Case Presentation Acute Cal

Case Presentation

Acute Calculous Cholecystitis

Presented by:

Esguerra, Krizia Syrene
Esmao, Gerard Louise
Espina, Gwenmae Pearl
Espina, Martin Greimon
Espiritu, Alec
Espiritu, Jessica
Estella, Camille Caridad
Estrella, Gellie Ann
Estrella, Jennifer
Evangelista, Lousel
Faeldan, Marie Angeline
Feji, Carl Anthony
BSN114 Group 55
Presented to:

Mrs. Marilou Choa, RN, MAN
Clinical Instructor

December 02, 2010
FAR EASTERN UNIVERSITY
Institute of Nursing
Case Presentation
Acute Calculous Cholecystitis

I. Introduction

Last November 18, 2010, a group of students with twelve members were assigned to Mrs. Marilou Choa RN, MAN at FEU NRMF to complete their affiliation and to gain lots of new knowledge, and develop their skills and passion on the field of nursing.

Each members of the group were required to submit an individual nursing care plan. We are told that we will be assigned on the station 4A and will handle assigned patients hospitalized on that area.

WHAT IS ACUTE CALCULOUS CHOLECYSTITIS?

II. Objectives

General Objectives:

My general objective is to understand what Acute Calculous Cholecystitis is.

Specific Objectives:

Specifically:

1.) To know what causes to have Acute Calculous Cholecystitis.
2.) To know the anatomy and physiology of the body organ involved in Acute Calculous Cholecystitis
3.) To understand the pathophysiology of Acute Calculous Cholecystitis.
4.) To relate my patient chief complaint on her condition having Acute Calculous Cholecystitis.
5.) To improve ourself on formulating Nursing Care Plans.
6.) To relate the medications and medical procedures done to the patient on her condition of Acute Calculous Cholecystitis

III. Biographic Data

Name: CdC
Address: #114 Oxford Street, Brgy. Faeldani, Quezon City
Age: 36 y/o
Gender: Female
Religious Affiliation: Roman Catholic
Birthday: December 7, 1973
Place of birth: Quezon City
Occupation: Employee
Nationality: Filipino
Marital Status: Married
Admitted: November 22, 2010
Room/Bed No. 316
Chief Complaint: Abdominal Pain
Provisional Diagnosis: Acute Calculous Cholecystitis
Attending Physician: Dr. Arnold Vitug
IV. Nursing History

A. Past Health History

The patient had a chicken pox and measles when she was still a baby, and encountered usual symptoms like cough, colds, and fever. She claims a complete vaccination. During her childhood days, she was hospitalized due to an injury because she accidentally bumps her head at the edge of the table while playing with her sister. Fifteen years ago, the patient was undergone through appendectomy. She denies any allergies in food and medications.

Analysis: The past health history provides a means for detecting any existing problems. The age of the individual must be considered when collecting data. Client’s health beliefs need to be clarified, particularly those beliefs that determine how they perceive control of their own health care status. The past health history an overall summary of the person’s general health to date, including past injuries, allergies, surgical procedures, immunizations, hospitalizations, and obstetric and psychiatric history. The past health information is obtained from the person or the person’s family at the initial interview and becomes part of the permanent record.

Kozier and Erb’s Fundamentals of Nursing 8th Edition Volume 2, pp.283, 285.

Interpretation: The past health history of the client is normal. Individuals have different history with regards to their health.
B. History of Present Illness

Last November 1, 2010, the patient experienced hyperacidity and self medicated with Buscopan and Flanax to relieve pain until she cannot tolerate it and was admitted at FEU NRMF with a chief complaint of abdominal pain last November 22, 2010. According to her, the pain is very severe and continuous. The pain is focused on the Right upper quadrant area and it radiates to the epigastric and back area. Due to the pain felt, she had an intake of mefenamic acid. There is also an episode of vomiting.
C. Family History

GENOGRAM
Legend:
MALE ASTHMA

FEMALE CHOLECYSTITIS

PATIENT
Demographic data:

Name Relationship with the Head of the Family Age Sex Occupation R.dC Head of the family 37 Male Private Employee C.dC Wife 36 Female Government Employee J.dC Eldest Son 11 Male Student C.dC Youngest daughter 6 Female Student
Same with the patient’s case, her mother also underwent through cholecystectomy but cannot recall the year of operation. The father as the head of the family and their eldest son has asthma. Other family members deny any diseases.

Analysis: Persons born into families with a history of certain disease, such as diabetes or cardiovascular disease, are at greater risk of developing these conditions. A detailed family health history, including genetically transmitted disorders, is crucial to the identification of persons and families at risk. These data are used not only to monitor the health of individual family members but also to recommend modifications in health practices that potentially reduce the risk, minimize the consequences, or postpone the development of genetically related conditions.

Kozier and Erb’s Fundamentals of Nursing 8th Edition Volume 2, pp.436

V. Patterns of Functioning

A. Psychological Health

1. Coping pattern

Shopping, treating herself in a spa or salon are her ways of coping mechanisms whenever she encountered problems and trials in her life. other than that, she also stated “Kapag may problema ako minsan, ginugulo ko yung cabinet ko, nilalabas ko lahat ng damit at gamit ko then kapag ok na ako, tatawagin ko ‘yung kasambahay namen para siya ang magligpit”. After doing those things, she feels well and less problematic. Patient stated that she never denies her feelings especially in times that she is down. She opens her feelings to the people significant to her. Furthermore, she verbalized that tries to move on and be better as fast as she can.

Analysis: Coping may be described as dealing with change-successfully or unsuccessfully. A coping strategy or coping mechanism is a natural or learned way of responding to a changing environment or specific problem or situation. Coping strategies vary among individuals and are often related to the individual’s perception of the stressful event.

Kozier and Erb’s Fundamentals of Nursing 8th Edition Volume 2, pp.1068

Stress can have physical, emotional, intellectual, social and spiritual consequences. Usually the effects are mixed, because stress affects the whole person. Physically, stress can threaten a person’s physiologic homeostasis. Emotionally, stress can produce negative or non-constructive feelings about the self. Intellectually, stress can influence person’s perceptual and problem-solving abilities. Socially, stress can alter a person’s relationships with others and spiritually, stress can challenge one’s belief and values.

Fundamentals of Nursing, Kozier and Erbs, Volume 2. page 61

Interpretation: the client’s coping pattern is normal. She has her own coping mechanisms that makes her feel better when she is down. She knows when to spend time with herself to cope and manage things on her own.

2. Interaction Pattern

The patient is very sociable to the people around her and has a good interaction with them. She is very cooperative in all aspects and able to establish good relationship. She is friendly and a good adviser to anyone. Open communication is very important for her and for her family so that, they could express their feelings to each and every one.

Analysis: Culture and social interactions also influence how a person perceives, experiences, and copes with health and illness. Each culture has ideas about health, and these often transmitted from parents children.

Fundamentals of Nursing, Kozier and Erbs 8th edition, Volume 2. page 1006

Interpretation: The Interaction pattern of the patient is normal. The patient is able to have a smooth relationship with the people around him, he follow rules and was able to establish a good relationship with people he encountered.
3. Cognitive Pattern

The patient’s cognitive pattern is suitable for her age. She was graduated with a course of Education and currently studying again in UP Law at the same time, she is a government employee. She is very fluent in speaking both in English and Filipino language. She knows how to read, write and compute.

Analysis: Young Adults (20-40 years old) are able to use formal operations, characterized by the ability to think abstractly and employ logic. Most adults identify strongly with the values and norms of their social group and will act in ways that are consistent with those norms (Pfaffenberger, 2005). They are able to comprehend and balance arguments created by both logic and emotion.

Fundamentals of Nursing, Kozier and Erbs 8th edition, Volume 1. page 394

Interpretation: The cognitive pattern of the client is normal because there is no deviations from the expected competency and characteristics based on her age and developmental level.
4. Self-Concept

She described herself as an outgoing and a happy-go-lucky person. She is not a shy type one because she claimed that she is very sociable to any people. She is very satisfied with her appearance and doesn’t want to change her image and appearance. She stated that she accepts everything that she has and she is contented.
Analysis: Self-concept is one’s mental image of oneself. A positive self-concept is essential to a person’s mental and physical health. Individuals with a positive self-concept are better able to develop and maintain interpersonal relationships and resist psychological and physical illness. An individual possessing a strong self-concept should be better able to accept or adapt to changes that may occur over the lifespan.

Fundamentals of Nursing, Kozier and Erbs 8th edition, Volume 2. page 1004

Interpretation: The client has a positive self-concept and it is normal.
5. Emotional Pattern

She is expressive enough and shows distress and anxiety whenever she has a problem in his life. She is not moody and some coping mechanisms are practiced just to help her lessen her problems. She usually asks for some advices from her husband and friends and able to apply it for her everyday life. As stated, she goes out and shop when she feels down. Most of the time she feels happy and contented with what she have.

Analysis: Young adults face a number of new experiences and changes in lifestyle as they progress to maturity. They make choices about education and employment, marriage and family. They are mature emotionally and mentally. Although changes are evitable, they are directed and have plans to attain contentment and satisfaction.

Fundamentals of Nursing, Kozier and Erbs 8th edition, Volume 1. page 396

Interpretation: the emotional pattern is normal.

6. Sexuality

The patient has a “regular” sexual contact with her husband. According to her, she is satisfied with her relationship with her husband. She is using some contraceptive methods like pills and withdrawals to prevent pregnancy because she does family planning. Two children are enough for her and for her husband.

Analysis: In young adulthood, people begin to initiate intimate relationships with long term implications. Those relationships may take the form of dating, co-habitation or marriage. Young adult men and women are often concerned about normal sexual response for themselves and their partners. Young adults should also be aware that because sexual needs and responses may change, each partner should listen and respond to the needs of the other.

Fundamentals of Nursing, Kozier and Erbs 8th edition, Volume 2. page 1021

Interpretation: The client’s sexual pattern is said to be normal.

7. Family coping

Whenever their family meets a problem whether personal problem of a member or their family per se, they make sure that they make early solution to the problem asking for every member’s opinion. For her, asking one’s opinion is essential for it helps them in solving their problems easily. She verbalized that she reprimands her kids when they commit something that is wrong. She is disciplinarian and a very loving mother. She considers her family as a strong because they can manage their problems and overcome them.

Analysis: Family coping mechanisms are the behaviors use to deal with stress or changes imposed from either within or without. Coping mechanism can be viewed as an active method of problem solving to meet life’s challenges. The coping mechanism families and individuals develop reflect their individual resourcefulness. Families may use coping patterns rather consistently overtime or may change their coping strategies when new demands are made on the family. The success of a family largely depends on how well it copes with the stresses it experiences.

Fundamentals of Nursing, Kozier and Erbs 8th edition, Volume 1. page 435
Interpretation: The family coping of the client is normal.

A. Socio-Cultural Patterns

1. Cultural Pattern

Whenever there are sick members in the family, she buys an OTC drugs like Tempra for fever, and some common medications for cough and colds which are not prescribed by the physician. But sometimes, she asks her brother – a physician, regarding the medications appropriate for a certain disease if one of the members has. She is taking herbal medications like Gingkobiloba. The client stated that she and her family also involve themselves in their local activities like fiestas and organizational activities. It was also emphasized that they practice hospitality and respect for the elders because it is part of their culture.
Analysis: The Filipino cultural orientation is supported by shared values which function as the basis of shared behavior common to most Filipinos. Values have reference to standards people use for evaluating what is right or wrong, good or evil. Values are related to norms which are rules of conduct specific to given social situations.
The Philippine Journal, 5th edition, Vol.1, January 2008

Interpretation: The cultural pattern is considered normal. Since cultures are highly individualized and is shared by the family or any other people with common interest, the culture of the patient is unique per se.

2. Significant Relationship

The patient is married and has two children. She is satisfied with her family and she loves them so much. She is open to her husband and to her children and able to spend more time with them by having a family bonding like going to the mall and watching movies. She shows respect to her husband and to the elders in their family because she wants to be the role model for her kids.

Analysis: The family is the basic unit of society. It consists of those individuals, male or female, youth or adult, legally or not legally related, genetically or not. The traditional family is viewed as an autonomous unit in which both parents reside in the home with their children.

Fundamentals of Nursing, Kozier and Erbs 8th edition, Volume 1. page 429

Interpretation: The significant relationship established by the client is normal.

3. Recreational Patterns

Bonding with her family, relatives, and friends is her form of recreational pattern. Other than that, she spends time for herself like treating herself in a spa or in a parlor and shopping around just to give herself a break from a stressful work in her office. Watching television in their house is also her way of relaxation.
Analysis: Recreation is any activity performed during one’s leisure or free time. Recreational activities are often done for amusement, enjoyment or pleasure and are considered to be fun. Almost any activity can be considered recreational when engaged in during one’s free time.

Reader’s Digest, 2nd Edition, May 2009

Interpretation: the recreational pattern of the patient is normal.

4. Environment

Their environment is good enough for the family. Ventilation is adequate and their house is wide in space. Purified drinking water is their source of drinking. They dispose their garbage regularly and maintains the cleanliness of their house. Although there are some vectors present like mosquitoes, they are trying to eradicate it to avoid any problems in their health.

Analysis: People are becoming increasingly aware of their environment and how it affects their health and level of wellness. Geographical location determines climate, and climate affects health. Ways of living, habits and lifestyle practices affects health.

Kozier & Erbs Fundamentals of Nursing Volume one pg. 301

Interpretation: The environment of the patient is normal. They have an enough space and ventilations in their house.

5. Economic

When it comes to their economic status, they are belong to the high level of the society because they can afford the things needed by their family specially the things needed by their children. The patient is working in Supreme Court and her husband is working in a private company but both of them claimed that their income is not enough for them due to high necessity and expenses. They also allot money for extra-curricular services and have savings for emergency situations. The children are both studying.

Analysis: An individual standard of living is related to health, morbidity and mortality. Hygiene, food habits, and the propensity to seek health care advice and follow health regimens vary among high-income and low-income groups.

Fundamentals of Nursing, Kozier and Erbs 8th edition, Volume 1. page 301

Interpretation: The economic status is stable, no deviations.

B. Spiritual Patterns

1. Religious Beliefs and Practices

As a Roman Catholic, she has a strong faith with God. She believes that God knows everything and only God has the power to cure sick people. She and her family always pray every morning, before and after meals, and every night just to be thankful for all the blessings she received. Attending in a mass every Sunday is also their form of family bonding.

She believes in albularyo and some superstitions but not that much. She stated that “Kung ipapatingin ko sa albularyo, o sige lang, wala naman din mawawala eh”. “Kung may sinasabe sila na bawal ang ganito, bawal ang ganyan, minsan sinusunod ko din, hindi naman din masama kung susubukan”.
Analysis: Many people are aware of the relationship between lifestyle and illness and are developing health-promoting habits. The beliefs and values of each person and the support he or she receives come in large part of the family and are reinforced by the community. Spiritual beliefs can affect a person’s interpretation of events in his or her life and, therefore, an assessment of spiritual well-being is a part of evaluating a person’s overall health.

Kozier and Erb’s, Fundamental’s of Nursing, 8th ed. Vol. 1 pp. 271, 284

Interpretation: It is normal for a person to practice his/her own religious beliefs in to actions. A way of professing one’s faith is through worshipping and so it is acceptable to pray and go to mass every Sunday.

2. Values and Valuing

She values her family so much and they are the most important people in her life. She teaches her children on how to give value and importance to their religion and at the same time, good manners and right conduct are practiced in their family because she wants her children to develop a good personality and attitude. Common values she has are respect, patience and honesty. These things are taught to her by her parents.

Analysis: Values are enduring beliefs or attitudes about the worth of a person, object, idea, or action. Values are important because they influence decisions and actions. Personal values are deriving values from society and subgroups. People need these to feel accepted and have a sense of individuality.
Kozier and Erb’s, Fundamental’s of Nursing, 8th ed. Vol. 1 pp. 80
Interpretation: The values of the client is considered normal.

VI. Activities of Daily Living
VII. Physical Examination
VIII. Laboratory and diagnostics Examinations

ULTRASOUND REPORT
Date: November 22, 2010

Whole Abdominal Ultrasound

The liver is normal in size with mild increase parenchymal echogenicity. No focal mass seen. Intra and extra hepatic biliary are not dilated. Common duct is normal in caliber measuring 3.0 mm.

The gallbladder is distended with mild diffuse wall thickening. There is a 1.3 bright shadowing echo seen embedded within the gallbladder neck and low echoes seen intraluminally. Sonographic Murphy’s sign is elicited.

Pancreas, abdominal and spleen are unremarkable.

Right Kidney – 10.7 x 5.2 cm cortical thickness – 1.6 cm
Left kidney – 10.8 x 4.8 x 4.1 cm cortical thickness – 1.4 cm

Both kidneys are normal in size with good cortico medullary differentiation. No focal mass, lithiasis, or hydronephrosis noted.

The urinary bladder is moderately distended with thin walls. No intraluminal echoes seen.

The uterus is not enlarged, anteverted with no focal mass noted. The endometrium is thin and intact.

Both ovaries are within sizes with several vanished follicles noted.

No adnexal mass noted.

Impression:

Mild fatty liver changes.

Cholecystolithiasis and bile sludge with signs of acute cholecystitis.

Normal sonogram of the bile ducts, punctures, spleen, abdominal aorta, kidneys, urinary bladder, uterus, and adnexae.
November 22, 2010

HEMATOLOGY
RESULT Reference Value
RBC Count 5.33 x 10 12/L F: 4.5 – 5.5 x 1012/L Hemoglobin (Hgb) 15.0 g/dl F: 12 – 14 g/dL Hematocrit (Hct) 0.42 L/L F: 0.37 – 0.47 L/L MCV 79.5 fl F: 82 – 92 fl MCH 28.1 pg F: 27 – 33 pg MCHC 35.4% F: 32 – 38 % Platelet Count 295 x 109L F: 16 – 38 x 109 /L White Blood Cells Count 8.10 x 9 L F: 5 – 10 x 109 /L
Differential Count:

Lymphocytes: 0.24 metanyelocytes
(0.2 – 0.35) (0.00)
Segmenters: 0.67 stabs
0.55 – 0.65) (0.00)
Monocytes 0.05 myelocytes
(0.02 – 0.06) (0.00)
Eosinophils 0.04 Promyelocyte
(0.03 – 0.05) (0.00)
Coagulation Studies
Test: 9.70 sec 139.0 % activity
Control: 11.21 sec
INR: 0.83

CLINICAL CHEMISTRY RESULTS

November 23, 2010
Preference Range Result Electrolytes Potassium 3.50 5.30 mmol/L 3.75
November 22, 2010
Preference Range Result Routine Test Architect
F: 50.40 – 98.0 umol/L 58.0 Liver Profile Albumin 35 – 50 g/L 38.0 Direct Bilirubin (B2) 0.00 – 8.6 umol/L 1.04 Indirect Bilirubin (B1) 3.4 – 11.90umol/L 2.26 SGPT / ALT TC – Matrix 10 – 40 U/L 21.0 ALP TC – Matrix 32 – 92 U/L 65.08 Electrolytes Sodium 135 – 148 mmol/L 140.5 Potassium 3.50 – 5.30 mmo;/L 3.17

URINALYSIS

MACROSCOPIC (PHYSICAL EXAMINATION AND CHEMICAL SCREENING)

Color: Light Yellow
Character: Slightly
Blood: +1
Bilirubin: Negative
Urobilinogen: Normal
Ketone: Negative
Protein: Negative
Nitrite: Negative
Glucose: Negative
pH: 6.5
Specific Gravity: 1.010
Leukocytes: Negative

MICROSCOPIC
Casts: Hyaline Cast = 0.1 / lpf
Crystals: none
Pus Cells: 1-2 / hpf
RBC: 2 -4 / hpf
Epithelial Cells: few
A. Urates / Phosphates: few
Bacteria: few
Others:
Renal Epithelial Cells: few

I.
IX. Drug Study
Generic name/Brand Name Classification Dosage Action of the drug Indication Contraindication Adverse effect Nursing responsibility
Ceftazidine
(Zeptrigen)
Antibiotic Cephalosporins
2 grams now then 1 g/vial (-) ANST
Bactericidal: inhibits synthesis of bacterial wall causing cell death.
Low respiratory infection, UTI.

Septicemia intra abdominal infections.
Hypersensitivity to cephalosporins and penicillin

Use cautiously with renal failure, lactation and pregnancy.

Head ache, dizziness, nausea, vomiting, nephrotoxicity,
Avoid alcohol while taking this drug and for three days after because severe reactions often occur.

Report severe diarrhea, difficulty breathing, unusual tiredness or fatigue, pain at injection site.

Pantoprazole
(Pantoloc)

Anti ulcer agent
40 mg TIV OD

Binds to an enzyme in the presence of acidic gastric PH, preventing the final transport of hydrogen ions into the gastric lumen.
Erosive esophagitis associated with GERD.

Decrease relapse rates of daytime and nighttime heartburn symptoms on patients with GERD.
Hypersensitivity
Headache, abdominal pain, diarrhea, hyperglycemia, flatulence
Assess patient routinely for epigastric or abdominal pain and for frank or occult blood in stool, emesis, or gastric aspirate.

Advise patient to report onset of black, tarry stools; diarrhea; or abdominal pain to health care professionals promptly.

Metoclopramide
(Plasil)
Antiemetics
10 mg IV
Blocks dopamine receptors in chemoreceptor trigger zone of the CNS.

Stimulates motility of the upper GI tract and accelerates gastric emptying.
Prevention of chemotherapy-induced emesis.

Treatment of post surgical and diabetic gastric stasis.

Facilitation of small bowel intubation in radiographic procedures.
Hypersensitivity, possible GI obstruction or hemorrhage, history of seizure disorders, pheochromocytoma, parkinson’s disease
Drowsiness, extrapyramidal reaction, restlessness, arrhythmias, HPN, Hypotension, constipation, diarrhea, gynecomastia
Assess patient for nausea, vomiting, abdominal distention, and bowel sounds before and after administration.

Assess for patient for extrapyramidal side effects.

Monitor for tardive dyskinesia.

Instruct patient to take metoclopromide exactly as directed.

May cause drowsiness.
Hyosine N Butyl Bromide
(Buscopan)
Anti cholinergic
10 mg/amp TIV PRN for pain
Inhibits the action of acetylcholine at postganglionic sites located in: Smooth muscle and secretory glands.
Acute GI, biliary, and genitourinary spasm including biliary and renal cholic.
TAB Myasthenia Gravis and mega colon.

Should not be used in patients who have prior sensitivity to Hyosine N Butyl Bromide or any component of
Buscopan.
Tachycardia, urinary retention, allergic and skin reaction, rarely dyspnea.
Monitor intake and output ratios in elderly or surgical patients.

Assess patients routinely for abdominal distention and Auscultate for bowel sounds.

May cause drowsiness.
Ketorolac
(Toradol)
NSAID
30 mg TIV q6 x 4 doses then q6 PRN
Inhibits prostaglandin synthesis, producing peripherally mediated analgesia.

Also has anti pyretic and anti inflammatory properties.
Short term management of pain.
Hypersensitivity; cross sensitivity with other NSAIDS may exist.
Drowsiness, abnormal thinking, dizziness, edema, pallor, oliguria, renal toxicity.
Patients who have asthma, aspirin-induced allergy and nasal polyps are at increased risk for developing hypersensitivity reaction.

Assess for rhinitis, asthma, and urticuria.

Instruct patient on how and when to ask for pain medication.5
X. Pathophysiology
XI. Ecologic Model
XII. Problem Prioritization
XIII. Nursing Care Plan
XIV. Discharge Plan