CHOLEDOCHOLITHIASIS

Prepared by: Joana Mae Gajigan, SN- SPUD

INTRODUCTION
Choledocholithiasis is the presence of a gallstone in the common bile duct. The stone may consist of bile pigments or calcium and cholesterol salts. Choledocholithiasis is frequently associated with obstruction of the biliary tree, which in turn can lead to acute ascending cholangitis, a serious infection of the bile ducts. This is a case of Mr. R.E., a 64 year old housekeeper, married with 4 children, who is a Filipino citizen, a Roman Catholic, and is currently residing at Piapi Dumaguete City, Negros Oriental. She was admitted last February 2, 2012 at 10:30pm in Holy Child Hospital with a medical diagnosis of Choledocholithiasis.

INTRODUCTION
The presenter decided to choose this case for clinical paper because it is interesting and she was able to appreciate the manifestations and complications of the patients disease. The presenter consider it a privilege to be able to cater the needs of the patient with such condition. Furthermore, the clients manifestations have built an intense curiosity to the presenter that led to queries needing answers thus opted to dwell deeper on the said case through this clinical paper. As a whole, these are all for the purpose of enhancing the presenter to become more efficient and more effective not only as student nurses but as well as hopeful nurses-to-be in the future.

OBJECTIVES
In the light of the making of a thorough and comprehensive clinical paper, certain objectives are made in order to guide the presenter as she went along this process. The said objectives are set that after three days of gathering pertinent facts and rendering utmost quality nursing care to the patient and his case, this clinical paper aims to:

 Identify the underlying condition of the patient, the etiology, clinical manifestations, diagnostic procedures and medical managements done. Trace a comprehensive pathophysiology of the provision of the patient. Correlate the pathophysiology to the clinical manifestations, nursing interventions, and medical and surgical managements done.

 Identify prioritized Nursing Care Problems and their suitable interventions for the disease process. Implement the prioritized nursing care interventions effectively and efficiently. Construct recommendations concerning patients case.

SCOPE AND LIMITATION

This clinical paper tackles the patients diagnoses of Choledocholithiasis and Diabetes Mellitus. It will cover the length of the days that the presenter was able to care for the patient during his stay at Holy Child Hospital (February 3-6, 2012). Likewise, this clinical paper includes the diseases definition, etiology, clinical manifestations, pathophysiology, treatments, and interventions that the patient has undergone and nursing care plans which were observed and rendered to the patient.

Conversely, this clinical paper has the following limitations: Some data, especially some of the clinical manifestations were not anymore manifested by the client upon the span of care of the presenter. Thus, data were just supported by verbalizations of the patient, his significant others and his physician.

BIOGRAPHICAL DATA
Name: Mr. R.S.E Address: Piapi, Dumaguete City Sex: Male Age: 64 years old Birthdate: November 29, 1947 Birth place: Piapi, Dumaguete City Race: Asian Nationality: Filipino Marital Status: Married Spouse: Ma. Elena A. Emia Religion: Roman Catholic

BIOGRAPHICAL DATA
Education: College level Occupation: Unemployed Attending Physician: Dr.JCA Source & Reliability: Patient- 90% Chart- 10% 100%

CHIEF COMPLAINT: dli man gud ko katulog dai mga 3 ka semana na, unya wala koy gana mo kaon as verbalized by the patient. HISTORY OF PRESENT ILLNESS: For about 3 weeks patient complaints that he was not able to sleep and for 1 week he had loss of appetite prior to admission. His family decided to bring him in Holy Child Hospital for check up and admission.

PAST HEALTH HISTORY: Childhood Illnesses: positive for chicken pox and measles Hospitalizations: First hospitalization was in Holy child hospital because of Diabetes Mellitus. Second hospitalization was at the same hospital because of eye surgery due to cataract. Serious Injuries: none Serious/Chronic Illnesses: patient had Choledocholithiasis and DM Immunizations: had a complete immunization Allergies: No known allergies to food, medication and environment

Medications: Metformin Euglocan Verile 750mg Konakion

Travel: no recent travel Military Service: never served in military.

FAMILY GENOGRAM

PSYCHOSOCIAL PROFILE: Health practices and beliefs: Patient occasionally believes in hilot and seeks medical care when condition cannot be managed. Typical day: Wakes up at 4:00am and jog at 5:00am, eats his breakfast at around 8:00am and watch TV or cleaning, sweeping the house and eats his lunch at 12:00nn and eats his dinner at around 6-7:00pm. He go to bed and sleep at 8:00pm. Nutritional Pattern: Likes to eat fish, vegetables and meat. Activity and Exercise: He jogs early in the morning and clean the house.

Recreational hobbies: Enjoys staying at home, watching TV, cleaning and sweeping. Sleep/Rest Pattern: Patient stated that he had adequate sleep for about 10-11 hours, but for about 3 weeks, he was unable to sleep. Personal habits: Does not smoke, drink nor use commonly abused substances. Occupational Health Pattern: Patient had no work and only stays at home. Environmental health Patterns: Lives in a 2 bedrooms. He considers neighborhood as safe and friendly. Police department is far from home.

Roles and Relationship: Patient has a very close and healthy relationship with own family. Patient verbalized that he is contented and happy with self and family.
Sexuality Pattern: Currently sexually not active Social support: Patient stated that she can obtain immediate help from his children without initiating because his children are always willing to help. Stress and Coping mechanism: Patient verbalized that the most effective means of relieving stress is simply to rest.

PHYSICAL ASSESSMENT

LABORATORY EXAMINATIONS AND RESULTS

NORMAL ANATOMY AND PHYSIOLOGY

THEORETICAL BACKGROUND

PATHOPHYSIOLOGY

Medical Management: Pharmacologic management: Generic: metformin Brand: Glucophage Classification: Antidiabetic Mechanism of action: Decreases hepatic glucose production and intestinal absorption of glucose and improves insulin sensitivity(increases peripheral glucose uptake and utilization. Nursing responsibility: -Administer with meals -monitor patients glucose level to evaluate effectiveness of the therapy

Generic: glyburide Brand: Euglocon Therapeutic class: Hypoglycemic Mechanism of action: Increases insulin binding and sensitivity at receptor sites, stimulating insulin release from beta cells in pancreas and reducing blood glucose level. Also decreases production of basal glucose in liver, enhances sensitivity of peripheral tissue to insulin, inhibits platelet aggregation, and causes mild diuresis.

Nursing responsibility: -Monitor blood glucose level, especially during period of increase stress. -Advise patient to take daily dose with breakfast(and second dose, if prescribed, with dinner) -Encourage patient to drink plenty of Fluids. -Teach patient how to recognize signs and symptoms of hypoglycemia.

Generic: konakion Brand: Phytomnadione Classification: Procoagulant Mechanism of action: Hemorrhage or risk for hemorrhage as a result of hypoprothrombinemia of various etiologies, including overdosage of courrmarin-type anticoagulants, their combination with phenylbutazone, and other forms of hypovitaminosis K(e.g. obstructive jaundice as well as liver and intestinal disorders, and after prolonged treatment with antibiotics, sulphonamides or salicylates).

Nursing responsibility: Careful monitoring of INR is necessary after administration of konakion MM in patients with severely impaired liver function.

IVF Therapy: Plain NSS at 33 gtts/min A solution of common salt in distilled water, of strength of 0.9 percent, it is called a normal saline because the percentage of salt resembles that of the crystalloids in the blood plasma. It can be used to replace fluids in dehydration, go with blood transfusions, hyponatremia, and burn victims. It is an isotonic solution that has the same osmolarity as our body fluid.

5% Dextrose in Lactated Ringers solution are sterile, nonpyrogenic solutions each containing isotonic concentrations of electrolytes (with or without dextrose) in water for injection. The solutions containing dextrose and electrolytes are hypertonic; those containing only electrolytes are isotonic. They are administered by intravenous infusion for parenteral replacement of extracellular losses of fluid and electrolytes, with or without minimal carbohydrate calories. Diet: Diabetic diet

Other Management: Endoscopic Retrograde Cholangiopancreatography Endoscopic retrograde cholangiopancreatography is a procedure that combines upper gastrointestinal (GI) endoscopy and x rays to treat problems of the bile and pancreatic ducts. ERCP is also used to diagnose problems, but the availability of noninvasive tests such as magnetic resonance cholangiography has allowed ERCP to be used primarily for cases in which it is expected that treatment will be delivered during the procedure.

NURSING CARE PLAN

DISCHARGE PLANNING
Medications The patient is prescribed and instructed by the physician to take the medications at the right timing and dosage. These are the lists of the take-home medications. Medication should not be stopped unless the physician says so. Report or consult to the physician if adverse reactions may occur.

DISCHARGE PLANNING
Encourage significant others to assist the patient during medication administration and to encourage her to increase fluid intake to prevent further harm to the patients kidney.

DISCHARGE PLANNING
Health Teaching Patient will be instructed to increase fluid intake to prevent gastric discomfort due to the medications. Instruct patient and significant others to report any unusualities and occurrences of reactions due to drug therapy to the physician in order to prevent complications and further development of health problems. Significant others will be informed to be compliant on the health teachings by assisting the patient maintain a healthy lifestyle.

DISCHARGE PLANNING Spiritual Care Encourage patient to go to mass every Sunday and entrust everything to God but never forget to pray. Never lose hope and reflect on her life. Pray the rosary and talk to God. Read the Holy Bible to find enlightenment and wisdom. Find repentance on sins. Significant others should also walk with the patient in every struggle, assist her and encourage her to have strong faith.

CONCLUSION
After a thorough discussion and a deeper analysis of the case, the presenter have arrived to the following conclusions. First, in caring for a patient with Choledocholithiasis, it is very significant to provide a direct action towards what the patient is experiencing and manifesting to prevent progression of the conditions.

CONCLUSION
Second, time is the most important factor that must be considered in determining the reversibility of the pathologic changes brought about by this condition. Third, the availability of resources such as medical technologies utilized to gather sufficient data is necessary in order to come up with an accurate and timely diagnosis.

CONCLUSION Lastly, since this is very sensitive and complicating disorders, it is a must to provide measures in order to prevent such problems from occurring like safety measures, and regular check up.