cholelitiasis present case

7/18/2019 Cholelitiasis Present Case

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CHOLELITHIASIS

NAME:KHAIRUL AZLINA BT SHAHIMIID:57254313 31


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NURSING CARE AND

MANAGEMENT OF CLIENT

WITH

CHOLELITIASIS

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INTRODUCTION The gallbladder is a small, pear-shaped organ located

beneath the liver. The gallbladder stores bile, the greenish

yellow digestive fluid produced by the liver.

When bile is needed, the gallbladder contracts, pushing

the bile through the lower portion of the bile duct into the

small intestine. Bile flows out of the liver through the left and

right hepatic duct.

This duct then joins with a duct connected to the

gallbladder, called the cystic duct, to create the common bile

duct. The common bile duct enters the small intestine at the

sphincter of Oddi (a ring-shaped muscle), a few inches below

the stomach. 3


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Introduction

Gallstones develop insidiously, and they may

remain asymptomatic for decades. Migration of aa gallstone into the opening of the cystic duct may

block the outflow of bile during gallbladder

contraction.

The resulting increase in gallbladder wall

tension produces a characteristic type of pain

(biliary colic).

4
http://emedicine.medscape.com/article/1950020-overviewhttp://emedicine.medscape.com/article/1950020-overviewhttp://emedicine.medscape.com/article/1950020-overviewhttp://emedicine.medscape.com/article/1950020-overview


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Introduction

Pain at upper right quandrant is pain that comes on

quickly and usually last a short time.

The pain can range from mild to severe and is often

caused by an injury or sudden illnness such as sur

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PATHOFISIOLOGY

Gallstone formation occurs because certainsubstances in bile are present in concentrations thatapproach the limits of their solubility.

When bile is concentrated in the gallbladder, it canbecome supersaturated with these substances, whichthen precipitate from solution as microscopic crystals.

The crystals are trapped in gallbladder mucus,producing gallbladder sludge. Over time, the crystals

grow, aggregate, and fuse to form macroscopic stones.

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Pathophysiology

The flow of bile in the gallbladder is obstructed due to

the presence of stones.

When the bladder releases bile, it contracts and there is

spasm, thus it cannot adequately release bile due to the

stone, it stimulates the release of cytokines resulting to

pain .

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Etiology

Can be caused by an obstruction, gallstone or a tumor.

When there is an obstruction, gallstone or tumor itprevents bile from leaving the gallbladder.

Bile gets trapped and acts as an irritant which causes

cellular infiltration within 3 4 days.

This infiltration causes an inflammatory process

The gallbladder becomes enlarged and edematous. 8


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Etiology

Eventually this occlusion along with bile stasis causes themucosal lining of the gallbladder to become necrotic.

Gallbladder stasis associated with increased risk of

gallstones include high spinal cord injuries, prolonged fastingwith total parenteral nutrition, and rapid weight loss associated

with severe caloric and fat restriction

Rupture of the gallbladder becomes a danger, along with

spread of infection of the hepatic duct and liver.

If the disease is severe and interferes with the blood supply

it can cause the gallbladder to become gangrenous. 9


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MANIFESTASI CLINIKAL

Complaints of indigestion after eating high fat foods.

Localized pain in the right-upper quadrant epigastricregion.

Anorexia, nausea, vomiting and flatulence.

increased heart and respiratory rate

causing patient tobecome diaphoretic which in turn makes them think they

are having a heart attack.

Low grade fever. 10


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Manifestasi Clinical

Elevated leukocyte count.

Mild jaundice.

Stools that contain fat steatorrhea . Clay colored

stools caused by a lack of bile in the intestinal tract.

Urine may be dark amber- to tea-colored

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Presentation Of Case

Name :Mr K

Age:67years

Gender :Male

Race :Chinese

Register Number:HRPB176027

Indentity certificate:48020408xxxx

Date of admission:23/09/2013

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Genaral Health History

Patient have Hypertension over 10 years and follow upat Klinik Kesihatan Kampung Simee.

History last admission (2/7/2013) for Acute

Cholecyctitis.

Comuted Tomografy Abdomen/Pelvis done on17/7/2013,the result

-2 stones at neck of gallbladder

-acute cholangitis

-acute pancreatitis

-no gallbaldder empyema /intraabdomen collection

Plan for operation on 24/7/2013 (Laporoscopic

Cholecystectomy) 13


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General Health History

Currently presented with abdomen pain 1 weekmark on Right side,not radiating

Coliky in nature.

Complaint of vomiting 1day (multiple episode)-meal,no hematemisis,no bile

Have fever 1 day.

Ambulating with assistant

Full rest in bed and complain in pain

Lost of appetite 14


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General Health History

Vital sign on admission:Blood Pressure :153/92mmhg

Pulse :119 bpm

Tempreture:37 celcius

Saturation pulse oxymeter:98% (RA)Pain score:7/10

ECG done:normal

Blood Investigation taken:

Full Bloood Count

Liver function test

Serum amylase

Urine FEME 15


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Investigation

Full Bloood Count

Liver function test

Serum amylase

Urine FEME

Renal profile

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Blood Result Investigation

RESULT /DATE 23/9/2013 30/9/2013 Normal range

Hb 9.8 11.7 13.0-18.0 G/DL

platelet 197 313 150-400 G/DL

Creatinine 55 67 62-106umol/L

Urea 2.2 3.3 1.7-8.3mmol/L


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Investigation

Abdominal x-ray Ultrasound Abdomen

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Medical HistoryBiliary colic.

This is a severe pain in the upper abdomen. The pain is usuallyworst to the right-hand side, just below the ribs. It is caused by a

stone that gets stuck in the cystic duct. This is the small tube that

takes bile from the gallbladder to the bile duct. The gallbladder

then squeezes (contracts) hard to dislodge the stone, and thiscauses pain. The pain easy and goes if the gallstone is pushed

out into the bile duct (and then usually out into the gut), or if it falls

back into the gallbladder.

Pain from biliary colic can last just a few minutes but, more

commonly, lasts for several hours. A severe pain may only happenonce in your lifetime, or it may flare up from time to time.

Sometimes less severe but nigly pains occur now and then,

particularly after a fatty meal when the gallbladder contracts most

. 19


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Medical HistoryInflammation of the gallbladder.

This is called cholecystitis. This can lead to infection in

the gallbladder. Symptoms usually develop quickly andinclude abdominal pain, high temperature (fever), and being

generally unwell.

Pancreatitis.

This is an inflammation of the pancreas. The pancreas

makes a fluid rich in enzymes (chemicals which digest food).

The pancreatic fluid travels down the pancreatic duct. The

pancreatic duct and bile duct join together just beforeopening into the duodenum. If a gallstone becomes stuck

here it can cause pancreatitis which is a painful and serious

condition. See separate leaflet calledAcute Pancreatitis

which provides more details. 20
http://www.patient.co.uk/health/acute-pancreatitishttp://www.patient.co.uk/health/acute-pancreatitis


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Medical management

PLAN:

Keep nil By mouth

Intra Venous Drip(IVD) 5pint over 24hours,3pint

Dextrose 5% and 2 pint Normal saline.

Continued with the medication :

Iv flagyl 500mg tds

Iv Rocephine 1g OD

Iv Maxolon 10mg tdsStrictly intake out put chart

For operation laproscope cholecystectomy as

planned on 25/9/2013 21


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Surgical History

The laparoscope will be inserted through one of the

openings. It will provide images of the gallbladder and

surrounding area. Instruments will be inserted through the

small openings.

They will be used to grasp the gallbladder and clip off the

main artery and duct. The gallbladder will be removedthrough one of the small openings. Dye may be injected into

the duct to look for stones.

The entire abdomen will be carefully examined. Theincisions will be closed with sutures or staples. They will be

covered with bandages.

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Surgical management

Preoperative preparation

1)Prepared the consent before surgery for medical

legal

2)Advise patient to completely empty colon andcleanse intestines prior to surgery. And tell patient to

drink clear liquids only, for one or several days prior to

surgery.

3)After midnight the night before the operation, patientshould not eat or drink anything except medications to

empty of gaster.

4)Given ravin enema for preparation to help empty

bowels. 23


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Surgical management

5)Drugs such as aspirin, blood thinners, anti-

inflammatory medications (arthritis medications) andVitamin E will need to be stopped temporarily for several

days to a week prior to surgery.

6)Patient Teaching:

-must understand how to splint the abdomen fpr post

operation coughing,turning and deep breathing.

7)Monitor vital sign for baseline before surgery

8)Monitor Intake Output Chart

-urine and stool should be observe for alterations in theresent of bilirubbin 24


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Surgical management(Post operative surgery)

The belly button is the site where many surgeons put the

laparoscopic camera, is often the largest port for

cholecystectomy. It is often where the gallbladder is removed

from.During closure, the incision must be closed, or there is a

risk for a hernia to develop.

Some pain is common, up to several months afterwards,however if there is redness, tenderness and marked swelling,

After lap cholecystectomy, diarrhea once a day is fairly

normal. Occasional to frequent nausea is not uncommon,

sepia lily with fatty foods. Lethargy is a bit less expected. 25

Ch l t t


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Cholecystectomy or

Laparoscopic Cholecystectomy

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Nursing Intervension for pain

1)Document location,duration and intensity

(pain score o-10)

2)Advise patient completed rest in bed

3)Help patient in activities daily living(ADL)example feeding and elimination.

4)Teach patient excersice breathing for reduce pain

5)Encouragement to family members telling each

other personally feel concerned.6)Inform doctor if increased/persistent abdominal

pain.

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Pain management

1)Pain score asses using Numeric Scale

- pain scale on movement 7/10

-pain scale on rest 4/10

2)Continued medication for pain supported

-Tab Celebrex 200mg bd-Tab Paracetamol 1gm qid

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Nursing Diagnosis

1.Pain,related to inflamed gallbladder and surgical incision.

Patient outcomeVerbalize adequate pain control after surgery and with

activity

resumption

2.Pain at rt abdomen related to gallbladder is obstructed due

to the presence of stones.

Patient outcome:after 4hr of nursing intervention,the patient

shall have reported pain is controlled.

3.ineffective breathing pattern related to pain

Patient outcome :arter 1 hour nursing interventions,the

patient will demonstrate improve breating pattern. 29


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Nursing Diagnosis4.post operative acute pain

Patient outcome :after 2 hour nursing interventionsthe patient will report relief from pain.

5.Impaired physical mobility related to pain after

cholecystectomyPatient outcome:after 3hour of nursing intevention

patient will demonstrate behaviors that enable

resumption of activities.

6.disturrbed sleep paterrn related to pain

Patient outcome:Client will regularly fall asleep

without difficulty as measured by client verbalization

of easy of falling asleep consistently. 30


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Pharmacology management

Oral Dissolution TherapyDrugs, ursodiol (Actigall) and chenodiol

(Chenix), have been used and work best for

small cholesterol stones. These drugs can take

months or even years to dissolve thegallstones.

Contact Dissolution Therapy

This is an experimental treatment that involves

injecting methyl terbutyl ether directly into the

gallbladder. This drug can dissolve gallstones

in 1 to 3 days. 31


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Non pharmacology management

1)Don't skip meals. Try to stick to your usual mealtimes

each day. Skipping meals or fasting can increase the riskof gallstones.

2)Lose weight slowly. If you need to lose weight, go slow.

Rapid weight loss can increase the risk of gallstones.

Aim to lose 1 or 2 pounds (about 0.5 to 1 kilogram) aweek.

3)Maintain a healthy weight. Obesity and being

overweight increase the risk of gallstones. Work toachieve a healthy weight by reducing the number of

calories you eat and increasing the amount of physical

activity you get. Once you achieve a healthy weight, work

to maintain that weight by continuing your healthy diet

and continuing to exercise. 32


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Health Education1)Instructed the patient to continue medication as ordered

example:1. Cephalexin 500 mg cap 3 x day (8am-1pm-8pm)for 1 week 2. Mefenamic Acid 500 mg cap 3 x day (am-1pm-

8pm) for 1 week

2)Instructed the patient to do exercise as tolerated such as

walking.

3)Encouraged patient to increase fluid intake.

4) Encouraged patient to eat foods rich in Vitamin and

Nutritious foods.

5)Encourage patient to avoid salty and fatty foods.

6) Encourage patient to have enough rest. 33


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CONCLUSION

Patient well an allowed discharge with

tablet tramal 50mg for pain relieved.

Follow up at Klinik kesihatan Kg. Simee for

dressing at wound site.

Untreated cholelitiasis can cause serious,

include tissue death can lead to infection and

gangrane.

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cholelitiasis present case

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