1. CASE PRESENTATION ON CHOLELITHIASIS
PREPARED BY
MANJU SUNNY
OR DEPARTMENT

2. DIAGNOSIS : CHOLELITHIASIS SURGERY : CHOLECYSTECTOMY
DEMOGRAPHIC DATA
NAME : Mr. PQRS
AGE/SEX : 30YRS/ FEMALE
DATE OF ADMISSION : 20/05/13
DIAGNOSIS : CHOLELITHIASIS
SURGERY : CHOLECYSTECTOMY
SURGERY ON : 20/05/13
DATE OF DISCHARGE : 21/05/13

3. 1 .GENERAL APPEARANCE Patient is 30yrs old female look anxious
Physical assesment
1 .GENERAL APPEARANCE
Patient is 30yrs old female
look anxious
conscious and oriented with following vital signs
B.P : 110/70mmHg
PULSE : 88b/m
RESPIRATION : 20b/m
TEMPREATURE : 36.6 c
SpO : 99%

4. Hair is equally distributed. Absence of dandruff & alopecia. EYES
2. SKIN
Fair complexion.
Skin is warm.
3. HEAD
Hair is equally distributed.
Absence of dandruff & alopecia.
EYES
Both eyes are normal , able to move both eyes.
No discharges .
5. EARS
Patient pinna is same colour as fascial.
Able to hear sounds clearly.
No discharges.

5. No tenderness nodes. 6. NOSE Pink nasal mucosa. No nasal discharge
MOUTH
Pink and dry oral mucosa.
Tongue and uvula in midline position.
Teeth is properly aligned with no dentures.
8. NECK AND THROAT
No tenderness nodes.
No palpable mass and lesions

6. Thorax is symmetric on inspection. Clear breath sounds.
9. CHEST & LUNGS
Thorax is symmetric on inspection.
Dry cough present.
Clear breath sounds.
10. CARDIO VASCULAR SYSTEM
ECG is normal.
No cardiomegaly.
Apical pulse is 88 bpm
11. UPPER &LOWER EXTREMITIES
Normal range of motions.
12. ABDOMEN
Bowel sounds are normal.
On palpation Abdomen is slightly enlarged .

7. 13 . GENITO URINARY SYSTEM No bowel obstruction present. no discharges
GASTRO INTESTINAL
No bowel obstruction present.
Abdominal pain present.
15. NEUROLOGIC
Patient is mentally alert and oriented with circumstances.
Able to follow commands.
No neurovascular deficit

8. PATIENT HISTORY No past medical history .
PRESENT MEDICAL HISTORY
Patient came to OPD on with complaints of abdominal pain and vomiting . On examination they suspected cholelithiasis and send her for usg abdomen . After Usg abdomen she was diagnosed as having cholelithiasis .
PAST SURGICAL HISTORY
Patient has no past surgical history.
PRESENT SURGICAL HISTORY
Patient had under gone Laproscopic choleycystectomy on

9. USG Abdomen INVESTIGATIONS DONE FOR THE PATIENT X-ray chest
Blood investigations
CBC
ABORH
PT/INR
APTT
ELECTROLYTES

10. LAB INVESTIGATIONS ITEMS PATIENT VALUE NORMAL VALUE CBC HEMOGLOBIN(hb)
HCT
RBC
PLT
12.6 gm/dl
35.9 g/dl
3.85
2 10
gm/dl
40.1 – 51.g/dl
4.63 – 6.08*10^6/ul
/ul
SODIUM
143
POTTASSIUM
3.7
mmol/l PT
13.1
sec
I NR
0.85
2.4 therapeautic unit
APTT
29.2
ABRH
AB +VE

11. MEDICATION Inj. Perfelgan Drug Route Dose/frequency Action iv
1000mg /bd
Analgesis
Inj.Flagyl
500mg /bd
antibiotics
Inj.Augmentin
1.2gm/tid
Antibiotics
Inj.Premosan
10mg/bd
Antiemetic
Inj.Risek
40mg/od
H2 receptor antagonist

12. TOPIC
PRESENTATION
CHOLELITHIASIS

13. CHOLELITHIASIS
Cholelithiasis is the medical term for gallstone disease .
Presence of stone in the gall bladder is known as cholelithiasis.It is a crystalline concretion formed with the gall bladder by accretion of bile components.These gall stones are formed in the gall bladder but may distally pass in to other parts of biliary tract such as cystic duct,common bile duct, pancreatic duct or thae ampulla of vater.
Choledocholithiasis
It refers to the presence of one or more Gallstones in the common bile duct. Usually, this occurs when a gallstone
passes from the gallbladder into the common bile duct .
A gallstone in the common bile duct may impact distally in the ampulla of Vater, the point where the common bile duct and pancreatic duct join before opening into the duodenum

14. TYPES OF GALLSTONES Types of gallstones that can form in the gallbladder include:
Cholesterol gall stones
Pigment gall stones
Mixed gall stones

15. ANATOMY & PHYSIOLOGY

16. It is covered anteriorly and posteriorly by peritioneum.
Gallbladder is a pear-shaped sac that lies between the right medial and quadrate lobes of the liver. It is partly attachedand partly free.
It is covered anteriorly and posteriorly by peritioneum.
It sits in a shallow depression called the
gallbladder fossa.
The gallbladder is about 7.5–10 cm (3–4 inches) long and
about a 2.5 cm (1 inch) wide.
LAYERS OF GALL BLADDER
Muscular layer ( A layer of smooth muscle)
Perimuscular layer (connective tissue that covers the muscular layer.
Mucosa (inner layer of epithelium and connective tissue)
Serosa (outer covering of the gallbladder

17. Fundus of the gallbladder Body of the gallbladder Neck of gallbladder
For the purpose of description gallbladder is divided in to three;
Fundus of the gallbladder
Body of the gallbladder
Neck of gallbladder

18. BILE DUCT,HEPATIC DUCT,
CYSTIC DUCT ,BILE

19. BILE
It is a yellowish green fluid made by the liver. The gall bladder stores bile produced in the liver.The gall bladder can stores about 40 ml-70 ml of bile. Bile is important in the digestion of lipids.
Bile is mainly made up of:
bile salts
bile pigments (such as bilirubin)
cholesterol
water
COMMON BILE DUCT
Bile duct formed by the union of hepatic duct &cystic duct that carries bile from liver &gallbladder to the duodenum.

20. COMMON HEPATIC DUCT
Main excretory duct of liver which joins the cystic duct to form the common bile duct.
It drains bile from the liver through the left and right hepatic duct.
CYSTIC DUCT
The cystic duct joins the gallbladder to the common bile duct. It usually lies next to cystic artery.The Cystic duct of the gallbladder is 2-4 cm long

21. ARTERIAL SUPPLY,
VENOUS DRAINAGE &LYMPHATIC DRAINAGE

22. Etiology Of Cholelithiasis:
FUNCTIONS OF GALL BLADDER
Stores and mobilizes bile.
for digestion.
Promote physical coordination.
Maintain health of connective tissues.
Closed linked with the liver.
Defensive energy against catching infections.
Etiology Of Cholelithiasis
Female sex.
European or native american ancestry
Increasing age above 40 yrs
Obesity.
Pregnancy.
Gallbladder stasis.
Drugs.
Heredity.

23. Factors that may increase risk of gallstones include:
Being female
Being age 60 or older
Being an American Indian
Being a Mexican-American
Being overweight or obese
Being pregnant
Eating a high-fat diet
Eating a high-cholesterol diet
Eating a low-fiber diet
Having a family history of gallstones
Having diabetes
Losing weight very quickly
Taking some cholesterol-lowering medications

24. Signs and symptoms pain in the upper right portion of abdomen.
Back pain between shoulder blades
Pain in right shoulder.
Nausea and vomiting.
Jaundice.
Clay coloured stool .

25. DIAGNOSTIC TESTS DIAGNOSTIC STUDIES HIDA SCAN CT SCAN ERCP
ABDOMINAL ULTRA SOUND
BLOOD TESTS
DIAGNOSTIC STUDIES

26. PATHOPHYSIOLOGY

27. CHOLESTEROL AND CALCIUM BILIRUBINATE IN BILE ARE PRESENT IN CONCENTRATIONS THAT APPROACH THE LIMITS OF THEIR SOLUBILITY
BILE IS CONCENTRATED IN THE GALLBLADDER, IT CAN BECOME SUPERSATURATED WITH THESE. SUBSTANCES
PRECIPITATE FROM SOLUTION AS MICROSCOPIC CRYSTALS
CRYSTALS ARE TRAPPED IN GALLBLADDER MUCUS, PRODUCING GALLBLADDER SLUDGE
CRYSTALS GROW, AGGREGATE, AND FUSE TO FORM MACROSCOPIC STONES.
OCCLUSION OF THE DUCTS BY SLUDGE AND/OR STONES
GALLSTONE DISEASE

28. MEDICAL MANAGEMENT TREATMENT
ORAL BILE SALT THERAPY(URSODEOXYCHOLIC+URSODIOL
CONTACT DISSOLUTION
EXTRA CORPOREAL SHOCK WAVE LITHOTRIPSY

29. SURGICAL MANAGEMENT LAPROSCOPIC CHOLECYSTECTOMY
CHOLECYSTOSTOMY
OPEN CHOLECYSTECTOMY
ENDOSCOPIC SPHINCTEROTOMY

30. COMPLICATIONS GALL BLADDER EMPYEMA
ACUTE CHOLECYSTITIS
CHOLEY CYSTOENTRIC FISTULAS
GALL STONE ILEUS
PERFORATION AND PERI CHOLECYSTIC ABSCESS
GALL BLADDER ADENO CARCINOMA

31. COMPLICATIONS OF SURGERY Infection of an incision. Internal bleeding.
Injury to the common bile duct .
Injury to the small intestine by one of the instruments used during surgery.
Risk of general anaesthesia .
UNCOMMON COMPLICATIONS
Injury to the cystic duct,.
Gallstones that remain in the abdominal cavity.
Bile that leaks into the abdominal cavity.
Injury to abdominal blood vessels, such as the major blood vessel carrying blood from the heart to the liver (hepatic artery)..
A gallstone being pushed into the common bile duct.
The liver being cut.

32. NURSING INTERVENTION PRE-OPERATIVE INTERVENTION
The provision of psycho-educational care.
Provision of adequate and appropriate informastion thruogh out the day care experience .
Enhancement of patient self-efficacy via positive encouragement and information provision.
Reduction of the negative impact of the clinical environment and encouraging implicit and explicit messages of safety such as
the hospital performs many operations .
helps to create a warm, friendly and comfortable environment.
POST OP INTERVENTION
Management of pain and post-operative nausea and vomiting.
Initial assistance with mobilization.
Pain management should commence with an assessment of the patient’s pain at regular intervals.
Measures to manage patients’ anxiety should be implemented pre-operatively and continued throughout the post-operative recovery period until discharge

33. Care of Patient with Cholecystectomy
Preventing respiratory complications
Encouraging activity.
Promoting wound healing.
Maintaining normal body temperature.
Promoting bowel function ..
maintaining gastro intestinal function and resuming nutrition .

34. RISK FOR INFECTION RELATED TO SURGICAL INCISION
PRIORITZATION OF NURSING DIAGNOSIS
ACUTE PAIN RELATED TO GALL BLADDER REMOVEL
NAUSEA AND VOMITING RELATED TO SURGERY
RISK FOR INFECTION RELATED TO SURGICAL INCISION
KNOWLEDGE DEFICIT RELATED TO TREATMENT REGIMEN AND POST OP CARE

35. NURSING CARE PLAN

36. ASSESSMENT
NSG DIAGNOSIS
PLANNING
INTERVENTION
RATIONAL
EVALUATON
Subjective
I have severe pain as verbalized by the patient.
Painscale -5/10
As 0/10 is the lowest and 10/10 is the highest
{WONG –BAKER}
Objective data:
Fascial grimace
Reports pain on movement
Guarding behavior
Altered comfort,pain, related to tissue trauma secondary to surgical operation.
After series of nursing intervention patient will manifest a decrease in pain
Scale from 5/10 to 0/10
1.Assess patients pain scale and perception
2. provid comfort measures (backrub, position change, environmental control)
3. Encourage deep breathing exercises
4.Teach divertional activities(listening to music)
5. Monitor vital signs
6.Administer pain medication per doctor’s order prior to exercise or activities of daily living{INJ.PERFELGAN 1GM IV BD} .
1.To identify the onset ,intensity and duration of pain
2.to reduce the pain and to provide relaxation
3.To assist muscle and genarelised relaxation
4.To destract clients attention from pain
5.To identify the intensity of pain
6. To relieve the pain
After 12 hrs of nursing interventions the goals were fully met as evidenced by
verbalize relief of pain as evidenced by a pain scale of 0 out of 10
positive response during evaluation
verbalize & demon-strate willingness to partici-pate in activities

37. HEALTH EDUCATION Health education given on wound care and dressing .
Instructed her the signs of infection and asked him to notify if any signs occurs .
Instructed her to follow the physians order regarding diet and medication.
Educated her the the importance of follow up .
Instructed her she will have no restrictions to physical activities, however the patient should listen to their body in response to certain activities. Gradually increase activities at a comfortable and individual pace.
Advised her to contact if he develops any problems such as prolonged nausea/vomiting, temperature elevations above or other difficulties.
Advised her to take the medications accordingly.

38. Presented a case of patient with cholelithiasis.
CONCLUSION
Presented a case of patient with cholelithiasis.
Patient underwent laproscopic cholecystectomy on 20/05/13.
Presence of stone in the gall bladder is known as cholelithiasis
It is a crystalline concretion formed with the gall bladder by accretion of bile components.
Gallstones may cause no signs or symptoms.Gall stones may be asymptomatic even for years .these stones are called silent stones . If a gallstone lodges in a duct and causes a blockage, signs and symptoms may result.
Laproscopic cholecystectomy has now replaced open cholecystectomy as the first-choice of treatment for gall stones and inflammation of the gallbladder unless there are contraindications to the laparoscopic approach. This is because open surgery leaves the patient more prone to infection.

40. LIPPIN COTT WILLIAMS AND WILKINS.
BIBLIOGRAPHY
BRUNNER AND SUDDARTH TEXT BOOK OF MEDICAL –SURGICAL NURSING 9 TH EDITION .
LIPPIN COTT WILLIAMS AND WILKINS.
POTTER AND PERRY FUNDAMENTALS OF NURSING 5 TH EDITION

41. THANK YOU