Gallstones or cholelithiasis are collections of material that can form inside the

gallbladder. Some gallstones form when there is too much cholesterol in the bile,
while others may form if there are not enough bile salts, or if the gallbladder does
not empty properly. A gallstone is the fifth leading cause of hospitalization among
adults.The disease may also be occurring in persons who are obese, who have high
cholesterol, or who are on cholesterol lowering drugs. In most cases, gallbladder and
bile duct diseases occur during middle age. Between ages 20 and 50,they're six times
more common in women, but incidence in men and women
becomes equal after age 50.
In the Philippines, the gallbladder stone or the gallstones is one of the most common
medical conditions that affect mostly women. This kind of medical symptoms can be
treated with a surgery.
There is no scientific reason why this kind of situations frequently appears with the
women in the society. But study says that this may happen mostly in women because of
their excess estrogen, the primary female sex hormone. During pregnancy, hormone
replacement therapy, and birth control pills, that may appear to build up cholesterol
levels in the bile and decrease gallbladder movement that may lead eventually to
gallstones.
In research, it states that the women that may possibly have contains the 4 Fs these
are the female, forty, fat, fertile and last the flatus.
As well as the cause of this symptoms is very opaque for the human perspective to fully
understood, but it has thought to have a multiple factors. The gallbladder of the body
deposits bile and discharges it into small intestines when it is time to digest. The
gallstones maybe progressed if the bile contains too much cholesterol or too much
bilirubin which is one of the most components of the bile, in some cases, if the
gallbladder is dysfunctional and cannot release the bile.
There are many different types of gallstones that structure in cholelithiasis associated to
cholecystolithiasis, first is the cholesterol stone, it is the results of the presence of too
much cholesterol in the bile. Another type is the pigment stone it is molded from excess
bilirubin it is a waste product that creates by means of the failure of the red blood cells
in the liver. They differ depending on their size and number of gallstones in cholelitiasis,
gallbladder of the body can create many small stones or one large stones. Cholelithiasis
in the Philippines if a person has a symptoms that fits like this, often than not they are
recommended to eliminate the gallstones for their peace of mind as well as the reason
to live long, and this will eventually be cure if enough medications and attention maybe
given to the patients.

SIGNIFICANCE OF THE STUDY

Being exposed to the operating Room of PPL is another opportunity to the group
to enhance their formation of becoming caring nurses. Operating room is a special area
where many nursing skills are developed together with the challenge of efficiency and
effectiveness. The group decided to share this case in order to learn how to present an
OR case and to develop their clinical skills and judgement. The group is hopeful that
this case presentation will be a venue to integrate their foundational knowledge and
clinical skills.
For the Patient/s suffering from Cholecystolithiasis:Clients who suffer from many
medical conditions need medical and nursing care that will lessen their presenting signs
and symptoms. Through this case study, nursing care for these patients will be
enhanced. Thus, quality care will be provided.
For the Student Nurses: This case study will give opportunity to the student nurses to
evaluate their ability to perform quick but effective assessment and efficient operatively
nursing care. The student nurses attitude is also essential. Thus, through this case
study the student nurses also can describe how they have assisted this particular
patient during his arrival in the operating room.
For Clinical Instructors: Clinical Instructors will be able to evaluate the students
ability to integrate their knowledge, skills and attitude in operative nursing care. This
particular case study can also give the clinical instructors method of evaluating the
students in their ability to provide good and efficient operative nursing care.
SCOPE AND DELIMITATION
The group will present the anatomy/physiology, pathophysiology, clinical manifestation,
assessment, and management of this particular patient with Cholecystolithiasis. The
group will be limited in such a way that their presentation is focused on
Cholecystolithiasis. The data presented in this case study is based on their 8-hour duty
in OR last September 8, 2014.
DEFINITION AND ETIOLOGY
Cholelithiasis is the medical term for gallstone disease. Gallstones are concretions that
form in the biliary tract, usually in the gallbladder. There are different terminologies that
use to describe Cholelithiasis depending on site:
Cholecystolithiasis is the occurrence or presence of one or more
of gallstones within the gallbladder.
Choledocholithiasis refers to the presence of 1 or more gallstones in the common bile
duct (CBD).
The two types of gallstones are cholesterol and pigment stones:

Cholesterol stones, usually yellow-green in color, consist primarily of hardened

cholesterol. In the United States, more than 80 percent of gallstones are cholesterol
stones.1
Pigment stones, dark in color, are made of bilirubin.

Risk factors

Women are more likely to develop gallstones than men. Extra estrogen can
increase cholesterol levels in bile and decrease gallbladder contractions, which may
cause gallstones to form. Women may have extra estrogen due to pregnancy,
hormone replacement therapy, or birth control pills.
People over age 40 are more likely to develop gallstones than younger people.
People with a family history of gallstones have a higher risk.
American Indians have genetic factors that increase the amount of cholesterol in
their bile. In fact, American Indians have the highest rate of gallstones in the United
Statesalmost 65 percent of women and 30 percent of men have gallstones.
Mexican Americans are at higher risk of developing gallstones.
Other factors that affect a persons risk of gallstones include2
Obesity. People who are obese, especially women, have increased risk of
developing gallstones. Obesity increases the amount of cholesterol in bile, which
can cause stone formation.
Rapid weight loss. As the body breaks down fat during prolonged fasting and rapid
weight loss, the liver secretes extra cholesterol into bile. Rapid weight loss can also
prevent the gallbladder from emptying properly. Low-calorie diets and bariatric
surgerysurgery that limits the amount of food a person can eat or digestlead to
rapid weight loss and increased risk of gallstones.
Diet. Research suggests diets high in calories and refined carbohydrates and low in
fiber increase the risk of gallstones. Refined carbohydrates are grains processed to
remove bran and germ, which contain nutrients and fiber. Examples of refined
carbohydrates include white bread and white rice.
Certain intestinal diseases. Diseases that affect normal absorption of nutrients,
such as Crohns disease, are associated with gallstones.
Metabolic syndrome, diabetes, and insulin resistance. These conditions
increase the risk of gallstones. Metabolic syndrome also increases the risk of
gallstone complications. Metabolic syndrome is a group of traits and medical
conditions linked to being overweight or obese that puts people at risk for heart
disease and type 2 diabetes.
Pigment stones tend to develop in people who have

cirrhosisa condition in which the liver slowly deteriorates and malfunctions due to
chronic, or long lasting, injury

infections in the bile ducts

severe hemolytic anemiasconditions in which red blood cells are continuously
broken down, such as sickle cell anemia

Signs and symptoms

Gallstone disease may be thought of as having the following 4 stages:
1.
2.
3.
4.

Lithogenic state, in which conditions favor gallstone formation

Asymptomatic gallstones
Symptomatic gallstones, characterized by episodes of biliary colic
Complicated cholelithiasis

Symptoms and complications result from effects occurring within the gallbladder or from
stones that escape the gallbladder to lodge in the CBD.
Characteristics of biliary colic include the following:

Sporadic and unpredictable episodes

Pain that is localized to the epigastrium or right upper quadrant, sometimes radiating
to the right scapular tip
Pain that begins postprandially, is often described as intense and dull, typically lasts 15 hours, increases steadily over 10-20 minutes, and then gradually wanes
Pain that is constant; not relieved by emesis, antacids, defecation, flatus, or positional
changes; and sometimes accompanied by diaphoresis, nausea, and vomiting
Nonspecific symptoms (eg, indigestion, dyspepsia, belching, or bloating)
Patients with the lithogenic state or asymptomatic gallstones have no abnormal findings
on physical examination.
Distinguishing uncomplicated biliary colic from acute cholecystitis or other complications
is important. Key findings that may be noted include the following:

Uncomplicated biliary colic Pain that is poorly localized and visceral; an essentially
benign abdominal examination without rebound or guarding; absence of fever
Acute cholecystitis Well-localized pain in the right upper quadrant, usually with
rebound and guarding; positive Murphy sign (nonspecific); frequent presence of fever;
absence of peritoneal signs; frequent presence of tachycardia and diaphoresis; in
severe cases, absent or hypoactive bowel sounds
The presence of fever, persistent tachycardia, hypotension, or jaundice necessitates a
search for complications, which may include the following:

Cholecystitis
Cholangitis
Pancreatitis

Anatomy of the biliary system:

The biliary system consists of the organs and ducts (bile ducts,
gallbladder, and associated structures) that are involved in the
production and transportation of bile. The transportation of bile
follows this sequence:
When the liver cells secrete bile, it is collected by a system
of ducts that flow from the liver through the right and left hepatic
ducts.
These ducts ultimately drain into the common hepatic duct.
The common hepatic duct then joins with the cystic duct
from the gallbladder to form the common bile duct, which runs from
the liver to the duodenum (the first section of the small intestine).
However, not all bile runs directly into the duodenum. About
50 percent of the bile produced by the liver is first stored in the
gallbladder, a pear-shaped organ located directly below the liver.

Then, when food is eaten, the gallbladder contracts and releases stored bile into
the duodenum to help break down the fats.
Functions of the biliary system:
The biliary system's main function includes the following:
to drain waste products from the liver into the duodenum
to help in digestion with the controlled release of bile
Bile is the greenish-yellow fluid (consisting of waste products, cholesterol, and bile salts)
that is secreted by the liver cells to perform two primary functions, including the
following:
to carry away waste
to break down fats during digestion
Bile salt is the actual component which helps break down and absorb fats. Bile, which is
excreted from the body in the form of feces, is what gives feces its dark brown color.

The many functions of bile are best understood by knowing the composition of bile:
1. Bile Salts
2. Cholesterol and phospholipids
3. Bilirubin
Bile production and recirculation is the main excretory function of the liver. Tumors
that obstruct the flow of bile from the liver can also impair other liver functions.
Therefore, it is necessary to understand these other functions to understand the
symptoms that these tumors can cause.

PATIENTS PROFILE
Patients name:
Address:
Age:
Birthday:
Civil Status:
Admitting Doctor:
Attending Physician:
C/C:
Date Admitted:
Final Diagnosis:

Mrs. TBZ
San Juan, San Pablo City
58 years old
October 4, 1955
Married

Abdominal pain
September 8, 2014
Cholecystolithiasis with Open
Cholecystectomy

History of Patient Illness:

To weeks PTA, patient claims that she has lost weight. One week PTA, patient went to
Dr. Santiago of CGH for check-up and found out that she is having gallbladder stones.
But because of patients financial status, patient decided to go to PPL for another
consultation. Four days PTA, patient went to ER of PPL. Patient was found to having
inflammation of gall bladder which prompted the patient to be admitted and to undergo
Open Cholecystectomy last September 8, 2014.
Past Medical History:
Adult illness: Patient has previous illness/disease.
Previous Hospitalization: Patient has no previous hospitalization.
Medications: Patient is not taking any vitamins or supplements.
Allergies: Patient has no known allergies to any food or medicine.

Personal and Social History

Habits:
Watching television
Vices:
Patient is not drinking alcohol or smoking.
Travel: Patient has not travelled long distance.
Lifestyle: Patient is homebound and performing daily household chores
Social Affiliation: Patient has no social affiliation.
Medical History
Chief Complain: Abdominal pain
Family History: Mother has Diabetes mellitus, Father has respiratory disease but
unable to determine the type of respiratory disease
GORDONS FUNCTIONAL HEALTH PATTERN
A. Health Perception and Health management
Prior to Admission:
Has no known allergies.
Is not taking any medicines or supplements
Medical problem in the family include diabetes mellitus for her mother and
respiratory disease for her father
Doesnt go for regular check-up
Has no beliefs, practices or traditional concepts of health and illness since
she is knowledgeable.
Considers herself as healthy.
Stays healthy by trying to eating vegetables and fish and doing daily
household chores.
Is independent in activities of daily living.
Is not smoking or taking alcohol/drugs.
Is staying in a house with good water supply and toilet facilities.
Observes clean food preparation.
During Hospitalization:
Cant report current medications she is taking during her stay in the
hospital.
Has complained of discomfort from the incision.
Is admitted with chief complain of abdominal pain.
Has undergone Open Cholecystectomy.
B. Nutritional and Metabolic Pattern
Prior to Admission:
Typical food intake includes fish and vegetables.
Adequate amount of fluid intake a day (7-8 glasses per day).
Likes to eat food rich in uric acid such as internal organs (bopis, isaw)
Usually eats at their house with her husband.
Has no food allergies.

During Hospitalization:
Is normothermia.
Currently having sips of water only.
C. Elimination Pattern
Prior to Admission
Defecates once daily.
Has no problem with urination.
During Hospitalization:
Has no BM during the 2nd day of confinement.
D. Activity and Exercise Pattern
Prior to Admission:
Patient is homebound and performs household chores.
Is not doing any form of physical exercise.
Likes to watch television most of the time.
Is independent with the basic ADLs such as grooming, eating, bathing.
Is not using any assistive device.
During Hospitalization:
Is able to perform bed transfer, grooming and going to toilet
independently.
She is able to answer questions coherently.

E. Sleep and rest Pattern

Prior to Admission:
Is usually sleeping at 10pm to 6 am.
Is not taking any sleeping meds.
During Hospitalization:
Appears rested during her second day of confinement.
Has no signs of sleep deprivation such as dark-circle in the eyes,
sleepiness
Is able to express herself clearly.
F. Cognitive-Perceptual Pattern
Prior to Hospitalization
Has no impairment in vision or hearing that may influence her ability to
perform ADL
Can express herself clearly and logically.
Can remember past and present events.
Able to make decision for herself
During Hospitalization:

Is coherent and oriented to time, place and person during the second day
of confinement.
G. Self-Perception and Self Concept
Prior to Admission
Is a 58 years old woman, married and a native of San Pablo City
Is staying with her husband and youngest daughter and family
During Hospitalization
Can express her feelings and emotions verbally.
H. Role-Relationship Pattern
Prior to admission:
Has harmonious relationship with her husband and children.
Stays at home and being supported financially by her children.
I. Sexuality-Reproductive Pattern
Prior to admission:
Is married and have 2 daughters.
J. Coping-Stress Tolerance
Prior to admission
Copes with her problems by confiding to her husband and children.
Is close with her relatives too.
She has good support system from her family and relatives.
K. Value-Belief Pattern
Is a member of Catholic Church.

Date
Vital signs

IVF
Type of Anesthesia

COURSE IN THE OR
July 7, 2014
Patient came in the OR via stretcher.
BP: mmHg
RR: bpm
PR: breaths/min
Temp: deg C
D5NSS 1L x 12 hours ( 28 gtts/min)

PHYSICAL ASSESSMENT

Skin
Good skin turgor
Moist skin
Hair
Has shiny black hair
Hair is fine and thin
No infestation or infection
Head
Normocephalic
Symmetric facial features
Eyes
Eyelids close symmetrically
Light pinkish sclera of both eyes
Pupils are both round and reactive to light ( 4-5mm)
Ears
same color with the facial skin
symmetrical
auricle aligned with the outer canthus of the eye
mobile and elastic pinna
Nose
nasal septum intact and in midline
dry nasal mucosa
no nasal flaring noted
Mouth and Pharynx
slightly dry lips
no lesions in the mouth
light pinkish oral mucosal membrane
tongue in midline and moves freely

Neck
symmetrical with head in midline
has normal range of neck movements at all planes without any pain or discomfort
no distention of jugular vein
Thorax and Lungs
normal thoracic kyphosis
no use of respiratory accessory muscles
no tenderness/masses within the chest wall

clear breath sounds on both lung fields

no signs of respiratory distress such as use of accessory muscles
Cardiovascular
pulse is regular, strong and bounding
Abdomen
normal bowl sounds (11 sounds/minute)
tenderness on right upper quadrant
incision on right upper quadrant is covered with gauze.
Genital
not assessed
Neurologic System and Musculoskeletal System
Orientation: patient is coherent and oriented to person, time and place
Memory: has good short and long term memory
Muscle strength:
Gross muscle strength of Right and Left UL/LL intact and able to perform
movement against gravity and against resistance.
ADLs and Functional Activities:
Transfer bed > < toilet - needs 1 minimal to moderate assist
Grooming independent
Dressing needs +1 minimal assistance
Eating taking sips of water independently
Ambulation in short distances (from bed to toilet) needs +1 minimal to
moderate assistance

Laboratory Studies
CBC (September 8, 2014)
Parameters
Hemoglobin
Hematocrit
WBC
Diffrential Count
Segmenters
Lympoctes
Eosinohils
Monocytes
MEDS

Results
112
0.34
8.7

Normal Values
110-165 g/dL
0.35-0.50
5.0-10 g/L

56.4
35
2.5
6.1

43.0-76.0
17-48
1-40
4-10

Cefurax 750 mg TIV q8 (given last September 9, 2014 at 7pm)

Ultracid 40mg TIV OD (given last sept 9, 2014 at 6:30 pm
Ketorea 30g TIV q6 RTC x 6 doses