Our Lady of Fatima University

College of Nursing
Valenzuela Medical Center
Operating Room

HYDROPS GALLSTONE RELATED TO

CHOLELITHIASIS

In partial fulfillment of the requirements in

Nursing Care Management 103 and RLE Duty

Prepared by:

BSN 3Y1-4 GROUP 4C (1ST BATCH)

Nguyen, Uyen
Ojuope, Mercy
Pangindian, Justin
Payawal, Joshua
Ponseca, Jeannifer
Porlucas, Prince

Submitted to :
Rosanna Suva, RN MAN

October 2017
 TABLE OF CONTENTS

I. OBJECTIVES
II. INTRODUCTION
III. PATIENTS PROFILE
IV. PHYSICAL ASSESSMENT
V. ANATOMY AND PHYSIOLOGY
VI. PATHOPHYSIOLOGY
VII. LABORATORY EXAMINATIONS
VIII. DRUG STUDY
IX. NURSING CARE PLAN
X. RECOMMENDATION
 I. OBJECTIVES

General Objective:

To provide the students a guide line in caring for people with Gallbladder Disease
using the nursing process appropriately and effectively as well as to gain information
about the nature and the extent of Hydrops of the Gallbladder related to Cholelithiasis.

Specific Objectives:

1. To define the probable causative factors of the disease.

2. To identify the underlying signs and symptoms of the underlying disease.
3. To determine the progression of the illness and to present its
pathophysiology.
4. To obtain and present the diagnostic test and the laboratory results of the
patient.
5. To identify patient’s medication and determine its mechanism of action,
indication, side-effects, contraindications and corresponding nursing
responsibilities.
6. To conduct health teachings as one way of providing and promoting
holistic care to the patient.
7. To identify problems based from subjective data gathered from patient to
formulate appropriate nursing care plan.

Reason for case selection:

In the span of our duty, our group selected Hydrops of the Gallbladder related to
Cholelithiasis as a case study because this is a never heard topic and we wanted to
explore more about this interesting case presentation. We found this condition
educable to us student nurses who has a narrow thought about this condition so we
wanted to grab this opportunity to learn more about this fascinating study and to share
also our learnt knowledge to present in the class. With this study, as a student nurses
and future nurses we hope that we’ll bring you enough overview about the condition and
appropriate management to promote quality of life. In line with these, it will help us to
become efficient nurses and a better person in the near future.
 lII. INTRODUCTION

Inflammation causes the majority of gallbladder diseases due to irritation of the

gallbladder walls, which is known as cholecystitis. This inflammation is often due to
gallstones blocking the cystic ducts leading to the small intestine and causing bile to
build up which may trigger an acute “gallbladder attack” characterized by abdominal
pain, bloating, nausea and vomiting. When individual symptoms become frequent,
recurrent or severe, laparoscopic cholecystectomy (surgical removal of the gallbladder)
is usually indicated. The most common cause of cholecystitis is cholelithiasis
(gallstones). Gallstones develop when substances in the bile (such as cholesterol, bile
salts, and calcium) or substances from the blood (like bilirubin) form hard particles that
block the passageways to the gallbladder and bile ducts. Gallstones also tend to form
when the gallbladder doesn’t empty completely or often enough. They can be as small
as a grain of sand or as large as a golf ball.

Gallbladder disease is generally considered uncommon in childhood, but in recent years

the frequency seems to be increasing. Therefore, a review was made of children
appearing with gallbladder disease during the past 10 years at the Department of
Pediatric Surgery, St. Göran's Hospital, Stockholm. There were 32 patients, 15 boys
and 17 girls. Two-thirds of the cases were diagnosed in 1988 or later. One-half were
younger than 8 years; 7 were 2 years old or younger. Hemolytic disease was found in
2/32 patients. One patient had received total parenteral nutrition, but only for a period of
10 days. In 6/32 children the symptoms were interpreted to be caused by gallbladder
dysfunction, either as intermittent hydrops or a defect of emptying after a fatty meal.
One of these 6 also had a stone. Surgery was performed in 22 children:
cholecystectomy in 15 and cholecystotomy with stone extraction in 7. Analysis of 14
stones showed that pigmentary stones were most common. We conclude that
gallbladder disease in children seems to be increasing. The preoperative examination
should include both ultrasound and cholecystography. We also find that stone extraction
is an adequate procedure if there is good gallbladder function and no sign of
cholecystitis.

Abdominal pain in children is a common complaint; up to 10 years ago gallbladder

disease was rarely found to be cause. Cholelithiasis has generally been considered
uncommon in childhood unless associated with hemolytic disorder. In recent years,
however, there seems to be an increasing frequency of symptoms that can be
correlated to the gallbladder. Therefore, a review was made of children appearing with
gallbladder disease, stones, or dysfunction during the past 10 years.

III. PATIENT’S PROFILE

Name: Patient E.B.B Address: Gen T. De Leon, Valenzuela
Sex: F City
Age: 19 y/o Religion: Catholic
Birthday: September 10, 1998 Nationality: Filipino
Status: Single

Date of admission: September 18, 2017

Chief complaint: Epigastric Pain

Past Medical History

(-) Surgical Operation (-) DM
(-) Trauma/Accident (-) HPN
(+) Hydrops of Gallstone in 2012 (-) Allergic to food and drugs

Family History
(+) HPN (maternal)
(-) kidney disorders (maternal and paternal)
(-) DM (maternal and paternal)

Social and Personal History

(-) smoker
Likes sweet foods
Always eat street foods

HISTORY OF PRESENT ILLNESS

6 days prior to admission, patient had fever with associated nausea and
vomiting, anorexia. Patient took paracetamol for fever which gives slight relief. No
consult was done. 5 days prior to admission, fever was still present now with associated
sudden epigastric pain with occasional radiation to left upper quadrant, 7/10 not
precipitated nor relieved by anything. Due to persistence, patient was brought to a
hospital in Dalandanan where CBC and urinalysis were requested and turned out to be
normal. Patient was sent home and was given omeprazole or home medication. 4 days
prior to admission, patient experienced fever again with vomiting which made them seek
consult at a hospital in Dalandanan, and was again sent home. 3 days prior to
admission, due to persistence of symptoms, patient sought consult at our institution
where CBC and urinalysis turned out to be normal and epigastric pain was 8/10, patient
then was sent home. 2 days prior to admission, symptoms were persistent and patient
seek consult at Calalang Medical Center where WAB was done revealing Cholelithiasis.
Patient was referred to our institution for surgery thus admitted.

IV. PHYSICAL ASSESSMENT

VITAL SIGNS BP: 130/90 mmHg
Wt: 55 kg
Temp: 37.2 C
RR: 19 cycles per minute
O2 sat: 98%

General status: Conscious and not in cardio respiratory distress

HEAD Symmetrical facial features

EYES Eye movements are coordinated, anicteric sclera, pink palpebral

conjunctiva

EARS (-) aural discharge

NOSE Patent, (-) nasal discharge

THROAT (-) lumps, (-) bumps nor color discoloration.

NECK (+) neck vein engorgement

CHEST Symmetrical chest pain

HEART (-) murmur, normal rate and rhythm

LUNGS Symmetrical chest expansion, clear breath sounds, (-) wheeze

ABDOMEN Diffuse scars on the abdomen, (+) tenderness on deep palpation on

epigastric and RUQ, soft, flat, (-) murphy’s sign
EXTREMETIES Grossly normal extremities, (-) cyanosis, (-) edema on lower
extremities

NEUROLOGICAL conscious, coherent, cooperative, ambulatory

V. ANATOMY AND PHYSIOLOGY

The gallbladder is a small pouch that sits just under the liver. The gallbladder stores bile
produced by the liver. After meals, the gallbladder is empty and flat, like a deflated
balloon. Before a meal, the gallbladder may be full of bile and about the size of a small
pear.

In response to signals, the gallbladder squeezes stored bile into the small intestine
through a series of tubes called ducts. Bile helps digest fats, but the gallbladder itself is
not essential. Removing the gallbladder in an otherwise healthy individual typically
causes no observable problems with health or digestion yet there may be a small risk of
diarrhea and fat malabsorption.

VI. PATHOPHYSIOLOGY
Gallstone formation occurs because certain substances in bile are present in concentrations that
approach the limits of their solubility. When bile is concentrated in the gallbladder, it can become
supersaturated with these substances, which then precipitate from the solution as microscopic crystals.
The crystals are trapped in gallbladder mucus, producing gallbladder sludge. Over time, the crystals grow,
aggregate, and fuse to form macroscopic stones. Occlusion of the ducts by sludge and/or stones
produces the complications of gallstone disease.

Long-standing obstruction to the gallbladder’s outflow results in overdistention of the gallbladder;

occasionally, the gallbladder assumes massive proportions, and its volume may reach 1.5 L. The bile or
bile pigment is slowly resorbed, and continuing secretion from the mucosa of the gallbladder results in
clear and watery or mucoid content (white bile). The gallbladder wall may be of normal thickness, though
in long-standing cases, the mucosa atrophies and the wall becomes thin, sometimes even transparent.
Wall thickening can occur with recurrent attacks of cholecystitis.The contents are usually sterile, and any
bacterial contamination ends in empyema of the gallbladder.
VII. LAB RESULTS
HEMATOLOGY

Date: 09/17/17 @ 10:30am

REFERENCE
TEST NAME RESUL
T REMARK INTERPRETATION
RANGE

WBC 5.0- 7.8 Normal WBC of the patient is within normal

10.0x10^9/L range.

Hemoglobin 120-160 g/l 109 ↓ Low ↓ It may indicate that the patient has
anemia.

Platelets 150-350 x 10 289 Normal Patient’s platelet is within the normal

g/l range.

Hemotocrit 0.38-.050 0.33 ↓ Low ↓ The patient may indicate that she has
anemia.

Segmenters 0.40-0.60 .80 ↑ High ↑ It explains that the patient may have
an infection.

Lymphocytes 0.20-0.40 0.20 Normal It indicates that lymphocytes are within

normal range.

BLOOD CHEMISTRY

Date: 09/17/17 @ 1:35pm

REFERENCE
TEST NAME RESULT REMARK INTERPRETATION
RANGE

SGOT Up to 37 u/l 40.8 u/l Normal Patient’s result is within the normal
37 C range.

SGPT Up to 42 u/l 29.0 u/l ↓ Low ↓ Low result may indicate that the
37 C gallbladder is damaged.

VIII. DRUG STUDY

 DRUGS ACTION RATIONALE SIDE NURSING
EFFECTS CONSIDERATIONS
Generic name: Bactericidal: Treatment for No side - Monitored VS
Inhibiting infection effect.
Cefuroxime sodium bacterial cell wall - Observed patient
synthesis, for signs and
Brand name: Zinacef causing cell symptoms of
death due to lysis anaphylaxis
CLASSIFICATION: of bacteria. (rash, pruritus,
Cephalosporin laryngeal
Antibiotics edema,
wheezing)
DOSAGE: 1.5 grams
IV q8 then 750mg IV
q8
Generic name: Inhibition of Treatment for No side - Allergy skin test
prostaglandin moderate to effect.
Ketorolac synthesis by severe pain (-) ANST - Monitored VS
tromethamine competitive
blocking of the
Brand name: Toradol enzyme
cyclooxygenase
CLASSIFICATION: (COX), results
NSAIDs (analgesics) anti-
inflammatory,
DOSAGE: 30mg IV q8 antipyretic and
x3 doses ANST analgesic effects.

Generic Name: To suppress Treatment for No side - Monitored VS

gastric acid conditions effect. - Advised patient to
Omeprazole secretion. caused by (-) any side report any severe
To treat too much of GERD headache,
Brand Name: Losec gastroesophagea acid unresolved
l reflux disease production in severe diarrhea,
CLASSIFICATION: (GERD) the stomach. or changes in
respiratory status.
Proton pump inhibitor;
Anti-ulcer

Dosage: 40mg IV OD
Generic Name: Enhances To prevent No side - Assessed for
response to nausea and effect. gastrointestinal
Metoclopramide acetylcholine of vomiting complaints, such
tissue in the triggered by as nausea,
Brand Name: Reglan upper GI tract, most stimuli vomiting and
which results in constipation
CLASSIFICATION: contraction of
gastric muscle, - Advised patient
GI stimulant, that this drug can
Antiemetic Relaxes pyloric cause drowsiness
duodenal
Dosage: 10g IV segments,
(standby)
Blocks dopamine
in chemoreceptor
trigger zone of
CNS
 X. RECOMMENDATION

Medications

- Explained to patient and family member the importance of taking medicines.

Omeprazole 40 mg
Ketorolac
Metoclopramide

Environment/Exercise

- Advised the patient on deep breathing exercises.

- Advised the patient to maintain clean and safe environment.

Treatment

- Ensure follow up and self-care.

- Ensure to follow the primary healthcare providers’ instructions on when the
patient can bathe.
- Ensure gently washing of the part of the body that has the stitches.
- Do not rub on the stitches to dry skin.

Health teaching

- Instruct the patient to avoid any strenuous activities.

Outpatient/Follow up
- Advised patient on OPD checkup so that the physician can know his state of
health and his condition.
- Advised on healthy foods and get adequate of exercises.

Diet
- Encouraged client to eat healthy food such as fruit and vegetables.
- Advised on low fat diet.
- Advised patient on fat soluble vitamins.

Spiritual
- Advised relatives or significant others to provide moral support and widen their
understanding,
- Tell to the significant others to pray for the quick recovery of the patient.
- Advised the patient to pray for her fast and quick recovery.