St Anne College Lucena Inc.

Diversion rd. Bry Gulang Gulang, Lucena city

College of Nursing

IN PARTIAL FULFILLMENT OF OUR REQUIREMENTS

IN

RELATED LEARNING EXPERIENCE (105)

A CASE STUDY ABOUT CHOLECYSTITIS

Presented to:

Presented by:

DOLLY JOY SALOMES

BSN IV A

I Patient profile

Biographical Data

Name: Mr XXX

Age: 46 years old

Sex: Male

Nationality: Filipino

Date of Birth: August 28, 1962

Place of Birth: General Santos City

Civil Status: Married

Address: Lucban Quezon

Religion: Christianity (Roman Catholic)

Educational attainment: high School Graduate

Occupation:

II History

A, Nursing history

I chief complain: Right upper quadrant pain

II admitting diagnoses: Cholecystitis T/C Cholelithiasis

III physical Examination

IV final dx

B, Present Health history

I Symptom (PTA)

Pt prior to admission, Mr X experienced right upper quadrant pain associated with a sense of bloatedness, without nausea and vomiting. The pain was tolerable so he did not seek medical attention yet. He said he also had an increased level of pain tolerance so he also didn’t mind to take any pain relievers. Until three days prior to admission, patient had severe right upper quadrant pain, which was said to be intolerable. Moreover, when pressure is applied on the RUQ of the abdomen, pain is elicited. He had also lost his appetite because of the pain. His scleras were also slightly icteric during admission and he was positive with Murphy’s sign. So he sought consultation at Out-Patient Department- Emergency Room at Tayabas Community Hospital. Ultrasound revealed cholecystitis, so patient was advised admission and operation.

C, Past Health History

I Hospitalization

Mr. x experienced common illness such as colds, cough, and fever during his childhood. He also had chicken pox during his childhood. However, he could not recall at what age he got the disease and as well as the management of his chicken pox.

Two years ago (2007), he was admitted to Davao Medical Center due to loss of consciousness. Prior to that, he was experiencing palpitations, and pain on the suboccipital area (nape) associated with headache. He had blood pressure of 180/100 as he could remember during the VS taking at the emergency room. And his diagnosed with hypertension.

II Surgical management

None

III allergies

None

D family Health History

Mr. X is the eldest among Mr. Dad‘s and Mrs. Mom‘s two children. But his younger sister Anna died of car accident at the age of six years old,. He grew up at General Santos City where the relatives of his mother live. When Mr. X was a first year high school, his parents got separated because of third party. He lived with his mother and Mrs. Mom’s live-in partner at Davao City, while his father returned to Leyte where his other relatives live. With his mother’s second family, he had another two siblings, Step-brod and Step-sis. Step-brod died at the age of 18 because of suicide. He had suicide because of altered mental status due to shabu use. Today, Step-sis has her own family at Leyte.

Grandmot

Father Mother

Grandfather Hypertension

Patient X . Hypertension and cholo

Younger sister Anna died of car accident at age of six years

Step-brod died at the age of 18 because of suicide.

Grandfath Grandmother

Because Mr.X had been away from the relatives of his father, he does not know any significant disease they have or had. He doesn’t also know the causes of deaths of his grandmother and grandfather on the paternal side. On the other hand, what he only knows is that the eldest sister of her mother has hypertension, and that his grandfather on the maternal side died of hypertension.

IV Nutrition

A 24 hrs food result

B Regular Routine of diet

C habits

V Disease Entity

A Definition

Cholecystitis is an inflammation of the gallbladder wall and nearby abdominal lining.

Cholecystitis is usually caused by a gallstone in the cystic duct, the duct that connects the

gallbladder to the hepatic duct. The presence of gallstones in the gallbladder is called

cholelithiasis. Cholelithiasis is the pathologic state of stones or calculi within the gallbladder

lumen. A common digestive disorder worldwide, the annual overall cost of cholelithiasis is

approximately $5 billion in the United States, where 75-80% of gallstones are of the cholesterol

type, and approximately 10-25% of gallstones are bilirubinate of either black or brown pigment.

In Asia, pigmented stones predominate, although recent studies have shown an increase in

cholesterol stones in the Far East.

Gallstones are crystalline structures formed by concretion (hardening) or accretion

(adherence of particles, accumulation) of normal or abnormal bile constituents. According to

various theories, there are four possible explanations for stone formation. First, bile may

undergo a change in composition. Second, gallbladder stasis may lead to bile stasis. Third,

infection may predispose a person to stone formation. Fourth, genetics and demography can

affect stone formation.

B Etiology

C epidemiology

D Anatomy of Origin

HEPATOBILLARY TREE

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 ligament1. Left lobe- forms about one sixth of the liver2. Right lobe- forms about five sixths of the liver; divides into right lobe proper,

caudate lobe, and quadrate lobe3. Hepatic lobules- anatomical units of the liver; small branch of hepatic vein

extends through the center of each lobuleC. Bile ducts

1. Small bile ducts form right and left hepatic ducts2. Right and left hepatic ducts immediately join to form one hepatic duct3. Hepatic duct merges with cystic duct to form the common bile duct, which opens

into the duodenumD. 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 Metabolism7. 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 functionc. Cholesterol, products of detoxification, and bile pigments (e.g. bilirubin) are

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

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.BILIRUBIN PRODUCTION AND ELIMINATION

Bilirubin is the substance that gives bile its color. It is formed from senescent red blood cells. In the process of degradation, the hemoglobin from the red blood cell is broken down from biliverdin, which is rapidly converted to free bilirubin thru biliverdin reductase. Free bilirubin, which is not soluble in plasma, is transported in the blood attached to plasma albumin. Even when it is bound to albumin, this bilirubin is still called free bilirubin. As it passes through the liver, free bilirubin is released from its albumin carrier molecule and moved into the hepatocytes. Inside the hepatocytes, free bilirubin is converted to conjugated bilrubin thru glucoronyl transferase, making it soluble to bile. Conjugated bilirubin is secreted as a constituents of bile, and in this form, it passes through the bile ducts into the small intestine. In the intestine, approximately one half of the bilirubin is converted into a higly soluble substance called urobilinogen by the intestinal flora. Urobilinogen is either absorbed into the portal circulation or excreted in the feces. Most of the urobilinogen that is absorbed is returned to the liver to be re-excreted into the bile. A small amount of urobilinogen, approximately 5% is absorbed into the general circulation and then excreted by the kidneys.

VI pathophysilogy

Risk factor

Heredity Obesity Rapid Weight Loss, through diet or surgery Age Over 60 Female Gender Diet-Very low calorie diets, prolonged fasting, and

low-fiber/high-cholesterol/high-starch diets.

Bile must become supersaturated with

cholesterol and calcium

The solute precipitate from solution as solid crystals

Crystals must come together and fuse to form stones

Gallstones

Obstruction of the cystic duct and common bile duct

Jaundice Sharp pain in the right part of abdomen

Distention of the gall bladder

Venous and lymphatic drainage is impaired

Proliferation of bacteria

Localized cellular irritation or infiltration

or both take place

Areas of ischemia may occur

Inflammation of gall bladder

CHOLECYSTITIS

Cholecystotomy

Operation during which the gallbladder is opened, gallstones are removed, and excess bile is drained. The gallbladder is not removed.

VII management

A Medical Management

1. Chest X-ray- this is used to rule out respiratory causes of referred pain.

2. Intake and Output- I&O measurement provide an other means of assessing fluid

balance. This data provide insight into the cause of imbalance such as decrease

fluid intake or increase fluid loss. These measurement are not that accurate as

body weight, however, because of relative risk of errors in recording.

3. ultrasound (Also called sonography.) - a diagnostic imaging technique which

uses high-frequency sound waves to create an image of the internal organs.

Ultrasounds are used to view internal organs of the abdomen such as the liver

spleen, and kidneys and to assess blood flow through various vessels.

4. endoscopic retrograde cholangiopancreatography (ERCP) - a procedure that

allows the physician to diagnose and treat problems in the liver, gallbladder,

bile ducts, and pancreas. The procedure combines x-ray and the use of an

endoscope. A long, flexible, lighted tube. The scope is guided through the

patient's mouth and throat, then through the esophagus, stomach, and

duodenum. The physician can examine the inside of these organs and detect any

abnormalities. A tube is then passed through the scope, and a dye is injected

which will allow the internal organs to appear on an x-ray.

5. Cholecystotomy- the establishment of an opening into the gallbladder to allow

drainage of the organ and removal of stones. A tube is then placed in the

gallbladder to established external drainage. This is performed when the patient

cannot tolerate cholecystectomy.

B Nursing Management

C Pharmacology

VIII laboratory/ diagnoses procedure

A Blood Analysis

B urinalysis

C fecalysis

D x-ray

E ultrasound

F CT scan

IX ncp

X discharge plan .

M - Instructed the patient to continue medication as ordered

1. Cephalexin 500 mg cap 3 x day (8am-1pm-8pm) for 1 week

2. Mefenamic Acid 500 mg cap 3 x day (am-1pm-8pm) for 1 week

E - Instructed the patient to do exercise as tolerated such as walking

T - Instructed the patient to continue the medication

H - 1. Encouraged patient to increase fluid intake

2. Encouraged patient to eat foods rich in Vitamin and Nutritious foods

3. Encourage patient to avoid salty and fatty foods

4. Encourage patient to have enough rest

O - Instructed to come back for follow-up check-up on February 23, 2006,

Thursday.

D - Advised the patient to a diet as tolerated but preferably avoiding salty and

fatty foods.