Hernia

1. Institute of Health Science
Department of Nursing
Postgraduate Program of Adult Health Nursing
A Case Study & Acute Acalculous Cholecystitis Seminar Presentation
Set By: Rebira Workineh (AHN Student)
Rebira W. ( AHN student)
2/6/2024
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2. Outlines
Rebira W. ( AHN student)
 Acute acalculous cholecystitis real case study
 Acute acalculous cholecystitis
2/6/2024
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3. Biographic Data
 Name: Garitu Kitessa Ture
 Age/Sex: 54 years/Female
 Ethnicity: Oromo
 Religion: Orthodox
 Marital Status: Widowed
 MRN: 210865
 Address: Sibu Sire, 01
 Phone Number: 0917034326
 Source of Information: From Client
 Source of Referral: Sire Hospital
 Hospital: WURH
 Ward: Surgical Ward
 Medical diagnosis: A/A Cholecystitis
 Date of admission: 15/04/2016 E.C
 Date of assessment: 16/04/2016 E.C
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Rebira W. ( AHN student)

4. Chief Complaint
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 Right upper quadrant pain
of five days duration

5. History of Present Illness
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 A 54 year old female client comes to WURH with a five day chief complaint
of sudden onset of RUQ pain which radiates to the right upper part of the back
 The pain is constant and severity increases with taking deep breathing
 Associated symptoms include nausea, vomiting, food intolerance, bloating,
fever, dark urine and feeling of fullness.

6. History of past Illness
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 She had history of typhoid fever with, chills, malaise, fatigue, headache,
abdominal pain, & constipation of two weeks prior to her admission to this
hospital.
 The client visited Sire Hospital & received a seven-day course of antibiotics.
 Three days after the typhoid fever treatment ended, she developed excruciating
discomfort in her right upper quadrant.
 The client was re-examined at Sire Hospital & was then directed to this facility.

7. Past Medical History
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 This client had no history of hospitalization due to medical conditions such as:
 Diabetes, CHF, chronic asthma, cancer, HPN, UTI, & chronic liver disease
 Chronic renal disease, tuberculosis, & pelvic inflammatory disease
 However, she had already been admitted to the hospital because of infections with
malaria & typhoid fever.
 A recent HIV test indicated a negative result & had no history of risk factors.

8. Past Surgical History
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 This client had no prior surgical experience with procedures involving the
gallbladder, intestine, & appendix.
 She had also no history of gastroduodenal surgery, pancreatic surgery, and
bile duct surgery
 She had no history of any abdominal surgical incision such as C/S brought on
by pregnancy.
 The client had no history of any injury to the abdomen

9. Family History
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 The client has six children, one of them is female & the others are male
 All of her children are healthy & there is no known family history of
gallbladder disease risk factors, such as cholecystitis, chronic inflammation of
the gallbladder, congenital biliary abnormalities, or polyps.
 Her father was a known hypertensive patient who passed away in the last
seventeen years.
 Her family has no other known history of chronic illnesses.

10. Social History
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 She has no history of substances abuse such as:
 Alcohol
 Tobacco
 Drugs
 She has good relationship with her families & the society.
 She could afford medical services

11. Nursing Assessment
FHPApproach
Gordon’s FHP is developed by Marjorie Gordon in 1987
 Proposed to guide for establishing a comprehensive nursing data base
 Enables the nurse to determine 11 aspects of health and human function
(Lynda Carpenito, 2013)
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12. Health Perception-Management Pattern
Subjective data
 The client complained right upper quadrant pain.
 Her perceived health rating is fair
 She has no history of smoking cigarette & drinking alcohol
 She has not complained the current medication
 Any allergy to medication has not been reported by the client
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13. Health Perception Cont’d…
Objective Data:
 Appearance: ASL
 Her children take care of skin & hair hygiene, dressing, & make up.
 To: 38.1C
 BP:88/67 mmHg
 HR:59 beats per minute
 RR:25 breaths per minute
 PSO2: 96%
V/S
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14. Nutrition-Metabolism Pattern
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Subjective
 She has history of food intolerance, slight distension & nausea.
Objective
 She was initially put on fluid maintenance.
 Slight skin & nail pallor is present; however, no lesion and rash.
 She has no tenderness & clubbing of the nails.
 Her body mass index was 18Kg/m2 .

15. Elimination Pattern
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Subjective
 She always goes to the toilet once for defecation and four times for urination per
day.
Objective
 The color of urine is clear and pale yellow
 Slight distension & pain tenderness of the abdomen was present.
 The bowel sound was eight per minute

16. Activity Pattern
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Musculoskeletal
Subjective
 Body weakness is present
 No stiffness, & joint pain
 No epistaxis & blurred vision present
Objective Data
 No swelling of extremities, but slight muscular weakness

17. Activity Cont’d…
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Respiratory
 No chest pain, & pain tenderness
 The chest is symmetrical bilaterally
 Chest auscultation is clear and resonance on percussion.
 Tactile fremitus is the same in both side.

18. Activity Cont’d…
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Cardiovascular system
 Bradycardia
 No hypertension
 JVP is flat
 S1 & S2 well heard, no murmur & gallop sound

19. Sleep-Rest Pattern
Subjective
 Her usual sleep time is 5 hours per day which is inadequate; however, she has never
used sleep aid
Objective
 Moderate attention span is present
 Yawning
 There is dark circles & puffiness around the eyes
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20. Cognitive-Sensory
Subjective data: Assessment of the five senses
 The client has no visual, hearing, taste, smelling, & sensation problems.
Objective data: Assessment of conscious level
 She is oriented to TPP with Glasgow coma scale of 15.
 She is able to speak & articulate words.
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21. Self-Perception
Subjective Data
 She is unable to do activity of daily life, but she has started ambulation.
 She is worrisome about her surgery.
Objective
 She has kept eye contact with healthcare personals while expressing her suggestions.
 Her son has taken care of skin, & hair hygiene
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22. Role-Relationship Pattern
Subjective
 The client’s role is as grand mother.
 She lives with her children in her son’s house.
 They live on the farm & satisfied with it.
Objective
 She freely interacts with her family and other people.
 Many persons has come for visiting her.
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23. Coping-Stress Tolerance Pattern
Coping methods
 Treatment
 Support systems:
Healthcare providers
Families, most helpful person: Her eldest son
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24. Sexuality-Reproductive Pattern
Subjective
 She has no history of pain, lesion, & abnormal discharges/burning.
 STI- she did not report any symptoms of STI
Objective
 Breast- No mass, swelling and lesion are seen
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25. Value-Belief
Subjective
 The client is orthodox
 She strictly follows her religion
Objective
 Religious materials are presented near by the client
 They practiced ritual process/religious activities
 But, no one visited from clergy
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Study Results Reference Range
WBC 16 4-10*109/L
RBC 2.97 3.5-5.5*109/L
HGB 9 11-16 mg/dl
Urea 0.95 0.7-1.2 mg/dl
Creatinine 0.9 0.6-1.1 mg/dl
RBS 125 <140 mg/dl (7.8mmol/L)
ALB 5.8 3.4-5.4 g/dl
TP 8.5 6-8.3 g/dl
AST 114 10-36 units/L
ALT 52 4-36 units/L
U/A Blood +2 Negative
Protein +1 Negative
Laboratory Studies

27. Serum Electrolytes
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Study Results Reference Range
K+ 4.73 3.5-5.5 mEq/L
Na+ 141 135-145 mEq/L
Cl+ 102 98-106 mEq/L
HCO-3 17.4 > 15 mmol/L

28. Investigations Cont’d…
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CXR
 Unremarkable
Ultrasound report
 Gallbladder wall edema, pericholecystic fluid and distension
Widal Test
 Reactive

29. Summary of Subjective & Objective Data
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Objective
 Abdominal tenderness & bloating
 Pallor
 Lab tests: WBC, ALB, TP, AST, ALT, widal & U/A
Vital signs
 To: 38.1C - febrile
 HR: 53 beats per minute
Subjective
 RUQ pain
 Nausea/Vomiting
 Anorexia
 Abdominal pain
 Headache
 Chills

30. Medical Diagnosis
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 Acute Acalculous Cholecystitis secondary to typhoid fever
Treatment
 Maintenance fluid
 Metronidazole 500 mg IV TID
 Ceftazidine 500 mg IV BID
 Tramadol 50 mg IV TID
 Cimetidine 200 mg/2ml IV BID

31. Nursing Diagnosis
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 Acute pain R/T gallbladder tissue necrosis AEB the patient’s facial expressions.
 Risk for deficient fluid volume R/T increase in gastric fluid loss due to vomiting, &
gastric distention.
 Imbalanced nutrition less than body requirements R/T food intolerance, nausea, &
vomiting AMB dryness of mouth & pallor of the skin surface.
 Deficient knowledge about treatment needed R/T unfamiliarity with information
resources AEB patient’s verbal response.

32. Nursing Planning
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Goal with priority
 Relieve pain & promote rest.
 Maintain fluid & electrolyte balance.
 Maintain nutritional balance.
 Provide information about disease process, prognosis, and treatment needs.

33. Nursing Interventions
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Relieving Pain & Promoting Rest
 Location, severity & character of pain was observed & documented.
 Analgesics was given, response to this medication was noted
 Bed rest was provide & comfortable position was allowed.
 The client was maintain NPO & NG tube was inserted.

34. Nursing Cont’d…
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Maintaining Fluid & Electrolyte Balance
 In & out put was maintained accurately to note abnormality.
 Serum electrolytes was sent to lab for rechecking
Maintaining Nutritional Balance
 Oral hygiene was provided before meal.
 Her weight was also measured
 Oral food & fluid intake was consulted, she has taken on her preferences

35. Nursing Cont’d…
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Providing information about disease process, prognosis, & treatment needs
 Prior to each test procedures & preparations, the client was given information.
 The disease process & prognosis, reason for her hospitalization & prospective
treatment was informed.
 She was told about drug regimen & possible side effects.
 Information related to signs & symptoms requiring medical intervention was
reviewed for the client.

36. Overview
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37. Acute Acalculous Cholecystitis
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Definition
 AAC is defined as acute inflammation of the gallbladder in the absence of
gallstones.
 AAC is a severe illness that is a complication of various other medical or surgical
conditions.
 Patients are usually critically ill with atherosclerotic heart disease, recent
trauma, burn injury, surgery or hemodynamic instability.

38. Epidemiology
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 AAC comprises approximately 5%-10% of all cases of acute cholecystitis
 Usually associated with more serious morbidity and higher mortality rates than
calculous cholecystitis.
 AAC has male predominance with a male to female ratio of 9:2
 A higher frequency of AAC is reported in persons in their 40th & 80th years of life
(Iyer Shridhar Ganpathi et al, 2007)

39. Reasons For Variation
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Pregnancy
 Gallbladder disease is the 2nd most common cause of nonobstetric surgical intervention
in pregnancy.
 Transient changes in the biliary system during pregnancy increases the risk of gallbladder
disease.
 These changes include gallbladder stasis and the secretion of bile with ↑amounts of
cholesterol and ↓amounts of chenodeoxycholic acid
(Nahum Mendez-Sanchez et al, 2006)

40. Reasons Cont’d…
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Sex hormones
 Are most likely to be responsible for the increased risk
 Estrogen ↑ biliary cholesterol secretion causing cholesterol supersaturation of bile
 Hormone replacement therapy and oral contraceptive are associated with increased risk for
gallbladder disease.
 However, the effect of estrogen is dose dependent and new oral contraceptives with low
estrogen dose do not seem to increase the rate of gallbladder disease.
(Gottfried Novacek, et al, 2006)

41. Types of Cholecystitis
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Cholecystitis may be:
1. Calculous cholecystitis: A gallbladder stone obstructs the flow of bile
2. Acalculous cholecystitis: Acute inflammation in the absence of obstruction by
gallstones
3. Acute cholecystitis: A life-threatening situation that requires immediate attention.
4. Chronic cholecystitis: Recurrent episodes of moderate swelling & inflammation,
which causes the organ to thicken, shrink and lose proper function.

42. Etiology
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 Depressed motility and starvation: surgery, burns, more than three months of total
parenteral nutrition, narcotic analgesics, mechanical ventilation and trauma
 Hypoperfusion: arteriosclerosis, congestive cardiac failure ( MI), diabetes, shock
 Infection: AIDS, Candida, cholera, salmonella, and campylobacter
 Obstruction of cystic duct by extrinsic inflammation: lymphadenopathy &
metastasis
(Satyendra Dhar et al, 2023)

43. Etiology Cont’d…
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 A study conducted in Italy in 2022 noted that:
 AAC is a challenging diagnosis
 The similarity of symptoms & laboratory data mimicking CVD often result in under
& misdiagnosed cases.
 Due to lack of RCT, there is still lot of confusion regarding the relationship &
consequently clinical management of AAC & CVD.
 Conclusion: Which came first? Chicken & eggs debate.

44. Pathogenesis
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 This may be conceptualized as a paralytic ileus of the gallbladder
1. Lack of enteral nutrition & hypoperfusion → hypotonic, dilated gallbladder
 Distension of the gallbladder increases wall tension→impairing perfusion of the
gallbladder wall
 Biliary stasis causes concentration of biliary detergents→damage the wall of
gallbladder

45. Pathogenesis Cont’d…
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2. Further complications ensue
 Necrosis & perforation of the gallbladder
 Superinfection with enteric bacteria→empyema of the gallbladder

46. Clinical Manifestations
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 The most frequent signs and symptoms are:
 Right upper quadrant pain
 Nausea
 Vomiting
 Fever
 Abdominal distension
 Decreased bowel sounds
 Jaundice
(Howard R.I., 2007)

47. Investigations
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 History collection & physical examination ( Clinical findings)
 Laboratory tests
 CBC, LFT
 Blood culture
 Ultrasound
 CT scan

48. Investigations Cont’d…
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Hepatobiliary Iminodiacetic Acid (HIDA) Scan
 Is an imaging procedure used to dx. problems of the liver, gallbladder & bile ducts
 Radioactive tracer is injected into a vein in the arm
 The tracer travels through the bloodstream to the liver, where the bile-producing cells
take it up
 The tracer then travels with the bile into the gallbladder and through the bile ducts to
the small intestine
(Mayo Clinic Family Health Book, 5th Edition)

49. Investigations Cont’d…
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50. Differential Diagnosis
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 Other biliary disease
 Calculous cholecystitis
 Ascending cholangitis
 Choledocholithiasis
 Pancreatitis
 PUD with perforation
 Pyelonephritis
 Clostridioides difficile colitis
 Hepatic abscess
 Hepatitis
 AIDS cholangiopathy
 TPN-associated liver disease

51. Medical Management
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Medications
 Antiemetic : e.g., Promethazine
 Analgesics: Meperidine, hydrocodone & acetaminophen
 Antibiotics: Ampicillin & penicillin, meropenem, metronidazole &
ceftriaxone or ceftazidine

52. Medical Cont’d…
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 Diet: NPO, hydration with IV fluid
 Endoscopic gallbladder stenting (EGS)
 Percutaneous cholecystostomy
 Surgery: Cholecystectomy-definitive of acute acalculous cholecystitis

53. Prognosis
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 Morbidity and mortality rate associated with AAC can be high
 The illness is frequent observed in patients with sepsis or other serious conditions
 The reported mortality range is 10%-50% for AAC as compared to 1% for calculous
cholecystitis
 A study showed that AAC is found in higher frequency than calculous cholecystitis in
patients with cerebrovascular accidents with respective rates being 15.9% & 6.7%.
 Gangrenous cholecystitis is also greater in the AAC than in acute calculous cholecystitis

54. Complication
 Perforation of the gallbladder
 Gangrene of the gallbladder
 Extrabiliary abscess formation
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55. References
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 Brunner & Suddarth’s textbook of medical-surgical nursing, 13th Edition.
 A Book: Mayo Clinic Family Health Book, 5th Edition
 Anne Waugh, et al, (2012). Anatomy and physiology in Health and Illness, 11th edition
 Joyce M. Black et al, (2015). Medical Surgical Nursing: Clinical Management for
Positive Outcomes, 8th edition.
 F. Y. khan, et al, (2009). Acute acalculous cholecystitis complicating typhoid fever in an
adult patient: a case report and review of the literature, Travel Medicine and Infectious
Disease.

56. 2/6/2024
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HAPPY NURSING