I.

INTRODUCTION

A. Brief description

Calculi or gallstones, usually form in the gallbladder from the solid constituents
of bile; they vary greatly in size, shape and composition.

Sign and symptoms are right-upper-quadrant (RUQ) pain or epigastric pain and
discomfort, nausea and vomiting, bloating, dyspepsia, jaundice, changes in the color of
urine and stool

Risk factors are obesity, women especially those with multiple pregnancy,
frequent changes in weight, rapid weight loss, diabetes and cystic fibrosis.

Complication of cholelithiaisis are obstruction of the common bile duct,

inflammation or infection of the gallbladder (acute cholecystitis), inflammation or
infection of the common bile duct (cholangitis), which can occur when gallstones get
stuck in the common bile duct. Though rare, this can damage the liver or spread infection,
inflammation of the pancreas (pancreatitis), choledocholithiasis presence of gallstones in
the gallbladder ducts or common bile duct (CBD), gallstone ileus obstruction of the
intestines which is cause duodenal gallstones and biliary dyskinesia a motility disorder
that affects the gallbladder and Sphincter of Oddi.

Tests and procedures used to diagnose gallstones include:

Tests to create pictures of your gallbladder: abdominal ultrasound and a computerized

tomography (CT) scan to create pictures of your gallbladder. These images can be
analyzed to look for signs of gallstones.

Tests to check your bile ducts for gallstones. A test that uses a special dye to highlight
your bile ducts on images may help your doctor determine whether a gallstone is causing
a blockage.

Tests may include a hepatobiliary iminodiacetic acid (HIDA) scan, magnetic resonance
imaging (MRI) or endoscopic retrograde cholangiopancreatography (ERCP). Gallstones
discovered using ERCP can be removed during the procedure.

Blood tests to look for complications. Blood tests may reveal an infection, jaundice,
pancreatitis or other complications caused by gallstones.

Treatment

Laparoscopic cholecystectomy

1
Surgery to remove the gallbladder (cholecystectomy). Remove the gallbladder, since
gallstones frequently recur. Once your gallbladder is removed, bile flows directly from
your liver into your small intestine, rather than being stored in your gallbladder.

You don't need your gallbladder to live, and gallbladder removal doesn't affect your
ability to digest food, but it can cause diarrhoea, which is usually temporary.

Extracorporeal Shock-Wave Lithotripsy

Pharmacotherapy

II. Current trends

Diseases of the gallbladder are common and costly. The best epidemiological screening
method to accurately determine point prevalence of gallstone disease is ultrasonography.
Many risk factors for cholesterol gallstone formation are not modifiable such as ethnic
background, increasing age, female gender and family history or genetics. Conversely,
the modifiable risks for cholesterol gallstones are obesity, rapid weight loss and a
sedentary lifestyle. The rising epidemic of obesity and the metabolic syndrome predicts
an escalation of cholesterol gallstone frequency. Risk factors for biliary sludge include
pregnancy, drugs like ceftiaxone, octreotide and thiazide diuretics, and total parenteral
nutrition or fasting. Diseases like cirrhosis, chronic hemolysis and ileal Crohn's disease
are risk factors for black pigment stones. Gallstone disease in childhood, once considered
rare, has become increasingly recognized with similar risk factors as those in adults,
particularly obesity. Gallbladder cancer is uncommon in developed countries. In the U.S.,
it accounts for only ~ 5,000 cases per year. Elsewhere, high incidence rates occur in
North and South American Indians. Other than ethnicity and female gender, additional
risk factors for gallbladder cancer include cholelithiasis, advancing age, chronic
inflammatory conditions affecting the gallbladder, congenital biliary abnormalities, and
diagnostic confusion over gallbladder polyps.

Laparoscopic cholecystectomy is a minimally invasive surgical procedure for removal of

a diseased gallbladder. This technique essentially has replaced the open technique for
routine cholecystectomies since the early 1990s. At this time, laparoscopic
cholecystectomy is indicated for the treatment of cholecystitis (acute/chronic),
symptomatic cholelithiasis, biliary dyskinesia, acalculous cholecystitis, gallstone
pancreatitis, and gallbladder masses/polyps. These indications are the same for an open
cholecystectomy. Cases of gallbladder cancers are usually best treated with open
cholecystectomy. Approximately 20 million people in the United States have gallstones.

2
 Of these people, there are approximately 300,000 cholecystectomies performed annually.
Ten percent to 15% of the population has asymptomatic gallstones. Of these, 20% are
symptomatic (biliary colic). Of the 20% who are symptomatic approximately 1% to 4%
will manifest complications (acute cholecystitis, gallstone pancreatitis,
choledocholithiasis, gallstone ileus). The incidence of gallstones increases with an
increase in age, with females more likely to form gallstones than males. Age 50 to 65
approximately 20% of women and 5% of men have gallstones. Overall, 75% of
gallstones are composed of cholesterol, and the other 25% are pigmented. Despite the
composition of gallstones the clinical signs and symptoms are the same.

With an annual rate of greater than a quarter of a million hospital admissions and an
associated cost of greater than two billion dollars, cholelithiasis and cholecystitis have a
tremendous impact on the health care system. Their diagnosis and associated symptoms
are one of the most common reasons for clinic visits and the second most common reason
for gastrointestinal-related hospital admissions in the United States. Minimally invasive
surgery has revolutionized the way these patients are managed. This technique provides a
safe and effective therapy that also results in reduced wound-related complications
compared with open cholecystectomy. This enhanced recovery has made the laparoscopic
cholecystectomy one of the most commonly performed abdominal surgeries in the United
States, with more than 500,000 performed each year.

III. Reasons for choosing the case

The main reason why we choose this study is for the readers to have a broader knowledge about
Cholelithiasis of Gallbladder Hydrops. The researchers will also acquire knowledge about
how to give the best possible for the patient's condition, and to understand the concept therein.

IV. Objectives

1. General Objectives:

 At the end of the rotation we the BSN- 3A, Group 1 will enhance our knowledge,
skills and attitude in the care and management of patient who had Cholelithiasis
of Gallbladder Hydrops utilizing the nursing process and will improve the health
status of the patient.

3
2. Specific Objectives:
At the end of this case, the group will able to:

1. Assess the general health condition, routines of daily living as well as health
lifestyle factors affecting the health status of the client.
2. Recognize and prioritize nursing problems and create nursing diagnoses based
on assessment findings
3. Plan efficient nursing care to solve identified problems based from patient’s
condition and health needs.
4. Evaluate the effectiveness of nursing interventions rendered to be able to
improve patient’s condition for possible discharge.

4
II. NURSING PROCESS

A. ASESSMENT

1. PERSONAL DATA

a. Demographic data

Name: Patient x

Age: 44 years old

Address: Gerona, Tarlac

Gender: Female

Date of birth: 5/9/1974

Nationality: Filipino

Religion: Roman Catholic

Admitting Diagnosis: Cholecystolithiasis

Final Diagnosis: Cholelithiasis of Gallbladder Hydrops

Date admitted: 2/5/2019

Time admitted: 11:39:00 A.M.

b. Environmental status

She is a 44 years old female who lives in Don Basilio Gerona Tarlac. The house is
consists of 5 family members including her husband. They are nuclear type of family.
Their house is made of cement onsist of 3 rooms and 2 window located near the farm.
Their source of water is faucet for cooking and for house chores. They used
commercially available water for drinking.

b. LIFESTYLE (HABITS, RECREATION, HOBBIES)

She eats her meals on time three times a day. She usually eats fatty and salty foods.
Patient usually consumes 5-8 glasses of water a day. According to her she doesn’t drink
alcohol and smoke cigarettes. She’s a plain housewife and mostly spend her time in sari-
sari store that she owned, doing household chores and chatting with her neighbor.

5
Family history of health and illneses

6
 2. History of Past Illness
Patient had her complete immunization when she was a child and she had chicken
pox when she’s 16 years old. Her last hospitalization was October 2018 at Paniqui
Hospital for 4 days, she experienced abdominal pain and fever. She was
diagnosed with cholecystolithiasis and had a fatty liver.

3. History of present Condition

She was admitted at Tarlac Provincial Hospital last February 5, 2019 at exactly
11:39 am prior to hospitalization patient experienced fever and continuous pain
with the admitting diagnosis cholecytolithiasis. She was undergone
cholecystectomy with intraoperative cholangiography last February 6, 2019 at
8:15 am.

4. PHYSICAL ASSESSMENT
Weight- 82 kg
Height- 5’3
BMI- 31. 95 (obese)

13 Areas of Assessment
I. SOCIAL STATUS

She speaks tagalog and Ilocano, they are considered nuclear family with
patrecentric family based on authority. She is high school undergraduate according to
hert she has a good communication relation with neighbour and with her fellow
patient as testified by other patient in the ward. During the assessment she is
accommodating in answering questions. Patient has a good communication and
relation to her family members. And cellular phones and chatting is their means of
communication. According to patient’s mother she’s very close to every members in
their family since she is the youngest among siblings.

NORMS:

Social status includes family relationship that states patient’s support system in time
of stress and in time of need. It meets a fundamental human need for socialities
making life less stressful and social support buffers the negative effects of stress.
Thus indicating indirectly contributing to good health outcomes. (Fundamentals of
Nursing, Barbara Kozier, Seventh edition)

7
 Analysis/Interpretation:

Social status is normal.

II. MENTAL STATUS

She was seen in her laboratory gown weak in appearance pale in color with noted
facial grimace due to post operative incision. She is conscious during the assessment
and answer all the question being asked even though she’s having difficulties in
answering because of pain as verbalize by the patient. But was able to answer
correctly and sensibly with the names, time, date and objects being asked.

NORMS:

The content of the patient message should make sense. The ability to read
and write should match the educational level. The patient should be able to
correctly respond to the questions and to identify all objects as requested. The
patient should be able to evaluate and act appropriately in situations requiring
judgement. (health assessment and physical examination 3th edition by Mary
Ellen Zator Estes)

ANALYSIS:

Her current mental status is normal but noted difficulties in answering question
because of the pain. Indicates mental capabilities are still functioning well.

III. Emotional Status

She appears calm and accommodating to answer our questions that are being
asked. She said that she is happy because she can able to survive the
operation. And her husband is there to be with her through the situation.

Norms:
A human’s emotional status depends on his or her ability to cope up and
be ready for whatever can happen in their life. She or he may not be ready to
be emotionally stable of unfortunate happenings in life.
(www.nursingceu.com)
Analysis:
Emotional status is normal.

IV. Sensory Perception

Sense of sight
The eyes of the patient are equally round and her pupils are dark brown.
Her eyebrows are symmetric and with equally distributed hair. Patient’s

8
 eyes are equally reacting to light when using penlight. She is wearing
reading glasses when she needs to read small words but still her vision is
20/20 because she can able to read the words being asked 20 feet away.
No exopthalmia, lesions, and bruits observed.

Norms:

The normal vision of an average person is 20/20 in distance of 20 feet

away and doesn’t wear any corrective graded lenses. The eyes must
be symmetrical during the six cardinal gaze test and symmetrical in movement. (Health
assessment and physical examination, Mary Ellen Zator Estes)

Analysis: Based on the norms she has normal vision.

Sense of smell

Her nose is in the midline of the face and is symmetrical. With no

secretions noted. Common foods such coffee were provided and also
alcohol in a cotton ball. She was able to identify odor.

Norms:

The person can smell and identify the aroma of a given object like
perfume or any other. The person should be able to distinguish the foul and good
smelling.

Analysis:

She has normal sense of smell.

Sense of hearing

For the auditory assessment the voice whisper test was used. Words were
whispered while the patient was instructed to repeat every words being whispered.
The procedure was then repeated to the other ear. The ear are symmetrical and
matches the color of the rest of the skin. After whisper test patient was able to
hear them clearly with negative deformities. No swelling, discharged and lesions
noted except for minimal earwax observed on both ears.

Norms:
The auditory of the person is normal if the patient don’t have any
tinnitinus or any ear problem. He should be able to hear in the minimum

9
 of 2 feet away. ( health Assessment and physical examination, Mary Ellen
Zator Estes)

Analysis:
Based on the given data, auditory acuity is normal.

Sense of taste

Examined using variety of food which taste salty, bitter, and sweet
(granules of sugar and coffee). She was able to differentiate each taste. She has
pale lips slightly dry and chaps. With dry saliva deposited on her side mouth, her
tongue is slightly pinkish with whitish buds. Foul odor is being noted with no
deformities that can affect her sense of taste.

Norms:

A person usually identifies the taste of bitter, sweet and sour. By the use of
our sense of taste we can fix or adjust the taste of our cooked food based on our taste
capacity. ( health assessment and physical examination, Mary Ellen Zator Estes)

Analysis:
Based on the assessment the sense of taste is normal.

Sense of touch (tactile sensitivity)

The examination of sensation she was instructed to close her eyes and tell
what she feels when she was being pricked on her palm. She responded and
stated that the pricking is painful. Using a small glass with cold water pat on
her skin for few second, and was able to identify that is cold.
Norms:
The tactile sensitivity or hypersensitivity is an unusual or increased sensitivity
to touch that makes the person feel peculiar, noxious, or even in pain. It is
also called tactile defensiveness or tactile oversensitivity. Like other
sensory processing issues, tactile sensitivity can run from mild to severe.
Analysis:
The sense of touch or the tactile sensitivity is normal.

V. Motor Stability
Her neck is symmetrical with head in central position. Movement through full
range of motion can be done with discomfort, and gait was assessed using the
heel to toe method. She can’t able operative inscision. She can also move her
shoulder laterally and medially as well as rotate her shoulder in the same

10
 manner with complains of pain. She can also bend her elbows and extend
beyond the neutral position. The patient can’t flex her knees because she’s
still in pain.

Norms: Normal motor stability includes the ability perform different

activities. It should be firm and coordinated movements. (Estes, 2006)

Analysis:

The motor stability is noted abnormal due to impairment with some physical
mobility due to pain cause by post operative incision.

VI. Body Temperature

February 05, 2019 (1:00 36.8 C normal

pm)
February 06, 2019 (8::01 36.4 C normal
am)
February 06, 2019 (4:29 36. 7 C normal
pm)

Norms: Normal body temperature is within 36.4 C to 37.4 C. (Health

assessment and physical examination 3rd edition by Mary Ellen Zator Estes)

Analysis:
Upon assessing body temperature during assessment and follow-up are
normal.

VII. Respiratory Status

11
February 05, 2019 (1:00 23 Above normal
pm)
February 06, 2019 (8::01 20 normal
am)
February 06, 2019 (4:29 24 Above normal
pm)

Norms:
Normal respiratory rate for adult is 12-20 cpm, average is 18. In terms of
pattern, normal respirations must be regular and even in rhythm. The normal
depth of respirations in non-exaggerated and effortless (Health assessment and
physical examination 3rd edition by Mary Ellen Zator Estes)

Analysis:
Respiratory status are beyond normal because pain and post anesthetic during
follow- up.

VIII. Circulatory Status

February 05, 2019 (1:00 80 bpm normal

pm)
February 06, 2019 (8::01 78 bpm normal
am)
February 06, 2019 (4:29 105 bpm Above normal
pm)

February 05, 2019 (1:00 120/80 normal

pm)
February 06, 2019 (8::01 110/70 normal
am)
February 06, 2019 (4:29 130/70 Above normal
pm)

12
Norms:

Normal cardiac rate for an adult is 60-100 beats per minute while the normal
blood pressure is 120/80 mmHg. The working capacity of the heart diminishes
with aging. The heart rate of older people is slow to respond to stress and slow
to return to normal after stress. Reduced arterial elasticity results in
diminished blood supply to the parts of the body especially the extremities.
(Health assessment and physical examination 3rd edition by Mary Ellen Zator
Estes)

Analysis:
The pulse rate during the assessment and follow-up are in normal range. the
blood pressure on the follow- up are above normal.

IX. Nutritional Status

Prior to hospitalization she verbalized that she takes her meal 3x a day consist
of combination of meat, vegetables, fish and fruits. And consume 8-10 glasses
of water she’s fond of eating fatty and salty foods. Her BMI is 31.95 and
considered obese. Prior to pre operative she was ordered to carry NPO diet.
During post operative she carried NPO until normal peristalsis occurs
followed by soft diet and small amount of intake as ordered by the doctor less
salt and fat.
Norms:
Consider cultural and religious variations. Normal eating pattern is at on
the minimum of three times per day depending upon the metabolic demands
and needs of the patient. Fluid intake is on the average of 8-10 glasses per day
(Monahan, 2002).
Analysis:
The nutritional status was being altered for operation preparation (NPO).She
has above normal BMI.
X. Elimination Status
Prior to hospitalization she defecates at least once a day brown stool
moderately soft and urinates five times in a day. During 1st day before
operation she defecates once but after the operation she didn’t defecate and
still waiting to her normal peristalsis.
Norms:
An individual usually defecate one to two times a day or every 2 day and
urinates 30cc/hr. (Nutrition by Alex Abelos)
Analysis:
elimination status is normal.

13
XI. Reproductive Status
She had her first menstruation when she was 10 years old with 5 days duration
and consumes 5 pads in a day fully soaked, without abdominal cramps and
fundal pain every menstruation. She had her first sexual intercourse when she
was 16 years old. According to her she is sexually active and have sex once a
week due to the nature of her husband’s work. cramps.
Norms:
The first menstruation which is menarche occurs at an average of 9 to 17 years
old. (Maternal and Child Health Nursing 4th edition by Pilliterri)
Analysis:
Her menarche is normal because she had her menarche at 15 years old. The
reproductive status is normal.
XII. Sleep-rest Pattern
Prior to admission she normally sleeps 6 hours with nap in the afternoon.
During post operative/ admission she verbalized difficulty of sleeping due to
the environmental changes.
Norms:
Sleep refers to altered consciousness with general slowing of physiologic
process while rest refers to relaxation and calmness, both mental and physical.
A person usually sleeps for about 7 to 9 hours a day and takes a rest using
some of activities that will help you to relax including reading, watching
television and others.
Analysis:
Sleep-rest pattern is altered due to environmental factors.

XIII. State of skin appendages

She is brown in color and appropriate to the whole body with traces of scar
marks on her legs and arms and incision on the right upper quadrant. The hair
is evenly distributed brunette in color the skin is evenly warm to touch and no
presence of edema the nails are untrimmed and dirty with no presence of nail
clubbing. Normal capillary refill is noted that returns after 1-2 seconds.
Presence of surgical incision at right upper quadrant of the abdomen.
Norms: Obvious changes in the integumentary system (skin, hair, nails) with
age. The skin becomes drier and more fragile, the hair loses color, the finger
nails and toe nails become thickened and brittle, and i women over 60, facial
hair increases. These integumentary system changes accompany progressive
losses of subcutaneous fat and muscle tissues, muscle atrophy, and loss of
elastic fibers. (Fundamental of nursing 7th edition by Barbara kozier)
Analysis:

14
 The skin and appendages is not normal due to presence of incision.

III. Laboratory and diagnostic procedures

Laboratory Indication Findings Reference Interpretation Nursing

and value Responsibilities
diagnosis

15
 Laboratory Hemoglobin Hemoglobin -Normal -Monitor and
assessment regulate the
Hematology of blood 131 120-153 g/L Intravenous
formation fluid
and to
Date detect any Hematocrit Hematocrit -Normal
blood -Monitor vital
February 0.418 0.350-
associated signs
05, 2016 0.450%
disorders.

RBC -Normal
RBC -
4.33
3.9-5.7 /L

MCV -Normal
MCV
95.5
80-96 fL

MCHC -Normal
MCHC
313
334-355 g/L

MCH -Normal
MCH
30.3
27.5-32.2
pg
WBC -Normal

10.3 WBC

4.5-10.5 /L
POLYS -Abnormal

0.689 POLYS Often caused

by infection
(0.55-0.63)

16
 -Normal

LYMPHO

0.241 LYMPHO

(0.23-0.35) -Normal

PLATELET

221,000 PLATELET

150,000-
450,000

Laborator Indication Findings Referenc Interpretatio Nursing

y and e value n Responsibilitie
diagnosis s

Blood Analysis RBS RBS -Abnormal -Explain the

chemistry of blood procedure,
chemistry 8.14 2.5-7.2 why it is done
can mmol/L and its
Date provide purpose.
important Creatinine -Normal
informatio Creatinin
73.37 e
n about the
February
function of
05, 2019 53.0-
the kidney
106.0
and other
ELECTROLYTE umol/L
organs.
This S
common -Normal
panel of
blood tests Sodium
measures
levels of 141.1 Sodium
important

17
electrolyte 135.0- -Normal
s and other 148.0
chemical. Potassium mmol/L
4.60

Potassiu
m

3.50-5.30
mmol/L

18
Laboratory and Indication Date Findings
diagnosis
 Liver
Imaging January 14, -Normal in sized
procedure used 2019  Proximal
HBT to diagnose common duct
Ultrasound problems of the -Normal in sized (0.4 cm
liver, gallbladder )
, pancreas,
 Gallbladder
spleen and the -dilated (9.7x5.2cm)
kidneys
-within cystic duct

-Multiple intraluminal

-wall is not thickened

 Pancreas
-Normal in sized

 Spleen
-Normal in sized

-No masses

 Splenic vessels
-Not dilated

 Both Kidneys
-Normal in sized

-Not dilated

-No evident of lithiasis

19
Laboratory and Indication Date Findings
diagnosis
Chest x-ray  Lungs
produces images -Clear
of the hearth
 Hearth
Chest AP lungs, airways ,
-Normal in size
blood vessels and
 Diaphragm &
the bones of the
both
spine and chest. Costophrenic
An x-ray sulci
(radiograph) is a -Intact
noninvasive  Visualized Bony
medical test that Structures
helps physicians -Unremarkable
diagnose and treat
medical
conditions.

20
 7. Anatomy and Physiology

V. Anatomy and Physiology

a. Anatomy of the Gallbladder

A pear shape, hollow sac like organ, 7.5-10 cm in (3-4 in) long, lies in a shallow
depression on the inferior surface of the liver, to which it is attached by loose connective
tissue.

- The capacity of the gallbladder is 30-50 ml of bile.

- Its wall is composed largely of smooth muscles
- The gallbladder is connected to the common bile duct by the cystic duct.

21
 b. Physiology of Gallbladder
1. It acts as storage depot of bile duct
2. Between meals, when the sphincter of Oddi is closed, bile produced by the
hepatocytes enters the gallbladder.
3. During storage, a large portion of the water in the bile is absorbed through the
walls of the gallbladder, so that the gallbladder bile is 5-10 times more
concentrated than that originally secreted by the liver.
4. When food enters the duodenum, the gallbladder contracts and the sphincter of
Oddi relaxes, allowing the bile to enter the intestine.
5. This response is mediated by secretion of the hormones Cholecystokinin-
Pancreozymin (CCK-PZ) from the intestinal wall.

22
c. PATHOPHYSIOLOGY

Book-based
Modifiable Non- Modifiable

Obesity Gender (6 times more prevalent

to women)
Diet
Age (between 20 and 50)
Occupation
Race- Asian
Lifestyle

Lifestyle

Signs & Symptoms

-acute inflammation (cholecystitis) of gall

bladder

-abdominal pain tenderness and rigidity

of upper right abdominal quadrant that
may radiate to mid sterna area/ right
shoulder and is associated with nausea
and vomiting and usual signs of acute
inflammation

-presence of jaundice

-dysuria

-fever

Laboratories

-abdominal X-ray
-ultrasound
-Cholecystography
-endoscopic retrogate
23
 Cholelithiasis

Pathophysiology
Gallstone formation occurs because certain substances in bile are present in
concentrations that approach the limits of their solubility. When bile is concentrated in
the gallbladder, it can become supersaturated with these substances, which then
precipitate from the solution as microscopic crystals. The crystals are trapped in
gallbladder mucus, producing gallbladder sludge. Over time, the crystals grow,
aggregate, and fuse to form macroscopic stones. Occlusion of the ducts by sludge and/or
stones produces the complications of gallstone disease.
The 2 main substances involved in gallstone formation are cholesterol and calcium
bilirubinate.
Cholesterol gallstones
More than 80% of gallstones in the United States contain cholesterol as their major
component. Liver cells secrete cholesterol into bile along with phospholipid (lecithin) in
the form of small spherical membranous bubbles, termed unilamellar vesicles. Liver cells
also secrete bile salts, which are powerful detergents required for the digestion and
absorption of dietary fats.
Bile salts in bile dissolve the unilamellar vesicles to form soluble aggregates called mixed
micelles. This happens mainly in the gallbladder, where bile is concentrated by
reabsorption of electrolytes and water.
Compared with vesicles (which can hold up to 1 molecule of cholesterol for every
molecule of lecithin), mixed micelles have a lower carrying capacity for cholesterol
(about 1 molecule of cholesterol for every 3 molecules of lecithin). If bile contains a
relatively high proportion of cholesterol to begin with, then as bile is concentrated,
progressive dissolution of vesicles may lead to a state in which the cholesterol-carrying
capacity of the micelles and residual vesicles is exceeded. At this point, bile is
supersaturated with cholesterol, and cholesterol monohydrate crystals may form.
Thus, the main factors that determine whether cholesterol gallstones will form are (1) the
amount of cholesterol secreted by liver cells, relative to lecithin and bile salts, and (2) the
degree of concentration and extent of stasis of bile in the gallbladder.
Calcium, bilirubin, and pigment gallstones
Bilirubin, a yellow pigment derived from the breakdown of heme, is actively secreted
into bile by liver cells. Most of the bilirubin in bile is in the form of glucuronide
conjugates, which are water soluble and stable, but a small proportion consists of
unconjugated bilirubin. Unconjugated bilirubin, like fatty acids, phosphate, carbonate,

24
and other anions, tends to form insoluble precipitates with calcium. Calcium enters bile
passively along with other electrolytes.
In situations of high heme turnover, such as chronic hemolysis or cirrhosis, unconjugated
bilirubin may be present in bile at higher than normal concentrations. Calcium
bilirubinate may then crystallize from the solution and eventually form stones. Over time,
various oxidations cause the bilirubin precipitates to take on a jet-black color, and stones
formed in this manner are termed black pigment gallstones. Black pigment stones
represent 10-20% of gallstones in the United States.

Bile is normally sterile, but in some unusual circumstances (eg, above a biliary stricture),
it may become colonized with bacteria. The bacteria hydrolyze conjugated bilirubin, and
the resulting increase in unconjugated bilirubin may lead to precipitation of calcium
bilirubinate crystals.
Bacteria also hydrolyze lecithin to release fatty acids, which also may bind calcium and
precipitate from the solution. The resulting concretions have a claylike consistency and
are termed brown pigment stones. Unlike cholesterol or black pigment gallstones, which
form almost exclusively in the gallbladder, brown pigment gallstones often form de novo
in the bile ducts. Brown pigment gallstones are unusual in the United States but are fairly
common in some parts of Southeast Asia, possibly related to liver fluke infestation.
Mixed gallstones
Cholesterol gallstones may become colonized with bacteria and can elicit gallbladder
mucosal inflammation. Lytic enzymes from the bacteria and leukocytes hydrolyze
bilirubin conjugates and fatty acids. As a result, over time, cholesterol stones may
accumulate a substantial proportion of calcium bilirubinate and other calcium salts,
producing mixed gallstones. Large stones may develop a surface rim of calcium
resembling an eggshell that may be visible on plain x-ray films.
Etiology
Cholesterol gallstones, black pigment gallstones, and brown pigment gallstones have
different pathogeneses and different risk factors.
Cholesterol gallstones
Cholesterol gallstones are associated with female sex, European or Native American
ancestry, and increasing age. Other risk factors include the following:
 Obesity
 Pregnancy
 Gallbladder stasis
 Drugs
 Heredity
The metabolic syndrome of truncal obesity, insulin resistance, type II diabetes mellitus,
hypertension, and hyperlipidemia is associated with increased hepatic cholesterol
secretion and is a major risk factor for the development of cholesterol gallstones.
Cholesterol gallstones are more common in women who have experienced multiple
pregnancies. A major contributing factor is thought to be the high progesterone levels of

25
pregnancy. Progesterone reduces gallbladder contractility, leading to prolonged retention
and greater concentration of bile in the gallbladder.
Other causes of gallbladder stasis associated with increased risk of gallstones include
high spinal cord injuries, prolonged fasting with total parenteral nutrition, and rapid
weight loss associated with severe caloric and fat restriction (eg, diet, gastric bypass
surgery).
A number of medications are associated with the formation of cholesterol gallstones.
Estrogens administered for contraception or for the treatment of prostate cancer increase
the risk of cholesterol gallstones by increasing biliary cholesterol secretion. Clofibrate
and other fibrate hypolipidemic drugs increase hepatic elimination of cholesterol via
biliary secretion and appear to increase the risk of cholesterol gallstones. Somatostatin
analogues appear to predispose to gallstones by decreasing gallbladder emptying.
About 25% of the predisposition to cholesterol gallstones appears to be hereditary, as
judged from studies of identical and fraternal twins. At least a dozen genes may
contribute to the risk. [3] A rare syndrome of low phospholipid–associated cholelithiasis
occurs in individuals with a hereditary deficiency of the biliary transport protein required
for lecithin secretion. [4]
Black and brown pigment gallstones
Black pigment gallstones occur disproportionately in individuals with high heme
turnover. Disorders of hemolysis associated with pigment gallstones include sickle cell
anemia, hereditary spherocytosis, and beta-thalassemia. In cirrhosis, portal
hypertension leads to splenomegaly. This, in turn, causes red cell sequestration, leading
to a modest increase in hemoglobin turnover. About half of all cirrhotic patients have
pigment gallstones.
Prerequisites for the formation of brown pigment gallstones include intraductal stasis and
chronic colonization of bile with bacteria. In the United States, this combination is most
often encountered in patients with postsurgical biliary strictures or choledochal cysts.
In rice-growing regions of East Asia, infestation with biliary flukes may produce biliary
strictures and predispose to formation of brown pigment stones throughout intrahepatic
and extrahepatic bile ducts. This condition, termed hepatolithiasis, causes recurrent
cholangitis and predisposes to biliary cirrhosis and cholangiocarcinoma.
Other comorbidities
Crohn disease, ileal resection, or other diseases of the ileum decrease bile salt
reabsorption and increase the risk of gallstone formation.
Other illnesses or states that predispose to gallstone formation include burns, use of total
parenteral nutrition, paralysis, ICU care, and major trauma. This is due, in general, to
decreased enteral stimulation of the gallbladder with resultant biliary stasis and stone
formation.

26
Client based:

Non-Modifiable Modifiable

 Age: 44  Hobby: eat fatty food and

 Race: Filipino salty food
 Gender: Female

Signs and Symptoms

 Severe pain in RUQ

radiating to back

Diagnostic Test

 HEMATOLOGY  BLOOD CHEMISTRY

o Hemoglobin:131  RBS 8.14
o Hematocrit: 0.418  Creatinine 73.37
o RBC: 4.33 ELECTROLYTES
o MCV: 95.5  Sodium : 141.1
o MCHC: 313
 : Potassium 4.60
o MCH: 30.3
o WBC: 10.3
o POLYS: 0.689 Chest AP
o LYMPHO: 0.241  Lungs : Clear
o PLATELET: 221,000  Hearth : Normal in size
 Diaphragm & both Costophrenic sulci intact
 Visualized Bony Structures Unremarkable

Surgical Procedure

 Cholecystectomy

27
 VI. Nursing Care Plan

B. IMPLEMENTATION

VII. MEDICAL MANAGEMENT

a. Drug Study
b. Surgical management

Treatment Date performed Description Indication Client Reaction Nursing

Resposibilities

Cholecystectomy 02/06/2019 -surgical removal of -performed to treat -patient is in pain -Monitor the vital
with Intraoperative gallbladder cholelithiasis and due to procedure signs of the pt.
Cholangiogram cholecystitis done.

28
 -it is consist of -billiary coli -Health teachings
excising the given about
gallbladder from the -billary pancreas appropriate diet of
posterior liver wall -gallbladder cancer the pt.
and ligating the
cystic duct, vein and -choledocholithiasis
artery the surgeon
usually approaches
the gallbladder
through a right
subcostal incision

C. Activity and exercise

ACTIVITY TYPE OF INDICATION CLIENT’S RESPONSE

AND EXERCISE PURPOSE
EXERCISE

Change position Activity tolerance To promote patient The patient was relived and
in bed every 2 comfort was comfortable
hours

29
 f. NURSING MANAGEMENT

(1)

Subjective:

Objective:

BP: 120/70

PR: 85 bpm

RR: 24 cpm

T: 36.1

0.9 NaCl 1L 84 cc/ min.

Pale in appearance

Crackles heard on both lungs

Chest ultrasound : right massive pleural effusion and left minimal pleural effusion

Analysis:

Ineffective breathing pattern related to pleural effusion

Planning:

After 1 hour of nursing intervention the patient maintain an effective breathing pattern as
evidence by relax breathing, at normal rate and depth and doesn’t use any accessory
muscles

Intervention:

 Auscultated the chest

 Noted rate and depth of respirations which is 24 cpm tachypnic
 Assisted client to sit up for comfort measures
 Instructed deep breathing exercise

30
Evaluation:

After 1 hour of nursing intervention the patient maintained an effective

breathing pattern as evidenced by relax breathing, at normal rate and depth
and doesn’t use any accessory muscles

CONCLUSION

After our exposure in surgery ward, we the student nurses, had acquired
knowledge about the patient’s condition that will help us in our path to
become a registered nurse, after handling patient who has cholelithiasis of
gallbladder hydrops, we learned a lot about the manifestations, risks factors,
etiology, pathophysiology, proper management and treatment. The group
established good nurse-patient rapport, unity, teamwork and effective
collaboration with our group mates. We were able to enhance our skills,
knowledge, attitude and rendered appropriate nursing interventions based on
patient’s health problems and needs. The group emphasized and able to give
proper health teachings that will help to improve the general health condition
of the patient.
Based on the data compiled in this case study, we therefore conclude that all
the objectives and goals were achieved.

RECOMMENDATION

A. Student Nurse

To our fellow student nurses, to enhance our knowledge, attitude and skills in
having a proper nursing care management, a case study is a helpful instrument that will
serve as an educational companion to have a better understanding about specific cases
including our case cholelithiaisis. To establish a good rapport to the patient is also like
building an effective collaboration with your groupmates. Unity, teamwork, patience,
trust, prioritization, and focus are necessary things to accomplish a good case study.

B. Patient

31
 Patient must keep in mind the diet changes of decreased fat intake is prudent; this
may decrease the incidence of biliary colic attacks.to appropriate eating lifestyle: eating
nutritious foods like dark, green leafy vegetables, fresh fruits and high protein diet, avoid
eating salty, gas-forming and fatty foods. Drinking plenty of water to maintain the
hydration of the body and restricting lifting of heavy things or straining for 6 weeks is a
must. Walking daily should be performed. Following the regimen of discharge
medications is also important.

C. Health Care Provider

Healthcare providers have the great responsibility to help others, to keep them
healthy and free of danger. It is necessary to know all about the patient’s condition and
how to properly manage it that is why they can use this study in order for them to have
more knowledge on how to render the specific care to their patients.

REVIEW OF RELATED LITERATURE

1. Early surgical management of acute cholecystitis: A quality improvement

initiative

Background

Acute cholecystitis is seen commonly in the emergency room and is a leading cause of
gastrointestinal-related hospital admissions. Cholecystectomy is the accepted standard of
care to manage cholecystitis; however, the timing of surgery has been the subject of
debate. In the past, conservative management with a course of antibiotics was thought to
reduce inflammation and facilitate definitive surgical management at a later date, usually
6 weeks after the initial presentation. This approach was felt to reduce operative risks and
was endorsed as recently as 2013 for grade II (moderate) and grade III (severe)
cholecystitis as outlined in the Tokyo guidelines. However, research has shown
convincingly that early laparoscopic cholecystectomy (ELC), defined as occurring 24 to
72 hours from time of admission, is preferred for treatment of acute cholecystitis in the
modern laparoscopic era. Surgery within 72 hours has become a benchmark after being
associated with lower costs and better outcomes, namely reduced complication and
mortality rates. When compared with delayed laparoscopic cholecystectomy (DLC), early
laparoscopic cholecystectomy has been shown to be safe, to have similar or better rates of
conversion to an open procedure, and to reduce duration of hospital stay. Looking at data
from 77 case-control studies, early laparoscopic cholecystectomy was also found to be
associated with statistically significant reductions in mortality, total complication rate,

32
bile duct leaks, bile duct injuries, wound infections, conversion rates, length of hospital
stay, and blood loss. In a Canadian model, performing surgery early was also estimated to
save approximately $2129 per patient. The most recent consensus statement in the 2018
Tokyo guidelines reflects this by extending adoption of early laparoscopic
cholecystectomy for both grade II and grade III severity as the ideal preferred approach.

Methods

In 2014 all practising general surgeons in the Fraser Health Authority were approached to
complete an online survey about surgeon attitudes, preferences, and practice patterns
regarding management of acute cholecystitis. This was followed by a retrospective
database audit of records for all patients presenting with acute cholecystitis in Fraser
Health between April 2012 and June 2013 who underwent a surgical intervention from
April 2012 to December 2013. Baseline data were collected for the entire health authority
as well as for each individual hospital within the authority. Regional analysts collected
data as part of an approved quality audit using ICD and Canadian Classification of Health
Intervention codes.

Our educational intervention took place at Langley Memorial Hospital, a 166-bed facility
serving a population of approximately 130 000 in Langley, British Columbia. The
intervention began in May 2015 with the distribution of information by email to
emergency room physicians and with educational rounds for operating room nurses. A
practice algorithm for acute cholecystitis was then developed and distributed to staff in
the emergency room and operating rooms. The algorithm included a recommendation for
early surgical consultation for all confirmed or suspected cases of acute cholecystitis.
After the educational intervention, data were collected from electronic and paper charts
from July 2015 to June 2016. Outcomes included times from admission to surgery and
from booking to surgery, as well as preoperative American Society of Anesthesiologists
(ASA) scores and duration of operations, conversion to open surgery rates, length of stay,
and readmission rates.

Results

Survey respondents included 26 general surgeons (48% of active/provisional regional

members) representing all Fraser Health sites. When surgeons were asked how they
would manage acute uncomplicated cholecystitis in a medically fit patient, 73% chose
early laparoscopic cholecystectomy and 27% chose a trial of conservative management
with delayed cholecystectomy. Of those who opted for delayed surgery, 75% cited
limited access to the operating room as their main reason for choosing this strategy.
Among those who opted for early laparoscopic cholecystectomy, 84% would book the
case as needing to be done within 24 hours, although only 23% said they felt surgery was
“usually” or “always” completed within this time frame. The majority of respondents
(88%) supported an institutional policy allowing for early laparoscopic cholecystectomy.

33
Between April 2012 and December 2013, a total of 1329 patients were admitted to Fraser
Health sites with a diagnosis of cholecystitis, and 611 (46%) had an intervention on their
initial admission. Of these, 569 (93%) had laparoscopic cholecystectomies and the
remaining 48 (7%) had drainage procedures (either operative or radiologic). This left 718
patients (54%) who had no intervention for cholecystitis on their initial admission.
Among these patients, 359 (50%) went on to have a delayed cholecystectomy during the
study period. Average hospital length of stay in the ELC group receiving early treatment
was 5.8 days compared with 6.4 days for the DLC group receiving delayed treatment.

Before the educational intervention, 135 patients presented to Langley Memorial Hospital
with acute cholecystitis over 13 months, and 61 (45%) had an intervention on their initial
admission. Of these, 59 (97%) underwent cholecystectomies and 2 (3%) had drainage
procedures. This left 74 patients (55%) who had no intervention for acute cholecystitis on
their initial admission. Among these, 34 patients (25%) went on to have a delayed
procedure during the study period. Overall, management of acute cholecystitis at Langley
Memorial Hospital before the educational intervention was comparable to that seen at
other Fraser Health sites.

Management approaches

While our results suggest it would be worthwhile to increase access to early laparoscopic
cholecystectomy, some degree of caution must be exercised before instituting a strict
policy of ELC with rigid scheduling benchmarks, since such a policy could lead to
markedly increased after-hours surgery. Data regarding the safety of nighttime
laparoscopic cholecystectomy are somewhat conflicting; a retrospective review at two
large urban centres found an increased risk of conversion to an open procedure for
patients receiving laparoscopic cholecystectomies between 7 p.m. and 7 a.m. Another
slightly larger and more recent retrospective review found no increased risk of
complications for patients undergoing laparoscopic cholecystectomies after 5 p.m., and
statistically significant reduced length of stay among the nighttime laparoscopic
cholecystectomy group. While performing after-hours surgery may be safe, the long-term
impacts on the surgeon and operating room staff, which can include burnout, exhaustion,
and job dissatisfaction, must be considered. It is important to note that we were able to
achieve our increased rates of early cholecystectomy while adhering to a policy of
operating after 11 p.m. only if conditions were life- or limb-threatening.

Conclusions

With a modest educational intervention, we were able to achieve significant clinical

impact: an 85% increase in early cholecystectomy rates and a 47% reduction in time from
admission to surgery for patients with acute cholecystitis. In addition to providing better
patient care, increasing patient access to early cholecystectomy resulted in a 44%
reduction in hospital length of stay. The length of stay for early cholecystectomy patients

34
after the educational intervention was appreciably shorter (2.57 days) than for patients in
the Fraser Health early cholecystectomy group (5.1 days). Interestingly, the hospital stay
after the educational intervention was also shorter than the 5.1 days seen in pooled data
for patients undergoing early cholecystectomy. One possible explanation for this
substantial reduction in length of stay is that our intervention focused on education for
both emergency room physicians and perioperative staff, which may have facilitated
more streamlined care for patients with acute cholecystitis and expedited their access to
surgery. This outcome is significant from both a system and a patient perspective.
Reducing hospital length of stay will reduce the costs associated with cholecystitis for an
already overburdened system. Less time in hospital also reduces the impact of acute
cholecystitis on patients by facilitating a faster return to baseline function and work.

2. Gallbladder Hydrops Associated with an Episode of Acute Liver Toxicity in the

Adult: May It Be Considered a Surgical Emergency or Not?

INTRODUCTION

Gallbladder disease is classified into acute and acalculous, acalculous ones can be further
subclassified into gallbladder hydrops and acalculous cholecystitis. Gallbladder hydrops
is defined as an increase in the volume of the gallbladder without any inflammatory sign,
bacterial infection, or the presence of any abnormalities of biliary ducts or of the
gallbladder. The absence of inflammation is one of the characteristics of a good prognosis
and it differentiates gallbladder hydrops from acute acalculous cholecystitis.2 Gallbladder
hydrops is sometimes reported in children.3 We present the rare case of a male patient
with calculous gallbladder hydrops simultaneous with an episode of acute toxic hepatitis.

CASE PRESENTATION

A male patient, VA, from a rural area, aged 52 years, was admitted to the Department of
Internal Medicine for one week complaining for approximately 3–4 days before ad-
mission of moderate pain in the right upper quadrant, low fever, fatigue, general
weakness, symptoms stemming from an excessive food intake (meals abundant in animal
protein, fat, and alcohol), which appeared after a food restriction of 6 weeks (religious
fasting). The patient's his-tory included significant hypertension diagnosed in 2005, under
chronic treatment with antihypertensives. Physical examination revealed the following:
height 1.8 m, weight 124 kg and waist size 130 cm. Inspection showed a globular
abdomen, sensitive to deep palpation in the right upper quadrant, with impalpable liver

35
and spleen. Blood tests performed at admission, during hospitalization and at discharge
(the patient was hospitalized for a week): GGT 754 U/L, AST 381 U/L, ALT: 446 U/L,
direct Bi: 2.37 mg%, total Bi: 1.72 mg%, platelet count: 72,000/mm3; during
hospitalization: GGT 602 U/L, AST 145 U/L, ALT 274 U/L, direct Bi: 2.04 mg%, total
Bi: 2.94 mg%, platelet count: 96,000/mm3; and before discharge: GGT 558 U/L, AST:
96 U/L, ALT: 175 U/L, direct Bi: 0.42 mg%, total Bi: 0.8 mg%, platelet count:
151,000/mm3.Abdominal ultrasound revealed the following features: hepatomegaly with
homogeneous echostructure, slightly increased echogenicity with rear attenuation, with
no focal images, intrahepatic biliary duct dilation, or dilated suprahepatic veins. The
gallbladder looked dropsical, long axis: 12 cm, short axis: 4 cm, slender walls, with
images of hyperechoic infundibular calculi with a posterior shadow cone, the largest
having 14 mm. The portal vein had nor-mal size and hepatopetal flow in the main portal
vein. The main biliary duct also had normal size. One week after the discharge from the
Department of Internal Medicine the patient was admitted to a surgical department where
laboratory tests were repeated: ESR 7 mm/h, INR: 0.98, platelet count: 162,000/mm3,
direct Bi: 0.35 mg%, total Bi 0.81 mg%, AST: 25 U/L, ALT: 41 U/L, GGT: 64 U/L. The
patient underwent surgery (laparoscopic cholecystectomy) and the surgeon described the
following intraoperative aspects: distended gallbladder with signs of pericholecystic and
multiple lax cholecystojejunal posterior and infundibular adhesions. The gallbladder was
about 15 cm long and 5 cm in transverse diameter, with a thin wall, containing a semi-
transparent fluid (about 300 ml).

DISCUSSIONS

Cholelithiasis does not always have clinical symptoms and may be found occasionally
when performing an abdominal ultrasound. From an epidemiological point of view, about
1–4% of patients may experience yearly symptoms, the most common presentation is
biliary colic (56%), or acute cholecystitis (36%).4 More than 90% of the cases of acute
cholecystitis are due to cholelithiasis. Most patients are asymptomatic.5 Of the 1–4% of
cases, about 20% develop clinical symptoms.6 Such patients are often elderly ones and
some have bouts of acute cholecystitis with no previous bile symptoms.7–9 After an
attack of acute chole-cystitis, symptoms such as pain or inflammation are com-mon.10
Although gallstone disease is more common in the elderly, the incidence of acute
cholecystitis has dropped, because patients are operated on by laparoscopic chole-
cystectomy when gallstone symptoms occur.11 Regarding the frequency of acute
cholecystitis according to gender, 60% of patients are women and half of these cases are
due to gallstones, but the one occurring in men tends to be more severe.

182Journal of Interdisciplinary Medicine 2016;1(2):180-182cholecystitis after 7–10 days,

the patient did not present any of these forms of acute cholecystitis, ultrasound ex-
amination revealed only the expansion of the gallbladder (gallbladder

36
hydrops).17Frequently, a slight increase in transaminases and bili-rubin can occur in
cases of acute calculous cholecystitis.18Here we had a large increase in serum
transaminases with normal bilirubin. According to the guidelines for acute hepatitis, ALT
(SGPT) values between 50–2,000 IU are considered significant, while in our case the
highest value was recorded for gamma-GT, which is suggestive for the effect of ethanol
on liver function.19 The toxic effect of ethanol on liver function is well known. We
consider this case an episode of acute hepatitis caused by acute alcohol consumption, and
not a chronic one. This was also proved by liver transaminase levels, which tended to
normalize within a short time of about a week, and by ultrasound ex-amination, which
revealed no hepatic steatosis typical for a chronic consumer of ethanol. Feverishness,
moderate pain in the right upper quad-rant, nausea are common symptoms of clinical
hepatitis and gallbladder disease. In uncomplicated acute chole-cystitis liver tests are
normal or slightly elevated.20 After a sparing diet, antibiotic treatment (ampicillin),
hepatopro-tective medication and bed rest, the clinical outcome and laboratory tests were
favorable.

Conclusion

A condition seen most often in children, gallbladder hydrops can be encountered in adults
less frequently, more-over it occurs simultaneously with an episode of acute toxic
hepatitis. Surgery was performed only after normalization of liver function tests and it
was not imposed urgently by the patient's clinical condition and laboratory test results.
This case demonstrates the need for flexible medical judgment at the bedside, and not a
strictly standardized one according to medical guidelines.

BIBLIOGRAPHY

a. Reference books
-Health assessment and physical examination 3rd edition Mary Ellen Zator
Estes
-Brunner and Suddarth textbook of Medical and Surgical Volume 1 twelfth
edition
-Brunner and Suddarth textbook of medical and Surgical Volume 2 10th
edition
-Nursing 92 drug handbook
-Lynda Juall Carpenito-Moyet, Hand of Nursing Diagnosis 12th edition
- Wolters Kluwer Nursing Drug hand Book 2017

37
Website

https://www.researchgate.net/profile/Maryna_Van_de_venter/publication/248
568168_Isolation_and_identification_of_a_novel_anti-
diabetic_compound_from_Euclea_undulata_Thunb/links/54bcd6e40cf253b50
e2d6855/Isolation-and-identification-of-a-novel-anti-diabetic-compound-
from-Euclea-undulata-Thunb.pdf "Inguinal hernia". Mayo Clinic. 2017-08-11
Ncbi.nlm.nih.gov
https://courses.lumenlearning.com/boundless-ap/chapter/overview-of-the-
urinary-system/
http://www.who.int/news-room/fact-sheets/detail/diabetes
https://www.sciencedirect.com/science/article/pii/S2214999615012643

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