CASE PRESENTATION ON CHOLELITHIASIS PREPARED BY MANJU SUNNY OR DEPARTMENT

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

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 SpO2 : 99%

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.

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

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 .

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

PATIENT HISTORY No past medical history . PRESENT MEDICAL HISTORY Patient came to OPD on 17.5.2013 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 20.5.2013.

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

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 13.7 - 16 .5 gm/dl 40.1 – 51.g/dl 4.63 – 6.08*10^6/ul 163-337/ul SODIUM 143 135 - 150 POTTASSIUM 3.7 3.5-5.0mmol/l PT 13.1 10.0-17 sec I NR 0.85 2.4 therapeautic unit APTT 29.2 26.1-36.3 ABRH AB +VE

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

TOPIC PRESENTATION CHOLELITHIASIS

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

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

ANATOMY & PHYSIOLOGY

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

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

BILE DUCT,HEPATIC DUCT, CYSTIC DUCT ,BILE

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.

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

ARTERIAL SUPPLY, VENOUS DRAINAGE &LYMPHATIC DRAINAGE

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.

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

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 .

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

PATHOPHYSIOLOGY

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

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

SURGICAL MANAGEMENT LAPROSCOPIC CHOLECYSTECTOMY CHOLECYSTOSTOMY OPEN CHOLECYSTECTOMY ENDOSCOPIC SPHINCTEROTOMY

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

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.

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

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 .

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

NURSING CARE PLAN

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

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 101.5 or other difficulties. Advised her to take the medications accordingly.

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.

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 WWW.WIKIPEDIA.ORG.

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