1 .GENERAL APPEARANCE• Patient is 30yrs old female

• look anxious• conscious and oriented with following vital signs

• B.P : 110/70mmHg• PULSE : 88b/m• RESPIRATION : 20b/m• TEMPREATURE : 36.6 c

• SpO2 : 99%

2. SKIN•Fair complexion.•Skin is warm.3. HEAD • Hair is equally distributed.• Absence of dandruff & alopecia.

4.EYES

• Both eyes are normal , able to move both eyes.• No discharges .

5. EARS •Patient pinna is same colour as fascial.• Able to hear sounds clearly.• No discharges.

6. NOSE

•Pink nasal mucosa.No nasal discharge 7. MOUTH• Pink and dry oral mucosa.• Tongue and uvula in midline position.• Teeth is properly aligned with no dentures.8. NECK AND THROAT• No tenderness nodes.• No palpable mass and lesions

9. CHEST & LUNGS

• Thorax is symmetric on inspection.• Dry cough present.• Clear breath sounds.10. CARDIO VASCULAR SYSTEM

• ECG is normal.• No cardiomegaly.• Apical pulse is 88 bpm11. UPPER &LOWER EXTREMITIES

•Normal range of motions.12. ABDOMEN•Bowel sounds are normal.•On palpation Abdomen is slightly enlarged .

13 . GENITO URINARY SYSTEM• no discharges 14. GASTRO INTESTINAL• No bowel obstruction present.• Abdominal pain present.15. NEUROLOGIC

• Patient is mentally alert and oriented with circumstances.• Able to follow commands.• No neurovascular deficit

PATIENT HISTORY

PAST MEDICAL HISTORY No past medical history .

PRESENT MEDICAL HISTORY

Patient came to OPD on 17.5.2013 with complaints of abdominal pain and vomiting . On examination they suspected cholelithiasis and send her for usg abdomen . After Usg abdomen she was diagnosed as having cholelithiasis .PAST SURGICAL HISTORY • Patient has no past surgical history.PRESENT SURGICAL HISTORY•Patient had under gone Laproscopic choleycystectomy on 20.5.2013.

INVESTIGATIONS DONE FOR THE PATIENT

• USG Abdomen• X-ray chest• Blood investigations

oCBCoABORHoPT/INR oAPTToELECTROLYTES

ITEMS PATIENT VALUE NORMAL VALUE

CBCHEMOGLOBIN(hb)HCTRBCPLT

12.6 gm/dl 35.9 g/dl 3.85 2 10

13.7 - 16 .5 gm/dl 40.1 – 51.g/dl 4.63 – 6.08*10^6/ul 163-337/ul

SODIUM 143 135 - 150

POTTASSIUM 3.7 3.5-5.0mmol/l

PT 13.1 10.0-17 sec

I NR 0.85 2.4 therapeautic unit

APTT 29.2 26.1-36.3

ABRH AB +VE

Drug Route Dose/frequency Action

Inj. Perfelgan

iv 1000mg /bd Analgesis

Inj.Flagyl iv 500mg /bd antibiotics

Inj.Augmentin

iv 1.2gm/tid Antibiotics

Inj.Premosan

iv 10mg/bd Antiemetic

Inj.Risek iv 40mg/od H2 receptor antagonist

Presence of stone in the gall bladder is known as cholelithiasis.It is a crystalline concretion formed with the gall bladder by accretion of bile components.These gall stones are formed in the gall bladder but may distally pass in to other parts of biliary tract such as cystic duct,common bile duct, pancreatic duct or thae ampulla of vater.Choledocholithiasis

It refers to the presence of one or more Gallstones in the common bile duct. Usually, this occurs when a gallstone passes from the gallbladder into the common bile duct .A gallstone in the common bile duct may impact distally in the ampulla of Vater, the point where the common bile duct and pancreatic duct join before opening into the duodenum

TYPES OF GALLSTONES Types of gallstones that can form in the gallbladder include:

Cholesterol gall stones

Pigment gall stones

Mixed gall stones

Gallbladder is a pear-shaped sac that lies between the right medial and quadrate lobes of the liver. It is partly attachedand partly free.It is covered anteriorly and posteriorly by peritioneum.It sits in a shallow depression called the gallbladder fossa.The gallbladder is about 7.5–10 cm (3–4 inches) long and about a 2.5 cm (1 inch) wide.

LAYERS OF GALL BLADDER Muscular layer ( A layer of smooth muscle) Perimuscular layer (connective tissue that covers the muscular layer.Mucosa (inner layer of epithelium and connective tissue) Serosa (outer covering of the gallbladder

For the purpose of description gallbladder is divided in to three;

Fundus of the gallbladder Body of the gallbladder Neck of gallbladder

BILE DUCT,HEPATIC DUCT,

CYSTIC DUCT ,BILE

Bile is mainly made up of: •bile salts•bile pigments (such as bilirubin)•cholesterol•waterBile duct formed by the union of hepatic duct &cystic duct that carries bile from liver &gallbladder to the duodenum.

The cystic duct joins the gallbladder to the common bile duct. It usually lies next to cystic artery.The Cystic duct of the gallbladder is 2-4 cm long

ARTERIAL SUPPLY, VENOUS DRAINAGE &LYMPHATIC DRAINAGE

FUNCTIONS OF GALL BLADDER

• Stores and mobilizes bile. for digestion.• Promote physical coordination.• Maintain health of connective tissues.• Closed linked with the liver.• Defensive energy against catching infections.

:

Etiology Of Cholelithiasis Etiology Of Cholelithiasis

• Female sex.• European or native american ancestry• Increasing age above 40 yrs• Obesity. • Pregnancy.• Gallbladder stasis.• Drugs.• Heredity.

Factors that may increase risk of gallstones include: •Being female•Being age 60 or older•Being an American Indian•Being a Mexican-American•Being overweight or obese•Being pregnant•Eating a high-fat diet•Eating a high-cholesterol diet•Eating a low-fiber diet•Having a family history of gallstones•Having diabetes•Losing weight very quickly•Taking some cholesterol-lowering medications

• pain in the upper right portion of abdomen.• Back pain between shoulder blades• Pain in right shoulder.• Nausea and vomiting.• Jaundice.• Clay coloured stool .

DIAGNOSTIC STUDIES

HIDA SCANCT SCAN

ERCPABDOMINAL ULTRA SOUND

BLOOD TESTS

ORAL BILE SALT THERAPY(URSODEOXYCHOLIC+URSODIOL

CONTACT DISSOLUTION

EXTRA CORPOREAL SHOCK WAVE LITHOTRIPSY

COMPLICATIONS OF SURGERY •Infection of an incision.•Internal bleeding.•Injury to the common bile duct .•Injury to the small intestine by one of the instruments used during surgery.•Risk of general anaesthesia .UNCOMMON COMPLICATIONS

• Injury to the cystic duct,.• Gallstones that remain in the abdominal cavity.• Bile that leaks into the abdominal cavity.• Injury to abdominal blood vessels, such as the major blood

vessel carrying blood from the heart to the liver (hepatic artery)..

• A gallstone being pushed into the common bile duct.• The liver being cut.

PRE-OPERATIVE INTERVENTION •The provision of psycho-educational care.• Provision of adequate and appropriate informastion thruogh out the day care experience .• Enhancement of patient self-efficacy via positive encouragement and information provision.•Reduction of the negative impact of the clinical environment and encouraging implicit and explicit messages of safety such as the hospital performs many operations .•helps to create a warm, friendly and comfortable environment.

POST OP INTERVENTION • Management of pain and post-operative nausea and vomiting.• Initial assistance with mobilization.• Pain management should commence with an assessment of the patient’s pain at regular intervals.• Measures to manage patients’ anxiety should be implemented pre-operatively and continued throughout the post-operative recovery period until discharge

Care of Patient with Cholecystectomy Preventing respiratory complications Encouraging activity. Promoting wound healing. Maintaining normal body temperature. Promoting bowel function .. maintaining gastro intestinal function and

resuming nutrition .

ACUTE PAIN RELATED TO GALL BLADDER REMOVELNAUSEA AND VOMITING RELATED TO SURGERY

RISK FOR INFECTION RELATED TO SURGICAL INCISIONKNOWLEDGE DEFICIT RELATED TO TREATMENT REGIMEN AND POST OP CARE

ASSESSMENT

NSG DIAGNOSIS

PLANNING INTERVENTION RATIONAL EVALUATON

Subjective I have severe pain as verbalized by the patient.Painscale -5/10 As 0/10 is the lowest and 10/10 is the highest {WONG –BAKER}

Objective data:

Fascial grimace

Reports pain on movement Guarding behavior

Altered comfort,pain, related to tissue trauma secondary to surgical operation.

After series of nursing intervention patient will manifest a decrease in pain Scale from 5/10 to 0/10

1.Assess patients pain scale and perception

2. provid comfort

measures (backrub,

position change,

environmental control)3. Encourage deep breathing exercises

4.Teach divertional activities(listening to music)

5. Monitor vital signs

6.Administer pain

medication per doctor’s

order prior to exercise

or activities of daily

living{INJ.PERFELGAN

1GM IV BD}.

1.To identify the onset ,intensity and duration of pain 2.to reduce the pain and to provide relaxation

3.To assist muscle and genarelised relaxation 4.To destract clients attention from pain

5.To identify the intensity of pain

6. To relieve the pain

After 12 hrs of nursing interventions the goals were fully met as evidenced by

verbalize relief of pain as evidenced by a pain scale of 0 out of 10

positive response during evaluation

verbalize & demon-strate willingness to partici-pate in activities

HEALTH EDUCATION • Health education given on wound care and dressing .• Instructed her the signs of infection and asked him to notify if any signs occurs .• Instructed her to follow the physians order regarding diet and medication.• Educated her the the importance of follow up .• Instructed her she will have no restrictions to physical activities, however the patient should listen to their body in response to certain activities. Gradually increase activities at a comfortable and individual pace.• Advised her to contact if he develops any problems such as prolonged nausea/vomiting, temperature elevations above 101.5 or other difficulties.• Advised her to take the medications accordingly.

CONCLUSION• Presented a case of patient with cholelithiasis.• Patient underwent laproscopic cholecystectomy on 20/05/13.• Presence of stone in the gall bladder is known as cholelithiasis • It is a crystalline concretion formed with the gall bladder by accretion of bile components.•Gallstones may cause no signs or symptoms.Gall stones may be

asymptomatic even for years .these stones are called silent stones . If a gallstone lodges in a duct and causes a blockage, signs and symptoms may result.

•Laproscopic cholecystectomy has now replaced open cholecystectomy as the first-choice of treatment for gall stones and inflammation of the gallbladder unless there are contraindications to the laparoscopic approach. This is because open surgery leaves the patient more prone to infection.

BIBLIOGRAPHY

• BRUNNER AND SUDDARTH TEXT BOOK OF MEDICAL –SURGICAL NURSING 9 TH EDITION .

• LIPPIN COTT WILLIAMS AND WILKINS.

• POTTER AND PERRY FUNDAMENTALS OF NURSING 5 TH EDITION

• WWW.WIKIPEDIA.ORG.