Lyceum of the Philippines University-

Batangas
College of Nursing
Batang as , R eg io nal Ho sp ital (BR H)
A Case Study
On
CHOLELITHIASIS
In partial fulfillment on Related
Learning Experiences
Presented by BSN III
Group B/C
Ab anil la , Lo vely M.
Dim aano , Valer ie Gra ce
Guerra , Sa rah P.
Ma causig, Ma ry Ros e
Ma teo, Ka therin e Ma e
Orn ale s, Ma rk Alvin
Pa nga niba n, Mhy li ss S.
Pa ng ilina n, Meria m
Ra mo s, Ma ria Ro na lyn
Ro bles, Grego rio
Tamet a, Ha iz el May
Za mont e, Ma rk Pa ul M.

Submitted to:
Mrs. Esteban, Irene R.N
Clinical Instructor

September 25, 2009

INTRODUCTION
 INTRODUCTION
Ch olel it hiasis is the fif th lea di ng ca use of hos pit aliz ati on amon g
adult s. The di sea se may als o be oc cu rri ng in pe rs on s wh o are obes e,
wh o have hig h ch oles ter ol, or wh o are on chole ste rol lower in g dru gs .
In mos t ca ses , gallbl adde r and bi le duct dis eases oc cu r duri ng middl e
age. Be twee n ages 20 and 50, th ey 're six ti mes mor e common in
wome n, bu t in cide nce in men and wom en becom es eq ual after age 50.
Incide nce ris es with ea ch succ ee din g dec ade . Disea ses of the
ga llbl adder and bil ia ry tra ct are com mon and pa inful con di ti on s that
may be lif e thre aten in g and mos tl y req uir e surge ry . They are ge ner ally
assoc ia ted with depos iti on of ca lc uli and in fla mmation .

This con dit ion oc cu rs wh en ston es pa ss ou t of th e ga llb la dder and

lodg e in the hepa tic and comm on bile du cts , obs tr uct ing the flow of
bil e in to the du oden um. Chola ngit is , in fect ion of the bil e du ct, is
com mon ly associa ted with ch ol edoc holit hia sis. Predi spos in g factors
may in cl ude ba cte ri al or met abolic alte ra ti on of bil e acid s.
Chole cy st iti s, acute or ch ron ic in fla mm ati on of the ga llbl adder is
usuall y assoc ia ted wit h a ga ll ston e impa ct ed in th e cy stic du ct that
may cause pa in ful dis ten ti on of the ga llb la dder . Postch olec ys tec tom y
syn dr ome common ly res ult s from re sidu al ga ll st on es or stric tu re of the
com mon bi le duct . It ma y be occu rs in 1 % to 5 % of all patien ts
wh os e ga llbl adde rs have bee n surgi ca lly rem ove d and may produ ce
ri gh t upper qu adr ant abdom in al pa in, bil ia ry coli c, dy spep sia and
in dige sti on .
 Ga lls ton es dev el op in ma ny peopl e wit hou t ca using symptom s.
The ch ance of symptom s or compl ic ation s res ulti ng from
ch olel it hia sis is abou t 20%. Wit h curren t surgi ca l app roa ches, the
ou tc om e is exc ell en t wit h no rec urr en ce of sy mpt oms in ov er 99% of
in div idu als.

We have chos en th is case not on ly bec ause it is on ly the ch oi ce

bu t som eh ow, we obs er ve d and not ice d that du rin g ou r age s, 20-
60,we can have th is . An d for furt her kn owled ge to con trol the
number of the ca se , that will st art on us ev en thou gh we are ju st
stu den t nurses .
OBJECTIVES Of THE STUDY
GENER AL OB JE CTIV ES:

This st udy aim s to de velo p the

kno wle dge, ski lls and atti tudes of
student nu rses thro ugh effective
ut ili zat ion of nurs ing pro cess in
de aling wit h the cours e treat ment
of pa tien t with Chol eli thias is.
Speci fic Object iv es

At th e end of th e s tu dy, th e stud ent nu rs es will be ab le to:

1. Stat e the de fini tio n of Ch olel it hia si s.

2. Discu ss the pat ie nt’s pr ofile , pa st hea lt h his to ry ,
fami ly hist ory, per so na l hist ory, an d socia l
hi st ory as wel l as the prese nt il ln es s of the
pa tien t.
3. Iden ti fy differ en t la bo ra tory exa min ati ons done the
pa tien t and it s s ig nif ican t findi ngs.
4. Descr ibe the spe cific organ that is af fected by the
di se ase and its function.
5. Di scu ss the pat hoph ysio lo gy o f the di se ase .
6. Ut ili ze the nursi ng process as a base lin e guid e for
the de li ve ry of heal th car e to th e p ati en t.
7. En umer at e an d discus s the di fferen t dru gs th at
wer e admi nis te re d t o the pat ien t.
8. Pr ovi de inf ormat io n of the pr ognosi s of the
di se ases of the pat ie nt.
Patient's Profile
 Patient's Profile
Na me : M rs. M.T .
Ag e : 3 8 y ears ol d
Gender : Fema le
Ad dr ess : Brg y. Sa nt iag o, Ma lvar , Ba tan ga s
Date of B ir th : Dec ember 3, 1 970
Rel ii gi on : Roman C at hol ic
Na tiona li ty : Fil ip ino
Ci vi l Sta tus : Mar ri ed
Date of Ad mis si on : Se ptember 13, 2 009 ;
9;45 am
Chi ef Compl ai nt : Ri ght u pper Qua dra nt P ain
Ad mit ti ng D ia gnosi s : choleli thia sis
At tend in g Phys icia n : Dr . Ma cal alad
Clinical Appraisal
 Clinical Appraisal
Mrs . MT , a 38 yea rs ol d female,
was admi tted at Bata nga s
Regi ona l Hosp ital fo r th e fi fth tim e
last Septe mber 13, 20 09 with the
chi ef com pl aint of rig ht5 upper
qu adra nt pai n. She is unde r the
care of dr. ma calalad. The fi nal
di agnosi s is ch olelith iasi s.
 Past Health History
Mrs. M.T had childhood illness like measles
when she was 28 years old even though she has
complete immunization. She does not have any
allergies to drugs, animals, insects, or other
environmental agents. It is her fifth (5) time to be
hospitalized. The reasons for her hospitalizations
before are appendicitis, she undergone
appendectomy last 1990 and post partum
hemorrhage last 2003, she was given IV fluids and
home medication but she cannot remember the
name of the drugs.
 The patient is married to Mr. X, 48 years
old. They have 4 children the eldest is 20
years old followed by 18 years old, next is 16
years old and the youngest is 12 years old.
The patient is 7th among 11 siblings. Both her
parents are still alive. They don’t have any
history of disease in the family.
 PERSONAL HISTORY

Mrs. M.T used to eat salty foods before

she was hospitalized. She prefers to eat
meat, especially the fatty part of the skin of
the meat, than eating fish and vegetables.
She does not drink any alcoholic beverages,
she does not smoke too. She is the one who
cooks and shops for her family, but
sometimes her children helps her. When she
does not feel the pain, she does not have any
difficulties in sleeping and doing basic
activities like eating, grooming dressing,
eliminating and locomotion. doing her daily
house hold task is her exercise
 Social History
The patient’s support system in times of stress
is her family. Her husband and her eldest son
helps her in paying her medical care and hospital
bills, we can say that she is bonded to her children
because her eldest son is on the bed side to
monitor her condition. She also considers going to
albularyo’s because of financial problem.. Mrs..
M.T is a college under graduate and is currently
unemployed. Her husband, who is a laborer, earns
225 /day which is not enough for their daily needs
that’s why her eldest son started to work in an
early age . They are currently living in a barangay
where houses are close to each other. It is a quiet
and safe environment and there are available
health centers which is just a walking distance
from their house.
 Psychological Status

The major stressor experienced by

the patient is her present condition. But
instead of thinking of her illness, she
focused on her house hold task and her
children. She is able to verbalize
appropriate emotions. While sitting her
bed, she uses non verbal
communication such as eye movement
and use of touch.
 History of Present illness
The condition of Mrs. MT started
more than 3 years ago and she kept it to
her self. She was not aware that she was
in a serious condition. Last May 16, 2009
she was diagnosed to have
cholelithiasis. She had undergone
ultrasound and given home meds like
Buscopan for her abdominal pain. Last
September 12, at around 10 in the
evening, she felt the symptoms like right
upper quadrant abdominal pain, difficulty
of breathing followed by dizziness.
 The following day her family
decided to bring her in Batangas
Regional Hospital last September 13,
2009 at 9:45 am. She had undergone
some laboratory examinations, X-ray,
ECG, and ulrasound. She was adviced
to under go cholecystectomy. She is
still under the care of BRH for further
monitoring of her condition.
Laboratory examination
Laboratory examination
Laboratory examination
Laboratory examination
Laboratory examination
 Laboratory examination X-ray

Lun gs fi el d are clea r

Heart great and vessels are wi thi n no rm al
Ot her chest st ruc ture are not remarkab le.
Ultra sonog raphi c Rep or t

The liver is no rm al in si ze wi th diff use inc rea se in parenc hymal echo geni ci ty. It s
bord ers are sm oo th. The int rahep at ic duc ts (4 mm) are und ilated . The vasc ul ar
st ruc tures are unre mark able.
The gal lbladder is dist end ed wi th sm oot h unt hi ck ene d wal ls . Mult iple hi gh int ensi ty
echo es wi th post eri or so nic shad owi ng wi th aggreg ate diameter of 1.1 cm are
seen int ral um inal ly .
The panc rea s and sp leen are both nor mal in size and echop at tern. No foc al lesi ons
no ted.
The ao rt a and paraaor ti c areas are unr em arkab le.
The kidneys are nor mal in si zean d ec hop at tern.t he rig ht kidne y measures
10. 8x4 .0 x4 .9 cm wi th cor ti cal thi ck ness of 1. 1 cm. the lef t kid ney meas ures
10. 8x4 .4 x5 .0 cm wi th cor tic al thi ckness of 1.0 cm. the cent ral echoc omplex es
are int act .
The ur inary blad der is d ist end ed . It s wal ls are u nt hi ckened .
The ut erus mea sur es 7.1 x4. 1x4 .8 cm wi th ho mog eneou s echo patt ern. The
end ome trium is tri lami na r me asuri ng 8m m. no ad nex al masse s not ed . No fl ui d
in the post eri or cut d e sac.
Ana lysis :
Nor mal s iz e w ith fatt y i nf iltra tion
Cho le lithi asis
Summary of Laboratory results

Mrs. T was und erg one the fo ll ow ing ex am inat ion; Cl ini cal ch emist ry and the
resul t are gluco se and creat inin e is no rm al whi le BUN is dec rea se because
there is ex cessiv e pro tien breakd own. In cl ini cal chemis try, most of the resul ts
of ex am inat ion is norma l excep t pus cel l bec ause the resul t is 1-2 hp f whi ch is
ab normal because it ind icates infec tion and UTI . In X-ray the resul t is no rm al
and in the Ul trasound , the gal lblad der is dist end ed wit h sm oot h unt hi ckened
wal ls . Mul tiple high int ensi ty echo es wi th post eri or soni c shad owi ng wi th
ag greg at e d iam et er of 1.1 cm are s een int ral um inal ly.
No rm al si ze wi th fat ty in fi lt rat io n.
Cho lel ithi asi s
No rm al Ultra sound of pa nc reas sp lee n,k idne ys, uri nary blad der and u ter us
PATHOPHYSIOLOGY
 Summary of
pathophysiology
 Summary of pathophysiology
Ch ol elith iasis or gallstones is cau sed by pr eci pi tation of
substances con tai ned in bil e, ma inly chol esterol an d bili ru bi n.
The bil e of which gall stones are form ed usual ly is
supersa tu rate d with cho les te ro l or bil irub inate. Three factors
contr ib ute to th e formation of gal ls ton es: abnormal iti es in the
comp os ition of bil e, sta sis of bil e, and infl amma tion of the
gallbl add er. The formation of chol est erol ston es is as soci ated
with ob esity and occu rs mor e frequ entl y in women, especial ly
women who have had mu lti pl e preg nan cies or who are ta kin g
oral contrace pti ves . All of th es e factors cause the li ver to
ex crete more ch oles te rol into th e bile. Gallbl add er slud ge
(th ick ened gallbl ad der mucop rotei n with ti ny trapp ed
chol este rol cry stals ) is th oug ht to be a pr ecu rs or of gall ston es .
Slu dge freq uently develop s dur in g pr egnancy, starv at ion , and
rap id weig ht l os s.
Infl amma ti on of the gallb ladder alters the ab sorp tiv e
charact eri sti cs of the mucos al layer, all ow ing ex ce ss iv e
absorp tion of wa ter an d bile salts. the upper rig ht quad rant ,
or ep ig as tri c area, is th e usual loca ti on of th e pain, often with
referred pain to the bac k, ab ove the wa ist, the ri ght shoul ders,
and th e rig ht s capu la or the m id s cap ul ar regi on . A f ew p erson s
ex peri ence pain on th e left sid e. Th e pain usuall y persists for 2
to 8 hou rs and is f ol lowe d in the up per rig ht qu adr ant.
ANATOMY AND
Physiology
 ANATOMY AND Physiology
Ga stroin ste sti nal Tra ct
The ga st rointes tin al tra ct (G IT) con sists of a hollow muscu la r tu be
sta rt in g from th e or al ca vi ty , wh er e food en te rs the mou th, con tin uing
throu gh th e ph aryn x, es oph agu s, stomach and intes tin es to the rect um
and anus, wh ere food is exp ell ed. Ther e are va ri ous acce ssory orga ns
that assist th e tra ct by secr et in g en zym es to help br eak down food into
it s com pon ent nutr ie nts. Thus th e saliv ary gl ands , liv er, pa ncr ea s and
ga ll bla dder have impor ta nt funct ion s in the dige sti ve sys tem . Food is
prope ll ed alon g the len gt h of th e GI T by per is talti c move me nts of the
muscu la r wa lls . The pri ma ry purpo se of the gastroin te sti nal tra ct is to
bre ak do wn food in to nutri en ts, wh ich ca n be abs orb ed into th e bo dy
to pr ovi de energy .

Focu s: GA LLB LA DDER

 The ga llbl add er (or chol ecy st, som et im es ga ll bla dder ) is a sm all org an
wh os e funct ion in th e bo dy is to harb or bi le and aid in th e di ges tiv e
proc es s.
Anatom y
 The cys tii c du ct con nec ts the ga ll bla dder to th e com mon hepa tic du ct
to for m the com mon bi le du ct .
 The com mon bi le rome ro du ct then join s the pancre atic duct , and
en te rs th rough the hepa topa ncre atic ampu lla at th e majo r dou den al
pa pill a.
 The fundus of the ga llbl add er is the pa rt farth es t from th e du ct ,
loca te d by the lower borde r of the liv er. It is at th e same le ve l as the
Micros cop ic anatomy
The di fferent layer s of the gallb ladd er are as fol lo ws:
 The gal lb ladder has a simp le colum nar ep ith elial lini ng
ch aracte ri zed by rece sse s call ed Asc hof f's re ces ses , which are
pou ches in side the li nin g.
 Under the epi theli um th ere is a layer of conn ec ti ve ti ssue
( lami na pr op ria ).
 Beneath th e conn ecti ve tis sue is a wall of smoot h mu cle
( musc ulari s exte rna ) that con tra cts in res pons e to
ch olecytok in in, a pep tide h ormon e secrete d by th e duoden um.
 There is es sent iall y no subm ucos a separati ng th e con nectiv e
ti ssue from seros a and ad ven titi a.
Size and Locati on of th e Gal lb ladder
Th e gallbl add er is a hol low, pear-s haped sac from 7 to 10
cm (3-4 inch es) lon g an d 3 cm broa d at its widest poi nt. It
consist s of a fu nd us, bod y and neck. It can hol d 30 to 50 ml of
bile. It li es on the un dersur fac e of th e liver’s ri ght lob e and is
atta ch ed there by areol ar con necti ve t is sue.
Structu re of th e Gallbl add er
Se rous, mus cu lar, and mu cous layers comp os e th e wall of
th e gallbl add er. The mu cos al li nin g is arr anged in fol ds cal led
ru gae, simil ar i n structu re t o th os e o f th e stomach.
 Th e gal lb ladder st ores bil e th at enters it by wa y of the
hepatic an d cysti c du cts . Durin g th is ti me th e gal lb ladder
concent ra tes bil e fivefol d to te nfold. Then lat er, when digestion
occur s in the stomach and in tes tin es , the gall blad der con trac ts,
eje ctin g the con ce ntrat ed bil e into th e duod enum . Ja und ice a
yello w disc olorati on of th e ski n and mu cos a, res ul ts when
ob stru ction of bil e flow into the duod enu m occ urs . Bi le is
th ereby den ied its normal ex it from th e body in the feces .
Inste ad , it is ab sorb ed into the blood , and an exc es s of bile
pigmen ts with a yello w hu e ente rs the blo od and is depos ited in
th e ti ssues.

Th e gallb ladder stores ab out 50 m L (1.7 US flui d oun ce s /

1.8 Imp eri al fl uid ou nces ) of bil e, which is rel eas ed when food
cont aini ng fat enters th e di gestiv e tra ct, stim ul ati ng the
secretion of ch olec ystok in in (CCK ). The bil e, prod uce d in the
liv er, emul sifi es fats and neu tra lizes aci ds in partly digested
food .

Af ter bei ng stored in th e gall bladd er th e bil e become s more

concent ra ted th an when it left the liver, in cre as ing its pote ncy
and in tens ifyi ng its eff ect on fats . Mo st dig estion occ urs in the
duo denu m.
Nursing care plan
DRugs
Cefotaxime Sodium

Claforan
2 grams

IV
PTOR
Anti - infectives
Third generation cephalosporin
that inhibits cell – wall
synthesis, promoting osmotic
instability, usually bacteriacidal
 Treatment of infections
caused by susceptible
microorganism, especially serious
and life threatening infections.
Brain abscess, gonorrhea ,
intensive care, and typhoid fever.
 Contraindicated in patient
hypersensitive to cephalosporins.
Possibility of cross sensitivity in patient
who have shown allergy in penicillin.
Intramuscular administration in
condition with impaired hemostasis and
severe sepsis.
GI : Anorexia, diarrhea, nausea
and vomiting, abdominal cramps,
and colitis

Hema : transient neutropenia,

granulocytopenia, leucopenia,
eosonophila,thrombocytopenia
and agranulocytopenia
Assess patients previous sensitivity
reaction to penicillin or other
cephalosporins

Assess patients for signs and symptoms

of infection before and during treatment

Assess for allergic reaction and

anaphylaxis
• May increase in alkaline
phosphatase, ALT,
• AST, bilirubin,GST and LDH levels.
• May increase eusinophil count
• May decreased granulocytes,
neutrophil and platelet count
• May result positive coombs test
result
Diclofenac Sodium

Abicfen
75 mg
SIVP

PTOR
Analgesic, muscle relaxant
Inhibits cyclooxygenase an
enzyme needed for the
biosynthesis of prostaglandin
result to the analgesics anti
pyretic and anti – inflammatory
effects
Use mainly as sodium salt for the relief of
pain and inflammation of various
conditions : musculoskeletal and joint
disorder such as ostroarthritis, and
ankylosing spondilitis, periarticullar
disorder soft tissue disorder and other
painful condition. Post – opretive
inflammation.
 Sensitivity to aspirin or non – steroidal anti –
inflammatory drug ( NSAID ), soft contact lenses,
benzyl alcohol, polyethylene glycolmonomethyl
ether 350, and hyaluronate severe renal
impairment, hypovolemia, or dehydration, in
patient with history of hemorrhagic diathesis,
serebrovascular bleeding or asthma and in
patient undergoing surgery or hemorrhage.
 Edema , water retention,
hypertention, congestive heart failure.
Headache ,vertigo, drowsiness,
dizziness,. Rash, urticaria ,fasciitis,
photosensitivity, contact dermatitis,
exfoliation (topical).
Diarrhea, vomiting , abdominal pain,
dyspepsia, peptic ulcer, gastrointestinal
bleeding, acute renal failure, nephritic
• Assess characteristics of pain and
inflammation.
• Check ROM.
• Monitor possible adverse reaction
• Assess for hypersensitivity or
anaphylactic reaction
• Assess hepatic status and function
before and during therapy.
• Assess patients for eye pain,
inflammation, redness, and swelling.
• May increase ALT, AST,
bilirubin, BUN, and
creatinine levels
• May increase or decrease
glucose level.
Parecoxib
Dynastat
40 mg
IV
Every 4 hours
 Non – steroidal anti –
inflammarory drugs

Inhibits prostaglandin
synthesis by selectively
inhibiting cyclo-oxygenase 2
( cox – 2 ). Relieve pain nad
inflammation
Short term treatment of
acute pain nad post
operative pain. It maybe
used pre – operative to
prevent or reduce post
operative pain
 Hypersensitibity to parecoxib.
Patients with active peptic ulceration
or gastrointestinal bleeding. Thierd
trimester of pregnancy and breast
feeding. Patient with severe hepatic
dysfunction, inflammatory bowel
disease. Patient history of coronary
artery bypass graft stroke, heart
Hypersensitivity, blood
pressure changes,
peripheral edema,
dyspnea, insomia,
pruritis and oliguria
•Assess patients range of
motion
•Assess patients degree of
swelling and pain in affected
joints before and
periodically throughout the
Prognosis
 Prognosis
The pati ent Mrs . M. wa s ad mi tted at BRH female surg ical
wa rd stati on III las t Septemb er 13, 2009, aro un d FO9: 45a m
for th e chi ef comp lain of abdomi nal pain. She is sti ll in
mon ito r for differe nt kind s of ex ami nati ons. She wa s
und erg one fo r ECG last Au gu st 18, 2009 she has a normal
fin din gs of Sinu s Rhyth m (electrical imp ul se starts at th e
reg ul ar rat e and rh yt hm) , and also she un derg on e for
ultras on og raph y las t June 26, 2009. The physici ans fin d out
th at the gall blad der was distend ed with smooth, unth ick ened
wa ll, mu lti ple hig h echo es with pos terior son ic shadow ing with
agg reg ate di amet er of 1 .1 cm seen in ternal ly .

Th e doctor diag nos ed Mrs . M with ch ol elith ias is. The

med ication th at was bee n giv en prior to op erati on
(chol ecyste ctomy ) are the follow ing : Ce fota xi me 2mg IV for
anti bacte ria and Di clof ema c 75mg IV for anti pyr eti c and
analg es ic.

Sh e was sc hedu led twice for ch olecy ste ctomy but at th e

Discharge planning
 Discharge planning
M
E- Instructed the patient to do exercise as tolerated such as walking
T
H- 1. Encouraged patient to increase fluid intake
2. Encouraged patient to eat foods rich in vitamin and nutrition foods
3. Encourage patient to avoid salty and fatty foods
4. Encouraged patient to have enough rest
•Advised the patient to a diet as tolerated but preferably avoiding salty and fatty
foods.
O
D
S- Advised patient to go to church every Sunday with their family.
BIBLIOGRAPHY
 BIBLIOGRAPHY
>Laboratory Tests & Diagnostic Procedures by Cynthia C. Chernecky & Barbara J.
Berger (5th edition)
>Laboratory Tests & Diagnostic Procedures in Medicine by John H. Dirckx, M.D.
>Nurses pocket Guide, Diagnoses, Prioritized Interventions and Rationales by Marilynn
E. Doenges, Mary Frances Moorhouse, and Alice C. Murr (11th edition)
>Fundamentals of Nursing Concepts, Process, and Practice by Barbara Kozier, Glenora
Erb, Audrey Berman, and Shirlee Synder (7th edition)
>davi's drug guide for nurses by: judith hopfer deglin & april hazard vallerand (9th edition)
>Textbook of Medical-Surgical Nursing 11th edition
>Essentials of Pathophysiology, Carol Mattson Porth, 2nd edition
PictuRes
Our clinical instructor
Our clasmates on duty
With ma’am esteban
Zaimon & Joker
With rose
Robles,zaimon & alvin
lovely, zaimon & rona
Robles and our
clasmates
Rose, zaimon & rona
Rose, lovely, zaimon &
rona
Valerie
With ma’am esteban
Sorry, for the following
member’s who are not
included in this
pictures..

Kat-kat mateo
Pangilinan, meriam