CASE PRESENTATION ON CHOLELITHIASIS

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CASE PRESENTATION ON
CHOLELITHIASIS

• PREPARED BY
• MANJU SUNNY
• OR DEPARTMENT

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DEMOGRAPHIC DATA NAME
Mr. PQRS AGE/SEX
30YRS/ FEMALE DATE OF ADMISSION
20/05/13 DIAGNOSIS
CHOLELITHIASIS SURGERY
CHOLECYSTECTOMY SURGERY ON
20/05/13 DATE OF DISCHARGE 21/05/13
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Physical assesment
1 .GENERAL APPEARANCE

• Patient is 30yrs old female
• look anxious
• conscious and oriented with following vital signs
• B.P 110/70mmHg
• PULSE 88b/m
• RESPIRATION 20b/m
• TEMPREATURE 36.6 c
• SpO2 99

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• 2. SKIN
• Fair complexion.
• Skin is warm.
• 3. HEAD
• Hair is equally distributed.
• Absence of dandruff alopecia.
• EYES
• Both eyes are normal , able to move both eyes.
• No discharges .

• 5. EARS
• Patient pinna is same colour as fascial.
• Able to hear sounds clearly.
• No discharges.

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• 6. NOSE
• Pink nasal mucosa.No nasal discharge

• MOUTH
• Pink and dry oral mucosa.
• Tongue and uvula in midline position.
• Teeth is properly aligned with no dentures.

• 8. NECK AND THROAT
• No tenderness nodes.
• No palpable mass and lesions

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• 9. CHEST LUNGS
• Thorax is symmetric on inspection.
• Dry cough present.
• Clear breath sounds.

• 10. CARDIO VASCULAR SYSTEM
• ECG is normal.
• No cardiomegaly.
• Apical pulse is 88 bpm

• 11. UPPER LOWER EXTREMITIES
• Normal range of motions.
• 12. ABDOMEN
• Bowel sounds are normal.
• On palpation Abdomen is slightly enlarged .

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• 13 . GENITO URINARY SYSTEM
• no discharges

• GASTRO INTESTINAL
• No bowel obstruction present.
• Abdominal pain present.
• 15. NEUROLOGIC
• Patient is mentally alert and oriented with
  circumstances.
• Able to follow commands.
• No neurovascular deficit

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PATIENT HISTORY PAST MEDICAL
HISTORY No past medical history
. PRESENT MEDICAL HISTORY Patient came to OPD
on 17.5.2013 with complaints of abdominal pain
and vomiting . On examination they suspected
cholelithiasis and send her for usg abdomen .
After Usg abdomen she was diagnosed as having
cholelithiasis .

• PAST SURGICAL HISTORY
• Patient has no past surgical history.
• PRESENT SURGICAL HISTORY
• Patient had under gone Laproscopic
  choleycystectomy on 20.5.2013.

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• INVESTIGATIONS DONE FOR THE PATIENT

• USG Abdomen
• X-ray chest
• Blood investigations
• CBC
• ABORH
• PT/INR
• APTT
• ELECTROLYTES

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LAB INVESTIGATIONS
ITEMS PATIENT VALUE NORMAL VALUE
CBC HEMOGLOBIN(hb) HCT RBC PLT 12.6 gm/dl 35.9 g/dl 3.85 2 10 13.7 - 16 .5 gm/dl 40.1 51.g/dl 4.63 6.08106/ul 163-337/ul
SODIUM 143 135 - 150
POTTASSIUM 3.7 3.5-5.0mmol/l
PT 13.1 10.0-17 sec
I NR 0.85 2.4 therapeautic unit
APTT 29.2 26.1-36.3
ABRH AB VE
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MEDICATION
Drug Route Dose/frequency Action
Inj. Perfelgan iv 1000mg /bd Analgesis
Inj.Flagyl iv 500mg /bd antibiotics
Inj.Augmentin iv 1.2gm/tid Antibiotics
Inj.Premosan iv 10mg/bd Antiemetic
Inj.Risek iv 40mg/od H2 receptor antagonist
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TOPIC PRESENTATION CHOLELITHIASIS
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CHOLELITHIASIS Cholelithiasis is the
medical term for gallstone disease .
Presence of stone in the
gall bladder is known as cholelithiasis.It is a
crystalline concretion formed with the gall
bladder by accretion of bile components.These
gall stones are formed in the gall bladder but
may distally pass in to other parts of biliary
tract such as cystic duct,common bile duct,
pancreatic duct or thae ampulla of vater.
Choledocholithiasis It refers to the
presence of one or more Gallstones in the common
bile duct. Usually, this occurs when a gallstone
passes from the gallbladder into the common
bile duct . A gallstone in the common bile duct
may impact distally in the ampulla of Vater, the
point where the common bile duct and pancreatic
duct join before opening into the duodenum
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• TYPES OF GALLSTONES Types of gallstones
  that can form in the gallbladder include
• Cholesterol gall stones
• Pigment gall stones
• Mixed gall stones

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ANATOMY PHYSIOLOGY
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Gallbladder is a pear-shaped sac that lies
between the right medial and quadrate lobes of
the liver. It is partly attachedand partly
free. It is covered anteriorly and posteriorly by
peritioneum. It sits in a shallow depression
called the gallbladder fossa. The gallbladder
is about 7.510 cm (34 inches) long and about a
2.5 cm (1 inch) wide.

• LAYERS OF GALL BLADDER
• Muscular layer ( A layer of smooth muscle)
• Perimuscular layer (connective tissue that
  covers the muscular layer.
• Mucosa (inner layer of epithelium and connective
  tissue)
• Serosa (outer covering of the gallbladder

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• For the purpose of description
  gallbladder is divided in to three
• Fundus of the gallbladder
• Body of the gallbladder
• Neck of gallbladder

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BILE DUCT,HEPATIC DUCT,
CYSTIC DUCT ,BILE
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BILE It is a yellowish
green fluid made by the liver. The gall bladder
stores bile produced in the liver.The gall
bladder can stores about 40 ml-70 ml of bile.
Bile is important in the digestion of
lipids.

• Bile is mainly made up of
• bile salts
• bile pigments (such as bilirubin)
• cholesterol
• water

COMMON BILE DUCT
Bile duct formed by the union of hepatic duct
cystic duct that carries bile from liver
gallbladder to the duodenum.
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COMMON HEPATIC DUCT Main excretory duct of
liver which joins the cystic duct to form the
common bile duct. It drains bile from the liver
through the left and right hepatic duct.
CYSTIC DUCT
The cystic duct joins the gallbladder to the
common bile duct. It usually lies next to cystic
artery.The Cystic duct of the gallbladder is 2-4
cm long

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ARTERIAL SUPPLY,
VENOUS DRAINAGE LYMPHATIC DRAINAGE
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• FUNCTIONS OF GALL BLADDER
• Stores and mobilizes bile.
• for digestion.
• Promote physical coordination.
• Maintain health of connective tissues.
• Closed linked with the liver.
• Defensive energy against catching infections.

Etiology Of Cholelithiasis

• Female sex.
• European or native american ancestry
• Increasing age above 40 yrs
• Obesity.
• Pregnancy.
• Gallbladder stasis.
• Drugs.
• Heredity.

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• Factors that may increase risk of gallstones
  include
• Being female
• Being age 60 or older
• Being an American Indian
• Being a Mexican-American
• Being overweight or obese
• Being pregnant
• Eating a high-fat diet
• Eating a high-cholesterol diet
• Eating a low-fiber diet
• Having a family history of gallstones
• Having diabetes
• Losing weight very quickly
• Taking some cholesterol-lowering medications

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Signs and symptoms

• pain in the upper right portion of abdomen.
• Back pain between shoulder blades
• Pain in right shoulder.
• Nausea and vomiting.
• Jaundice.
• Clay coloured stool .

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DIAGNOSTIC TESTS

• HIDA SCAN
• CT SCAN
• ERCP
• ABDOMINAL ULTRA SOUND
• BLOOD TESTS

• DIAGNOSTIC STUDIES

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PATHOPHYSIOLOGY
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TREATMENT

1. MEDICAL MANAGEMENT

ORAL BILE SALT THERAPY(URSODEOXYCHOLICURSODIOL
CONTACT DISSOLUTION
EXTRA CORPOREAL SHOCK WAVE LITHOTRIPSY
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SURGICAL MANAGEMENT
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COMPLICATIONS
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• COMPLICATIONS OF SURGERY
• Infection of an incision.
• Internal bleeding.
• Injury to the common bile duct .
• Injury to the small intestine by one of the
  instruments used during surgery.
• Risk of general anaesthesia .

UNCOMMON COMPLICATIONS

• Injury to the cystic duct,.
• Gallstones that remain in the abdominal cavity.
• Bile that leaks into the abdominal cavity.
• Injury to abdominal blood vessels, such as the
  major blood vessel carrying blood from the
  heart to the liver (hepatic artery)..
• A gallstone being pushed into the common bile
  duct.
• The liver being cut.

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NURSING INTERVENTION

• PRE-OPERATIVE INTERVENTION
• The provision of psycho-educational care.
• Provision of adequate and appropriate
  informastion thruogh out the day care
  experience .
• Enhancement of patient self-efficacy via
  positive encouragement and information
  provision.
• Reduction of the negative impact of the clinical
  environment and encouraging implicit and
  explicit messages of safety such as
• the hospital performs many operations .
• helps to create a warm, friendly and comfortable
  environment.
• POST OP INTERVENTION

• Management of pain and post-operative nausea and
  vomiting.
• Initial assistance with mobilization.
• Pain management should commence with an
  assessment of the patients pain at regular
  intervals.
• Measures to manage patients anxiety should be
  implemented pre-operatively and continued
  throughout the post-operative recovery period
  until discharge

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Care of Patient with Cholecystectomy

• Preventing respiratory complications
• Encouraging activity.
• Promoting wound healing.
• Maintaining normal body temperature.
• Promoting bowel function ..
• maintaining gastro intestinal function and
  resuming nutrition .

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PRIORITZATION OF NURSING DIAGNOSIS
ACUTE PAIN RELATED TO GALL BLADDER REMOVEL
NAUSEA AND VOMITING RELATED TO SURGERY
RISK FOR INFECTION RELATED TO SURGICAL INCISION
KNOWLEDGE DEFICIT RELATED TO TREATMENT REGIMEN
AND POST OP CARE
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NURSING CARE PLAN
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ASSESSMENT NSG DIAGNOSIS PLANNING INTERVENTION RATIONAL EVALUATON
Subjective I have severe pain as verbalized by the patient. Painscale -5/10 As 0/10 is the lowest and 10/10 is the highest WONG BAKER Objective data Fascial grimace Reports pain on movement Guarding behavior Altered comfort,pain, related to tissue trauma secondary to surgical operation. After series of nursing intervention patient will manifest a decrease in pain Scale from 5/10 to 0/10 1.Assess patients pain scale and perception 2. provid comfort measures (backrub, position change, environmental control) 3. Encourage deep breathing exercises 4.Teach divertional activities(listening to music) 5. Monitor vital signs 6.Administer pain medication per doctors order prior to exercise or activities of daily livingINJ.PERFELGAN 1GM IV BD . 1.To identify the onset ,intensity and duration of pain 2.to reduce the pain and to provide relaxation 3.To assist muscle and genarelised relaxation 4.To destract clients attention from pain 5.To identify the intensity of pain 6. To relieve the pain After 12 hrs of nursing interventions the goals were fully met as evidenced by verbalize relief of pain as evidenced by a pain scale of 0 out of 10 positive response during evaluation verbalize demon-strate willingness to partici-pate in activities
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HEALTH EDUCATION

• Health education given on wound care and dressing
  .
• Instructed her the signs of infection and asked
  him to notify if any signs occurs .
• Instructed her to follow the physians order
  regarding diet and medication.
• Educated her the the importance of follow up .
• Instructed her she will have no restrictions to
  physical activities, however the patient should
  listen to their body in response to certain
  activities. Gradually increase activities at a
  comfortable and individual pace.
• Advised her to contact if he develops any
  problems such as prolonged nausea/vomiting,
  temperature elevations above 101.5 or other
  difficulties.
• Advised her to take the medications accordingly.

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CONCLUSION

• Presented a case of patient with
  cholelithiasis.
• Patient underwent laproscopic cholecystectomy
  on 20/05/13.
• Presence of stone in the gall bladder is known
  as cholelithiasis
• It is a crystalline concretion formed with the
  gall bladder by accretion of bile
  components.

• Gallstones may cause no signs or symptoms.Gall
  stones may be asymptomatic even for years .these
  stones are called silent stones . If a gallstone
  lodges in a duct and causes a blockage, signs and
  symptoms may result.
• Laproscopic cholecystectomy has now replaced open
  cholecystectomy as the first-choice of treatment
  for gall stones and inflammation of the
  gallbladder unless there are contraindications to
  the laparoscopic approach. This is because open
  surgery leaves the patient more prone to
  infection.

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BIBLIOGRAPHY

• BRUNNER AND SUDDARTH TEXT BOOK OF MEDICAL
  SURGICAL NURSING 9 TH EDITION .
• LIPPIN COTT WILLIAMS AND WILKINS.
• POTTER AND PERRY FUNDAMENTALS OF NURSING 5 TH
  EDITION
• WWW.WIKIPEDIA.ORG.

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