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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.

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Presentation on theme: "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."— Presentation transcript:

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3 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 SpO2 : 99%

4 2. SKIN Fair complexion. Skin is warm. 3. HEAD Hair is equally distributed. Absence of dandruff & alopecia. 4.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 6. NOSE Pink nasal mucosa. No nasal discharge 7.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 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 discharges 14.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 PAST MEDICAL 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 INVESTIGATIONS DONE FOR THE PATIENT USG Abdomen X-ray chest Blood investigations o CBC o ABORH o PT/INR o APTT o ELECTROLYTES

10 ITEMSPATIENT VALUENORMAL VALUE CBC HEMOGLOBIN(hb) HCT RBC PLT 12.6 gm/dl 35.9 g/dl gm/dl 40.1 – 51.g/dl 4.63 – 6.08*10^6/ul /ul SODIUM POTTASSIUM mmol/l PT sec I NR therapeautic unit APTT ABRHAB +VE

11 DrugRouteDose/frequencyAction Inj. Perfelgan iv1000mg /bdAnalgesis Inj.Flagyliv500mg /bdantibiotics Inj.Augmenti n iv1.2gm/tidAntibiotics Inj.Premos an iv10mg/bd Antiemetic Inj.Risek iv40mg/od H2 receptor antagonist

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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.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

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16 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 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 is mainly made up of: bile salts bile pigments (such as bilirubin) cholesterol water Bile duct formed by the union of hepatic duct &cystic duct that carries bile from liver &gallbladder to the duodenum.

20 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 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 CholelithiasisEtiology 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 medication s

24 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 STUDIES  HIDA SCAN  CT SCAN  ERCP  ABDOMINAL ULTRA SOUND  BLOOD TESTS

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

29 SURGICAL LAPROSCOPIC CHOLECYSTECTOMY CHOLECYSTOSTOM Y OPEN CHOLECYSTECTOMY ENDOSCOPIC SPHINCTEROTOMY

30 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 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 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

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36 ASSESSMEN T NSG DIAGNOSIS PLANNING INTERVENTIONRATIONALEVALUATON 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,pai n, 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 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.

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40 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

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