Ibn-Sina nursing and midwifery collage

Case study
Nursing Management
Clinical site: COV. HEBRON.HOSPITAL
STUDENT NAME: Areej Al-Hawareen

A. Demographic Data:
Client initials:Y.D
Age:52
Admission data:11/11/2014 Gendar: female Religion:
Islam
Diagnosis: Cholelithiasis
dates of nursing care:11/11/2014
Allergies: food
yes no

Medications
yes no

Others: Do not suffer from an allergy to anything
Social and environmental assessment:
1.socioeconomic status:

Educational level : 8TH CLASS

Occupational level: house wife

Economic status : below average
average

average

above

2.housing:

Number of rooms: the house contain 4 rooms

Number of family members: 5 members

Sanitation bathroom: 2 bath room

Water supply : from municipality

Ventilation and sun exposure of rooms : good sun and air enter the house

Activites of daily living :

Diet and meals at home , hospital : she is eating everything and in her home
but on heavy meals she stomachache developed and right upper quadrant
pain, now in hospital she eat light meal and prepared for op to be NPO after
mid night

Dental care: once daily. Before going to sleep.

Exercises : She said at times practiced walking exercises in the home garden

Sleep habit at home Vs. hospital: she sleep 8 hour at night

B. History:
Chief Complaints as patient described:
The patient said 2 years ago she start complain from heart burn and stomachache with heavy
meals , after this 1 years ago sharp pain start to develop in right upper quadrant, she did U/S and
show GBS she came to surgical clinic and make an appointment to surgery, she now in hospital
for surgery.

History of present illness:

2 years ago she start complain from heart burn and stomachache with heavy meals, and she take
antacid for this, 1 years ago sharp pain start to develop in right upper quadrant and antiacid
dont affect to decrease this pain, she did U/S and show GBS she came to surgical clinic and make
an appointment to surgery, she now in hospital for surgery.

Past medical surgical history:

Medical
The patient came to hospital many time because she complain the same symptom in after
surgery in last month.

Surgical
The patient has free past surgical history.

Physical assessment
Vital Signs
Pulse : Normal pulse ( 64 beats/minute); regular in rhythm.
Temperature: 36 C axillary
Respiration: 16 Breathing / min
Blood pressure: Normal blood pressure (126/78 mm Hg)

General Appearance:
The patient awake, alert, and responsive, she seem healthy appearance her facial expression
at rest, during conversation, and during the physical examination, and she interact with
others patient in room and with relative.

Hight & weight:

She has good body built and 160 cm height and 78 kg weight,
BMI= 78 /(1.6)^2 = 30

Ability to care for self:

She has relaxed and coordinated movement, she is clean and neat and able to care with
herself.

Eyes:
She said Both eyes are normal vision, eye brows symmetrical and coordinated in movement.
green in color, equal in size, round pupils.
Hair of eyebrow evenly distributed.

Ears:
She has symmetrical, same as facial in color.
Able to hear in both ears; Normal voice tones audible.

Mouth
Pink in color, soft, moist, smooth in texture of 'lips and gum and inner mucosa'
Some teeth loss
The tongue central position, pink in color, slightly rough and move freely .

Integumentary:
She has normal light brown in color . moist, smooth , warm . with no problem or lesions .

Head:
She has normal rounded, symmetrical skull, with no masses or nodules, good hear
distribution.

Chest and Lungs:

She has symmetrical chest, right and left shoulder and hips are at same height.
Chest wall intact, no tender ness or masses.
When incpection the rate was normally 16 b/m .
Heart rate is64 beat per minute.

Musculoskeletal system:
The patient has equal size on both side of body and smooth coordinated movement.

Genitourinary
Pt urinate 5-6 times daily and as she said no any problem Genitourinary system, the
menstruation stopped 5 years ago.

Affected Part (Abdomen):

Smooth and relaxed abdomen, is flat rounded shape and symmetrical.
The umbilicus in the middle.
No any large dull areas.
Fat distributed in abdominal area
Pain developed and increase in right upper quadrant with palpitation
Stomachache with heavy meals

Nursing diagnoses list (NANDA) prioritized for Cholelithiasis Pre

OP
1. Acute Pain related to:
biological trauma obstruction / spasm tract inflammatory processes, iskhemia /
tissue necrosis
characterized by:
Complaints of pain, colik billiary (pain frequency)
Facial expressions as pain, a cautious attitude.
Autonomic responses (changes in blood pressure, pulse)
Focus on self-limited.
2. Risk for Deficient Fluid Volume related to:
Increase in gastric fluid loss: vomiting, gastric distention and hipermolity.
Treatment has the effect of reducing the fluid.
The freezing process
characterized by:
Signs and symptoms of unstable can not be applied to the actual diagnosis.
3. Imbalanced Nutrition Less Than Body Requirements related to:
Risk factors that affect:
Imposed on themselves and given limited food, nausea, vomiting, dyspepsia, pain.
Loss of nutrients, affect digestion due to disturbance / narrowing of the bile duct.
4. Deficient Knowledge: about prognosis and treatment needs related to:
misinterpretation.
Have not / do not know the source of information.

Laboratory data
Test

Patient value

Normal value

Meaning of
abnormal value

13.3 g/dl
4.3 million/mm3
6500 /mm3
238*103/mm3

12 16 g/dl
4 5.3 million/mm3
4500 11000/mm3
(150-350)*103/mm3

Normal
Normal
Normal
Normal

Straw
clear
Acid
Nil
Nil
Nil
Nil

Straw
clear
Acid
Nil
Nil
Nil
Nil

Normal
Normal
Normal
Normal
Normal
Normal
Normal

11 mg/dl
0.8 mg/dl
24 U/l
1
92 mg/dl

10 20 mg/dl
0.7 1.4 mg/dl
4 36 U/l

Normal
Normal
Normal
Normal
Normal

CBC test
Hb%
RBC
WBC
PLTS

Urine
Color
Appearance
PH
Sugar
Blood
Epithelia cell
WBCs

Chemistry
BUN
Creatinine
ALT (SGPT)
INR
FBS

70-126 mg/dl

Result of other diagnostic procedure

Abdomen Ultrasound:

Conclusion:
Gallblader stone seen with 3.4cm * 2 cm

Medication
Drug Name
& Dose

Rational

Action

Side effect

NSG Implications

Ceftriaxone
(Cephalosporin
3rd generation)

For treatment of
infection because
its broad
spectrum
antibiotic and
culture test
sensitive

antibiotics for
ACUTE
BACTERIAL
Infection
affecting the cell
wall of bacteria,
Rocephin helps
kill bacteria(

Pain, warmth,
and/or minor
swelling at
injection site,
Unexplained
rash ,
Diarrhea
Increase in liver
enzymes

1. Observe for signs of

adverse reactions or
Hypersensitiviy to
cephalosporins
2. Monitor renal, hepatic,
hematopoietic functions
3. IV administration:
Infusion over 30 minutes.

used to treat
bacterial
infections
particularly for
anaerobic
bacteria and
protozoa,
and prophylactic
post op

It inhibits nucleic
acid synthesis by
disrupting the
DNA of microbial
cells.

nausea, diarrhoea,
weight loss,
abdominal pain,
vomiting,
headache,
dizziness, and
metallic taste in
the mouth.

Monitor for S&S of:

hepatotoxicity, even with
moderate doses,
Avoid use unless
necessary. Metronidazole
is carcinogenic in some
rodents.
Administer oral doses
with food.
Apply topically after
cleansing the area.
Advise patient that
cosmetics may be used
over the area after
application.
Reduce dosage in hepatic
disease.

Decreases the
heart pain cause
by high amount
of HCl

Decreases amount
of HCl produced by
stomach by
blocking action of
histamine on
histamine receptors
of parietal cells in
the stomach
Acting as an agonist
at the -opioid
receptor.

headache, nausea, Administer oral drug

fatigue, , dizziness, with meals and hs.
Decrease doses in renal
and liver failure.
Administer IM dose
undiluted, deep into large
muscle group.

T(Rocephin)

1g X 2
Rout :IV
Time
6am
6 pm
metronidazole
T(Flagyl)
500 mg X 3
Rout :IV
time
6am
10pm

2pm

Ranitidine
hydrochloride
T(Ratidine)
50 mg X 3
Rout :IV
Time
6am
2pm
10pm
Pethidine
T(Dolestine)
50 mg PRN
Rout :IV

synthetic opioid
analgesic for the
treatment of
moderate to
severe pain

nausea, vomiting, Administer to lactating

sedation, dizziness, women 46 hr before the
diaphoresis,
next feeding to minimize
urinary retention the amount in milk.
and constipation. Keep opioid antagonist
and facilities for assisted
or controlled respiration
readily available during
parenteral administration.

Pathophysiology of the current disease.

Cholelithiasis is the presence of one or more calculi (gallstones) in the gallbladder. In developed
countries, about 10% of adults and 20% of people > 65 yr have gallstones. Gallstones tend to be
asymptomatic. The most common symptom is biliary colic; gallstones do not cause dyspepsia or
fatty food intolerance. More serious complications include cholecystitis; biliary tract obstruction
(by stones in the bile ducts [choledocholithiasis]), sometimes with infection (cholangitis); and
gallstone pancreatitis. Diagnosis is usually by ultrasonography. If cholelithiasis causes symptoms
or complications, cholecystectomy is necessary.
Risk factors for gallstones include female sex, obesity, increased age, American Indian
ethnicity, a Western diet, rapid weight loss, and a family history. Most disorders of the biliary
tract result from gallstones.

Pathophysiology
Biliary sludge is often a precursor of gallstones. It consists of Ca bilirubinate (a polymer of
bilirubin), cholesterol microcrystals, and mucin. Sludge develops during gallbladder stasis, as
occurs during pregnancy or use of TPN. Most sludge is asymptomatic and disappears when the
primary condition resolves. Alternatively, sludge can evolve into gallstones or migrate into the
biliary tract, obstructing the ducts and leading to biliary colic, cholangitis, or pancreatitis.
There are several types of gallstones.
Cholesterol stones account for > 85% of gallstones in the Western world. For cholesterol
gallstones to form, the following is required:

Bile must be supersaturated with cholesterol. Normally, water-insoluble cholesterol is

made water soluble by combining with bile salts and lecithin to form mixed micelles.
Supersaturation of bile with cholesterol most commonly results from excessive cholesterol
secretion (as occurs in obesity or diabetes) but may result from a decrease in bile salt
secretion (eg, in cystic fibrosis because of bile salt malabsorption) or in lecithin secretion
(eg, in a rare genetic disorder that causes a form of progressive intrahepatic familial
cholestasis).

The excess cholesterol must precipitate from solution as solid microcrystals. Such
precipitation in the gallbladder is accelerated by mucin, a glycoprotein, or other proteins in
bile.

The microcrystals must aggregate and grow. This process is facilitated by the binding effect
of mucin forming a scaffold and by retention of microcrystals in the gallbladder with
impaired contractility due to excess cholesterol in bile.

Black pigment stones are small, hard gallstones composed of Ca bilirubinate and inorganic
Ca salts (eg, Ca carbonate, Ca phosphate). Factors that accelerate stone development include
alcoholic liver disease, chronic hemolysis, and older age.

Brown pigment stones are soft and greasy, consisting of bilirubinate and fatty acids (Ca
palmitate or stearate). They form during infection, inflammation, and parasitic infestation (eg,
liver flukes in Asia).
Gallstones grow at about 1 to 2 mm/yr, taking 5 to 20 yr before becoming large enough to
cause problems. Most gallstones form within the gallbladder, but brown pigment stones form
in the ducts. Gallstones may migrate to the bile duct after cholecystectomy or, particularly in
the case of brown pigment stones, develop behind strictures as a result of stasis and infection.
Symptoms and Signs
About 80% of people with gallstones are asymptomatic. The remainder have symptoms
ranging from a characteristic type of pain (biliary colic) to cholecystitis to life-threatening
cholangitis. Biliary colic is the most common symptom.
Stones occasionally traverse the cystic duct without causing symptoms. However, most
gallstone migration leads to cystic duct obstruction, which, even if transient, causes biliary
colic. Biliary colic characteristically begins in the right upper quadrant but may occur
elsewhere in the abdomen. It is often poorly localized, particularly in diabetics and the elderly.
The pain may radiate into the back or down the arm. Episodes begin suddenly, become intense
within 15 min to 1 h, remain at a steady intensity (not colicky) for up to 12 h (usually < 6 h),
and then gradually disappear over 30 to 90 min, leaving a dull ache. The pain is usually severe
enough to send patients to the emergency department for relief. Nausea and some vomiting
are common, but fever and chills do not occur unless cholecystitis has developed. Mild right
upper quadrant or epigastric tenderness may be present; peritoneal findings are absent.
Between episodes, patients feel well.
Although biliary colic can follow a heavy meal, fatty food is not a specific precipitating factor.
Nonspecific GI symptoms, such as gas, bloating, and nausea, have been inaccurately ascribed
to gallbladder disease. These symptoms are common, having about equal prevalence in
cholelithiasis, peptic ulcer disease, and functional GI disorders.

Little correlation exists between the severity and frequency of biliary colic and pathologic
changes in the gallbladder. Biliary colic can occur in the absence of cholecystitis. If colic
lasts > 12 h, particularly if it is accompanied by vomiting or fever, acute cholecystitis or
pancreatitis is likely.
Diagnosis
Ultrasonography
Gallstones are suspected in patients with biliary colic. Abdominal ultrasonography is the
method of choice for detecting gallbladder stones; sensitivity and specificity are 95%.
Ultrasonography also accurately detects sludge. CT, MRI (see MRI), and oral cholecystography
(rarely available now, although quite accurate) are alternatives. Endoscopic ultrasonography
accurately detects small gallstones (< 3 mm) and may be needed if other tests are equivocal.

Laboratory tests usually are not helpful; typically, results are normal unless complications
develop.
Asymptomatic gallstones and biliary sludge are often detected incidentally when imaging,
usually ultrasonography, is done for other reasons. About 10 to 15% of gallstones are calcified
and visible on plain x-rays.
Prognosis
Patients with asymptomatic gallstones become symptomatic at a rate of about 2%/yr. The
symptom that develops most commonly is biliary colic rather than a major biliary
complication. Once biliary symptoms begin, they are likely to recur; pain returns in 20 to 40%
of patients/yr, and about 1 to 2% of patients/yr develop complications such as cholecystitis,
choledocholithiasis, cholangitis, and gallstone pancreatitis.
Treatment
For symptomatic stones: Laparoscopic cholecystectomy or sometimes stone dissolution
using ursodeoxycholic acid

For asymptomatic stones: Expectant management

Most asymptomatic patients decide that the discomfort, expense, and risk of elective surgery
are not worth removing an organ that may never cause clinical illness. However, if symptoms
occur, gallbladder removal (cholecystectomy) is indicated because pain is likely to recur and
serious complications can develop.
Surgery:
Surgery can be done with an open or a laparoscopic technique.
Open cholecystectomy, which involves a large abdominal incision and direct exploration, is
safe and effective. Its overall mortality rate is about 0.1% when done electively during a
period free of complications.

Laparoscopic cholecystectomy is the treatment of choice. Using video endoscopy and

instrumentation through small abdominal incisions, the procedure is less invasive than open
cholecystectomy. The result is a much shorter convalescence, decreased postoperative
discomfort, improved cosmetic results, yet no increase in morbidity or mortality.
Laparoscopic cholecystectomy is converted to an open procedure in 2 to 5% of patients,
usually because biliary anatomy cannot be identified or a complication cannot be managed.
Older age typically increases the risks of any type of surgery.

Cholecystectomy effectively prevents future biliary colic but is less effective for preventing
atypical symptoms such as dyspepsia. Cholecystectomy does not result in nutritional
problems or a need for dietary limitations. Some patients develop diarrhea, often because bile
salt malabsorption in the ileum is unmasked. Prophylactic cholecystectomy is warranted in

asymptomatic patients with cholelithiasis only if they have large gallstones (> 3 cm) or a
calcified gallbladder (porcelain gallbladder); these conditions increase the risk of gallbladder
carcinoma.
Stone dissolution:
For patients who decline surgery or who are at high surgical risk (eg, because of concomitant
medical disorders or advanced age), gallbladder stones can sometimes be dissolved by
ingesting bile acids orally for many months. The best candidates for this treatment are those
with small, radiolucent stones (more likely to be composed of cholesterol) in a functioning
nonobstructed gallbladder (indicated by normal filling detected during cholescintigraphy or
oral cholecystography or by absence of stones in the neck).

Ursodeoxycholic acid 4 to 5 mg/kg po bid or 3 mg/kg po tid (8 to 10 mg/kg/day) dissolves

80% of tiny stones < 0.5 cm in diameter within 6 mo. For larger stones (the majority), the
success rate is much lower, even with higher doses of ursodeoxycholic acid. Further, after
successful dissolution, stones recur in 50% within 5 yr. Most patients are thus not candidates
and prefer laparoscopic cholecystectomy. However, ursodeoxycholic acid 300 mg po bid can
help prevent stone formation in morbidly obese patients who are losing weight rapidly after
bariatric surgery or while on a very low calorie diet.
Stone fragmentation (extracorporeal shock wave lithotripsy) to assist stone dissolution and
clearance is now unavailable.

Nursing care
Nursing Priorities

Relieve/control pain.

Prevent/minimize development of complication .

Provide information about disease process/prognosis and treatment.

Support patient/SO in initiating necessary lifestyle/behavioral changes.

NURSING CARE PLAN

Discharge Goals
 Complications prevented or minimized.
 Adjusting to perceived or actual changes.
 Self-care needs met by self or with assistance, as necessary.
 Procedure, prognosis, therapeutic regimen, and potential complications
understood and sources of support identified.
 Plan in place to meet needs after discharge.

Home health teaching and continuing care until rapier done:

Instructions For Care Following cholecystectomy

Medicines:
Keep a current list of your medicines: Include the amounts, and when, how, and why you take them.
Take the list or the pill bottles to follow-up visits. Carry your medicine list with you in case of an
emergency. Throw away old medicine lists. Use vitamins, herbs, or food supplements only as directed.

Take your medicine as directed: Call your primary healthcare provider if you think your medicine is not
working as expected. Tell him about any medicine allergies, and if you want to quit taking or change your
medicine.

Antibiotics: This medicine is given to fight or prevent an infection caused by bacteria. Always take your
antibiotics exactly as ordered by your primary healthcare provider. Do not stop taking your medicine
unless directed by your primary healthcare provider. Never save antibiotics or take leftover antibiotics
that were given to you for another illness.

Pain medicine: You may need medicine to take away or decrease pain.
o

Learn how to take your medicine. Ask what medicine and how much you should take. Be sure you know
how, when, and how often to take it.

Do not wait until the pain is severe before you take your medicine. Tell caregivers if your pain does not
decrease.

Pain medicine can make you dizzy or sleepy. Prevent falls by calling someone when you get out of bed or
if you need help.

Wound Care
Look at your wound daily. Watch for signs of infection. Your wound will be slightly red, swollen, and there may
be a small amount of pink drainage for a few days. This is normal. Keep your wound dry for 2 days. When you
can shower, wash the wound with a mild soap and water. Pat it dry. You do not need to wear a bandage unless
the wound is draining, your clothes rub on it, or it is in a skin fold. If you do wear a bandage, change it at least
daily and more often as needed. Do not soak your wound in a hot tub, bathtub, or swimming pool until it is
healed, which may be 2 weeks.
Activity
Do not lift more than 10 pounds for 4-6 weeks if you had the open surgery. If you had the laparoscopic surgery,
do not lift greater than 10 pounds for 2-3 weeks. Check with your doctor before going back to work. Sexual
activity may be resumed when you feel ready. You may not be able to drive for 1 week or longer. You may not
drive while taking narcotic pain pills.

Diet
You may eat what you like after surgery. It is best to avoid fatty foods at first and slowly add them to your diet.
Constipation
A diet with enough water and fiber can prevent constipation. Eat a well balanced diet daily. Include:
6-8 (8 oz.) glasses of fluid each day.
At least 4 servings of fruits or vegetables.
At least 4 servings of breads or cereals (2 of these servings should be whole grain).
You may also take stool softeners (docusate sodium) and a bulk fiber laxative (Metamucil, etc.). Follow package
directions.
CONTACT A CAREGIVER IF:
You have a fever.
You have chills, a cough, or feel weak and achy.
You have nausea (upset stomach) or vomiting (throwing up.(
Your bandage becomes soaked with blood.
Your skin is itchy, swollen, or has a rash.
You have chest pain or trouble breathing that is getting worse over time.
You have questions or concerns about your surgery, condition, or care.
SEEK CARE IMMEDIATELY IF:
You feel so full and cannot burp or vomit (throw up.(
You have pain in your abdomen that does not go away or gets worse.
You have problems having a bowel movement.
You have pus or a foul-smelling odor coming from your incision.
You have sudden, severe shoulder pain.
Your vomit is greenish in color, looks like coffee grounds, or has blood in it.
You suddenly feel lightheaded and have trouble breathing.
You have new and sudden chest pain. You may have more pain when you take deep breaths or cough. You may
cough up blood.
Your arm or leg feels warm, tender, and painful. It may look swollen and red.
Your symptoms come back.

References
1. Brunner & Suddarth's Textbook of Medical - Surgical Nursing (11th edition)
Philadelphia: Lippincott Williams & Wilkins(2009).
2. Kozier & Erb's Fundamentals of Nursing Concepts, Process, and Practice
(7th edition) (2007)
3. Amy M. Karch lippincott's nursing drug guide: Lippincott Williams &
Wilkins (2009).
4. Bates Instructors Manual Guide to Physical Exam and History Taking (8 th
edition) Philadelphia: Lippincott Williams & Wilkins(2006).
5. Meg Gulanick, Judith L. Myers Nursing Care Plans : Nursing Diagnosis and
Intervention (6th edition) : Elsevier Health Sciences (2006)