Asymptomatic Cholelithiasis

3ACN, Group 2
General Objective
The study of Cholelithiasis is a broad topic
yet the group is expected to define the
disease mentioned in order for the
researchers and readers to understand
deeper what is cholelithiasis.To maximize the
branches on which cholelithiasis has a
connection to. After this case study, the
group will be able to learn informations and
apply all the things which have been stated in
the data that will be shown.
Specific Objectives (Knowledge,
Skills, Attitude)
After reading and analyzing this case study:
a. The readers will determined on how Cholelithiasis are formed.
b. The readers will be able to identify the Signs and Symptoms of Cholelithiasis.
c. Other researchers will find this case study as a guide journal fo prevention
and medical treatment of Cholelithiasis.
d. This will serve as a simple reference for proper and effective nursing care
management for those who have undergone medical treatment for
cholelithiasis.
e. The readers will be able todifferentiate Cholesterol stones from Pigment
stones.
f. The stundents who are involve in this case study will be able to share skills in
nursing intervention in which other nurses, family members and the patient
itself should do to with cholelithiasis.
g. The readers will be able to determine what are the risk factors for having
cholelithiasis.
h. To be able to act as as a Disciplined and Vigilant when handling patients
with cholelithiasis.
i. To perform all the nursing responsibilities/management with confidence and
dedication when caring for a person with cholelithiasis.
INTRODUCTION
Definition of the Disease
A Cholelithiasis also known as Gallstones, usually form in the
gallbladder from the solid constituents of bile; they vary greatly
in size, shape and composition. They are uncommon in children
and young adults but become increasingly prevalent after 40
years of age. The incidence of cholelithiasis increases after the
age of 40 years, affecting 30% to 40% of the population by the
age of 80 years. Many patients complain of unlocalized
abdominal discomfort, eructation, and intolerance to certain
foods. Others have no symptoms. Cholelithiasis causes severe
upper right abdominal pain radiating to the right shoulder, as a
result of blocked bile flow. A gallstone's size can vary and may
be as small as a sand grain or as large as a golf ball. The
gallbladder may develop a single, often large stone or many
smaller ones. They may occur in any part of the biliary system.
 Risk Factors
1. Gender
2. Obesity and diet
3. Age
4. Family history of gallstones
5. Pregnancy
6. Lack of physical activity
7. Ethnicity
8. Past diseases of the small
intestines
9. medication
 Gender
It is said that women tend to get more gallstones than men due to their high
estrogen levels.
 Obesity and diet
Having too much of abdominal fat increase the risk of getting gallstones. Also being
overweight increases cholesterol in the bile which lead to formation of the
gallstones.
 Age
The age of 40 and above increases the risk of gallstone formation.
 Family History of Gallstones
Like some other diseases, gallstones also tend to run in families.
 Pregnancy
During pregnancy a woman’s progesterone levels increases, therefore
increasing the risk of gallstones
 Lack of Physical Activity
Lack of Exercise can also lead to gall stone formation because the gall bladder
contracts less.
 ethnicity
It is said that Native Americans, Hispanic, and those of northern European descent
develop gallstones more frequently than any other ethnicity in the United States.
Gallstones occur less frequently among Asians and African-Americans.
past diseases of the small intestines
The diseases include Crohn’s Disease, Diabetes, Sickle cell anemia, Major
Trauma, Paralysis.
 Medications
The patient is prone to gallstones if he/she is using these medications:
Ceftriaxone,Octeotride, Somastatin,Fibrates.
Epidemiology
Gallstones are quite prevalent in most
western countries. In the United states,
several series have shown gallstones in at
least 20% of women and in 8% on men over
the age of 40 and in up to 40% of women
over the age of 65 years. It is estimated that
at least 25million persons in the united states
have gallstones and that 1million new cases
of cholelitiasis develop each year.
Reason for choosing the case for
presentation
The group chooses this topic because the members would
like to expand their knowledge about Cholelithiasis.
Another reason is that, it is important for us as students
to learn this disease because we know that it will be useful
for us in the future as nurses, to be able to share it with
people in our own community and to improve their health
and ways of preventing gallstones. Their group would
also like to know what is the perfect health care for
cholelithiasis that we can provide for our patients. We
know that studying this disease would help us know what
to separate from facts and fictions when it comes to
Gallstones. Studying this disease would give us benefits
and broaden our knowledge to be a better bedan nurse.
Patient’s Profile
Name: Patient BR
Address: Dasmarinas Cavite
Gender: Male
Age: 46 years old
Religion: Roman Catholic
Height: 5’7.5’’
Weight: 67kgs
Citizenship: Filipino
Civil Status: Widow
Occupation: Seaman
Date of Admission: May 12,2010
Attending Physician: Dr. Miguel Mendoza MD
Service: Surgery
Allergies: Have no known allergies
Chief complaint/s: Pain at the lumbar area (Cholecystolithiases)
Admitting Diagnosis: Cholecystolithiases
 
Final Diagnosis: Cholecystolithiases
Socioeconomic and cultural factor
The patient with cholelithiasis works as a seaman and he earns 60,000 –
80,000 a month. He and his family believes in “Hilot” as a way of curing.
 Environmental factor
He lives in a subdivision at 50 kamagong St. Villa Vista Luisa Homes phase 1 Dasmarinas Cavite.
He’s been a single parent for about two years. He drinks alcohol frequently, and in his age of 46,
it is not advisable or good to drink too much. It may be one of the contributing factors of having
cholelithiasis. Eventhough, in his diet he includes fruits and vegetables and he avoid foods that
are rich in fats and cholesterol. The patient is not obese still he was diagnosed of having
cholelithiasis.
History of past illness
Date / Year Events

1996 The patient undergone to an Surgical operation (Appendectomy)

2008 The Patient had an accident while on work as a seaman. He fall 15
meters to the water, but no Major Injury Happen
2009 The Patient had an incident of motor accident with his Son. Only
minor bruises have been obtain
May 13, Patient Undergone Laparoscopic Cholecystectomy
Allergies Medical Problem and Medication Taken
2010
The patient have no known allergies to >The patient have no known medical
foods and medication problem
>The patient doesn’t have any
maintenance medication
>The patient regularly taking Multivitamins
History of present illness
Date / Year Events

April 14, 2010 Patient undergoes to hepatobiliary ultrasound (a

requirement for his work) and found out that he have
multiple stones at gallbladder which measures up to
1.5cm
April 20, 2010 Patient comeback for the follow-up checkup. On the
same day he was given a schedule for Laparoscopic
Cholecystectomy on May 18, 2010
April 23, 2010 The Patient inform on change of date of operation thru
text. It is re-schedule on May 13, 2010
May 13, 2010 Patient Undergone Laparoscopic Cholecystectomy
Family health history
HPN Asthma DM

HPN

Chole pt. ESRD

DM

Dead Dead
female male female male
Gordon’s health Pattern
of functioning
 Health-Perception and Health
Management Pattern
Before Hospitalization During / After Hospitalization
The Patient is well oriented on his environment. Vision is in good
status as evidenced by 20/20 vision acuity on both eyes; both He was still well- oriented with time, place and person. When
pupils are normal and reacting to stimuli. Hearing is also in good interviewing the patient, he is very cooperative. (-) numbness and
condition. Patient sensory of taste is in normal state, tongue tingling. He is also currently working as a seaman and living in a
movement and appearance are normal. The patient’s sense of touch subdivision townhouse. Patient doesn’t have problems in healing,
identify accurate on each stimuli. Patient’s sense of smell is also but he had past accident last year (Vehicular Accident).
normal.
The patient describes his health status in a good condition and he
also said that he is satisfied with his health status. He is not a
smoker but he is an alcohol drinker with an average of 2 bottles a
day. (-) history of chronic disease but reported that he had previous
operation last 1996 (appendectomy). The usual over the counter
drug that he purchased in the drugstore is a multivitamins but he
often followed the routine prescribed to him. He felt that the
multivitamins were effective to him most especially when he is
working during wee hours. He exercise in a regular basis. As much
as he want to have his check up regularly he can’t because not all
the time he has money and time going to the hospital. So he just go
to the hospital and have his check up when he feels that there is
something wrong in his body.
Analysis: Analysis:
The patient was active and cooperative during our interview. He The patient do know what is happening around him. And he
also know that he should have regular check- ups with his doctor answered our question in knowledgeable way.
but it was not one of his priorities which is why he goes only to the
Nutrition and Metabolic Pattern
Before Hospitalization During / After Hospitalization
No signs of rash noted, have a firm skin turgor and
has a pink color of skin. He has moist lips and no Patient has lesion on his right lower abdominal
signs of lesions noted, has normal teeth but has quadrant, mid epigastric and two in his right upper
dentures (upper). He have a normal gums and normal abdominal quadrant and one on his umbilicus. He
tounge. No general edema noted. And has a moist still eats what he wants.
eyes and no lesions noted in both eyes.
Patient doesn’t have restrictions in his diet he eats
just enough, his daily intake of fluid is more than 8
glasses of water a day and he is not choosy when it
comes to food. He sometimes have problem in
indigestion. He always wants to be active. His food
was more on fish and soup he seldom eats meat.
Analysis: Analysis:
Patient has a typical diet. He always eats what he Patient decides what he will eat without any
wants. He was not really aware that the kind of food restrictions even after his operation.
he was eating may contribute to make his illness
worsen.
Interpretation Interpretation
Problem Identification Problem Identification
 Elimination and Metabolic Pattern
Before Hospitalization During / After Hospitalization

His bowel movement frequency is two to three times a His elimination pattern changes after his operation. No
day. The character of his stool was soft, yellow in color straining noted and he has the same cycle of bowel
but no signs of bleeding in his bowel movements. He movements a day. He voids freely without pain.
said that he doesn’t have history of constipation and he
doesn’t use laxatives for his bowel movement. His
voiding pattern frequency is 5 to 6 times per day, color
yellow in color no incontinence noted. He feel burning
sensation in his urethral meatus every time he voids.
Analysis: Analysis:
Before the patient was confined, his elimination pattern After the procedure done to him, the elimination
is normal. And he does not take any laxatives for him pattern of the patient changed. The medication may
to defecate. But there is pain whenever he voided which have affected the GIT’s peristalsis; it may have
is not normal. decreased its movement because of the procedure.
Interpretation Interpretation
Interpretation Interpretation
Impaired urinary elimination R/T anatomical obstruction as Risk for constipation related to rescent environment changes
evidenced by dysuria
Before Hospitalization During / After Hospitalization
 Activity and Exercise Pattern
Before Hospitalization During / After Hospitalization
He has abnormal hair distribution, (-)
claudication. Patient has no difficulty of Patient has (+) cyanosis in his left hand, his
breathing and he sometimes cough with extremities are cool, normal and pink except
sputum. He walks around the subdivision and in his left hand. He usually walks in the
exercise. Patient has normal range of motion, hallway as a substitute to his daily exercises
gait, balance, muscle mass, strength, posture. before he was hospitalized.
No deformities noted and missing limbs.
Patient can do all his activities without the
help of others, he can climb 12 steps in a
stairs in a thirteen floors and he can walk few
without difficulties, his usual leisure time is
going to the gym.
Analysis: Analysis:
The patient exercised regularly by walking. He The patient still do exercise even he is in pain
can move freely without any pain felt. He can but it is also to facilitate wound healing as
do things without any assistance. tolerated.
Interpretation Interpretation
Sleep and Rest Pattern
Before Hospitalization During / After Hospitalization
Patient sleeps 8 hours per night and feel
rested after, he is not an insomniac and has The patient have enough time to sleep and
no difficulty going to sleep but awaken rest. He do not have any difficulties falling
during night and awakens early. He doesn’t asleep.
us relaxation techniques.

Analysis: Analysis:
Patient’s sleeping pattern is good. He The patient still have adequate time to sleep
always have enough time to rest even when and rest.
he is at work.

Interpretation Interpretation
Problem Identification Problem Identification
Cognitive Perceptual Pattern
Stage of Definition Client’s Analysis Interpretatio
development behavior n
Formal Can think Calm during Patient is well- The patient is
Operational logically about decision Making oriented and cooperative and
abstract alert. answers our
propositions question honestly
and test and precise
hypotheses
systematically 
Self Perception Pattern
Before Hospitalization During / After Hospitalization
Patient appears calm, no physiologic
parameters change noted, Voice quality didn’t change. (+) gestures
Patient has a positive outlook in life. observed. His main concern this time is to be
treated and go back to work immediately, he
strongly believes that there is no lifestyle
changes that will happen to him after the
operation. His level of control in his current
situation is 3.
Analysis: Analysis:
The patient looks fine. He was optimistic The patient use gestures when elaborating
about his outlook. things. He wanted to speed up his recovery
for him to return to work immediately. Make
sure that the current situations is under
control.
Interpretation Interpretation
Readiness for enhanced self concept as evidenced by Readiness for enhanced power as evidenced by
expression of confidences and abilities awareness of possible changes to be made.
Role-Relationship Pattern
Stage of Definition Client’s behavior Analysis Interpretation
development
Middle Adulthood: Ego Development Afraid to lose his The patient feels the patient wants to
35 to 55 or 65 job if he do not that the only thing recover faster so
Outcome:
return immediately that needed to do is that he could
Generativity vs. Self to earn money for support the needs
absorption or his children to have of his family.
a better life
Stagnation
Basic Strengths:
Production and
Care
 Sexuality – Sexual Function
Stage of Definition Client’s Analysis Interpretation
development behavior
 As the child's He is not The patient The patient will
The Genital energy once again satisfied in his feels that the have face another
focuses on his sexual moment his wife perspective of
Stage genitals, interest relationship died, his sexual life.
turns to with his wife function will not
heterosexual but he doesn’t be like as
relationships. The believe that before.
less energy the child there will be no
has left invested in impact on their
unresolved sexual
psychosexual functioning.
developments, the
greater his capacity
will be to develop
normal relationships
with the opposite
sex. If, however, he
remains fixated,
particularly on the
phallic stage, his
development will be
troubled as he
struggles with
further repression
and defenses.
Value Belief System
Before Hospitalization During / After Hospitalization
No signs of any alterations in his mood
Patient is not satisfied in what way his life Patient’s mood do not change quickly. He
has been developing, and he believed that believed that what happened to him before
this may interfere with his plans in the have a huge effect on what is happening to
future. He doesn’t want to be visited by a him right now. He rarely attend mass
priest but he believed that his belief to God because also of the kind of work he has.
helped him deal with his problems in the
past.
Analysis: Analysis:
The patient do not switch moods easily. He He do not have any mood problems. He
have faith in God but do not exercise his also feels that his way of life during his
faith because also of the kind of work he younger years has a big effect on his life
have. right now. Do not practice his religious
rights because his work is like a barrier for
him to do religious practices and beliefs.
Interpretation Interpretation
Impaired religiousity r/t life transition as evidenced by need to Same
Physical Assessment
General appearance
The patient is 46 y/o Male, with a height of 5’7.5’’ and a
weight of 67kgs (147.4lbs). Patient’s Posture is erect and
steady. Nails skin and hair are well maintained but there is
visible hair loss at the anterior part of the head. The patient
also has a scar at the lower right quadrant of his abdomen
because of appendectomy incision. The patient is wearing a
hospital gown properly tied. He use slippers when walking
around the ward. The patient is well kept no signs of body
odor, The patient participate willingly on our interview.
Feeling of sadness is conveyed by the patient through facial
expression. Patient’s speech is clear and with coherence.
Area Assessed Technique Normal Findings Actual Findings Evaluation

SKIN

Color Inspection light brown, tanned skin Light brown normal

lighter colored palms, lighter colored palms,

Soles and Palms Inspection Normal
soles soles

Moisture Inspection/Palpation skin normally dry skin normally dry normal

Temperature Palpation normally warm Warm normal

Texture Palpation smooth and soft Smooth normal

skins snaps back skins snaps back

Turgor Palpation normal
immediately immediately

SKIN APPENDAGES

transparent, smooth and

Nails Inspection Smooth and convex normal
convex

Nail Beds Inspection Pinkish Pinkis Normal

Nail Base Inspection Firm Firm normal

white color of nail bed

white color of nail bed
under pressure should
Capillary Refill Inspection/palpation under pressure return to Normal
return to pink within 2-3
pink within 2-3 seconds
seconds

Not evenly distributed

Hair Distribution Inspection evenly distributed Hair loss due to age.
and but well kept.
Color Inspection Black Black normal

Moderately rough
Texture Inspection/palpation Smooth normal
(wavy hair)

EYES

Eyes Inspection parallel to each other Parallel to each other normal

PERRLA

Inspection -pupils equally round

Visual acuity PERRLA normal
(penlight) react to light and

accommodation

symmetrical in size, symmetrical in size,

extension, hair extension, hair

Eye Brows Inspection normal
texture and texture and

movement movement

Eyelashes Inspection distributed evenly Evenly distributed. Normal

same color as the

skin

Blinks voluntarily and

No discolorations,
bilaterally up to
blink reflex is present
Eyelids Inspection 20x/min. normal
and its proportional
 transparent with
Conjunctiva Inspection Pinkish normal
light pink color

Sclera Inspection color is white White colored- normal

Transparent and
Cornea Inspection transparent, shiny normal
shiny

Colored black and

black, constrict
Pupils Inspection reacts well to the normal
briskly
environment.

Iris Inspection clearly visible Visible normal

EARS

free of lesions, free of lesions,

discharge of discharge of
Ear canal opening Inspection
inflammation inflammation normal

canal walls pink canal walls pink

client normally Client hears

Hearing acuity Inspection hears words when words and react normal
External
free of Free of
part of the Inspection normal
lesions lesions
Ear

NOSE

smooth,
Symmetrica
Shape, Size symmetric
l to face
and Skin Inspection with same normal
and is free
color color as
of lesions.
the face

oval,
Oval and
symmetric
does not
MOUTH AND PHARNYX

Lips Inspection pink, moist symmetric moist symmetric normal

glistening pink Soft, moist, pink, and no

Buccal Mucosa Inspection normal
soft moist lesions

slightly pink color, moist and tightly Pink, wet, no signs of

Gums Inspection normal
fit against each tooth bleeding and intact.

moist, slightly rough on dorsal Slightly rough, slippery, and

Tongue Inspection normal
surface medium or dull red is in place without lesions.

Teeth Inspection firmly set, shiny No teeth present normal.

hard palate hard palate

-dome shaped is dome shaped and

Hard and Soft Palate Inspection normal
soft palate soft palate

-light pink is light pink

NECK

symmetry of neck muscles, neck is slightly hyper extended Neck is symmetrical and has
normal
alignment of trachea Inspection without masses or asymmetry no masses present.

neck moves freely without neck moves freely without

Neck Roll Inspection normal
discomfort discomfort

Skin same color with the rest

Post-op
Skin same color with the rest of the of the body
Abdomen Inspection Laparoscopic
body With 4 dressings one of it is
EXTREMITIES

Symmetry Inspection symmetrical symmetrical Normal

same with the color of same with the color of

Skin Color Inspection Normal
other parts of the body other parts of the body

Hair Distribution Inspection evenly distributed evenly distributed Normal

Skin Temperature Palpation Normally warm warm normal

Presence of Lesion Inspection no lesions No lesions Due to present condition

moves freely without Unable to move freely Post op laparoscopic

ROM Inspection
discomfort because of discomfort cholecystectomy

NEUROLOGY SYSTEM

fully conscious, able to Patient fully conscious,

Level of Consciousness Observation respond to questions, able to respond to Normal

perceptive of events questions.

makes eye contact with makes eye contact with

examiner, hyperactive examiner, hyperactive

Behavior and Appearance Observation expresses feelings with expresses feelings with Normal

response to the response to the

situation situation
Course in the ward
IVF
Date Given Type of IVF Indication Client Response to

Treatment

D5LR 1L x hypertonic Regulate urine To maintain

33gtts/min solution it pulls output; stabilize client’s fluid

fluid out of the blood pressure; electrolyte balance

cells into the reduce risk of and prepare for

intravascular space edema; Post-op NPO diet

(veins). Patients
Diet
Date ordered Type Indication / Purpose Type of Foods Taken Client’ Response to

of Diet Treatment

May 12,2010 Preparation for the None He have an idea why

NPO starting upcoming Operation he is in NPO diet,

midnight because of the

upcoming Procedure.

Patient is very thirsty

May 13, 2010 undergo certain Clear liquids or Patient is not

General Liquid until medical tests, opaque fluids that satisfied on the foods

dinner then shift to surgery or any other are completely or that he prescribed to

Full Diet medical procedures partially fluid in eat.

that require your consistency.

stomach or intestine
 Laboratory and diagnostic procedure
Procedure Definition Actual findings Normal values Interpretati Analysis

on

Urinalysis Is produced as the end product of urine 4.62 mmol/L 1.78- High Uratee crystals readily

metabolism in humans. Uric acid is 3.45mmol/L precipitate from urine

synthesized primarily in the liver, a with high concentrations

reaction catalyzes by the enzyme of urine. The crystals iin

xanthine oxudase. On a low-purine diet, tissues cause an

daily excretion is about .5g. on a normal inflammatory response

diet, excretion is about 1g. daily. with release of enzymes

UA. 4.62 from leukocytes & local

tissue damage that leads

to an acid environment

favorable to formation of

more urate crystals

Globulin Some globulins are produced in the 3.5 2.8-3.2 High

liver, while others are made by the

immune system
Total bilirubin 1.21 .2-1 High

Direct bilirubin It is measured by a specific .87 0.2 High

chemical reaction without any

modificaton and it is also

water-soluble

Indirect .25 0-.8 Normal

bilirubin

Ultrasound Is a preferred test for Gallbladder is normal No stone Presence

confirming the presence of in size and of stone in

gallstones as well as their configuration. The the

number, color, size gallbladder is noth gallbladde

thickened, multiple r

bright echoes

w/posterior sonic

shadowing are seen in

the lumen.
 Anatomy
and
physiology
Gastrointestinal Tract
The gastrointestinal tract (GIT) consists of a hollow muscular
tube starting from the oral cavity, where food enters the mouth,
continuing through the pharynx, esophagus, stomach and
intestines to the rectum and anus, where food is expelled.
There are various accessory organs that assist the tract by
secreting enzymes to help break down food into its component
nutrients. Thus the salivary glands, liver, pancreas and gall
bladder have important functions in the digestive system.
Food is propelled along the length of the GIT by peristaltic
movements of the muscular walls.
The primary purpose of the gastrointestinal tract is to break
down food into nutrients, which can be absorbed into the body
to provide energy.
Focus: GALLBLADDER
Formation and flow of bile in the biliary
tree. The liver is found in the right upper If the sphincter of Oddi is closed, bile is
corner of the abdomen, below the diaphragm. prevented from draining into the intestine and
It weighs 3-4 pounds. It is divided into right instead flows into the gallbladder, where it is
and left lobes, and each of these have several stored and concentrated to up to five times its
segments. Bile is produced original potency between meals.
in the tiny tubules called sinusoids which lie
This concentration occurs through the
between rows of liver cells called hepatocytes.
absorption of water and small electrolytes,
Bile then flows Through the tiny canals while retaining all the original organic
called cannalliculi, these tiny cannals forms molecules.
the billiary tree.
Cholesterol is also released with the
From the biliary tree, bile flows to the bile, dissolved in the acids and fats found in
Common hepatic duct which with the cystic the concentrated solution.
duct from the gallbladder to form the common
When food is released by the stomach
bile duct.
into the duodenum in the form of chyme, the
The gallbladder is a collection sac for duodenum releases cholecystokinin, which
bile, which enters and leaves through a narrow causes the gallbladder to release the
tube called the cystic duct. The gallbladder is concentrated bile to complete digestion.
about the size of an egg when full.
The human liver can produce close to
The bile duct below the cystic duct is one litre of bile per day (depending on body
usually called the common bile duct. The size).
common bile duct and the common hepatic
About 95% of the salts secreted in bile
duct together constitute the main bile duct.
are reabsorbed in the terminal ileum and re-
The lower end of the bile duct sweeps used.
around behind the duodenum and through the
Blood from the ileum flows directly to
head of the pancreas before joining the
the hepatic portal vein and returns to the liver
Pancreatic duct at the main papilla (of Vater).
where the hepatocytes reabsorb the salts and
return them to the bile ducts to be re-used,
sometimes two to three times with each meal.
Biliary system  Cystic duct- connects the
gallbladder and the common bile
duct
The biliary system is made up of  Common bile duct- is formed
the ducts arising in the liver, the when the common hepatic duct
gall bladder and its duct and the and the cystic duct unites.
common bile duct. Starting in the  Pancreatic duct- joins the pancreas
liver, the small biliary ducts to the common bile duct
converge to form the larger right
and left hepatic ducts. These, in
turn, join to form the common The gall bladder receives bile from
hepatic duct which joins with the the liver by way of the common
cystic duct to form the common hepatic duct into the cystic duct.
bile duct. The gall bladder stores and
concentrates its contents and also
excretes its bile back through the
 Hepatic ducts- drain the liver L
cystic duct to join the common
hepatic duct from the L lobe, R
hepatic duct to become the
hepatic duct from the R lobe of the
common bile duct which then
lober
carries the bile into the duodenum.
 Common hepatic duct- unites the L The fundus of the gallbladder is
and R hepatic duct. the part farthest from the duct,
located by the lower border of the
liver.
Microscopic anatomy
The different layers of the gallbladder are as follows:
The gallbladder has a simple columnar epithelial lining
characterized by recesses called Aschoff's recesses,
which are pouches inside the lining.
Under the epithelium there is a layer of connective
tissue (lamina propria).
Beneath the connective tissue is a wall of smooth
muscle (muscularis externa) that contracts in response
to cholecystokinin, a peptide hormone secreted by the
duodenum.
There is essentially no submucosa separating the
connective tissue from serosa and adventitia.
Gallbladder
The gallbladder is a hollow, pear-shaped sac, 7 to 10 cm (3-4 inches) long and 3
cm broad at its widest point. It consists of a fundus, body and neck. It lies on the
undersurface of the liver’s right lobe and is attached there by areolar connective
tissue.
It stores about 50 mL of bile, which is released when food containing fat enters
the digestive tract, stimulating the secretion of cholecystokinin (CCK). The bile,
produced in the liver, emulsifies fats and neutralizes acids in partly digested food.
The gallbladder stores bile by the hepatic and cystic ducts. During this time the
gallbladder concentrates bile fivefold to tenfold. When digestion occurs in the
stomach and intestines, the gallbladder contracts and ejects the concentrated bile
into the duodenum.

Jaundice a yellow discoloration of the skin and mucosa, results when obstruction
of bile flow into the duodenum occurs. Bile is thereby denied its normal exit from
the body in the feces. Instead, it is absorbed into the blood, and an excess of bile
pigments with a yellow hue enters the blood and is deposited in the tissues.
After being stored in the gallbladder the bile becomes more concentrated than
when it left the liver, increasing its potency and intensifying its effect on fats.
Most digestion occurs in the duodenum
Serous, muscular, and mucous layers compose the wall of the gallbladder. The
mucosal lining is arranged in folds called rugae, similar in structure to those of
the stomach.
Enterohepatic circulation
Enterohepatic circulation is the reabsorption/recycling of bile acids. Used Bile acids are
absorbed from the terminal ileum and transported back to the liver by the portal system.
This is achieved by passive and active transcellular absorption. The most important
mechanism is a sodium-coupled transport system that is present in the apical membrane of
the enterocytes.
It is known as the ileal bile acid transporter (IBAT)
In the distal ileum and large intestine, intestinal bacteria deconjugate bile acids, which are
absorbed passively in solution.
A small amount of the bile acid is lost from the body in feces. This fecal loss is
compensated by synthesis of new bile acids. In healthy adults, less than 3% of bile acids are
present in hepatic bile is newly synthesized.
In the portal system, bile acids are bound to albumin. The ability of the albumin binding
depends on the nuclear substitures. For trihydroxy bile acid, this is around 75%, thereas it is
98% for dihydroxy bile acids. On the first pass, the hepatic circulation extraction is between
50-90%; the level of bile acids in the systemic circulation is directly proportional to the load
presented to the liver, and it increases after meals. The plasma level of total bile acids is 3-
4umol/L in the fasting state and increases twofold to threefold after digestion.

Normally, bile salts pass 18times before being expelled in the feces.
 Client centered
pathophysiology
Nursing management
 Problem prioritization
Problem Identified Score Justification

1. Acute pain R/T disruption High Pain is an unpleasant sensation

of skin integrity and localized in a part of the body.

injuring agent as evidence This is the highest priority

by verbalization of pain because pain is subjective, there is

(1/10 when lying on bed, damage to the tissues due to the

3/10 when standing and invasive procedure made to the

2/10 when sitting). patient.

2. deficient knowledge HIGH Deficient knowledge is one of the

regarding self-care needs high priorities in the problems we

R/T lack of information as have encountered because the

evidenced by verbalization patient does not know what he will

of concerns do after his operation. The patient

do need to know about how to

3. Risk for infection related to tissue HIGH This is also a high risk because there is

destruction as evidenced by a tissue destruction if not managed

invasive procedures. properly, this may lead to infection. And

there is an open wound where in

bacteria may enter inside the patient’s

body.

4. Ineffective health maintenance MODERATE The patient does not prioritize his

R/T perceptual impairment as health care needs because he was

evidenced by demonstrate lack of already aware of his illness but then he

knowledge regarding basic health seek help to treat his illness. The

practices patient do not know what he was

suppose to do with his illness.

5. Ineffective therapeutic regimen Patient didn’t complied in his health

management R/T knowledgeable needs even though he know that he has

deficits as evidenced by choices in deficiency in his health goals but proper

daily liing for meeting the health health teaching & monitoring will help

goals. the patient improve his knowledge in

his health condition.

Nursing care plan
 Assessment
Subjective Objective Nursing intervention Rationale

“Sumasakit ang tiyan ko kpag Grimacing Independent: -to evaluate effectiveness

umuubo ako.” as verbalized of pain relieving meds

-Pallor -assess/monitor pain
by patient
scale -to splint above the
P-scale of 3/10
abdomen when coughing
-provide pillow
Q- sharp stabbing pain
-to promote oxygenation
-encourage patient to
R-pain when standing for faster wound healing
perform deep breathing
S-abdomen
exercises. -to promote blood
nursing diagnoses
circulation for faster
Acute pain R/T post op incision as evidence by verbalization -assist patient with early
wound healing
of pain (1/10 when lying on bed, 3/10 when standing and and progressive

2/10 when sitting). ambulation - give mefenamic acid to,

Scientific Rationale inhibits prostaglandin

Dependent:
synthetase
Mechanical, thermal -take medications as pain
occurs
or chemical stimuli > Nociceptor > Afferent Nerves >End
Evaluation of Nursing Care
terminals >unmyelinated C fibers and myelinated > A delta fibers >
Goals fully achieved

spinal cord > brain cortex > Pain

-Client was able to report pain scale of 2 out
Nursing Objectives and Goals
of 10
Short Term:
-Patient will report pain reduction through pain scale, from 5
-Client is able to perform deep breathing
to 2 out 10.
exercises and was able to ambulate as pain
 Assessment Nursing intervention Rationale
Subjective Objective Determin client’s ability Individual may not be
“Wala akong alam ( sa >NPO / readiness and barrier physically emotionally.
operayon at mga >coherent to learning Or mentually capabl at
gagawin makatapos ng >For laparoscopic Be alert signs of thi time
operasyon)” as Cholecystectomy under avoidance
Client may need to
verbalized of the Dr. Mendoza Provide positive
suffer consequences of
patient reinforcement
lack of knowledge
nursing diagnoses Diffeentiate “Critical”
before he is ready to
Deficient knowledge regarding self-care Content form
accept information
needs R/T lack of information as evidenced “desirable” content
State objective clearly Can encourage
by verbalization of concerns
in learner’s terms continuation of efforts
Scientific Rationale
Patient Verbalize his problem because of specific Identifies information

information necessary for the client is lack that can be addressed

Nursing Objectives and Goals at later time

After ! hour of nursing intervention client will
To meet learner’s needs
demonstrate 2/3 relaxation techniques
Evaluation of Nursing Care
prescribed for clients after laparoscopic
Goal met after 1 hour of nursing intervention
cholecystectomy
cilent will demonstrate 2/3 relaxation
techniques prescribed for clients after
 Assessment
Nursing intervention Rationale
Subjective Objective Independent: A first line of defense
N/A -inflammation of against healthcare
Stress proper hygiene
post-op site associated infection
Educate patient Reduces risk of cross
Redness
infection control infection
Swelling
nursing diagnoses Monitor medication To determine

regimented client effectiveness of therapy

Risk for infection releted to injuring agents
response To promote faster
(laparoscopic Cholecystectomy) as evidenced
wound healing due to
by post operative puncture Eat foods high in
proteins which help
Scientific Rationale protein
tissue repair
Risk for infection due to surgical opening on RUQ
Encourage ambulation Helps in oxygenation
of the Abdomen and lack of knowledge due to
which lets the blood
wound care
circulate to transfer
Nursing Objectives and Goals
nutrients
Short Term:
After 8 hours of nursing intervention patient / Evaluation of Nursing Care
significant others will be able to demonstrate 3/5 Reassess patient knowledge on wound
techniques of proper wound care and selfcare
Patient will continue medication and know the
After 8 hours of nursing intervention and
knowledge of proper wound and selfcare toprevent
infection health teaching the patient or the
  
Medical Management
Diagnostics Test
 Ultrasonography
is preferred because of its accuracy in diagnosing presence of gallstones, as well the
numbers, color and size. Ultranosography of the gallbladder and biliary tract may be
used to determine gallstones location and detect tumors
 Radiologic studies
is performed to determine patency of biliary or cystic ducts and help rule out
other conditions that mimic gallstones disesase.
Hepatoiminodiacetic acid scan
highly sensitive for diagnosis of acute cholecystitis.
 Oral Cholecystogram
measures gallbladder function and demonstrate number and size of gallstones. This
test requires ingestion of iodine-based tablets (i.e) at night. With x-ray films taken
the following morning.
 CT-Scan
detects dilated bile ducts and presence of gallbladder cysts, tumors abscesses
perforated gallbladder and other complication of gallbladder disease
Endoscopic retrograde Choleangiopancreatography (ECRP)
visualization and evaluation of the biliary tree or pancreatic duct. This is the
gold standard for diagnosing choledocholithiasis
 ECG
rules out cardiac disease
Prothrombin time (PT) Assess for
prolonged clotting time secondary
to faulty vitamin K absorption
Bilirubin Test (serum and urine) and
urobilinogen test (urine and fecal)
used to differentiate between
hemolytic disorders,
hepatocellular disease, and
obstructive disease
Serum liver enzyme test usually
normal in cholecystitis but often
becomes abnormal in the
presence of prolonged
cholecystitis or common duct
stones
Collaborative
management
 Analgesics
NSIADS may be indicated depending on pain severity. For Postoperative patients,
epidural , continues IV and patient-controlled infusions of opiod analgesics are used
with increasing frequency and superior efficacy
 Acid suppression Therapy
neutralized gastric hyperacidity and reduces associated pain
Antibiotics
For infection
 Antiemetic
for nausea and vomiting
 Bile sequestrant therapy
Cholestyramine and colestipol bind with bile salts in the intestine to facilitate
their excretion and may be given to provide relief from pruritus
 Generic Name: Mefenamic Acid 500mg BID
Brand name: Algicap
Drug Class/Dosage Mode of Action Indication Contraindication Adverse effect Nursing Consideration

 Non steroidal  Inhibition of cyclo  Analgesic for  Use in  Dizziness  Do not take more

anti- oxygenase, mild to client with  Rash than 3.2g/day of

inflammatory inhibition of cyclo moderate aspirin  Nausea prescription

drug. oxygenase results pain. triad(bronch  Epigastric products.

in decreased ial asthma, pain  If GI distress

prostaglandin rhinitis,  Diarrhea occurs with any

synthesis. aspirin product take with

intolerance). meal or milk.

 Use to treat  Do not use as an

perioperativ anti pyretic for

e pain in more than 3 days

setting of or as an analgesic

coronary for more than 10

artery days unless

bypass graft medically

surgery. prescribed.
Generic Name: Cefuroxime 1.5g IV
Drug Class/Dosage Indication Contraindication Effect on Laboratory Adverse effect Nursing Consideration

test Results

 Preoperative  Use only after

 Cephalosporin,  Sensitivity to  False /  Diarrhea /
prophylaxis in negative skin test
second generation cephalosporins negative loose stools
clients undergoing  For IM use inject
reaction in the  Nausea and
surgical procedure deep into large
ferrcyanide Vomiting
classified as clean muscles mass
test for blood  Abdominal
contaminate or  Do not add
glucose Pain
potentially cefuroxime sodium

contaminated to solution of

aminoglycosides if

both required give

separately

 Prior to

reconstitution,

protect drug from

light. The powder

and reconstituted

drug may darken

without affecting

potency
Surgical management
Laparoscopic cholecystectomy
 Is a surgical removal of the gallbladder. This is the most common method of treating gallstones
 This requires several small incisions in the abdomen to allow the insertion of operating ports, small cylindrical
tubes approximately 5-10 mm in diameter, through which surgical instruments and a video camera are placed
into the abdominal cavity
 The camera illuminates the surgical field and sends a magnified image from inside the body to a video monitor,
giving the surgeon a close-up view of the organs and tissues. The surgeon watches the monitor and performs
the operation by manipulating the surgical instruments through the operating ports.
  A scalpel is used to make a small incision at the umbilicus. Using either a Veress needle or Hasson technique the
abdominal cavity is entered. The surgeon inflates the abdominal cavity with carbon dioxide to create a working
space. The camera is placed through the umbilical port and the abdominal cavity is inspected.
 Additional ports are placed inferior to the ribs at the epigastric, midclavicular, and anterior axillary positions. The
gallbladder fundus is identified, grasped, and retracted superiorly. With a second grasper, the gallbladder
infundibulum is retracted laterally to expose and open Calot's Triangle (the area bound by thecystic artery, cystic
duct, and common hepatic duct).
 The triangle is gently dissected to clear the peritoneal covering and obtain a view of the underlying structures.
The cystic duct and the cystic artery are identified, clipped with tiny titanium clips and cut. Then the gallbladder
is dissected away from the liver bed and removed through one of the ports. This type of surgery requires
meticulous surgical skill, but in straightforward cases can be done in about an hour.
Discharge planning
Medications: OPD:
Take home meds: Comply to the date of follow-up check up
Cefuroxime 500mg TID Diet:
Mefenamic acid 500mg BID On DAT
Exercise Advice to eat small meals frequently
Encourage patient to have mild exercises to contribute Encourage to drink at least 8 glasses of water a day
to his speeding recovery Avoid salty and fatty foods.
   
Treatment: Spirituality:
The treatment that is done for the patient is the Have time to go to the church.
introduction of oral medications such as
Cefuroxime to reduce the risk for infection and
Mefenamic Acid to relieve pain.
 
Health Teaching:
Encourage to increase fluid intake
Advice proper wound care to avoid any infections
Encourage early ambulation to facilitate healing
Instruct to maintain appropriate nutritional
requirements
Teach about their medications and their actions
Instruct patient to report any symptoms of jaundice,
dark urine, pruritus or signs of infections
Emphasize the importance of follow- up check- ups.
 
Bibliography
 
1. T.r. Harrison (2008) . Harrison’s Principle of Internal
Medicine
mcgraw-hills companies. Inc. USA.
2. S.gorge (2008). Nurses Drug Handbook
Thompson del mar learning inc. New York
3. D.marilynn, M. marry francis & M. alice (2006). Nurses
pocked guide
Davi’s co. L.A.
4. P. Clavien and J. Baillie (2006) diseases of the
gallbladder and bile ducts, diagnosis and treatment 2nd
edition
Blackwell publishing.