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CHOLECYSTITIS
( Inflammation of the Gall Bladder)
IN TRODUCTION
CHOLECYSTITIS
• Very rarely, even in the absence of cholelithiasis, gall bladder can become inflamed and infected. This is known as acute acalculous cholecystitis, where the pain lasts longer and is severe
• Typically, people have abdominal pain that lasts more than 6 hours, fever, and nausea.
• Ultrasonography can usually detect signs of gallbladder inflammation.
OBJECTIVES
• To determine the content on the nursing assessment, diagnosis, planning, Implementation and evaluation for this specific disease condition
• To know the underlying causes and health history on the clients medical diagnosis upon admission
• To search the medical management as being
ordered based upon the clients diagnostic and laboratory results
• To compare and contrast the ideal and actual nursing care management for this specific disease condition
• Utilize the nursing process as a framework for care of patients with cholecystitis
• To evaluate the effectiveness of the interventions and detect any progress of the clients condition.
PATIENT PROFILE
PRESENT MEDICAL HISTORY
• THREE DAYS PTA: The patient has epigastric pain with a pain scale of 5/10 accompanied with 2 bouts of vomiting of previously ingested food.
• ( - fever )• No medication taken; no consultation.• ONE DAY PTA: still with above condition. Patient given Tromadol
offered no relief.• FEW HOURS PTA: persistence of above condition. Consult advised
admission.• VITAL SIGNS (taken May 15,2010)• Temperature: 37.1C• Pulse rate: 120• Respiratory rate: 19• Blood Pressure: 140/90
Past medical history• ( + ) Hypertension highest BP 170/100 (1999)
usual BP 130/80• (amlodipine 10mg OD)• • ( + ) CVA infarct in the left hemisphere (april
23,2010)• (Citicoline 1g BID)• (ASA 325mg OD)• (Simvastatin 20mOD)• (Combizar 1tab OD)• (Lexapin 10mg OD ½ cap)• (Iron OD)
THEORETICAL FRAMEWORK
Self – Care Deficit Theory of Nursing
Self Care
Agency
Self care
Therapeutic Self care
demands
Nursing Agency
Deficit
R R
R
R R
GORDON’S FUNCTIONAL
HEALTH PATTERN
Before Hospitalization During Hospitalization
Health Perception and Health Management Pattern
- Knows the importance of being healthy; observes proper hygiene; consults doctor
- Knowledgeable about her condition
Nutritional and Metabolic Pattern
- Eats vegetables; loves sour foods; loves to drink softdrinks;
-Loss of appetite
Elimination Pattern - Defacates twice a day; micturates 8-9 times a day
- Uses commode
Activity-Exercise Pattern - Walking and cleaning the house; watching tv is her past time
- Stays in bed
Gordon’s Functional Health Pattern
Before Hospitalization During Hospitalization
Sleep-Rest Pattern - 6 hours of sleep and 2 hours of nap in the afternoon
- Sleeps more often than the usual sleep pattern
Cognitive-Perceptual Pattern - Hearing is clear; has difficulty in writing
- Hearing is clear; has difficulty in writing
Self Perception and Self Concept Pattern
- Visualizes herself as a strong person; focuses on her family
- Tries to be more stronger for her family and herself
Religion - Roman Catholic; goes to church and prays the rosary
- Never forgets to pray the rosary
Vices - Doesn’t have any vices - Doesn’t have any vices
Sexual Pattern - Believed in family planning Decreased interest in sexual activity
PHYSICAL ASSESSMENT
PHYSICAL ASSESSMENTPhysical assessment done:
May 19, 2010
GENERAL
HEENT Unremarkable
RESPIRATORY Unremarkable
CARDIOVASCULAR Unremarkable
GASTRO-INTESTINAL Remarkable
GENITO-URINARY Unremarkable
ENDOCRINE Unremarkable
MUSCULO-SKELETAL Unremarkable
PSYCHIATRIC Remarkable
ANATOMY AND PHYSIOLOGY
PATHOPHYSIOLOGYCHOLECYSTITIS WITH
CHOLELITHIASIS
Cause: UNKNOWN PREDISPOSING FACTORS:
(5 F’s)
Forty
Fertile: (multigravida; use
of OCP)
Fat (obese)
Decrease bile acid synthesis in the liver
Fair (Caucasian)Increase cholesterol synthesis in the liver
Bile supersaturated with cholesterol
Bile stone
CHOLELITHIASIS
Female
Hemolysis
Hemoglobin
Bilirubin
CA bilirubinate/ Calcified bilirubin
Gallstones
Irritation of the gall bladder (inflammation) CHOLECYSTITIS
> Biliary colic> N&V> Murphy’s sign> Jaundice
>RUQ pain that may radiate to midsternal/ right shoulder>N&V>Fever>Leukocytosis
LEGEND:Predisposing factors
Pigmented gallstonesCholesterol gallstones
S/S of CholelithiasisS/S of Cholecystitis
Bile flow obstrnBILE STASIS
Cause: UNKNOWN PREDISPOSING FACTORS:
(5 F’s)
Forty
Fertile: (multigravida; use
of OCP)
47
2 children
CHOLELITHIASIS
Female
Hemolysis
Hemoglobin
Bilirubin
CA bilirubinate/ Calcified bilirubin
Gallstones
Irritation of the gall bladder (inflammation)
CHOLECYSTITIS
> Biliary colic> N&V
>RUQ pain that may radiate to midsternal/ right shoulder>N&V>Leukocytosis - 39
LEGEND:Predisposing factors
Pigmented gallstonesCholesterol gallstones
S/S of CholelithiasisS/S of Cholecystitis
Bile obstruction BILE STASIS
RBC:3.29 (4.2-5.4 X10 /L)Slightly anisocytosis and slightly poikilocytosis
Hgb: 97 (117-157 g/L)
Direct Bilirubin: 9.48umol/LIndirect BIlirubin:18.51umol/L
SGPT: 168 (5-40 U/L)SGOT: 233 (0-35 U/L)
LABORATORY AND
DIAGNOSIS
Date Lab/Dx Diagnostic Use Px Result Normal Values Signifi-cance05-15-2010 FBS 8.60 3.9-6.05 mmol/L Transient hypergly-
cemiaCholes-terol CVA
Cholesterol bile stone2.62 3.64-6.50 Hypocholes-
terolemia (CVA)SGPT Liver Fxn 168 5-40 U/L Biliary stasisSGOT Liver Fxn 233 0-35 U/L Biliary stasisDirect Bilirubin Measure bilirubin from hgb
breakdown9.48 0-8.55 umol/L Biliary stasis
Indirect Bilirubin Measures bilirubin that has been processed by the liver
18.51 8.55-17.1 umol/L Biliary stasis
Amylase R/O acute inflammation of the pancreas
31 30-110 U/L
Na Check for electrolyte imbalance
120 135-148 mmol/L Hyponatre-mia
K Check for electrolyte imbalance
2.4 3.5-5.3 mmol/L Hypokale-mia
F/A R/O other abdominal diseases that causes abdominal pain like rotavirus, amoebiasis etc.
Color: Greenish brownMicroscopic reading: NOPS
Brown (diet dependent)
Bile leakage into the feces
U/A To screen for metabolic and kidney disorders and for urinary tract infections
Color: d. yellowCHON: tracePus: 3-5RBC: 1-2Hyaline cast:5-7/lpfFine granular cast:1-2/lpf
Straw/amberNegative0-1/hpf0-1/hpf0/lpf0/lpf
Stressed kidney
Date Lab/Dx Diagnostic Use Px Result Normal Values Signifi-cance
5-15-2010 CBC Act as baseline diagnosis; broad screening test to check for disorders such as anemia, infection and other disorders
Hgb: 97Hct: .27RBC: 3.29Remarks: Slghlty anisocytosis, slighltly poikilocytosisWBC: 39Neu: 0.95Platelet: 440
117-157 g/L.37-.47 %3.80-5.20x10/L4.5-11 x 10/L.40-.70 %150-400x 10/L
ANEMIAINFECTIONBacteria
5-16-2010 CBC Hgb:90Hct:.26RBC: 3.27WBC:25Neu:0.93
5-17-2010 CBC Hgb: 91Hct:.28RBC:3.31WBC: 22Neu: 0.93
1hr post BT 1u PRBC250 cc10-04-1600
5-18-2010 CBC Hgb: 93Hct:.27RBC:3.39WBC: 22.4Neu: .87
1hr post BT 1u PRBC250 cc09-25-1962
5-19-2010 CBC Hgb: 113Hct:..33RBC:4.06WBC: 21.3Neu: .88
Date Lab/Dx Diagnostic Use Impression Significance5-15-2010 Portable CXR (AP
view)CP clearnce Probable Cardiomegaly CVA
Abdominal UTZ Check for bowel obstruction
Mild pelvocaliec-tasis/ R kidney Suspected stones
Gall bladder and liver UTZ
Measure the size of the organ and suggestive diagnosis
Minimal fluid collection right sub-hepatic area
Cholecystitis with cholelithiasis and bile sludge formation
Pericholecystic collection Borderline common bile duct size Suggestive of diffuse
parenchymal liver diease
Inflammation of the gall bladder with stone formation
Gynecology and fertility UTZ
Check for reproductive system abnormality
Anteverted sized uteru with homogenous myometrium
Secretory phase-like endometrium N ovaries Encysted fluid (+) fluid in the cul-de-sac Remarks: anterior to uterus is an
irregular fluid collection with thin septations measuring 37x26x34 mm.
Suggestive of encysted fluid
Date Lab/Dx Diagnostic Use Px Result Normal Values Signifi-cance
5-15-2010 Potassium Electrolyes Imbalnce; CVA
2.4 3.5-5.3 mmol/L Hypokalemia- vomiting
5-16-2010 K 2.8 1 hr after K correctionPNSS 85cc + 30 meqs KCl 3hrs x 1 cycle
5-17-2010 K 3.1
5-18-2010 K 3.5 1 hr after K correctionPNSS 80cc + 40 meqs KCl 3hrs x 1 cycle
5-19-2010 K 3.6 1 hr after K correctionPNSS 90cc + 20 meqs KCl 2hrs x 2 cycle
5-20-2010 K 3.9
PRE AND POST OPERATIVE
PLAN
• On admission to the hospital, an informed consent form acknowledging that the patient understands the procedure, the risks, and that they will be receiving anesthesia and possibly other medications must be signed.
• IV fluid to replace fluid electrolyte losses due to vomiting.
• DBCT exercises to prevent respiratory complications.
Pre – Operative Care
Post – Operative Care
• Position low /semi – fowler’s position to promote lung expansion.
• NGT to prevent gastric distention.• DBCT exercises to avoid atelectasis.• Low fat diet for 2 – 3 months.• Ambulation after 24 hours post –
operatively.
Surgical Procedure
Laparoscopic Cholecystectomy
Laparoscopic cholecystectomy is performed through a small incision or puncture made through the abdominal wall at the umbilicus. The fiberoptic scope is inserted through the small umbilical incision. Several additional punctures or incisions are made in the abdominal wall to introduce other surgical instruments into the operative field. The surgeon visualizes the biliary system through a laparoscope, the gallbladder is then removed from the abdominal cavity after bile and small stones are aspirated.
DRUG STUDY
DRUG INDICATION MECHANISM OF ACTION
CONTRAINDICATION ADVERSE EFFECT NURSING RESPONSIBILITIES
Generic: clonidine hydrochlorideBrand: CatapresClassification:antihypertensiveDosage:75 pcg/ tabRoute: SLFrequency: PRN for BP 160/90 mmHg
Management of mild to moderate
hypertension.
Stimulates alpha-adrenergic receptor in the CNS; w/c results in decreased sympathetic
outflow inhibiting cardioacceleration and
vasoconstriction centers. Decreased
blood pressure.
Contraindicated w/ hypersensitivity to clonidine or any adhensive layer
components of the transdermal system.
bradycardia, hypotension,
palpitation, drowsiness, dry mouth
Monitor blood pressure and pulse frequently during initial dosage adjustment and periodically throughout therapy.Instruct patient to take clonidine @ the same time each day, even if feeling well.Inform patient that clonidine may cause drowsiness; w/c usually diminishes w/ continued use. If dry mouth occurs, advise patient to rinse mouth frequently.Instruct patient and family on proper teaching for blood pressure monitoring at least weekly.
5-15-2010
DRUG INDICATION MECHANISM OF ACTION
CONTRAINDICATION ADVERSE EFFECT
NURSING RESPONSIBILITIES
Generic: metronidazoleBrand: FlagylClassification: antibacterialantiprotozoalantibioticDosage: 5 mg/ml infused over 30-60 mins.Route: IVFrequency: q8
Acute infection w/ susceptible anaerobic bacteria.Acute intestinal amebiasis.Perioperative, intraoperative, postoperative prophylaxis for patients undergoing colorectal surgery.
Inhibits DNA synthesis in specific anaerobes causing cell death.amebicidal action.
Contraindicated with hypersensitivity to
metronidazole.
seizures, dizziness, headache,
abdominal pain, darkening of the urine, nausea, vomiting and metallic taste
Monitor neurologic status during and after IV infusion. Inform physician if seizure, dizziness or headache occur.Inform the patient that his urine will be darker than usual.Take full course of drug therapy; take the drug with food or milk if GI upset occurs.Instruct the patient to take medication exactly as directed evenly spaced times between dose, even if feeling better. Do not skip doses or doble up missed doses. If a dose is missed, take as soon as remembered if not almost time for next dose.Inform patient that medication may cause an unpleasant metallic taste.
5-16-2010
DRUG INDICATION MECHANISM OF ACTION
CONTRAINDICATION ADVERSE EFFECT
NURSING RESPONSIBILITIES
Generic: ciprofloxacinBrand: CiproClassification: anti infectivesDosage: 40 mg.Route: IVFrequency: qid
Treatment of the following bacterial infections: Urinary tract infections including cystitis,gynecologic infections, respiratory tract infections.
Inhibit bacterial DNA synthesis by inhibiting DNA gyrase.Therapeutic effects: Death of susceptible bacteria.
Hypersensitivity. Cross-sensitivity among agents within class may occur .Use cautiously in: Known or suspected CNS disorder; Renal Impairment.
dizziness, headache,
drowsiness, diarrhea, nausea, vomiting,
abdominal pain
May cause dizziness & drowsiness. Caution patient to avoid driving or other activities requiring other activities requiring alertness until response to medication is known.Assess for infection prior to & during theraphy.Instruct patient to notify health care profesiional if fever & diarrhea develop, especially if stool contains blood, pus, or mucus. Advise patient not to treat diarrhea without consulting health care professional.If gastric irritation occurs, ciprofloxacin may be administered with meals.
5-16-2010
DRUG INDICATION MECHANISM OF ACTION
CONTRAINDICATION ADVERSE REACTION NURSING RESPONSIBILITY
Generic: diphenhydramineBrand: Hizon diphenhydramine injectionClassification: antihistamine/ sedative hypnoticDose: 25 mgRoute: IMFrequency: 1 dose
Relief of allergic symptoms caused by histamine releaseMild sedation
Competitively blocks the effects of
histamine at H1-receptor sites; antipruritic and sedative effect.
HypersensitivityAcute attacks of asthmalactation
drowsiness, dizziness, blurred vision and dry
mouth
Monitor patient response; and arrange for adjustment of dosage to lowest possible effective dose.Inform the patient before administering that the medication may cause drowsiness, dizziness and blurred vision.Report DOB, hallucination, unusual bleeding and irregular heartbeat.
5-20-2010
DRUGS:Indication
Action: Contra-Indication Adverse Reactions
Nursing responsibilities
Generic: Nalbuphine Dose: 5mgFrequency:q6Brand:NubainRoute: IVClassification: Opioid Analgesic
Moderate to severe pain. Also provide: sedetion before surgery, supplement to balance anesthesia.
Binds to opiaite receptor in the CNS. Alter the perception of or/ and response to painful stimuli while producing generalized CNS depression.
HypersensitivityPatient who are physically on opioids and have not been detoxified.
Dizziness, headache , dry mouth, N/V, clammy feeling.
Assess bp, pr, rr bef. And periodically during administration.
(<10min assess for level of sedation) Instruct pt. on how and when to ask for pain
medication. May cause dizziness. Advice pt. to call for
assistance when ambulating until response to the med is known.
Advice pt. that freq. mouth rinses, good oral hygiene, can decrease dry mouth.
DATE: MAY 20, 2010
DRUG INDICATION MECHANISM OF ACTION
CONTRAINDICATION ADVERSE EFFECT
NURSING RESPONSIBILITIES
Generic: omeprazoleBrand: omepronClassification: anti ulcer agentDosage: 40 mgRoute: POFrequency: OD
GERD/ maintenance of healing in erosive esophagitis.Short term treatment of active benign gastric ulcers.
Binds to an enzyme on gastric parietal cells in the presence of acidic gastric pH, in preventing the lumen.
Contraindicated with hypersensitivity to
omeprazole.
drowsiness, headache,
abdominal pain,diarrhea,
PO: Administer doses before meals, preferable in the morningMay cause occasional drowsiness. Caution patient to avoid driving or other activities requiring alertness until response to medication is known.Assess patient routinely for epigastric/ abdominal pain & frank or occult blood in the stool,emesis.Advise patient to avoid alcohol, products containg aspirin/ NSAIDS & foods that may cause an increase in GI irritation.Advise patient to report onset of black, tarry stools, diarrhea; abdominal pain or persistent headache to health care professional promptly.
5-20-2010
DRUG INDICATION MECHANISM OF ACTION
CONTRAINDICATION ADVERSE REACTION
NURSING RESPONSIBILITY
Generic: parecoxibBrand: DynastatClassification: NSAIDDose: 40 mgRoute: IVFrequency: 1 dose
Short term treatment of acute pain and
post-op pain
Inhibits prostaglandin synthesis by selecting
inhibiting cyclo-oxygenase-2.
Relieves pain and inflammatory
Contraindicated w/ allergies to celecoxib, NSAIDs and aspirinSignificant renal impairment
headache, dizziness, fatigue, flatulence,
abdominal pain
Asses BP, RR, PR before and periodically during administration.Inform the patient that he will experience adverse effect such as dizziness and drowsiness.Advise patient that frequent mouth rinse, good oral hygiene and candy can decrease dry mouth.
5-21-2010
NURSING CARE PLAN
LEGEND:ProfileSubjectiveObjectiveDiagnosisInterventionRationaleEvaluation
Patient A41 F
Dr. Romcilla
“ Ang sakit ng tiyan ko” as verbalized by the patient
After 8 hours of nursing intervention the client will be able to demonstrate use of relaxation skills and diversional activities as indicated, for individual situation
Guarding Behavior protective gestures and positioning to avoid pain
Facial Grimace
RUQ PainPain Scale: 5/10BP: 140/90PR:90
Accepted client’s description of pain.
Encouraged use of relaxation techniques. (eg. Music)
Administer analgesics as indicated, to maximum dosage, as needed
After 8 hours of nursing intervention the client will be able to demonstrate use of relaxation skills and diversional activities as indicated, for individual situation
Provide comfort measures touch, repositioning, use of hot and cold packs, quiet environment
To distract attention and reduce tension.
Promotes non – pharmacological pain mngt.
LEGEND:
ProfileSubjectiveObjectiveDiagnosisInterventionRationaleEvaluation
Pre - Operative Acute pain related to inflammation of the gallbladder
DISCHARGE PLANNING
• M – Medication (geltasine, omeprazole, ciprofloxacin, catapres, metronidazole)
• E – Exercise
• T – Treatment
• H – Health Teaching
• O – Outpatient
• D – Diet (what and what not to eat)
• S – Spiritual