Nursingcasestudy.blogspot.

com

TABLE OF CONTENTS
CHAPTER I – OBJECTIVES AND INTRODUCTION
CHAPTER II – ASSESSMENT
A. Nursing Health History
Personal Data
Past Medical History
Present Medical History
Family Health History
B. Physical Assessment
C. Laboratory Exams
D. Anatomy and Physiology
E. Pathophysiology
CHAPTER III - PLANNING
A. List of Prioritized Nursing Diagnosis
B. Nursing Care Plan
C. Drug Study
CHAPTER IV – IMPLEMENTATION
A. Discharge Planning
CHAPTER I
OBJECTIVES

We did this case study for us to enhance our knowledge and to understand more information
about Cholecystectomy, thus to give us an idea of how we could give proper nursing care for our clients
with this condition, and so that we could apply them on our future exposures as students and eventually
as nurses. We also did this case study as a part of our requirement in our clinical exposure.
INTRODUCTION
The purpose of this case study is to be familiar with a patient that undergo Cholecystectomy;
How it start, what are the causes and what are the signs and symptoms; especially how to prevent,
treat and manage the patient by giving medication for treatment and providing rapport. We chose this
case study because this is the first time that we’ve encountered a case like this in our entire rotation.
PAST MEDICAL HISTORY

The patient is a smoker and alcohol drinker but stopped 2 years ago. The patient stated that
he was confined at Mandaluyong City Medical Center because of jaundice and stomachache.
Then after 4 hours in the operating room, he was transferred to UERM.
PRESENT MEDICAL HISTORY
 - The patient was admitted December 31, 2007 at 3pm with a chief complaint of abdominal
pain.
- 1 day PTA, the patient developed fever and vomiting with abdominal pain; epigastric area
radiating to RUQ area.
- Patient consulted at the Emergency Room, Patient was managed at ER and subsequently
admitted.
FAMILY HEALTH HISTORY
The patient stated that his family has a history of liver cirrhosis. He also stated that they
don’t have a history of Diabetes, Tuberculosis and other hereditary disease.
HEAD TO TOE ASSESSMENT
Skin
Uniform color with slightly warmer than normal temperature, dry and smooth. No scars and
hairs are evenly distributed.
Nails
Pale and Clean
Head and Face
The skull is proportionate to body size, no tenderness and there is a scar. Hair is oily, thick
and evenly distributed. Face is symmetrical with symmetrical facial movement.
Eyes
The client has straight normal eye condition; with yellowish sclera. Pupil is black in color and
equal in size. Have thin eyebrows.
Nose
The nasal septum is in the midline, mucosa is moist.
Mouth
The lips are pale and dry, symmetrical, pale mucosa, tongue is in midline.
Neck
The skin is uniform in color. Neck muscles are equal in size. No tenderness and masses upon
palpation.
Breast and Axilla
No masses and tenderness upon palpation
Abdomen
Uniform in color. There is a wound dressing at RUQ, dry and intact.
Upper Extremities
There is resistance for muscle strength.
Lower Extremities
*Not done because of present condition*
 C. LABORATORY EXAMINATIONS

COMPLETE BLOOD COUNT

HEMATOLOGY NORMAL VALUES RESULT INTERPRETATION

HEMOGLOBIN 120 – 170 g/L 53 Decreased protein production causing jaundice

HEMATOCRIT 0.37 – 0.54 0.18 Decreased because the patient have a bile infection

RED BLOOD CELL 4.0 – 6.0 x 1012L 1.96 Decreased oxygen production due to bile infection
that cause anemia
WHITE BLOOD CELL 4.5 – 10 x 109L 33.2 Increase because infection started

DIFFERENTIAL
COUNT
NEUTROPHILS 0.38 – 0.68 0.70 Slightly increase because of WBC elevation
(segmenters)
LYMPHOCYTES 0.22 – 0.53 0.30 Normal range

EOSINOPHILS 0.01 - 0.07 NOT DONE NOT DONE

MONOCYTES 0.05 - 0.12 NOT DONE NOT DONE

BASOPHILS 0.002 - 0.01 NOT DONE NOT DONE

STABS 0.0 - 0.05 NOT DONE NOT DONE

DEFINITION OF TERMS INDICATED IN THE LABORATORY EXAMINATION

COMPLETE BLOOD COUNT (CBC):

A complete blood count (CBC), also known as full blood count (FBC) or full blood exam (FBE) or
blood panel, is a test requested by a doctor or other medical professional that gives information
about the cells in a patient's blood. A Medical technologist performs the requested testing and
provides the requesting Medical Professional with the results of the CBC. A CBC is also known as a
"hemogram".
The cells that circulate in the bloodstream are generally divided into three types: white blood cells
(leukocytes), red blood cells (erythrocytes), and platelets or thrombocytes. Abnormally high or
low counts may indicate the presence of many forms of disease, and hence blood counts are
amongst the most commonly performed blood tests in medicine.

RED BLOOD CELLS (ERYTHROCYTES):

Are the most common type of blood cells and the vertebrate body’s principal means of delivering
oxygen from the lungs or grills to body tissue via blood.
The number of red cells is given as an absolute number per litre.

HEMOGLOBIN:
Is a protein that is carried by the red cells. It picks up oxygen in the lungs and delivers it to the
peripheral tissues to maintain the viabilty of the cells.
The amount of hemoglobin in the blood, expressed in grams per litre. (Low hemoglobin is called
anemia.)

HEMATOCRIT OR PACKED CELL VOL. (PCV):

This is the fraction of whole blood volume that consists of red blood cells.

WHITE BLOOD CELLS (LEUKOCYTES):

Are cells of the immune system which defend the body against both infectious disease and foreign
materials.
All the white cell types are given as a percentage and as an absolute number per litre.

A complete blood count with differential will also include:

NEUTROPHILS:
This is the main defender of the body against infection and antigens. High levels may indicate an
active infection.
May indicate bacterial infection. May also be raised in acute viral infections.

LYMPHOCYTES:
Is a type of blood cell in the vertebrate immune system.
Elevated levels may indicate an active viral infections.
Higher with some viral infections such as glandular fever and. Also raised in lymphocytic
leukaemia CLL.

MONOCYTES:
May be raised in bacterial infection
Is a leukocyte, part of the immune system that protects against bloodborne pathogens and moves
quickly to sites of infections in the tissue.
Elevated levels may indicate an allergic reactions or parasites.

EOSINOPHILS:
Are white blood cells of the immune system that are responsible for combating infection by
parasites in vertebrates. They are granulocytes that develop in the bone marrow before migrating
into blood.
Increased in parasitic infections.
 High levels are found in allergic reactions.

BASOPHILS:
Circulates vhite blood cells.
Basophils degranulate to release histamine, proteoglycans (e.g. heparin and chondroitin), and
proteolytic enzymes (e.g. elastase and lysophospholipase). They also secrete lipid mediators like
leukotrienes, and several cytokines.

PLATELET COUNT:
Platelets or thrombocytes are the cell fragments circulating in the blood that are involved in the
cellular mechanisms of primary hemostasis leading to the formation of blood clots. Dysfunction or
low levels of platelets predisposes to bleeding, while high levels, although usually asymptomatic,
may increase the risk of thrombosis.
Functions of Platelets can be generalised into a number of categories: Adhesion, Aggregation, Clot
retraction, Pro-Coagulation, Cytokine signalling, Phagocytosis.
A normal platelet count in a healthy person is between 150,000 and 400,000 per mm³ of blood
(150–400 x 109/L). 95% of healthy people will have platelet counts in this range. Some will have
statistically abnormal platelet counts while having no abnormality, although the likelihood
increases if the platelet count is either very low or very high.
Low platelet counts are generally not corrected by transfusion unless the patient is bleeding or the
count has fallen below 5 x 109/L; it is contraindicated in thrombotic thrombocytopenic purpura
(TTP) as it fuels the coagulopathy. In patients having surgery, a level below 50 x 109/L) is
associated with abnormal surgical bleeding, and regional anaesthetic procedures such as epidurals
are avoided for levels below 80-100.

RED BLOOD CELL MORPHOLOGY:

Also known as Blood Smear, and Manual differential.
Was once prepared on nearly everyone who had a complete blood count (CBC) performed. With
the automated blood cell counting instruments currently used, an automated differential is also
provided. However, if the presence of abnormal WBCs, RBCs, or platelets is suspected, a blood
smear examined by a trained eye is still the best method for definitively evaluating and identifying
immature and abnormal cells.
Findings from the blood smear evaluation are not always diagnostic in themselves and more often
indicate the presence of an underlying condition and its severity and suggest the need for further
diagnostic testing. Blood smear findings may include: RBC, WBC and differential count.

PERIPHERAL SMEAR:
- A Peripheral smear is a blood test that gives information about the number and shape of blood
cells.

URINALYSIS REPORT

PHYSICAL EXAMINATION:
Color- amber
Transparency- turbid
PH- 6.0
sp.gr- 1.020

CHEMICAL EXAMINATION:
Leukocytes-
Albumin- negative
Ketons-
Billirubin- positive (+++)
Nitnte-
Sugar- negative
Urobilinogen- Blood-
 MICROSCOPIC EXAMINATION:
Epithelial cells- occasional
Mucus thread-
Amorphous urates-
PUS or WBC- 0-1/hpf
RBC-
Casts-
Crystals-
Bacteria- moderate

LABORATORY MEDICINE (CLINICAL CHEMISTRY I)

Test SI Values Conventional Values

Result Ref. Values Result Ref. Values
Urea nitrogen 8.30 1.70-8.30mmol/L 49.84 10-50mg/dL
Creatinine 116.30 80-115umol/L 1.31 0.9-1.29mg/dL
Sodium 129.50 135-148mmol/L 129.50 135-148meg/L
Potassium 4.54 3.5-5.3mmol/L 4.54 3.5-5.3meg/L

ELECTROLYTES

Result Ref. Values

Sodium 138.8 135-145mmol/L
Potassium 4.48 3.5-5.3

X-RAY

Endoscopic Retrograde Cholangiopancreatogram

Plain film is unremarkable. ERCP shows good filling of the common, right & left hepatic ducts. The
common bile duct & common hepatic duct are slightly dilated. No evidence of lithiasis & filling
defects are noted.

ULTRA SOUND

EXAMINATION 4 ORGANS: (Liver, Gallbladder, Biliary tree, and Pancreas)

The liver is normal in size and outline. The hepatorenal interface is intact. Parenchumal
echogenicity is increased w/ no focal mass or calcifications seen. Intrahepatic duct are dilated.
The common bile duct has diameter of 1.2cm.

The gallbladder is normal in size & configuration, the wall is smooth & not thickened. There are
two shadowing hypere chor foci seen in the area of gallbladder neck/cystic duct measuring about
1.1cm & 0.9cm.
The pancreas is not well visualized in this study due to abundant bowel gas obscuring it.

IMPRESSION:
1) Fatty infiltrative changes of the liver considered.
2) Biliary tract obstruction most likely secondary to lithiasis formation. Exact location not well
determined.
3) Lithiase formation in the gallbladder neck/cystic duct.

Removal of the Gallbladder?

 In some cases, the gallbladder must be removed. The surgery to remove the gallbladder is
called a cholecystectomy (pronounced co-lee-sist-eck-toe-mee). In a cholecystectomy, the
gallbladder is removed through a 5- to 8-inch long cut in your abdomen.
Once the gallbladder is removed, bile is delivered directly from the liver ducts to the upper
part of the intestine.

Function of liver

The liver has many functions. Some of the functions are: to produce substances that break
down fats, convert glucose to glycogen, produce urea (the main substance of urine), make certain
amino acids (the building blocks of proteins), filter harmful substances from the blood (such as
alcohol), storage of vitamins and minerals (vitamins A, D, K and B12) and maintain a proper level
or glucose in the blood. The liver is also responsible fore producing cholesterol. It produces about
80% of the cholesterol in your body.

Function of gall bladder

The function of the gallbladder is to store bile and concentrate. Bile is a digestive liquid
continually secreted by the liver. The bile emulsifies fats and neutralizes acids in partly digested
food. A muscular valve in the common bile duct opens, and the bile flows from the gallbladder
into the cystic duct, along the common bile duct, and into the duodenum (part of the small
intestine).

Function of duodenum

The duodenum is largely responsible for the breakdown of food in the small intestine.
Brunner's glands, which secrete mucus, are found in the duodenum. The duodenum wall is
composed of a very thin layer of cells that form the muscularis mucosae. The duodenum is almost
entirely retroperitoneal. The pH in the duodenum is approximately six. It also regulates the rate
of emptying of the stomach via hormonal pathways.

Function of pancreas

The pancreas is a small organ located near the lower part of the stomach and the beginning
of the small intestine. This organ has two main functions. It functions as an exocrine organ by
producing digestive enzymes, and as an endocrine organ by producing hormones, with insulin
being the most important hormone produced by the pancreas.
The pancreas secretes its digestive enzymes, through a system of ducts into the digestive
tract, while it secretes its variety of hormones directly into the bloodstream.
Abnormal pancreatic function can lead to pancreatitis or diabetes mellitus.

Function of cystic duct

 Bile can flow in both directions between the gallbladder and the common hepatic duct and
the (common) bile duct.
In this way, bile is stored in the gallbladder in between meal times and released after a
fatty meal.

Function of transverse colon

The large intestine comes after the small intestine in the digestive tract and measures
approximately 1.5 meters in length. Although there are differences in the large intestine between
different organisms, the large intestine is mainly responsible for storing waste, reclaiming water,
maintaining the water balance, and absorbing some vitamins, such as vitamin K.
C. DRUG STUDY

Name of Drug: Ceftriaxone

Phil. Brand: Rocephin, Patrixon
Therapeutic Class: Anti-infective
Indication: Treatment of susceptible infections including chancroid, gastroenteritis (invasive
salmonellosis, shegilosis), lyme disease, meningitis (including meningococcal
magnetism prophylaxis), syphilis, typhoid fever, whipple’s disease. Pre-operative
prophylaxis to reduce chance of post-operative surgical infections.
Dosage: Adult usual dosage – 1g/day in a single injection and up to 2g/day once daily according
to the infection
severity and the patient’s body weight.
Contraindication: Ceftriaxone is contraindicated in patients with hypersensitivity to cephalosporins
and penicillins, lidocaine or any other local anesthetic product of the amide type.

Adverse Reaction: Pain, induration, phlebitis after IV administration, rash, diarrhea, eosinophilia,
casts in urine, thrombocytosis and leukopenia
Nursing Responsibilities: Use with caution in patients with history of gastrointestinal disease

Name of Drug: Ketorolac

Phil. Brand: Acular, Kortezor, Toradol
Therapeutic Class: Analgesic
Indication: Short term management of moderate to severe acute post operative pain
Dosage: IM injection – adult less than 35 yrs: 60mg, greater than 35 yrs:30mg. IV injection -
adult less than 65 yrs: 30mg. Adults more than 65 yrs: 15mg
Contraindication: Active peptic ulcer disease, recent gastrointestinal bleeding or perforatin,
moderate to severe renal impairment, hypovolemia or dehydration
Adverse Reaction: Gastrointestinal ulceration, bleeding and perforation, post-operative bleeding.
Hypertension, pruritus, rash, GI disturbances, nausea, dyspepsia, diarrhea, headache,
drowsiness, dizziness, sweating, edema
Nursing Responsibilities: Check if the client takes the medication. Check for the doctor’s order and
if it is the right patient. Observe for any effect and if any side effects occur inform
physician.

Name of Drug: Tramadol

Phil. Brand: Dolotral, Milador, Peptrad, Sivedol, Tradonal, Tramal
Therapeutic Class: Analgesic
Indication: Used for moderate to severe pain
Dosage: Usual dose by mouth are 50 to 100 mg every 4-6 hrs. Total daily dosage by mouth
should not exceed 400 mg.
 Contraindication: Hypersensitivity. Acute intoxication with alcohol, hypnotics, centrally acting
analgesics, opioids, or psychotropic agents.
Adverse Reaction: Vasodilation; dizziness/vertigo, headache, somnolence, stimulation, anxiety,
confusion, coordination disturbances, euphoria, nervousness, sleep disorder, seizures.
Nursing Responsibilities: Give with antiemetic for nausea, vomiting. Administer when pain is
beginning to return; determine dosage interval by patient response

Name of Drug: Ranitidine

Phil. Brand: Ceranid, Cygran, Drug Maker’s Biotech Ranitidine, Incid, Pharex Ranitidine,
Ramadine, Raxide, Ulcin, Zantac/Zantac FR
Zantac 75/Zantac Ampule
Therapeutic Class: Gastrointestinal Drug
Indication: Used in the management of various gastrointestinal disorders such as dyspepsia,
gastro-esophageal reflux disease (GERD), peptic ulcer, and Zollinger-Ellison syndrome.
Dosage: Tablet/Fast-release (FR) tablet: Adult duodenal/gastric ulcer 150mg twice a day or
300mg at bedtime for 4 wks. Maintenance 150mg at bedtime. NSAID-associated
peptic ulcer 150mg twice a day or 300mg at bedtime for 8-12 wks. For children, 2-
4mg/kg 3x a day.
Route: Oral; may be given with or without meals. Give antacids 1hr before or 1hr after this drug.
IV: give by direct IV after diluting 50mg/20mL of 0.9% D5W, NaCl over 5 mins or
more
Contraindication: Hypersensitivity. History of acute porphyria. Long-term therapy.
Adverse Reaction: Cardiac arrhytmias, bradycardia. Headache, somnolence, fatigue, dizziness,
hallucinations, depression, insomnia.
Nursing Responsibilities: Advice patient to not take any new medication during therapy without
consulting a physician. Allow 1hr between any other antacids and ranitidine.

CHAPTER IV – IMPLEMENTATION
DISCHARGE PLANNING

M – MEDICINE
- Advice patient to continue taking his prescribed medicines like Ceftriaxone and
Tramadol.
E – ENVIRONMENT AND EXERCISE
- Maintain a quiet, pleasant, environment to promote relaxation.
- Provide clean and comfortable environment.
- Encourage walking everyday.
T – TREATMENT
- Continue home medications.
- Teach patient about wound care
- Encourage patient to take multivitamins for immunity
H – HEALTH TEACHING
- Provide written and oral instructions about wound care, activity, diet recommendations,
medications, and follow-up visits.
- Instruct patient to limit his activity for 24 to 48 hrs after discharge.
O – OUT PATIENT FOLLOW-UP
- Patient will be advised to go back in the hospital in a specific date to have a follow-up
check up after discharge.
- Consult doctor for are any problems or complications encountered.
D – DIET
- Encourage patient to increase protein intake for tissue repair
- Advice patient to eat smaller-than-normal amounts of food at mealtime.
S – SPIRITUALITY
- Encourage patient to communicate with God.
- Encourage patient to communicate with other people.
CHAPTER III - PLANNING

A. LIST OF PRIORITIZED NURSING DIAGNOSIS

Priority: 1. Acute pain
2. Anxiety

B. NURSING CARE PLAN

Assessment Nursing Planning Nursing Rationale Evaluation

Diagnosis Intervention

Subjective: Pain discomfort, > After 3hrs. of > Monitor v/s of > To obtain > After 3hrs. of
related to Nursing the patient baseline data Nursing
“Samasakit ang surgical incision. Intervention the Intervention the
tahi ko sa pain will be pain will be
tiyan”as lessen. > Encourage > To lessen the lessen.
verbalized by the verbalization of pain of the
patient. Pain scale feelings about patient. Pain Scale
> 5/10 to 3/10 pain. > 5/10 to 3/10
Objective:
> Provide non- > To relax &
>Temp. 37.7°c pharmacological provide comfort
>RR: 36 cpm Therapies ex.: to the patient.
>PR: 103 bpm Radio, Books,
>BP: 120/80 Socialization w/
others.
>(+)Facial
Grimace > Provide calm > To lessen the
activities. pain of the
>Irritable patient.

Pain Scale: > If all the above > Analgesic can

>5/10 doesn’t work, lessen the pain.
Administer
analgesic.
ASSESSMENT NURSING PLANNING NURSING RATIONALE EVALUATION
DIAGNOSIS INTERVENTION

Subjective: Anxiety related to Short term: > Assess > To establish Short term:
“Nahihirapan ako change in health At the end of patient’s level of baseline data. At the end of
ngayon sa sakit status, as 5Hrs. of nursing anxiety. 5Hrs. of nursing
ko”. As evidence by fear intervention intervention
verbalized by the of specified patient will be > Place patient in > To help the patient was able
patient. consequence. able to reduce comfortable patient have to reduce feeling
anxiety. position. adequate period of anxiety.
Objective: of rest and sleep.
Vital signs taken
and recorded: > Provide non- > To relax &
Long term: pharmacological provide comfort Long term:
BP: 120/80 After two weeks Therapies such to the patient. After two weeks
PR: 103 BPM of nursing care, as: of nursing care,
RR: 36 CPM patient will be T.V, Radio, patient was able
Temp: 37.7°C able to accept Books, to accept
changes in health Socialization w/ /understand his
status. others. health status.

> Provide calm > Can lessen the

activities. anxiety of the
patient.

> Provide health > To give more

teaching about information about
hepatitis disease. his health status.
E. PATHOPHYSIOLOGY

Middle age (female > male before

age 50), obesity, infection,
pregnancy, hormonal
contraceptive, celiac disease.
Cirrhosis, pancreatitis, diabetes
mellitus
Cholelithiasis
Refers to the formation of calculi
(e.g. gallstones in the gallbladder)

Major constituents are cholesterol

and pigment

Gallstone in bile Pain Fever

Nausea and Jaundice
Cholecystectomy
duct vomiting

There is inflammation
Removal of the Increase
due to infection Gastric
Bile stasis bilirubin
gallbladder after ligation irritation
of the cystic duct

Bile accumulates Bacterial Abnormal fat There is restlessness

Body will return to in the liver proliferation digestion and Increase in RR,
normal function
temp, PR and WBC
values
Diarrhea
Gallbladder and
Recovery Cholestatic
duct infection

Biliary Cholecystitis
cirrhosis Rupture of if If not treated
gallbladder

Peritonitis Death