Case study on cholelithiasis

Puspa Gauro
MN 1st year
2068/10/

 To gain in-depth knowledge about the study
subject/disease condition.
 To gain the confidence in handling such cases in
future.
 To fulfill the partial course objective of M.N.
curriculum.
 To share experience and knowledge to friends,
juniors and seniors.

 Cholelithiasis is one of the common problems
encountered in Nepal.
 In the United States, about 20 million people
(10-20% of adults) have gallstones.
 Every year 1-3% of people develop gallstones
and about 1-3% of people become symptomatic.
 To provide holistic nursing care to the patient
using the nursing process by Appling different
nursing theories.

 History taking and interviewing to the
patient and his visitors.
 Observation and, physical examination to the
patient
 Discussion with teachers, senior staffs and
doctors
 Using various text books and references of
Medicine and related internet search
technology

 Patient’s Name : Ms. Kalpana Pandit
 Age/ sex :-24yrs/female
 Marital status : - Married
 Education : - Literate
 Occupation : - house wife
 Religion : - Hindu
 Address :-Khaireni , Parsa-7, Chitwan
 Ward :- surgical ward
 Bed No. : - 28

Contd…
 IP No. :- 48870
 Provisional Diagnosis :- cholelithiasis
 Date of admission :- 2068/07/29
 Date of operation :2068/07/30
 Interview date :- 2068/07/30
 Date of discharge :- 2068/08/3
 Final Diagnosis :- cholelithiasis
 Operative procedure : laproscopic
cholesystectomy.
 Attending physician :- Dr Chandra Prakash
Pandey
 Informants Obtained From :- Patient (self) & his
husband

B.Chief complain
 Fever, vomiting, indigestion, diarrhea.
 Pain on the right side

C. Present Illness/ Health Status
 Ms. Kalpana Pandit had Fever, vomiting, indigestion,
diarrhea was occurred before 15th of hospitalization and
Pain on the right side was from about 2 months but pain
was dull. Then she used to take pain killer from medical
hall. Pain gradually increased. She came to the hospital
when there was fever, vomiting and diarrhoea. She took
the medical treatment from OPD of medical ward 15th
before. She was advised to admit on 2068/7/29 for
surgery.

 Past health history
 No history of any childhood illness.
 No history of hospitalization
 No history of psychiatric problem.
 No history of past illness of any kind of Injuries
and Accidents.
 Family history
 No history of Hypertension, Diabetes, TB or
asthma.
 Socio economic history
 Middle class family.
9

 Allergies:- no allergies to any food, Drugs and
others
 Medication Taken at Home: she used to take
medicine from medical hall in minor cases.
 Traditional Healer’s Prescription: she
believes on traditional healer and obeys them
but give emphasize to hospital also

 Medical Practioner’s prescription:- if they
get health problem they use to come to
hospital and take the prescribed medicine.
 Self prescription: she use to take certain
drugs like cetamol when suffering from
fever.

 Client’s Reaction to illness:
she was worried about the pain that occur during
surgery.
 Client’s Coping Pattern:
she copes illness by expressing her feelings to her
husband.

Client’s Value of Health:
 She things health is important.
Client’s Perception of the Care Giver:
 She things that nurses are caring and giving
health education effectively.

Family Relationship:
 Client’s Position in the Family: she use to help in the
family. she is not head of the family.
 Person Living With Client (Support System) : her
husband was caring her in hospital.
 Recent Family Crisis or Changes: there is family crisis,
she is unable to care her son as he is of 5years and her
child is with his grandmother.

 Menstrual history
Regular menstrual period
 Obstetric history:
 Antenatal checkup: done in hospital
 Postnatal checkup: done in hospital
 Place of Delivery: hospital
 Type of Delivery: Spontaneous Vaginal delivery
 Any complication: No

 Personal history
 Smoking :-No smoking habit
 Alcohol : - No alcohol habit
 Food habit : - 3 times a day
 Food allergy : - Not known
 Drugs allergy : - Not known
 Bowel and bladder : - Regular bowl habit
 Sleeping Pattern : - 6-8 hrs. per day
16

 Environmental history
 Type of family :- joint Family
 No. of family :- 5 members
 Type of house :- cement house
 NO. of rooms :- 4
 Kitchen :- Separated
 Fuel used :- Firewood , Gas
 Drinking Water :- tap water
 Toilet :- pit latrin
 Drainage System :- open
drainage
17

45
33
Patie
nt
Male
Femal
e
5
53
3023
03
42
0

 General Inspection:
 Gait : Normal
 Body Build : fat
 Consciousness : conscious and alert
 Facial expression : looking anxious
 Vital signs
 Temperature : 980 f
 Pulse :78 b/minute and regular
 Respiration : 18b /minute, regular
 Blood Pressure : 100/60 mm Hg in both arms (supine)
 Height : 5' 2"
 Weight : 65kg
19

 Examination of head ,face and neck
 Inspection of head-
 Hair color and texture normal, clean hair no any
injury
 Inspection of eyes- No discharge and redness of
the eye
 Inspection of ears- No discharge and pain
 Nose- No discharge , bleeding and smelling
problem.
 Mouth- Poor oral hygiene, no bleeding,
 Neck- No enlarged lymph node and thyroid gland
normal neck mobility is present
20

 Inspection; symmetrical shape, sternum is
located at the midline, expansion of the
chest , lateral diameter wider than
anteriposterior diameter.
 Palpation : no tenderness, no lump or
depression along the ribs, expansion of the
chest on both sides
 Percussion : deep resonent sound over the
lungs
 Auscultation : breath sounds are heared in all
areas of lungs, no rales ronchi wheezing sounds.
21

 Inspection: no enlargement of neck vein,
 Palpation - Non tender, no thrill
 Auscultation - clear and regular heart rate
between 60-80 beats per minute. No murmur
sound present.
22

 Higher mental function normal
 Motor examination e.g. position of limbs normal
no atrophy.
 No abnormal movement.
 Normal muscle tone.
 Normal power in all limbs.
 Deep tendon jerk (bicep, tricep, knee and
ankle)normal
23

 localized pain in the right upper quadrant,
usually with rebound.
Comfort sleep ,rest
 Slightly anxious about the operation.

In Books In patient
1. Selecting a mate She had selected mate for her life
partner to form marital relationship.
2. Learning to live with a marriage
partner
She is married since 7 Yrs and live
with her husband with happy life
3. Starting a family She has one children and stayed with
joint family
4. Rearing children She is house wife. She was rearing
her children very well and now she is
unable to do due to illness.

In Books In Patient
5. Managing a
home
She was Establishing and maintaining a home and managing a
time schedule.
But now her physical and cognitive capacity is decreased due to
illness.
6. Getting started
in an occupation
She has no other job, she manage home, caring and rearing her
children as well as older parents.
7. Taking on civic
responsibility
She has housewife of the family and is taking care of all family
members and also taking part in some social activities, e.g. in
festivals, marriage etc.
8. Finding a
friendly social
group
She has good relation in her neighborhoods and friendship group.
She also involved in social activities.

 Cholelithiasis is the medical term for
gallstone disease.
 Gallstones are concretions that form in the
biliary tract, usually in the gallbladder.
 Calculi, or gallstones, usually form in the
gallbladder from the solid constituents of
bile; they vary greatly in size, shape, and
composition.

 Cystic duct obstruction, if it persists for more
than a few hours, may lead to acute
gallbladder inflammation (acute cholecystitis).
 Common bile duct stone (choledocholithiasis)

 In the United States, about 20 million people
(10-20% of adults) have gallstones.
 Every year 1-3% of people develop gallstones and
about 1-3% of people become symptomatic.
 Each year, in the United States, approximately
500,000 people develop symptoms or
complications of gallstones requiring
cholecystectomy
 Gallstones may be present at any age but are
unusual before the third decade

 The prevalence is two to three times higher
in women than in men, although this
difference is less marked in the sixth and
seventh decade.
 At this age the prevalence ranges between
25% and 30%.

1.Cholesterol gallstones:
 Liver cells secrete cholesterol into bile along with
phospholipid (lecithin) in the form of small
spherical membranous bubbles, termed unilamellar
vesicles.
 Liver cells also secrete bile salts, which are
powerful detergents required for digestion and
absorption of dietary fats.
 Bile salts in bile dissolve the unilamellar vesicles to
form soluble aggregates called mixed micelles.
 This happens mainly in the gallbladder, where bile
is concentrated by reabsorption of electrolytes and
water.

 Compared with vesicles (which can hold up to 1
molecule of cholesterol for every molecule of
lecithin).
 mixed micelles have a lower carrying capacity for
cholesterol (about 1 molecule of cholesterol for
every 3 molecules of lecithin).
 If bile contains a relatively high proportion of
cholesterol to begin with, then as bile is
concentrated, progressive dissolution of vesicles
may lead to a state in which the cholesterol-
carrying capacity of the micelles and residual
vesicles is exceeded.
 At this point, bile is supersaturated with
cholesterol, and cholesterol monohydrate
crystals may form

 Bilirubin, a yellow pigment derived from the breakdown of
heme, is actively secreted into bile by liver cells.
 Most of the bilirubin in bile is in the form of glucuronide
conjugates, which are quite water soluble and stable, but
a small proportion consists of unconjugated bilirubin.
 Unconjugated bilirubin, like fatty acids, phosphate,
carbonate tends to form insoluble precipitates with
calcium.
 Calcium enters bile passively along with other electrolytes.
 In situations of high heme turnover, such as chronic
hemolysis or cirrhosis, unconjugated bilirubin may be
present in bile at higher than normal concentrations.
 Calcium bilirubinate may then crystallize from solution and
eventually form stones.

 Gallstone formation is multifactorial, and the
factors involved are related to the type of
gallstone .
Risk factors for cholelithiasis:
 Obesity
 Women, especially those who have had
multiple pregnancies .
 Frequent changes in weight

 Rapid weight loss (leads to rapid development
of gallstones and high risk of symptomatic
disease)
 Treatment with high-dose estrogen.
 Low-dose estrogen therapy—a small increase in
the risk of gallstones
 Cystic fibrosis
 Diabetes mellitus

 Impaired gallbladder emptying
 Pregnancy
 Gallbladder stasis
 Fasting
 Total parenteral nutrition
 Spinal cord injury
 PATHOGENIC FACTORS LEADING TO THE PRODUCTION
OF LITHOGENIC BILE
 Defective bile salt synthesis
 Excessive intestinal loss of bile salts
 Excessive cholesterol secretion
 Abnormal gallbladder function

According to book According to patient
 Gallstones may be silent, producing no
pain and only mild gastrointestinal
symptoms.
 Epigastric distress, such as fullness,
abdominal distention
 The patient may have biliary colic with
excruciating upper right abdominal pain
that radiates to the back or right
shoulder, is usually associated with
nausea and vomiting, and is noticeable.
several hours after a heavy meal.
 The patient develops a fever and may
have a palpable abdominal mass.
 Pain on the right side of the
abdomen.
 No abdominal distention.
 Vomiting, undigestion and
diarrhea present.
 fever
 Not present

According to book According to patient
 Jaundice occurs in a few patients with
gallbladder disease and usually occurs with
obstruction of the common bile duct. .
 The excretion of the bile pigments by the
kidneys gives the urine a very dark color.
 The feces, no longer colored with bile
pigments, are grayish, like putty, and
usually described as clay-colored
 Obstruction of bile flow also interferes with
absorption of the fatsoluble vitamins A, D,
E, and K.
 Therefore, the patient may exhibit
deficiencies (eg, bleeding caused by
vitamin K deficiency,
 Not present
 Urine normal colour
 Presence of diarrhea
 No any sign of bleeding

 Choledocholithiasis
 Pancreatitis
 Fistulae between the gallbladder and
duodenum or colon
 Pressure on/inflammation of the common
bile duct by a gallstone in the cystic duct
 Cancer of the gallbladder

According to book According to my patient
 History taking
 Asymptomatic gallstones
 without causing symptoms or complications
 evidence to support a causal association
between gallstones and chronic abdominal
pain, heartburn, postprandial distress,
bloating, flatulence, constipation, or
diarrhea.
 Biliary colic
pain resolves over 30 to 90 minutes as
the gallbladder relaxes and the
obstruction is relieved.
 indigestion, dyspepsia, belching, bloat, and
fat intolerance
Fever, vomiting, indigestion, diarrhea.
Pain on the right side

 physical examination:
 asymptomatic gallstones have no abnormal
findings on physical examination.
 In acute cholecystitis
 localized pain in the right upper quadrant, usually
with rebound and guarding.
 a positive Murphy sign (inspiratory arrest on deep
palpation of the right upper quadrant during deep
inspiration)
 Tachycardia and diaphoresis may be present as a
complications of cholelithiasis consequence of
pain
 In severe cases of acute cholecystitis, ascending
cholangitis, or acute pancreatitis, bowel sounds
are often absent or hypoactive.
 Choledocholithiasis with obstruction of the
common bile duct produces cutaneous and scleral
icterus.
 Acute gallstone pancreatitis is often characterized
by epigastric tenderness
Fever, vomiting, indigestion,
diarrhea.
Pain on the right side

Blood Studies
 complete blood cell (CBC) count
with differential
 , liver function panel, and
 amylase and
 lipase.
 CBD) obstruction initially
produces an acute increase in
the level of liver transaminases
(alanine and aspartate
aminotransferases), followed
within hours by a rising serum
bilirubin level.
•Liver function test done in my
patient and values are normal.
•alkaline phosphatase done in my
patient and slight low value.

 If obstruction persists, a progressive
decline in the level of
transaminases with rising alkaline
phosphatase.
 . Prothrombin time may be
elevated in patients with prolonged
CBD obstruction,
 Concurrent obstruction of the
pancreatic duct by a stone in the
ampulla of Vater may be
accompanied by increases in serum
lipase and amylase levels.
•Prothrombin time is done and it is
normal.
• Not done.

Abdominal Radiography
 Black pigment or mixed gallstones may contain
sufficient calcium to appear radiopaque on
plain films
Ultrasonography
 useful investigation for the diagnosis of
gallstone-related disease:
(a) gallstones within the gall bladder,
particularly when these are obstructing the
gall bladder neck or cystic duct
(b) focal tenderness over the underlying gall
bladder
(c) thickening of the gall bladder wall.
Computed Tomography
CT can be used in diagnostic challenges or to
further characterize complications of gallbladder
disease
•Abdominal radiography not done in
my patient.
•Utrasonography done in my patient:
Two calculi noted in the GB lumen,
largest one measuring 10mm.

From St. Luke’s Health System Resource Library

•Magnetic Resonance Imaging
Magnetic resonance imaging (MRI) with
magnetic resonance cholangiopancreatography
(MRCP) has emerged as an excellent imaging
study for noninvasive identification of gallstones
anywhere in the biliary tract, including the
common bile duct
•Endoscopic Retrograde
Cholangiopancreatography
•Not done in my patient
•Not done in my patient

Date Test In Patient Reference Range
068/7/27 Haematological report
WBC
Neutrophil
Lymphocytes
Monocytes
Eosinophil
Basophil
Hb
Platelet Count
PT( test)
PT(control)
16,400 mm3
72%
26%
01%
01%
00%
10.7gm/dl
142000 mm3
16.3 sec
14sec
4000-11,000 mm3
40-70%
20-40%
2-10%
2-6%
0-1%
M: 12-18 gm , F: 12-
16 gm/dl
150000- 400000 mm3
13-15sec

Date Test In Patient Reference Range
068/7/27
INR
Bleeding time
Clotting time
Biochemistry
SGOT/AST
SGPT
Bilirubin Total
Bilirubin direct
Blood sugar (R)
Creatinine
alkaline phosphate
Blood group/Rh type
HIV 1 &11
HbsAg
Anti Hcv
1.20
2min
10min
34U/L
36u/L
0.61mg/dl
0.21mg/dl
110mg/dl
0.8 mg/dl
81.0 IU/L
o+ve
Non reactive
Non reactive
Non reactive
2-7min
6-12min
M-<37 F <31
<40
0.4 - 1.4
0.1 – 0.4
70-120
0.4-1.4mg/dl
( M-64 -306 F: 84-306

 Differentials diagnosis:
 Appendicitis
 Bile Duct Strictures
 Bile Duct Tumors
 Cholecystitis
 Gallbladder Cancer
 Gastritis and Peptic Ulcer Disease
 Gastroenteritis
 Pancreatic Cancer

Treatment of Asymptomatic Gallstones:
Surgical treatment
 Surgical treatment of asymptomatic gallstones
without medically complicating diseases is
discouraged.
 cholecystectomy for asymptomatic gallstones may
be indicated in the following patients:
 Patients with large gallstones greater than 2 cm in
diameter

 Patients with risk factors for complications of
gallstones may be offered elective
cholecystectomy.

Medical dissolution of gallstones
 Ursodeoxycholic acid (ursodiol) is a gallstone
dissolution agent.
 In humans, long-term administration of
ursodeoxycholic acid reduces cholesterol
saturation of bile, both by reducing liver
cholesterol secretion and by reducing the
detergent effect of bile salts in the gallbladder
(thereby preserving vesicles that have a high
cholesterol carrying capacity).
 Desaturation of bile prevents crystals from
forming and, in fact, may allow gradual extraction
of cholesterol from existing stones.

 In patients with established cholesterol gallstones,
treatment with ursodeoxycholic acid at a dose of
8-10 mg/kg/d PO divided bid/tid may result in
gradual gallstone dissolution.
 This intervention typically requires 6-18 months
and is successful only with small, purely
cholesterol stones.
 The recurrence rate is 50% within 5 years.
 Moreover, after discontinuation of treatment, most
patients form new gallstones over the subsequent
5-10 years.

 Cholecystectomy
 Removal of the gallbladder (cholecystectomy) is
generally indicated in patients who have experienced
symptoms or complications of gallstones
 Open versus laparoscopic cholecystectomy
 Currently, laparoscopic cholecystectomy is commonly
performed in an outpatient setting. By reducing
inpatient stay and time lost from work, the
laparoscopic approach has also reduced the cost of
cholecystectomy.
 Cholelithiasis patients whose laparoscopic
cholecystectomy was uncomplicated may be sent
home the same day if postoperative pain and nausea
are well controlled

 Stone Removal by Instrumentation. Several
nonsurgical methods are used to remove
stones that were not removed at the time of
cholecystectomy or have become lodged in
the common bile duct (Fig. 40-4A, B).

 A catheter and instrument with a basket
attached are threaded through the T-tube
tract or fistula formed at the time of T-tube
insertion; the basket is used to retrieve and
remove the stones lodged in the common
bile duct.
 A second procedure involves the use of the
ERCP endoscope (see Fig. 40-4C).

 After the endoscope is inserted, a cutting
instrument is passed through the endoscope into
the ampulla of Vater of the common bile duct.
 It may be used to cut the submucosal fibers, or
papilla, of the sphincter of Oddi, enlarging the
opening, which may allow the lodged stones to
pass spontaneously into the duodenum.
 Another instrument with a small basket or
balloon at its tip may be inserted through the
endoscope to retrieve the stones (see Fig. 40-4D–
F ).

 Although complications after this procedure
are rare, the patient must be observed
closely for bleeding,
 perforation, and the development of
pancreatitis or sepsis.

Surgical Trocar (both
are often 5mm)
Optical
Trocar
Retraction
of gall
bladder/liv
er

Cystic Duct
Cystic Artery
Infundibulum of
Gall Bladder

 Extracorporeal Shock-Wave Lithotripsy.
Extracorporeal shockwave therapy (lithotripsy or
ESWL) has been used for nonsurgical fragmentation
of gallstones. The word lithotripsy is derived from
lithos, meaning stone, and tripsis, meaning rubbing
or friction.
 After the stones are gradually broken up, the stone
fragments pass from the gallbladder or common
bile duct spontaneously, are removed by
endoscopy, or are dissolved with oral bile acid or
solvents.

 Intracorporeal Lithotripsy
 Stones in the gallbladder or common bile
duct may be fragmented by means of laser
pulse technology.
 A laser pulse is directed under fluoroscopic
guidance with the use of devices that can
distinguish between stones and tissue.

 Endoscopic sphincterotomy
 If surgical removal of common bile duct stones
is not immediately feasible, endoscopic
retrograde sphincterotomy can be used.
 In this procedure, the endoscopist cannulates
the bile duct via the papilla of Vater.
 Using an electrocautery sphincterotome, the
endoscopist makes an incision measuring
approximately 1 cm through the sphincter of
Oddi and the intraduodenal portion of the
common bile duct, creating an opening through
which stones can be extracted.

 laparoscopic cholecystectomy
 2068/7/30
 Inj Cifran 200mg IV BD
 Inj Aciloc 50mg IV BD
 Inj tramadol 50mg IM SOS
 Inj phenargan 25mg IM SOS
 Tab Becto 500mg O BD
 Tab Rloc 150mg O BD
 Tab Nise 100mg O BD

 The mortality rate for an elective
cholecystectomy is 0.5% with less than 10%
morbidity.
 The mortality rate for an emergent
cholecystectomy is 3-5% with 30-50% morbidity.
 Following cholecystectomy, stones may recur in
the bile duct.

 Mrs. Kalpana Pandit was admitted for the first time
 She was anxious about outcome of disease as well
as adjusting in new environment.
 She was fully conscious, alert and she can do care
herself by minimal assistance.
 So, I applied Peplau’s Theory: Interpersonal
Relationship with the mutual understanding of
patient and family members while caring her.

Peplau’s Theory: Interpersonal Relationship
 According to Peplau, nursing is therapeutic in that it
is a healing art, assisting in individual who is sick or
in need of health care.
 Nursing can be viewed as an interpersonal process
because it involves interaction between two or more
individuals with a common goal.
 In nursing, this common goal provides the incentive
for the therapeutic process in which the nurse and
patient respect each other as individuals, both of
them learning and growing as a result of the
interaction.

Peplau identifies four sequential phases in
interpersonal relationship:
 Orientation phase
 Identification phase
 Exploitation phase
 Resolution phase

 Orientation phase:
Nurse and patient come together as strangers;
meeting initiated by patient who expresses felt
need; work together to recognize, clarify and
define facts related to need. It is also called
problem defining phase.
 Identification phase:
Interdependent goal setting, patient has feeling of
belonging and selectively responds to those who
can meet needs. Each patient responds differently
in his phase. Selection of appropriate professional
assistance.

 Exploitation phase:
Patient actively seeking and drawing on knowledge
and expertise of those who can help, use of
professional assistance for problem solving
alternatives.
 Resolution phase:
Occurs after other phases are successfully
completed and have been met, leads to
termination.

 Asses health history: note history of smoking or
prior respiratory problems.
 Asses respiratory status: note shallow
respirations, persistent cough, or ineffective or
adventious breath sounds
 Evaluate Nutritional status is evaluated through
a dietary history and general examination
performed at the time of preadmission testing
 Obtain laboratory results to obtain information
about the patient’s nutritional status

 Ask for pain in the in the operative site
 Regarding pain, discussion was made to
assess the severity and the type and duration
of pain.

 Acute pain and discomfort related to surgical
incision
 Impaired skin integrity related to altered biliary
drainage after surgical intervention
 Imbalanced nutrition, less than body
requirements, related to inadequate bile
secretion
 Deficient knowledge about self-care activities
related to incision care, dietary modifications
(if needed), medications, reportable signs or
symptoms (eg, fever, bleeding, vomiting)

The goals for the patient include:
 Relief of pain
 Adequate ventilation intact skin and
 improve biliary drainage
 Anxiety related to hospital admission
 optimal nutritional intake
 absence of complications
 understanding of self-care routines.

Postoperative:
 Place the patient in the low Fowler’s position.
 Provide Intravenous fluids.
 Provide water and other fluids and soft diet is
started when bowel sounds return.
 Relieving pain:
 Administer analgesic agents as prescribed to
relieve the pain
 Help the patient to turn, cough, breathe deeply,
and ambulate as indicated.
 Use of a pillow or binder over the incision during
these maneuvers.

Improving respiratory status
 Remind patients to take deep breaths and
cough every hour to expand the lungs fully and
prevent atelectasis.
 Promote early ambulation. Early ambulation
prevents pulmonary complications as well
 Monitor elderly and obese patients must closely
for respiratory problem.
.

Promoting skin care and biliary drainage:
 observed for indications of infection, leakage
of bile into the peritoneal cavity, and
obstruction of bile drainage, clay colored
stool and vital sign.
 note and report right upper quadrant
abdominal, pain, nausea and vomiting,
 Observe for jaundice.
 changes frequently the outer dressings and
protection of the skin from irritation.
 Maintain a careful record of fluid intake and
output

Improving nutritional status
 Encourage the patient to eat a diet low in fats
and high in carbohydrates and proteins
immediately after surgery.
 At the time of hospital discharge, there are
usually no special dietary instructions other
than to maintain a nutritious diet and avoid
excessive fats.

Monitoring and managing potential
complications
 Closely monitor vital signs and inspects the
surgical incisions and drains, if in place, for
evidence of bleeding.
 Periodically assesses the patient for increased
tenderness and rigidity of the abdomen and
report to the surgeon.
 Instructs the patient and family to report to the
surgeon any change in the color of stools
because this may indicate complications.

Contd…
 After laparoscopic cholecystectomy, assesses the
patient for loss of appetite, vomiting, pain,
distention of the abdomen, and temperature
elevation.
 These may indicate infection or disruption of the
gastrointestinal tract and should be reported to the
surgeon promptly.
 Instruct verbally and in writing about the
importance of reporting these symptoms promptly
after discharge.

Teaching Patients Self-Care
 Instruct the patient about the medications that
are prescribed (vitamins, anticholinergics, and
antispasmodics) and their actions.
 Inform the patient and family about symptoms
that should be reported to the physician,
including jaundice, dark urine, pale-colored
stools, pruritus, or signs of inflammation and
infection, such as pain or fever.
 Emphasize importance of keeping follow up
appointments.

 Asses the knowledge of patient and family of
the therapeutic regimen. (medications, gradual
return to normal activities)
 Emphasizes the importance of keeping follow-up
appointments and reminds the patient and
family of the importance of participating in
health promotion activities and recommended
health screening.
 Shower can be taken 48 hours after surgery.
 No restrictions to physical activities.
 Gradually increase activities at a comfortable
and individual pace.

Postoperative:
 Placed the patient in the low Fowler’s position.
 Provided Intravenous fluids.
 Provided water and other fluids and soft diet is
started when bowel sounds return.
 Relieving pain:
 Administerd analgesic agents as prescribed to relieve
the pain
 Helped the patient to turn, cough, breathe deeply,
and ambulate as indicated.
 Used of a pillow or binder over the incision during
these maneuvers.

Improving respiratory status
 Remind patients to take deep breaths and
cough every hour to expand the lungs fully
and prevent atelectasis.
 Promoted early ambulation. Early ambulation
prevents pulmonary complications as well
 Monitored elderly and obese patients must
closely for respiratory problem.
.

Promoting skin care and biliary drainage:
 observed for indications of infection, leakage
of bile into the peritoneal cavity, and
obstruction of bile drainage, clay colored
stool and vital sign.
 noted and report right upper quadrant
abdominal, pain, nausea and vomiting,
 Observed for jaundice.
 changed frequently the outer dressings and
protection of the skin from irritation.
 Maintained a careful record of fluid intake
and output

Improving nutritional status
 Encouraged the patient to eat a diet low in
fats and high in carbohydrates and proteins
immediately after surgery.
 At the time of hospital discharge, therewere
usually no special dietary instructions other
than to maintained a nutritious diet and
avoid excessive fats.

Monitoring and managing potential
complications
 Closely monitord vital signs and inspects the
surgical incisions and drains, if in place, for
evidence of bleeding.
 Periodically assessesd the patient for
increased tenderness and rigidity of the
abdomen and report to the surgeon.
 Instructed the patient and family to report to
the surgeon any change in the color of stools
because this may indicate complications

 After laparoscopic cholecystectomy, assessed
the patient for loss of appetite, vomiting,
pain, distention of the abdomen, and
temperature elevation.
 These may indicate infection or disruption of
the gastrointestinal tract and should be
reported to the surgeon promptly.
 Instructed verbally and in writing about the
importance of reporting these symptoms
promptly after discharge.

Teaching Patients Self-Care
 Instructed the patient about the medications
that are prescribed (vitamins, anticholinergics,
and antispasmodics) and their actions.
 Informed the patient and family about symptoms
that should be reported to the physician,
including jaundice, dark urine, pale-colored
stools, pruritus, or signs of inflammation and
infection, such as pain or fever.
 Emphasized importance of keeping follow up
appointments.

 Assesed the knowledge of patient and family
of the therapeutic regimen. (medications,
gradual return to normal activities)
 Emphasized the importance of keeping
follow-up appointments and reminds the
patient and family of the importance of
participating in health promotion activities
and recommended health screening.
 No restrictions to physical activities.
 Gradually increase activities at a
comfortable and individual pace

Expected patient outcomes
 Expected patient outcomes may include:
 Reports decrease in pain
 Demonstrates appropriate respiratory
function
 Exhibits normal skin integrity around biliary
drainage site (if applicable)
 Obtains relief of dietary intolerance
 Absence of complications

Date: - 2068/7/29
Admission day
 A patient was admitted in surgical ward from opd for
laproscopic laprotomy.
 On admission patient’s vitals sign were:
 B.P=100/60 mm of hg, R.R=20/min, Pulse=88/min,
Temp. =98ºf, SPO2 98% according to nursing report.
 All investigation report were collected.
 Patients general condition was fair.
 Patient was kept NPO from 10pm.

Date: - 2068/7/ 30
1st day of admission
 She slept well but slightly anxious about the surgery.
 She is Alert and conscious
 History taking and physical examination done
 B/P- 110/70 mmof Hg, RR- 20/min, P- 92/min, T- 98 ºf,
SPO2 99%
Preoperative care was done:
 Send for bath.
 Psychological support given
 Consent was taken.
 Removed all ornaments.
 IV infusion was given.
 Gown was given to wear.
 Chart was completed.

Date: - 2068/8/1
2nd day of admission(1st post op day)
 B/P- 110/80 mmof hg, RR- 22/min, P- 80/min, T- 98.2 ºf, SPO2 98%
 Intake= 2100ml, output= 1450ml
 Patient GCS 15/15.
 Patient is self voiding.
 No soakage and bleeding from operation site.
 Inj NS Ipint and 5%dex IV pint was given.
 kept her in fowler position
 Slept well at night.
 Morning care was given.
 Caried out the prescribed medication.
 Coplain of pain so inj tramadol and inj phenargan was given and relieved
after one hour.
 Patient was ambulated.

Date: 2068/8/2
3rd day of admission(2nd post op day)
 Slept well at night.
 B/P- 120/80 mmof hg, RR- 22/min, P- 78/min, T- 97.2
ºf, SPO2 98%.
 Patients GCS -15/15
 Intake=1950ml, output=1350ml
 Cannula was removed.
 Patient transferred to surgical ward.
 No soakage and bleeding from wound site.
 Patient was ambulated.
 patient was given normal diet.
 Prescribed medication was given.

Date: 2068/8/3
4th day of admission(3rd post op day)
 Slept well at night
 Patients general condition was fair.
 B/P- 130/80 mmof hg, RR- 20/min, P- 88/min, T-
97.2 ºf, SPO2 98%
 No any complain.
 Normal voiding of urine and stool.
 Patient was discharged.
 Gave discharge teaching.

 Adequate fluid intake
 Diet
 Personal hygiene
 Rest and sleep
 Exercise.
 Prevention of Infection
 Medication
 Follow up: after 5 days

 Tab Nise 100mg “0” BD
 Cap Broclox 500mg 1cap QID 5days
 Follow Up after 5 days for removal of suture.

 Diversional Therapy “is a client centered practice
and recognizes that leisure and recreational
experiences are the right of all individuals.”
 Activities are designed to support, challenge, and
enhance the psychological, emotional and physical
well being of individuals.
 These are often quite diverse and can range from:
Games, outings, computers gentle exercise, music,
arts and craft.

 Gentle exercise.
 Deep breathing and coughing exercise
 Talking with other patient
 Listening music by mobile phone.
 Gossiping with her
 Allowing her husband to talk with her.

 Sphygmomanometer
 Stethoscope
 X-ray machine
 Thermometer
 Pulse oxymeter
 BP instrument.

 Fever, vomiting, indigestion, diarrhea.
 Pain on the right side
Utrasonography done in my patient:
 Two calculi noted in the GB lumen, largest one
measuring 10mm.

I learned many things from the case study
which are as following:
 Identified the complete health need,
development Task of Young adult and compared
it with normal one.
 Provide comprehensive nursing care by using
Nursing Theories to the Young adult patient.
 Assist in different type of diagnostic procedure
for the patient.
 Analyze the concept and approach to nursing
practice according to trend and technology.

 Identified the factors influencing nursing
practice.
 Identified the plan, implement and evaluate
the educational need of the patient and
patient family.
 Develop therapeutic relationship to the
patient and family and understand their
religion, culture, customs and health care
belief and practices.
 Develop competency in handling various
gadgets which were used to patient.

 Chintamani, Lewis, Heitkemper, Dirksen, O’Brien and
Bucher, (2011). Lewis’s Medical Surgical Nursing:
Assessment and Management of Clinical Problems. 7th
Ed
 Black J.M. & Hawks J.M. (2005). Medical –Surgical
Nursing: Clinical management for positive outcomes.
(7th Ed.).
 Brunner & Siddhartha's (2004).Medical- Surgical
Nursing. (12th Ed.) .
 Mosby’s Nursing Drug Reference. (2010). 23rd Ed.
 Davidson’s principle and practice of medicine 20th
edition
 Retrieved on 2068/10/20 from
http://emedicine.medscape.com/article/175667-
overview#showall.
 Retrieved on 2068/10/20 from
http://www.nlm.nih.gov/medlineplus/ency/article/00
0273.ht

Case study on cholelithiasis

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