INTRODUCTION

Cholelithiasis is the presence of one or more calculi (gallstones) in the gallbladder and is the fifth

leading cause of hospitalization among adults. The disease may also be occurring in persons who are

obese and who have high cholesterol. In most cases, gallbladder and bile duct diseases occur during

middle age. Between ages 20 and 50, they're six times more common in women, but incidence in men

and women becomes equal after age 50. Incidence rises with each succeeding decade. More serious

complications include cholecystitis; biliary tract obstruction (from stones in the bile ducts or

choledocholithiasis), sometimes with infection (cholangitis); and gallstone pancreatitis. Diagnosis is

usually by ultrasonography. If cholelithiasis causes symptoms or complications, cholecystectomy is

necessary.

Cholecystitis, acute or chronic inflammation of the gallbladder is usually associated with a

gallstone impacted in the cystic duct that may cause painful distention of the gallbladder.

Postcholecystectomy syndrome commonly results from residual gallstones or stricture of the common

bile duct. It may be occurs in 1 % to 5 % of all patients whose gallbladders have been surgically removed

and may produce right upper quadrant abdominal pain, biliary colic, dyspepsia and indigestion.

Gallstones develop in many people without causing symptoms. The chance of symptoms or

complications resulting from cholelithiasis is about 20%. With current surgical approaches, the outcome

is excellent with no recurrence of symptoms in over 99% of individuals.

DEMOGRAPHIC DATA

Name: Patient X

Sex: Male

Religion: Iglesia ni Cristo

Address: Tarlac

Age: 50 years old

Date of Birth: February 5, 1960

Date of Admission: January 7, 2011 at 8:45 pm

Chief Complaints: Right upper quadrant pain

Admitting Diagnosis: Acute Cholecystitis with Cholelithiases

Final Diagnosis: Acute Cholecystitis with Cholelithiases

ANATOMY AND PHYSIOLOGY

LIVER

A. Location and size of the liver- largest gland in the body, weighs approximately 1.5 kg;

lies under the diaphragm; occupies most of the right hypochondrium and part of the

epigastrium.

B. Liver lobes and lobules- two lobes separated by the falciform ligament

1. Left lobe- forms about one sixth of the liver

2. Right lobe- forms about five sixths of the liver; divides into right lobe proper,

caudate lobe, and quadrate lobe

3. Hepatic lobules- anatomical units of the liver; small branch of hepatic vein

extends through the center of each lobule

C. Bile ducts

1. Small bile ducts form right and left hepatic ducts

2. Right and left hepatic ducts immediately join to form one hepatic duct

3. Hepatic duct merges with cystic duct to form the common bile duct, which

opens into the duodenum

D. Functions of the liver

1. Glucose Metabolism

-after a meal, glucose is taken up from the portal venous blood by the liver and

converted into glycogen (glycogenesis), which is stored in the hepatocytes. Glycogen

is converted back to glucose (glycogenolysis) and release as needed into the blood

stream to maintain normal level of the blood glucose.

-glucose can be synthesized by the liver through the process gluconeogenesis

2. Ammonia Conversion

-use of amino acids from protein for gluconeogenesis result in the formation of

ammonia as a by product. Liver converts ammonia to urea

3. Protein Metabolism

-Liver synthesizes almost all of the plasma protein including albumin, alpha and

beta globulins, blood clotting factors plasma lipoproteins

4. Fat Metabolism

-Fatty acid can be broken down for the production of energy and production of

ketone bodies

5. Vitamin and Iron Storage

-stores vitamin A, D, E, K

6. Drug Metabolism

7. Bile Formation

-bile is formed by the hepatocytes

-composed of water, electrolytes such as sodium, potassium, calcium, chloride,

bicarbonate, lecithin, fatty acids, cholesterol, bile salts

-collected and stored in the gallbladder and emptied in the intestine when

needed for digestion

a. Lecithin and bile salts emulsify fats by encasing them in shells to form tiny

spheres called micelles

b. Sodium bicarbonate increases pH for optimum enzyme function

c. Cholesterol, products of detoxification, and bile pigments (e.g. bilirubin) are

wastes products excreted by the liver and eventually eliminated in the feces

GALLBLADDER

The gallbladder (or cholecyst, sometimes gall bladder) is a small organ whose

function in the body is to harbor bile and aid in the digestive process.

Anatomy

The cystic duct connects the gall bladder to the common hepatic duct to form the

common bile duct.

The common bile romero duct then joins the pancreatic duct, and enters through

the hepatopancreatic ampulla at the major duodenal papilla.

The fundus of the gallbladder is the part farthest from the duct, located by the

lower border of the liver. It is at the same level as the transpyloric plane.

Microscopic anatomy

The different layers of the gallbladder are as follows:

The gallbladder has a simple columnar epithelial lining characterized by recesses

called Aschoff's recesses, which are pouches inside the lining.

Under the epithelium there is a layer of connective tissue (lamina propria).

Beneath the connective tissue is a wall of smooth muscle (muscularis externa) that

contracts in response to cholecystokinin, a peptide hormone secreted by the

duodenum.

There is essentially no submucosa separating the connective tissue from serosa and

adventitia.

Size and Location of the Gallbladder

The gallbladder is a hollow, pear-shaped sac from 7 to 10 cm (3-4 inches) long

and 3 cm broad at its widest point. It consists of a fundus, body and neck. It can hold 30

to 50 ml of bile. It lies on the undersurface of the liver’s right lobe and is attached there

by areolar connective tissue.

Structure of the Gallbladder

Serous, muscular, and mucous layers compose the wall of the gallbladder. The

mucosal lining is arranged in folds called rugae, similar in structure to those of the

stomach.

Function of the Gallbladder

The gallbladder stores bile that enters it by way of the hepatic and cystic ducts.

During this time the gallbladder concentrates bile fivefold to tenfold. Then later, when

digestion occurs in the stomach and intestines, the gallbladder contracts, ejecting the

concentrated bile into the duodenum. Jaundice a yellow discoloration of the skin and

mucosa, results when obstruction of bile flow into the duodenum occurs. Bile is thereby

denied its normal exit from the body in the feces. Instead, it is absorbed into the blood,

and an excess of bile pigments with a yellow hue enters the blood and is deposited in

the tissues.

The gallbladder stores about 50 mL (1.7 US fluid ounces / 1.8 Imperial fluid

ounces) of bile, which is released when food containing fat enters the digestive tract,

stimulating the secretion of cholecystokinin (CCK). The bile, produced in the liver,

emulsifies fats and neutralizes acids in partly digested food.

After being stored in the gallbladder the bile becomes more concentrated than

when it left the liver, increasing its potency and intensifying its effect on fats. Most

digestion occurs in the duodenum.

PATHOPHYSIOLOGY

Modifiable Factorso Obesityo High intake of fatty

foodso High Cholesterol levelo Hormonal

replacement therapy

Non Modifiable Factorso Femaleo 40 years old

and above

imbalance on the component of bile

supersaturation of bile with cholesterol

crystal formation

causing obstruction on the cystic duct

inflammation of gallbladder

fever ↑ WBC

gallbladder contracts as it tries to release bile and expel

the stone

Biliary Colic characterized as right upper quadrant pain that may radiate to sternum, right shoulder and right scapula

nausea and vomiting

decrease production of bile in the GI tract

disruption in normal digestion process

indigestion flatulence pain after eating

fatty meal

infection

decreased emulsification

of fats

Increased concentrationof fats in blood

↑ Total Cholesterol

↑Triglycerides

gallstones in the gallbladder

LABORATORY DATA

Laboratory Procedure Date Ordered Results Normal Values

Analysis and Interpretation of

Results

HEMATOLOGY REPORT

Hemoglobin

Hematocrit

WBC Count

Differential Count:

Neutrophils

Lymphocytes

January 7, 2011

15.7

0.47

13.4 x 10 g/L

0.82

0.20

12.5-17.5 g/dL

.40-52

5-10 x 10 g/L

.45-.65

.20-.35

> Normal

> Normal

> Elevated. It indicates inflammation and possible infection.

> Elevated. It indicates an acute infection.

> Normal

Laboratory Procedure Date Ordered Results Normal Values

Analysis and Interpretation of

ResultsBlood Chemistry

Glucose (FBS)

Blood Urea Nitrogen

Creatinine

Cholesterol

Triglycerides

HDL

LDL

SGOT

SGPT

January 3, 2011

120.2

14.4

0.6

210

205.7

22.0

135.0

30.1

88.1

70-105 mg/dL

7-18 mg/dL

0.40-1.40 mg/dL

150-200 mg/dL

44-148 mg/dL

30-75 mg/dL

66-178 mg/dL

5-34 U/L

4-36 U/L

> Elevated. It indicates hyperglycemia

> Normal

> Normal

> Elevated. There is decreased production of bile in the GIT due to obstruction causing decreased emulsification of fats.

> Elevated. There is decreased production of bile in the GIT due to obstruction causing decreased emulsification of fats.

> Decreased. “Good cholesterol” is decreased in amount.

> Normal

> Normal

> Elevated. Suggest possible liver disease

Diagnostic Test Date Ordered Result

Abdominal Ultrasound January 5, 2011Abdominal sonography reveals a liver, within normal in size with no solid mass or cyst noted.There are focal fatty infiltration seen in the liver.The intrahepatic and common ducts are not dilated with common duct measuring 0.5 cm in diameter.There are multiple calculi in the gall bladder one measuring 0.9 cm. The gall bladder wall is thickened measuring 0.4 cm with tenderness elicited on pressure of the gall bladder.The pancreas is normal in size and echogenicity with the head and the body seen with no mass or cyst demonstrated.The proximal abdominal aorta is seen and not dilated.The spleen is homogeneous and not enlarged with no mass or cyst outlined.The kidneys are within normal in sizes and echogenicity with no solid mass, cyst, calculus or hydronephrosis demonstrated.There is minimal ascites in the Morrison’s pouch.There is pleural effusion seen bilaterally.

DRUG STUDY

Drug Name Action Dosage Indication Contraindication Side Effects Nursing ResponsibilitiesGeneric Name:Cefuroxime

Classification:Cephalosporin

Therapeutic Classification:Antibacterial

Cefuroxime binds to one or more of the penicillin-binding proteins (PBPs) which inhibits the final transpeptidation step of peptidoglycan synthesis in bacterial cell wall, thus inhibiting biosynthesis and arresting cell wall assembly resulting in bacterial cell death.

750 mg IVP q 8

Prophylaxis of surgical infections

Hypersensitivity to cephalosporin

GI: nausea, vomiting, diarrhea

GU: nephrotoxicity

Others: Steven-Johnsons syndrome, anaphylaxis, pseudomembranous colitis

> Explain to the client the purpose and action of the drug.> Administer slowly> Monitor for kidney and liver function test> Advise patient to immediately report rash or bleeding tendency.

Drug Name Action Dosage Indication Contraindication Side Effects Nursing Responsibilities

Generic Name:Ranitidine

Therapeutic classification:Antiulcer drug

Ranitidine blocks histamine H2-receptors in the stomach and prevents histamine-mediated gastric acid secretion. It does not affect pepsin secretion, pentagastrin-stimulated factor secretion or serum gastrin.

50 mg IVP q 8 Gastric acid reduction

Porphyria CNS: headache, dizziness, confusion

Hematology: thrombocytopenia, leukopenia

Others: hypersensitivity, gynaecomastia, impotence, somnolence, vertigo, hallucinations

> Explain to the client the purpose and action of the drug.> Administer slowly> Monitor CBC and liver function tests.

Drug Name Action Dosage Indication Contraindication Side Effects Nursing

ResponsibilitiesGeneric Name:Ketorolac

Classification:NSAIDS

Therapeutic classification:Analgesic, Anti inflammatory

Ketorolac inhibits prostaglandin synthesis by decreasing the activity of the cyclooxygenase enzyme.

30 mg IVP q 8

Moderate to severe pain

>Hypersensitivity to aspirin>hypovolemia or dehydration> history of peptic ulcer or coagulation disorders> moderate to severerenal impairment> GI bleeding> Cerebrovascular bleeding

GI: dry mouth, GI ulcer, nausea, bleeding and perforation

CNS: drowsiness, hypotension, headache

Cardio: bradycardia, chest pain

Skin: fever, sweating , rash, pallor, edema

Others: liver function changes

> Explain to the client the purpose and action of the drug.> Administer slowly> Instruct patient to avoid aspirin products and herbs during therapy.> Monitor patient for CNS changes> Provide safety

Drug Name Action Dosage Indication Contraindication Side Effects Nursing

ResponsibilitiesGeneric Name:Hyoscine N butyl bromide

Therapeutic classification:Antispasmodic

Hyoscine competitively blocks muscarinic receptors and has central and peripheral actions. It relaxes smooth muscle and reduces gastric and intestinal motility.

1 ampule IVP now

Gastrointestinal tract spasm

Narrow-angle glaucoma, acute haemorrhage, paralytic ileus, tachycardia due to cardiac insufficiency, myasthenia gravis

CNS: postural hypotension, drowsiness, dizziness, headache, memory loss

Skin: flushing, dry skin, erythema, increased sensitivity to light, rash

Cardio: tachycardia, fibrillation

GIT: constipation, dry throat, dysphagia, nausea, vomiting

GUT: dysuria, urinary retention

Musculoskeletal: tremor, weakness

EENT: Impaired accommodation, blurred vision, cycloplegia, dryness, narrow-angle glaucoma, increased intraocular pain, itching, photophobia, pupil dilation. Dry nose.

> Explain to the client the purpose and action of the drug.> Administer slowly> Check for mental status changes> Provide safety> Evaluate fluid intake and output.

NURSING CARE PLAN

ASSESSMENT DIAGNOSIS PLANNING NURSING INTERVENTION

RATIONAL E EXPECTED OUTCOME

S – “Masakit ang tiyan ko”, as claimed With pain scale of 7/10

O > grimace noted > muscle guarding behavior on the right upper quadrant > pain is aggravated by abrupt movements > pain is referred to the right shoulder and right scapula > use of abdominal muscles in breathing > diaphoretic > slightly exaggerated depth of respiration > tachypneic (25 cpm) > irritable at times

Acute pain r/t inflammation of the gall bladder

Scientific Explanation:As the gallbladder is inflamed and tries to contract to release bile and expel the obstructed stone it produces spasm.

Within 1 hour of proper nursing intervention the patients’ pain scale of 7/10 will decrease to 5/10.

> Assist and place on the preferred position > Assist when changing position > Encourage deep breathing exercise > Provide comfort measure such as back rub > Encourage verbalization of feelings > Eliminate additional stressors or sources of discomfort whenever possible > Administer analgesics and antispasmodic for as ordered

> promote comfort

> to conserve energy > to relieve muscle tension > to promote comfort

> decreases anxiety

> to divert the attention of the patient and to relieve muscle tension

> Decreases spasm and relieve the patient from pain

After one hour of proper nursing intervention the patients’ pain scale of 7/10 will be decreased to 5/10 as manifested by:

a. lessen grimaceb. lessen muscle

guarding behavior

c. lesser use of accessory muscles in breathing

d. RR will decrease within the normal range of 12-20 cpm

e. more comfortable

ASSESSMENT DIAGNOSIS PLANNING NURSING INTERVENTION

RATIONAL E EXPECTED OUTCOME

S – “Mainit ang pakiramdam ko”, as claimed

O > weak in appearance> flushed skin> irritable > febrile: body temperature of 38.1 degree Celsius > tachycardic: 103 > tachypneic: 24 cpm

Altered thermoregulation related to inflammation and presence of infection of the gallbladder

Scientific Explanation:The presence of inflammation and infection can activate immune response resulting to increased body temperature.

Within 30 minutes of proper nursing intervention the patients’ pain scale of 38.1 will decrease to 37.5 degree Celsius

> Remove excessive clothing

> Provide tepid sponge bath

> Maintain patient in bed rest

> Increase fluid intake.

> Encourage patient to eat fruits rich in Vitamin C

> Encourage patient to eat foods rich in carbohydrates and protein

> Administer medication as ordered

> promote cooling effect

> To help lowered body temperature and promote cooling effect. > To decrease metabolic demands > To replace loss fluids.

> To boost immune system

> To meet metabolic needs of the body.

> Antipyretic drugs help in lowering body temperature.

After 30 minutes of proper nursing intervention the patients’ pain scale of 38.1 will be decreased to 37.5 degree Celsius as evidenced by:

a. moist skin b. afebrile

EVALUATION

The patient undergoes cholecystectomy last January 8, 2011. The patient was given take home medications for management of pain and antibiotics as prophylaxis from surgical infection. Daily wound care was taught to the patient. Avoidance of strenuous activities was also advised. The patient was also encouraged to eat foods rich in protein and Vitamin C for wound healing and collagen formation. The prescribed diet is low fat and law salt since the gallbladder is removed. The client was also advised to comply with the follow up check-up for the removal of sutures.

After the surgical treatment done and postoperative management, patient condition is now stable.