be helpful.To confirm the suspicion of cholecystitis, a hydroxyiminodiacetic acid (HIDA) scan can be useful. The radionuclide material is concentrated in the liver and excreted into the bile but does not fill the gallbladder because of cystic duct obstruction.

C. HEMATOLOGY This is to determine blood components and the response to inflammatory process and streptococcal infection. Laboratory test hemoglobin Results 136g/L Normal Range M:140-180g/L F:120-160g/L WBC neutrophils lymphocytes 5.0-10x10g/L 0.60 0.21 5.0-10.0x10g/L 0.50-0.70 0.20-0.40 normal normal normal Values Interpretation normal

Conclusion: The results show that there is an infection. neutrophils indicates that there is a bacterial infection in the body.

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CHAPTER V Anatomy and Physiology Gallbladder, muscular organ that serves as a reservoir for bile,present in most vertebrates. In humans, it is a pear-shaped membranous sac on the undersurface of the right lobe of the liver just below the lower ribs. It is generally about 7.5 cm (about 3 in)long and 2.5 cm (1 in) in diameter at its thickest part; it has a capacity varying from 1 to1.5 fluid ounces. The body (corpus) and neck (collum) of the gallbladder extend backward, upward, and to the left. The wide end (fundus) points downward and forward, sometimes extending slightly beyond the edge of the liver. Structurally, the gallbladder consists of an outer peritoneal coat (tunica serosa); a middle coat of fibrous tissue and unstriped muscle (tunica muscularis); and an inner mucous membrane coat (tunica mucosa).The function of the gallbladder is to store bile, secreted by the liver and transmitted from that organ via the cystic and hepatic ducts, until it is needed in the digestive process. The gallbladder, when functioning normally, empties through the biliary ducts into the duodenum to aid digestion by promoting peristalsis and absorption, preventing putrefaction, and emulsifying fat. Digestion of fat occurs mainly in the small intestine, by pancreatic enzymes called lipases. The purpose of bile is to; help the Lipases to Work, by emulsifying fat into smaller droplets to increase access for the enzymes, Enable intake of fat, including fat-soluble vitamins: Vitamin A, D, E, and K, rid the body of surpluses and metabolic wastes Cholesterol and Bilirubin.

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Chapter VI Pathophysiology A. Schematic Diagram Gallstones

Liquid bile contains too much cholesterol, bile salts or bilirubinunder certain conditions it can harden into stones.

Cholesterol stones

Pigment Stones

Gallstones can block the normal flow of bile

Hepatic Duct

Cystic Duct

Common Bile Duct

Bile trapped in this Ducts

Other ducts open into the common bile duct

If a gallstone blocks the opening to that duct, digestive Enzymes can become trapped in the pancreas

CHOLELITHIASIS

Signs and Symptoms y y y y y y y Pain in the RUQ abdomen Stool clay-colored Nausea& vomiting Heart burn Gas or excessive Flatus Abdominal indigestion Abdominal fullness

Complications -Acute or chronic cholecystitis -Choledocolethiasis -Cholangitis -Empyema -Gallstone ileus -Acute Pancreatitis

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B. Narrative The exact pathophysiology of gallstone formation is not clearly understood, but abnormal metabolism of cholesterol and bile salts plays an important role in their formation. Contributing factors may include the the supersaturation of bile with cholesterol, excessive bile salts loss, decreased gallbladder-emptying rates. Changes in bile concentration or bile salts within the gallbladder. Gallstones may lie dormant within the gallbladder or may move to other areas of the biliary tree as the gallbladder empties and refills with bile. They may migrate and lodge within the gallbladder neck, cystic duct, or common bile duct causing obstruction. Gallstones interfere with or totally obstruct normal bile flow from the gallbladder to the duodenum, causing vascular congestion as a result of impeded vascular return. Edema and congestion occur and contribute to the initial inflammatory process. When bile cannot flow from the gallbladder, the stasis of bile and local irritation from the gallbladder lead to cholecystitis.

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CHAPTER VII

Nursing Care Management

The Prioritized Health Problems Based on Maslow s Hierarchy of Needs Each of us is motivated by needs. Our most basic needs are inborn, having evolved over tens of thousands of years. Abraham Maslow's Hierarchy of Needs helps to explain how these needs motivate us all. Maslow's Hierarchy of Needs states that we must satisfy each need in turn, starting with the first, which deals with the most obvious needs for survival itself. Only when the lower order needs of physical and emotional well-being are satisfied are we concerned with the higher order needs of influence and personal development. Conversely, if the things that satisfy our lower order needs are swept away, we are no longer concerned about the maintenance of our higher order needs. Based on Abraham Maslow s Hierarchy of Needs theory, we came up with these lists of health condition or problems ranked according to priority:

o Risk for impaired oxygen exchange o Acute Pain o Imbalanced Nutrition: less than body requirements o Risk for fluid volume deficit o Deficient knowledge about self-care activities related to dietary modification o Risk for impaired skin integrity related to surgical intervention

This is how the actual and potential diagnoses are sequenced according to Maslow's Hierarchy of Needs:

1. Acute pain

Pain is a physiological need for comfort. When the client is in pain, she

wasn t able to eat and drink normally, thus, contributed to her nutritional imbalance and risk fluid volume deficit. 2. Imbalanced nutrition: Less than body requirements A physiological need for food to balance her nutritional status, and with a good diet itself, this will increase her chance to reach the ideal weight. 3. Risk for fluid volume deficit of it. 17 A physiological need for fluid by having adequate intake

4. Risk for impaired oxygen exchange This is a physiological need for oxygen, and all of us do, as well, and oxygen is a basic need of an individual to survive, but our patient is just at risk because she is about to undergo surgery, which is Cholecystectomy. 5. Deficient knowledge A self-actualization need for growth by modifying her diet and

growing as an individual to be able to care for self. 6. Risk for impaired skin integrity threat. An anticipated need for safety from physiological

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