HOLY ANGEL UNIVERSITY Angeles

HOLY ANGEL UNIVERSITY
Angeles City
COLLEGE OF NURSING

In partial fulfillment of the requirements in
Nursing Care Management 104 – Related Learning Experience
Jose B. Lingad Memorial General Hospital
Surgical Ward

A Case Study on:
Cholelithiasis
Submitted By:

GROUP 2 / N-302
Atienza, Elysa M.
Cabrera, Ajay L.
Cruz, Christine Joy M.
Estacio, Kristine Joy P.
Manalang, Sweet Chairmaine V.
Maniulit, Jeffrey Joe A.
Naeg, Achilles Mikael
Paras, John Louie G.
Reyes, Mark Myco M.
Sarmiento, Lissette P.

Submitted To:
Mrs. Hazel Alcantara, RN, MAN
Mrs. Maritess Tejada, RN, MAN

Date of Submission:
February 17, 2012

I. I N T R O D U C T I O N

1. Description of the disease
The gallbladder is a pear-shaped organ which aids in the digestive process. Its function is to store and concentrate bile – a digestive liquid continually secreted by the liver. The bile in turn emulsifies fats and neutralizes acids in partly digested food. Despite its importance in the digestion of fat, many people are unaware of their gallbladder. Fortunately, the gallbladder is believed to be an organ that people can live without. Perhaps, this fact contributes to the laxity of the majority. The gallbladder tends to be taken for granted – ignored of the proper care and conditioning. Lifestyle together with heredity, sex, race and age are just some factors that leave a room for gallbladder complications to occur.

One of these complications that affect the gallbladder is the presence of stones which is called Cholelithiasis. As defined by some authors, Cholelithiasis is the presence of stones in the gallbladder or bile ducts. It came from the word “chole” which means bile, “lithia” which means stones, and “sis” which means process. Gallstones are small, hard deposits, primarily made up of cholesterol, calcium salts, and bile pigments called bilirubin, that form in the gallbladder. They usually remain asymptomatic initially. They start developing symptoms once the stones reach a certain size (>8 mm). A main symptom of gallstones is commonly referred to as a gallstone “attack”, also known as biliary colic, in which a person will experience intense pain in the upper abdominal region that steadily increases for approximately 30 minutes to several hours. Often, attacks occur after a particularly fatty meal and almost always happen at night. Other symptoms include abdominal bloating, intolerance of fatty foods, belching, gas and indigestion. Gallstones are diagnosed through a thorough physical examination and a series of diagnostic tests.

2. Reasons for choosing the case
The presenting case seized the interest of the student nurses and thus, motivates them to pursue with the case study. Moreover, they would like to give credit and to know more of the nature and function of the gallbladder. Much often this small organ is not given importance. Thus they are in a pursuit for knowledge to be able to impart it to others. This case is quite interesting since it does not always affect only females and elderly. It can affect everyone. It can be alarming since many people are confused and unaware of the symptoms presented.

As teen-agers living in a fast-phased world and governed by schedules, they too are predisposed to lifestyle modification – especially diet and food preferences which can contribute to the disease. With this study, the student nurses hope to apply their learning in taking care not only of their patients but also of themselves.

As nursing students and future nurses, they would want to understand and appreciate more on what is happening to a patient with Cholelithiasis. Consequently, they are interested on what will be the necessary management that will be given. With well-established data supported by facts from literature and sample patient case, the group will be able to share the information to the public and note the important implications of such condition in the delivery of effective care in the near future.

3. Statistics (Local and Global)
Cholelithiasis is less common among individuals from sub-Saharan Africa and Asia. It affected 20.5 million people (1988-1994) with record of 1,077 deaths in 2010. Hospitalizations total up to 636,000 in the same year and over 500,000 have undergone choletestectomies. In the Philippines alone, an extrapolated prevalence of 5,073,040 are affected by the disease last 2010.

4. Objectives (Nurse-centered)
After 2 days of student nurse-patient interaction and completion of this case study, the student nurses will be able to:
* Gather significant data from the patient’s chart which includes the doctor’s orders, laboratory exams, etc. in order to have complete information about the patient’s current condition.
* Research on the anatomy and physiology of the client’s affected system.
* Research on the possible causes and also the symptoms the patient experienced that may suggest the current condition of the patient.
* Research and understand the disease process of the patient’s illness.
* Define the disease condition, its signs and symptoms, risk factors, pathophysiology, and its underlying complications.
* Determine and interpret the medical management employed including laboratory and diagnostic procedures.
* Identify and study the drugs prescribed to the patient which affects the patient’s current situation.
* Provide recommendations in managing the illness.
* Create plan of care that is conducive for the patient.
* Establish a harmonious relationship with the patient and the family members.
* Integrate all the knowledge learned during the course of the accomplishment of the case study.

II.
N U R S I N G A S S E S S M E N T
1. Personal History
a. Demographic Data
Patient C is a 60-year old natural born Filipina and was born on April 3, 1950. She is married to a 72-year old man named Husband D and is a mother of six offspring namely Miss Q (35 years old), Miss R (34 years old), Miss S (32 years old), Mister T (30 years old), Mister U (26 years old), Mister V (19 years old), respectively. Only Miss Q and Mister V were delivered in the hospital via normal spontaneous delivery. The rest of the children were delivered at home. The family is currently residing at Calulut City San Fernando pampanga. She was admitted in the hospital on January 26, 2012 due to right upper quadrant abdominal pain.

b. Socio-Economic and Cultural Factors
Patient C is a plain housewife who is married to a retired utility worker in DSWD. Among their children, only Miss Q and Mister T do not reside with them. Patient C owns and runs a “sari-sari store” to suffice their needs. From there, she gets their daily expenses and their payment for monthly electric and water bills. She earns around five hundred to six hundred pesos daily.

Patient C graduated elementary at San Antonio School. Also, she is affiliated with the Roman Catholic religion; however the family seldom goes to church. In terms of health, Patient C believes in albularyo and herbal medicines such as “oregano” and “lagundi”. She usually uses such herbal medicines for minor illness like cough and colds. Patient C is the one who buys and cooks for their food. She is fond eating with fatty foods such as crispy pata, etc. She also chooses meat over other types of food and seldom adds vegetables to their meal since any of her children do not eat these.

Patient C’s sleeping pattern varies because she cannot sleep early because of aging, as stated by her. Concerning her elimination pattern, she is sometimes constipated. As stated by her, there is an interval of three days before she feels an urge to defacate. On the other hand, she urinates 4-5 times a day. Her usual form of exercise is walking and doing the household chores. The family’s primary medium of language is Filipino and Capampangan.

2. Family Health-Illness History

3. History of Past Illness
Patient C had measles at the age of 12 and chickenpox at the age of 6. She usually has colds, on and off coughs, fever and does not have any allergic reaction to any kinds of food and medicine taken. During those times she increases her fluid intake. Only hypertension is the major illness of patient C other than that, she was never hospitalized except when she gave birth for her children.

4. History of Present Illness
Chief Complaint: Right Upper Quadrant Abdominal Pain
One month prior to admission, the patient experienced epigastric pain at first she tolerates it and she limits herself to do strenuous activities in order to decrease the pain she feels. When the pain became more intense she consulted a doctor and an ultrasound was done which revealed presence of stones in her gallbladder. Three days prior to admission, Patient C started to feel pain in the right upper quadrant accompanied with fever. This RUQ pain radiates in her right shoulder as verbalized by her. She also complains of tenderness whenever she touches her abdomen. According to her, though she did not vomit, her abdomen felt bloated. Then, she was admitted at JBL on January 26, 2012 at around 1:00pm.

5. Physical Examination
Nurse – Patient Interaction (January 30, 2012 – 9:00am)
Patient C is conscious and coherent; oriented to time, place and event.
Vital signs taken are as follows:
Temperature: 36.8 C
Pulse Rate: 88 beat per minute
Respiratory Rate: 21 breaths per minute
Blood Pressure: 130/90 mmHg
> Skin:
– with fair skin color
– no edema noted
– dry skin
– skin color evenly distributed except for areas exposed to sun
> Head:
– Rounded
– hair is evenly distributed with no infestation and no dandruff noted
– there were no nodules or masses upon palpation
– with symmetrical facial movements
> Eyes:
– Anicteric sclera
– pink palpebral conjunctiva
– pupils are reactive to light and accommodation
– no discharge noted
> Ears
– Auricles are uniform in color
– symmetrically aligned with outer canthus of the eyes
– presence of wet cerumen noted
> Nose:
– no discharge
– color is uniform and no masses or tenderness upon palpation.
> Mouth:
– Pinkish
– moist lips and buccal mucosa
– presence of dental caries on upper and lower molar teeth

> Neck
– non-palpable lymph nodes
– no masses upon palpation
– no distention of jugular vein
> Thorax and Lungs:
– patient has clear breath sounds
> Abdomen:
– Skin uniform in color and temperature, soft, flabby
– presence of incision on RUQ
> Urinary:
– urinated with a yellow colored urine
> Extremities:
o Upper:
– skin uniform in color
– dry skin
– good skin turgor
– capillary refill of 2 seconds
– pinkish nail beds
o Lower:
– no edema noted
– uniform in color

Nurse – Patient Interaction (January 31, 2012 – 9:00am)
Patient C is conscious and coherent; oriented to time, place and event.
Vital signs taken are as follows:
Temperature: 36 C
Pulse Rate: 95 beat per minute
Respiratory Rate: 19 breaths per minute
Blood Pressure: 130/80 mmHg
> Skin:
– with fair skin color
– no edema noted
– dry skin
– skin color evenly distributed except for areas exposed to sun
> Head:
– Rounded
– hair is evenly distributed with no infestation and no dandruff noted
– there were no nodules or masses upon palpation
– with symmetrical facial movements
> Eyes:
– Anicteric sclera
– pink palpebral conjunctiva
– pupils are reactive to light and accommodation
– no discharge noted
> Ears
– Auricles are uniform in color
– symmetrically aligned with outer canthus of the eyes
– presence of wet cerumen noted
> Nose:
– no discharge
– color is uniform and no masses or tenderness upon palpation.
> Mouth:
– Pinkish
– moist lips and buccal mucosa
– presence of dental caries on upper and lower molar teeth

> Neck
– non-palpable lymph nodes
– no masses upon palpation
– no distention of jugular vein
> Thorax and Lungs:
– patient has clear breath sounds
> Abdomen:
– Skin uniform in color and temperature, soft, flabby
– presence of incision on RUQ
> Urinary:
– urinated with a yellow colored urine
> Extremities:
o Upper:
– skin uniform in color
– dry skin
– good skin turgor
– capillary refill of 2 seconds
– pinkish nail beds
o Lower:
– no edema noted
– uniform in color

III. D I A G N O S T I C A N D L A B O R A T O R Y P R O C E D U R E S
1. Complete Blood Count (CBC)
Laboratory Procedures Indication(s)/ Purposes Date
Ordered / Date Released Result Normal Values used in the hospital(s) Analysis and Interpretation of Results CBC
Used to evaluate the blood and the cellular components of Red Blood Cells (RBC), White Blood Cells (WBC) and platelets.
Date Ordered:
January 26, 2012
Date Released:
January 26, 2012
Hemoglobin The hemoglobin (Hgb) test is used to measure the severity of anemia which is characterized by a low hgb value or polycythemia which is characterized by a high hgb value.
Date Ordered:
January 26, 2012
Date Released:
January 26, 2012 12.9
12.00-16.00 g/dL
The patient’s Hgb is within normal range. Hematocrit
Hematocrit (Hct) test is used to evaluate blood loss, anemia, polycythemia and dehydration.
Date Ordered:
January 26, 2012
Date Released:
January 26, 2012 37.8
37.00-47.00 %
The patient’s Hct is within normal range. WBC count The WBC differential count test is used to assist in determining the presence of infection or inflammation. Date Ordered:
January 26, 2012

Date Released:
January 26, 2012
WBC: 4.4
Segmenters: 50
Lymphocyte: 33
Platelets: 145
4.30-10.00 x 109/L
44.20-80.20 %
28.00-48.00 %
140.00-440.00 x 109/L The patient’s WBC count is within normal range.
2. Whole Gyne Transabdomen Ultrasonography
Diagnostic Procedures Indication(s)/ Purposes Date
Ordered /
Date
Results were released Result Normal Result Analysis and Interpretation of Results Whole Gyne Transabdomen Ultrasonography To examine organs, blood vessels and structures of the body and to identify malposition, malformation, malfunction or the presence of a foreign body.

It is a major diagnostic tool which is used for the examination of the liver, hepatobiliary tract, spleen and pancreas to identify Date Ordered:
January 27, 2012

Date Released:
January 28, 2012 Presence of cholecystolithiases noted. Pancreas, spleen, both kidneys, both ureters, urinary blader and abdominal aorta – normal findings, normal sized anteverted uterus with myomata as prescribed. Thin endometrium. Cervix and both adnexae – unremarkable. The size and shape of the abdominal organs appear normal. The liver, spleen, and pancreas appear normal in size and texture. No abnormal growths are seen. No fluid is found in the abdomen. The diameter of the aorta is normal and no aneurysms are seen. The thickness of the gallbladder wall is normal. The size of the bile ducts between the gallbladder and the small intestine is normal. No gallstones are seen. The kidneys appear as sharply outlined bean-shaped organs. No kidney stones are seen. No blockage to the system draining the kidneys is present. The result of the ultrasound may be related to the stabbing pain that the patient feels in her right upper quadrant region for a month.

3. HBT Ultrasound

Laboratory Procedures Indication(s)/ Purposes Date
Ordered / Date Released Result Normal Values used in the hospital(s) Analysis and Interpretation of Results HBT Ultrasound
Preferred initial screening test as it is usually less expensive, does not use ionizing radiation and is very accurate in detecting gallbladder stones and bile duct and liver dilatation.

Date Ordered
January 27, 2012
Date Released:
January 28, 2012 The liver is enlarged with markedly dilated intrahepatic ducts. It has smooth contour and homogenous perenchymal echopattern. The cystic duct is 10mm with an 11mm shadowing calcification at the proximal segment. The gall bladder measures 102X53 with no luminal mass or stone. The gall bladder wall is thickened (0.36cm) Gallbladder:
Pear shaped saccular structure for bile storage in gallbladder fossa of posterior right lobe 10X4 cm, but depends on volume of bile (normal 40-70 ml)
Wall thickness- 1-2mm has fundus, body, and neck. Obstructed biliary disease with the presence of stones in the cystic duct. Intrahepatic ducts are dilated and gall bladder is distended. Consider Cholelithiasis
4. Other Laboratory Procedures
Laboratory Procedures Indication(s)/ Purposes Date
Ordered, Date Released Result Normal Values used in the hospital(s) Analysis and Interpretation of Results Sugar
(Fasting)
Measure the glucose level of the blood with 8 hours fasting
Date Ordered:
January 28, 2012
Date Released:
January 28, 2012 128
76.36-110.91 mg/d The patient’s Sugar level is increased. Total Cholesterol
The body uses cholesterol to help build cells and produce hormones. Too much cholesterol in the blood can build up inside arteries, forming what is known as plaque. Large amounts of plaque increase your chances of having a heart attack or stroke Date Ordered:
January 28, 2012
Date Released:
January 28, 2012 235.38
0.00-200.00 mg/dL
The patient’s total cholesterol level is increased. Triglycerides
Triglycerides are a type of fat the body uses to store energy and give energy to muscles. Only small amounts are found in the blood. Having a high triglyceride level along with a high LDL cholesterol may increase your chances of having heart disease more than having only a high LDL cholesterol level. Date Ordered:
January 28, 2012
Date Released:
January 28, 2012 135.40
35.40-132.74 mg/dL
The patient’s triglyceride level is slightly increased.

IV. T H E P A T I E N T A N D H I S I L L N E S S
1. Anatomy and Physiology
THE BILIARY SYSTEM
The biliary system consists of the organs and ducts (bile ducts, gallbladder, and associated structures) that are involved in the production and transportation of bile. The transportation of bile follows this sequence:
1. When the liver cells secrete bile, it is collected by a system of ducts that flow from the liver through the right and left hepatic ducts.
2. These ducts ultimately drain into the common hepatic duct.
3. The common hepatic duct then joins with the cystic duct from the gallbladder to form the common bile duct, which runs from the liver to the duodenum (the first section of the small intestine).
4. However, not all bile runs directly into the duodenum. About 50 percent of the bile produced by the liver is first stored in the gallbladder, a pear-shaped organ located directly below the liver.
5. Then, when food is eaten, the gallbladder contracts and releases stored bile into the duodenum to help break down the fats.
Functions of the Biliary System
The biliary system’s main function includes the following:
* to drain waste products from the liver into the duodenum
* to help in digestion with the controlled release of bile
Bile is the greenish-yellow fluid (consisting of waste products, cholesterol, and bile salts) that is secreted by the liver cells to perform two primary functions, including the following:
* to carry away waste
* to break down fats during digestion
Bile salt is the actual component which helps break down and absorb fats. Bile, which is excreted from the body in the form of feces, is what gives feces its dark brown color.
GALLBLADDER
The gallbladder is a small pouch that sits just under the liver. The gallbladder (or cholecyst or gall bladder) is a small non-vital organ that aids in the digestive process and stores bile produced in the liver. It 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.
The adult human gallbladder stores about 50 mL (1.7 US fluid ounces / 1.8 Imperial fluid ounces) 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 in partly digested food. 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.
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.
COMMON BILE DUCT
The common bile duct is a tube-like anatomic structure in the human gastrointestinal tract. It is formed by the union of the common hepatic duct and the cystic duct (from the gall bladder). It is later joined by the pancreatic duct to form the ampulla of Vater. There, the two ducts are surrounded by the muscular sphincter of Oddi.
When the sphincter of Oddi is closed, newly synthesized bile from the liver is forced into storage in the gall bladder. When open, the stored and concentrated bile exits into the duodenum. This conduction of bile is the main function of the common bile duct. The hormone cholecystokinin, when stimulated by a fatty meal, promotes bile secretion by increased production of hepatic bile, contraction of the gall bladder, and relaxation of the Sphincter of Oddi.

CYSTIC DUCT
The cystic duct is the short duct that joins the gall bladder to the common bile duct. It usually lies next to the cystic artery. It is of variable length. It contains a ‘spiral valve’, which does not provide much resistance to the flow of bile.
Bile can flow in both directions between the gallbladder and the common hepatic duct and the (common) bile duct.
In this way, bile is stored in the gallbladder in between meal times and released after a fatty meal.

COMMON HEPATIC DUCT
The common hepatic duct is the duct formed by the convergence of the right hepatic duct (which drains bile from the right functional lobe of the liver) and the left hepatic duct (which drains bile from the left functional lobe of the liver). The common hepatic duct then joins the cystic duct coming from the gallbladder to form the common bile duct.

BILE
Bile, required for the digestion of food, is excreted by the liver into passages that carry bile toward the hepatic duct, which joins with the cystic duct (carrying bile to and from the gallbladder) to form the common bile duct, which opens into the intestine.
Functions of Bile
The bile has two major functions in the body. Firstly, it breaks down the fats that we eat so that our body can utilize them. Without adequate bile we cannot metabolize your fats well which can result in a deficiency of the fat-soluble vitamins (A, D, E and K). We may also have problems digesting the essential fatty acids. Amongst other symptoms we could have trouble utilizing calcium, have dry skin, peeling on the soles of your feet, etc. One way we can tell we have trouble digesting fats is if we have excessive burping that starts shortly after eating a meal that has fat in it. We might feel nauseous or experience gas and bloating.

Secondly, bile is a very powerful antioxidant which helps to remove toxins from the liver. The liver filters toxins (bacteria, viruses, drugs or other foreign substances the body does not want) and sends them out via the bile, which is made in the liver. The pathway of departure is from the liver through the bile ducts and into the gallbladder or directly into the small intestine where it joins waste matter and leaves through the colon with the feces. A healthy liver produces about a quart to a quart and a half of bile daily. Many people with sluggish gallbladders have a tendency towards constipation.
2. Pathophysiology
A. Book-Based
a. Schematic Diagram

a. Synthesis of the Disease
The gallbladder provides an excellent environment for the production of gallstones. In particular, the gallbladder only occasionally mixes its normally abundant mucus and highly viscous, concentrated bile. The constant temperature within the gallbladder also contributes to stone formation by delaying bile emptying, causing biliary stasis.

b.1 Definition of the Disease
Cholelithiasis or cholecystolithiasis are gallstones which are caused by precipitation of substances normally found in bile: cholesterol, bilirubin, bile salts, calcium, lecithin, fatty acids, and water and the electrolytes normally found in plasma. Gallstone formation occurs by concretion (hardening) or accretion (adherence of particles, accumulation) of normal or abnormal bile constituents. When bile is concentrated in the gallbladder, it can become supersaturated with these substances, which then precipitate from 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 stones produces the complications of gallstone disease.

b.2 Predisposing/Precipitating Factors

PREDISPOSING FACTORS
Gender. Women have twice the risk as men of developing cholesterol gallstones because estrogen increases biliary cholesterol secretion. Before puberty this risk is negligible, and beyond menopause the increased risk disappears.
Age. The incidence increases with age. The occurrence is 75% in those over 25 years of age.
Race. Prevalence is greater in Northern Europe and North America than in Asia, lowest in Japan; familial disposition; hereditary aspects
Heredity. Family history alone imparts increased risk, as do a variety of inborn errors of metabolism that lead to impaired bile salt synthesis and secretion or generate increased serum and biliary levels of cholesterol, such as defects in lipoprotein receptors (hyperlipidemia syndromes), which engender marked increases in cholesterol biosynthesis. There appears to be a familial tendency toward the development of cholelithiasis, but this may be related to familial dietary habits (excessive dietary cholesterol intake) and sedentary lifestyles in some families.
Pregnancy. Pregnancy is an independent risk factor for cholesterol gallstones. The risk increases with increasing parity, especially with more than two children. During pregnancy, elevated estrogen and progesterone levels increase biliary cholesterol secretion. Elevated progesterone also inhibits gallbladder contractility. 40% of women develop biliary sludge in their gallbladder and 12% of women form their first stones during pregnancy. The incidence of gallstones is higher in women with multiple pregnancies.

PRECIPITATING FACTORS
Diet (high cholesterol, high calorie, high sodium). Increased intake of calories, refined carbohydrate, cholesterol, and saturated fats has all been postulated to cause cholesterol gallstones. Patients with cholesterol gallstones secrete a greater fraction of dietary cholesterol into bile than do normal subjects.
Medications and Oral Contraceptives. Hypolipidemic agents (clofibrate, gemfibrozil) that lower serum cholesterol by increasing biliary cholesterol secretion increase the risk of cholesterol gallstones by twofold to threefold. Competitive inhibitors of 3-hydroxy-3-methylglutaryl coenzyme A (HMGCoA) reductase (lovastatin, simvastatin, pravastatin) decrease biliary cholesterol saturation. Estrogen and birth control pills alter hormone levels and delay muscular contraction of the gallbladder, causing a decreased rate of bile emptying.
Obesity. Obesity is strongly associated with increased gallstone prevalence. The risk is proportional to the increase in total body fat. Obese people synthesize more cholesterol in both hepatic and nonhepatic tissues, transport it to the liver, and secrete more of it into the bile, leading to bile that is often greatly supersaturated with cholesterol.
Rapid weight loss. Obese patients undergoing rapid weight loss (1-2% of body weight or approximately 1-2 kg/week), either by very low caloric dieting or gastric stapling, have a 25-40% chance of developing gallstones within 4 months. During rapid weight loss, biliary cholesterol saturation increases acutely as cholesterol is mobilized from adipose tissue and skin and secreted into bile. Clients on sudden weight reduction diets that are low in fat will cause the bile to pool in the gallbladder, increasing the risk for gallstone formation.
Spinal Cord Injury. Patients with spinal cord injury have 10% incidence of forming gallstones within the first year after injury. This high risk, which is 20 times normal, is believed to be secondary to abnormal gallbladder motility and probably biliary hypersecretion of cholesterol from the progressive reduction in body mass.
Primary Biliary Cirrhosis. Patients with primary biliary cirrhosis have an increased prevalence of gallstones. Stone analysis has not been performed, but the elevated cholesterol saturation of bile in these patients suggests that they form cholesterol stones.
Diabetes Mellitus. Despite obesity and increased total body cholesterol synthesis and decreased gallbladder motility seen in patients with diabetes, diabetes mellitus itself does not appear to be an independent risk factor for cholesterol gallstone disease.
Hemolytic Syndromes. Inherited hemolytic anemia, sickle cell disease, sphericytosis, thalassemia, chronic hemolysis associated with artificial heart vavles, and malaria dramatically increase the risk of pigment stone formation because of increased biliary secretion of total bilirubin conjugates, especially bilirubin monoglucoronide, at the expense of the bilirubin diglucuronide, the predominant conjugate in healthy individuals.
Ileal Disease, Resection and Bypass. Patients with ileal dysfunction have a strikingly increased risk for developing gallstones. Gallstones develop in 30-50% of patients with ileal Crohn’s disease; the risk correlates positively with the extent and duration of ileal dysfunction, although ileal disease or resection leads to cholesterol supersaturation and cholesterol stone formation in some patients, careful studies now show that most patients with ilieal dysfuncyion form black pigment, not cholesterol stones.
Biliary Infection. Brown pigment stones are frequently found in the intrahepatic bile ducts and are always associated with infection by colonic organisms usually E.coli, or parasitic infestation (Ascaris lumbricoides, or other helminthes). Intraductal stones developing after cholecystectomy are invariable associated with bile stasis, biliary tree infection, and/or retained suture material. Inflammatory debris can form a nidus (point of origin) for stone growth. The related tissue injury may alter the composition of bile by increasing the reabsorption of bile salts and lecithin. Certain organisms may also play a part in stone formation by altering the composition of bile.
Total Parenteral Nutrition. TPN is a powerful risk factor for gallstone formation. Gallstones form during TPN because of decreased gallbladder motility from lack of meal-stimulated cholesystokinin (CKK) release, resulting in increased fasting and residual volumes.

*Combinations of causative factors increase the incidence of stone formation, especially in women. For example, an obese pregnant woman or an obese woman taking birth control pills may be at higher risk.

b.3 Pathologic Changes
Liver cells secrete cholesterol into bile along with phospholipid (lecithin) in the form of small spherical membranous bubbles, termed unilamellar vesicles. Liver cells also secrete bile salts, which are powerful detergents required for digestion and absorption of dietary fats. Bile salts in bile dissolve the unilamellar vesicles to form soluble aggregates called mixed micelles. This happens mainly in the gallbladder, where bile is concentrated by reabsorption of electrolytes and water.

Compared with vesicles (which can hold up to 1 molecule of cholesterol for every molecule of lecithin), mixed micelles have a lower carrying capacity for cholesterol (about 1 molecule of cholesterol for every 3 molecules of lecithin). If bile contains a relatively high proportion of cholesterol and as bile is concentrated, progressive dissolution of vesicles may lead to a state in which the cholesterol carrying capacity of the micelles and residual vesicles is exceeded. At this point, bile is supersaturated with cholesterol, and cholesterol monohydrate crystals may form. Thus, the main factors that determine whether cholesterol gallstones will form are: (1) the amount of cholesterol secreted by liver cells, relative to lecithin and bile salts, and (2) the degree of concentration and extent of stasis of bile in the gallbladder.

Bilirubin, a yellow pigment derived from the breakdown of heme, is actively secreted into bile by liver cells. Most of the bilirubin in bile is in the form of glucuronide conjugates, which are quite water soluble and stable, but a small proportion consists of unconjugated bilirubin. Unconjugated bilirubin, like fatty acids, phosphate, carbonate, and other anions, tends to form insoluble precipitates with calcium. Calcium enters bile passively along with other electrolytes.

In situations of high heme turnover, such as chronic hemolysis or cirrhosis, unconjugated bilirubin may be present in bile at higher than normal concentrations. Calcium bilirubinate may then crystallize from solution and eventually form stones. Over time, various oxidations cause the bilirubin precipitates to take on a jet black color, and stones formed in this manner are termed black pigment stones.

Bile is normally sterile, but, in some unusual circumstances (eg, above a biliary stricture), it may become colonized with bacteria. The bacteria hydrolyze conjugated bilirubin, and the resulting increase in unconjugated bilirubin may lead to precipitation of calcium bilirubinate crystals. Bacterial hydrolysis of lecithin leads to the release of fatty acids, which complex with calcium and precipitate from solution. The resulting concretions have a claylike consistency and are termed brown pigment stones. Unlike cholesterol or black pigment stones, which form almost exclusively in the gallbladder, brown pigment stones often form again in the bile ducts.

Also, when cholesterol gallstones may become colonized with bacteria and can elicit gallbladder mucosal inflammation. Lytic enzymes from bacteria and leukocytes hydrolyze bilirubin conjugates and fatty acids. As a result, over time, cholesterol stones may accumulate a substantial proportion of calcium bilirubinate and other calcium salts, producing mixed gallstones. All these processes of forming black pigment stones, brown pigment stones, and mixed stones lead to cholelithiasis.

After the formation of cholelithiasis, gallstones try to go out of the gallbladder. Because of the attempt to go out of the organ, these stones may cause an obstruction to the common bile duct, also called Choledocholithiasis. It can impede the flow of bile, thus, there is cholestasis. Prolonged interruption in the flow of bile may lead to hepatomegaly or enlargement of the liver. There will also be fibrosis of the liver which may lead to liver cirrhosis.

Moreover, because of the cholestasis brought about by the obstruction of the common bile duct, there will be absence of bile in the duodenum, characterized by indigestion, vitamin A, D, E, K deficiency, and gray stools. Also, there will be increased levels of bilirubin or bile pigments in the circulation. This may cause a person to present jaundice, ecteric sclera, pruritus, and dark colored urine.

On the other hand, the gallstone may also obstruct in the cystic duct. This activates the release of phospholipase from the epithelium of the gallbladder. This enzyme will hydrolyze lecithin into lysolecithin. There will also be disruption of mucous coat of the gallbladder epithelium and damage in the mucosal cells due to detergent action of bile salts. The hydrolization of lecithin and the detergent action of bile salts both contribute to the irritation of the gallbladder wall. This will signal the release of prostaglandins within the gallbladder wall and result to acute cholecystitis. The person now may experience biliary colic, tenderness, Murphy’s sign, nausea and vomiting, fever, elevated WBC, anorexia. Chronically, gallstones may cause progressive fibrosis of the gallbladder wall and loss of gallbladder function, termed chronic cholecystitis.

During the acute phase of cholecystitis, the person may undergo cholecystectomy or take ursodeoxycholic acid. If not treated, overgrowth of colonizing bacteria in the gallbladder often occurs, and, in severe cases, accumulation of pus in the gallbladder, termed gallbladder empyema, occurs. The external surface of the gallbladder becomes scarred and layered by fibrinous exudates and become distended. All of these will result to edema, hemorrhage, and suppuration of the gallbladder wall. This causes the compression of blood vessels which increases the intraluminal pressure of blood vessels. Due to this, blood flow to the mucosa will be compromised and there will be lymphatic stasis leading to ischemia. The gallbladder wall may become necrotic, resulting in perforation and pericholecystic abscess. Occasionally, a large stone may erode through the wall of the gallbladder into an adjacent viscus (typically the duodenum), producing a cholecystoenteric fistula. The stone, if sufficiently large, may obstruct the small intestine, usually at the level of the ileum, a phenomenon termed gallstone ileus. As the intestine becomes congested, its ability to absorb food and fluids decreases. The blood supply to the affected portion of the intestine will also be cut off. This results to ischemia, necrosis, followed by perforation in the intestinal wall. This perforation, together with the pericholecystic abscess cause generalized peritonitis. If not properly managed, will lead to sepsis, then septic shock (fever, chills, tachycardia may be experienced) and eventually death.

b.4 Signs and Symptoms
Biliary Colic/ Moderate to Severe Pain. The most common symptom is in pain the right upper part of the abdomen or epigastrium. This can cause an attack of abdominal pain, called biliary colic, which: develops quickly, is severe, and lasts about one to three hours before fading gradually. The pain may radiate to the back, right scapula or shoulder. The pain often begins suddenly following a meal. The pain of biliary colic is caused by the functional spasm of the cystic duct when obstructed by stones, whereas pain in acute cholecystitis is caused by inflammation of the gallbladder wall.
Tenderness. Palpation of the abdomen frequently elicits localized tenderness in the right upper quadrant which is associated with guarding and rebound tenderness.
Murphy’s Sign. The patient with acute inflammation of the gallbladder might have a positive Murphy’s sign, which is inspiratory arrest during deep palpation in the right upper quadrant.
Nausea and Vomiting. These signs and symptoms may accompany a gallbladder attack. Pain is usually accompanied by nausea and vomiting.
Fever and chills. Gallstones sometimes get trapped in the neck of the gallbladder and can cause persistent pain that lasts more than several hours and is accompanied by fever, also due to the irritation and inflammation of the gallbladder wall. Fever occurs in about one third of people with acute cholecystitis. The fever tends to rise gradually to above 100.4° F (38° C) and may be accompanied by chills.
Loss of appetite and Anorexia. The pain often begins suddenly following a large or rich meal. People tend not to eat, especially fatty or oily foods, in order not to experience that pain. Fat absorption is also impaired for the lack of bile salts; as a result, rapid loss of weight and anorexia can occur.
Jaundice, Icteric sclerae, pruritus, dark colored urine. These signs and symptoms occurred due to increased levels of bilirubin/bile pigments in the circulation. Bile pigments go to different parts of the body and can be evident through yellowish pigmentation of these body parts: eyes (jaundice, ecteric sclera), skin (pruritus)
Indigestion. This occurs because the fats are not digested and absorbed, thus the person may experience feeling of fullness, bloating, and nausea.
Vitamin A,D,E,K deficiency. bile/bile salts have detergent action that digest/absorb dietary fats. Vitamins ADEK are fat soluble vitamins that with the absence of bile, they cannot be absorbed and used by the body.
Gray stools. bile gives color to the fecal material, therefore, if there is no bile present in the duodenum, the patient may manifest gray stools.

B. Client-centered
a. Schematic Diagram

b. Synthesis of the Disease
b.1 Definition of the Disease
Cholelithiasis or cholecystolithiasis are gallstones which are caused by precipitation of substances normally found in bile: cholesterol, bilirubin, bile salts, calcium, lecithin, fatty acids, and water and the electrolytes normally found in plasma. 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 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 stones produces the complications of gallstone disease.

b.2 Predisposing/Precipitating Factors
PREDISPOSING FACTORS
Gender. Women have twice the risk as men of developing cholesterol gallstones because estrogen increases biliary cholesterol secretion. Before puberty this risk is negligible, and beyond menopause the increased risk disappears.
Age. The incidence increases with age. Less than 5-6% of the population under age 40 have stones, in contrast to 25-30% of those over 80.
Heredity. There appears to be a familial tendency toward the development of cholelithiasis, but this may be related to familial dietary habits (excessive dietary cholesterol intake).

PRECIPITATING FACTORS
Diet (high cholesterol, high calorie, high sodium). Increased intake of calories, refined carbohydrate, cholesterol, and saturated fats has all been postulated to cause cholesterol gallstones. Patient’s meal in a week consists mostly of meat products and minimal amounts of vegetables and fish.

b.3 Pathologic Changes
Liver cells secrete cholesterol into bile along with phospholipid in the form of unilamellar vesicles. Liver cells also secrete bile salts which dissolve the unilamellar vesicles to form soluble aggregates called mixed micelles.

Mixed micelles have a lower carrying capacity for cholesterol. This causes the bile to contain a relatively high proportion of cholesterol. At this point, bile is supersaturated with cholesterol, and cholesterol monohydrate crystals may form. The presence of crystals is a sign of Cholelithiasis.
The cystic duct is also obstructed due to gallstones from the bladder. This obstruction causes the biliary colic due to the spasm of the cystic duct. This condition of the patient was treated with Cholecystectomy (January 29, 2012).

b.4 Signs and Symptoms
Biliary Colic/ Moderate to Severe Pain. The most common symptom is in pain the right upper part of the abdomen or epigastrium. This can cause an attack of abdominal pain, called biliary colic, which: develops quickly, is severe, and lasts about one to three hours before fading gradually. The pain may radiate to the back, right scapula or shoulder. The pain often begins suddenly following a meal. The pain of biliary colic is caused by the functional spasm of the cystic duct when obstructed by stones. The patient experienced RUQ pain three days prior to admission. As verbalized by the patient, the pain also radiates in her right shoulder.
Tenderness. Palpation of the abdomen frequently elicits localized tenderness in the right upper quadrant which is associated with guarding and rebound tenderness.
IV.
T H E P A T I E N T A N D H I S C A R E
1. Medical Management
a. IVF
1. D5LRS
Type of IVF General Description Indication / Purposes Date Ordered, Date Started, Date Changed, Date Discontinued Client’s Response to Treatment 5% Dextrose in Lactated Ringers Solution (D5LRS) Lactated Ringer’s and 5% Dextrose Injection, USP is a sterile, nonpyrogenic solution for fluid and electrolyte replenishment and caloric supply in a single dose container for intravenous administration Used to supply water and electrolytes such as calcium, potassium, sodium chloride
Date Ordered:
January 26, 2012
Date Started:
January 26, 2012
Date Changed
January 26, 2012
Date Started:
January 27, 2012
Date Discontinued
January 27, 2012 No allergies were noted and inflammation on the site of infusion. Intact and infusing well. No pain verbalized by the patient
2.
D5NM
Type of IVF General Description Indication / Purposes Date Ordered Client’s Response to Treatment D5NM
Normosol-M and 5% Dextrose Injection (Multiple Electrolytes and 5% Dextrose Injection Type 1, USP) is a sterile, nonpyrogenic, hypertonic solution of balanced maintenance electrolytes and 5% dextrose injection in water for injection Maintenance of routine daily fluid and electrolytes requirement with minimal carbohydrate calories from dextrose.
-To keep the electrolytes in the body balanced and prevent dehydration
Date Ordered:
January 27, 2012
Date Started:
January 28, 2012
Date Changed
January 28, 2012 No allergies were noted and inflammation on the site of infusion. Intact and infusing well. No pain verbalized by the patient
Drugs
Type of Drugs General Classification and Mechanism of Action Indication / Purposes Date Ordered, Date Started, Date Discontinued Client’s Response to Treatment Generic name:
Etoricoxib
Brand name:
Arcoxia General Classification:
Non Steroidal Anti- Inflammatory Drugs

Mechanism of Action:
Etoricoxib selectively inhibits cyclooxygenase 2 (COX-2).
To treat moderate to severe pain.
Date Ordered:
January 26, 2012
Date Started:
January 26, 2012
Well tolerated and no complaints.

No complaints of adverse reaction and hypersensitivity.
Generic Name:
Ramipril
Brand Name:
Altace General Classification:
Antihypertensive, ACE Inhibitor

Mechanism of Action:
Blocks conversion of angiotensin I to angiotensin II, causing vasodilation, and reduces aldosterone secretion, which prevents water retention. Ramipril also reduces peripheral arterial resistance. Combined, these actions reduce blood pressure. To treat hypertension Date Ordered:
January 26, 2012
Date Started:
January 26, 2012 Well tolerated and no complaints.

No complaints of adverse reaction and hypersensitivity.

The patient’s blood pressure is 120/80 mmHg.

Generic Name:
Cefuroxime Sodium
Brand Name:
Zinacef General Classification:
Antibiotic

Mechanism of Action:
Interferes with bacterial cell wall synthesis by inhibiting the final step in the cross- linking of peptidoglycan strands. Peptidoglycan makes the cell membrane rigid and protective. Without it, bacterial cells rupture and die. Prophylaxis against infections in abdominal surgery. Date Ordered:
January 29, 2012
Date Started:
January 29, 2012
Well tolerated and no complaints.

No complaints of adverse reaction and hypersensitivity.
Generic Name:
Almitrine
Brand Name:
Duxaril General Classification:
Peripheral Vasodilator

Mechanism of Action:
Almitrine causes an increase in the partial pressure of oxygen in arterial blood (PaO2) and an increase in the oxygen saturation in arterial blood (SaO2), without modifying ventilatory parameters. To treat psychobehavioral disturbances associated with cerebral aging. Date Ordered:
January 28, 2012
Date Started:
January 28, 2012

Well tolerated and no complaints.

No complaints of adverse reaction and hypersensitivity.

b. Diet
Type of Diet General Description Indication / Purposes Date Ordered Client’s Response and/or Reaction to the Diet NPO (Nothing Per Orem) NPO orders are nothing per orem diets which means that the patient is not allowed any type of food or drink To assess the client’s lab results without any variance of affected food Date Ordered:
January 26 and 29, 2012 Administration of IVF prevented the patient from dehydration. The pt. cooperates well with the prescribed diet
General Liquid Diet Consist of foods that will pour or are liquid at room temperature. All liquids regardless of its color Patient in the post-operative state, or when the patient is unable to tolerate solid foods. Date Ordered:
January 31, 2012 Client was able to tolerate the fluids without experiencing aspiration. Patient exhibited good hydration status
c.
Exercise
Type of Exercise General Description Indication / Purposes Date Ordered Client’s Response and/or Reaction to the Diet Encourage deep breathing and passive exercise Teaching the patient to breathe deeply at a regular rhythm and rate with efficient depth and duration. Passive exercises are activities that facilitate the use of the client’s joints and muscles with the aid of the nurse as initiation of the movement. To facilitate the expansion of the lungs and passive exercise to let the patient move gradually. Free of the high abdominal incision patient’s underlying gallbladder surgery are at high risk for developing atelectasis following surgery thus major emphasis is given in teaching the patient on how to breathe deeply and cough effectively. Date Ordered:
January 30, 2012 The patient was able to establish a normal breathing pattern AEB adequate expansion of lungs. The patient was able to perform his ADL’s with assistance of the SO. May sit up on bed The client is instructed to turn and reposition bed every 1 to 2 hours during the postoperative period To improve circulation, to prevent venous stasis, thrombophlebitis, respiratory complications and skin breakdown Date Ordered:
January 30, 2012
Patient did not manifest pain in the calf upon dorsiflexion on he foot and maintained skin integrity. May ambulate The patient may be able to move and walk around. It is indicated for Patient C since he undergone surgical procedure and it helped prevent postoperative complications such abdominal distention and to hasten wound healing. Date Ordered:
January 30, 2012
The patient was not able to fully tolerate the activity during the first few days He experienced easy fatigability.
The patient was able to tolerate the activity without undue fatigue. 2. Nursing Management
a. Actual Soapie #1 (January 30, 2012)
S: “Masakit ku panandaman”
O: received pt. lying on bed conscious and coherent with an ongoing IVF of #5 D5NM running at 20 drops per minute, infusing well at left hand at 600 cc level; c dry and intact dressing on the RUQ of the abdomen; pain scale of 7/10; positive facial grimace; with guarding behavior on the right upper quadrant of the abdomen noted; unable to move freely; Vital signs are as follows: T- 36.8 C P- 88 bpm R- 21 bpm BP- 130/90 mmHg
A: Pain R/T surgical incision on the RUQ of the abdomen
P: After four hours of nursing intervention, the patient’s pain will be reduced from 7/10 to 5/10
I: Established rapport
V/s taken and recorded
Pm care rendered
Provided comfort measures such as repositioning
Encouraged use of relaxation technique such as deep breathing
Encouraged diversional activities such as socialization
Encouraged verbalization of feelings about pain
Instructed to avoid spicy foods, caffeinated drinks, and large heavy meals
Promoted bed rest
E: Goal met, as evidenced by patient’s pain scale was reduced from 7/10 to 5/10

b.
Actual Soapie #2 (January 30, 2012)
S: Ø
O: received pt. lying on bed conscious and coherent with an ongoing IVF of #5 D5NM running at 20 drops per minute, infusing well at left hand at 600 cc level; c dry and intact dressing on the RUQ of the abdomen; presence of surgical incision on the RUQ of the abdomen; Vital signs are as follows: T- 36.8 C P- 88 bpm R- 21 bpm BP- 130/90 mmHg
A: Impaired skin integrity related to break in the skin due to surgical incision on the RUQ of the abdomen
P: After four hours of nursing intervention, necessary surgical wound care will be carried out aseptically
I: Monitored and recorded Vital signs.
Provided comfort and safety.
Provided rest periods.
Changed position every two hours.
Stressed out importance of Vitamin C in timely wound healing.
Kept skin dry and intact.
Changed dressing.
E: Goal met, necessary surgical wound care was carried out aseptically
c. Nursing Care Plans
Problem No.1 : Pain
Cues DIAGNOSIS SCIENTIFIC EXPLANATION OBJECTIVES INTERVENTIONS RATIONALE EVALUATION S: “Masakit ku panandaman”

O:
– Guarding behavior on the RUQ of the abdomen noted.
– unable to move freely
– Presence of facial grimaces
– Pain scale of 7/10
Pain R/T surgical incision on the RUQ of the abdomen
Pain arises from the traumatized nerve endings due to the surgical incision on the RUQ of the abdomen. Thus, causing pain. After four hours of Nursing Interventions the patient’s pain scale will be reduced from 7/10 to 5/10
– take and record VS

– Provide comfort measures such as repositioning and changing bed linens

– Encourage diversional activities such as socialization

– Encourage verbalization of feelings about pain
– Instruct to avoid spicy foods, caffeinated drinks, large heavy meals

– Promote bed rest – For baseline data
– To promote comfort and reduce risk for infection

– To reduce tension
– To reduce concern about the condition

– To prevent possible complications
– To prevent fatigue

Problem No.2 : Impaired skin integrity secondary to Cholecystectomy.
Cues DIAGNOSIS SCIENTIFIC EXPLANATION OBJECTIVES INTERVENTIONS RATIONALE EVALUATION S: Ø

O:
– surgical wound on RUQ approximately six inches
Impaired skin integrity r/t break in the skin due to surgical incision in the RUQ Due to the surgical procedure, incision was made on the RUQ of the abdomen, thus, causing the integrity of the skin on it to be impaired. After four hours of nursing intervention, necessary wound care will be carried out.

– Monitor vital sign

– Note changes in skin color, texture, and turgor

– Keep the dressing clean and dry

– Change the dressing every morning
– Serve as a baseline data

-For baseline comparison
– To prevent infection
– To minimize risk for infection or contamination

V. C O N C L U S I O N
Generally, the student nurse’s exposure and duty at the JBL has been a memorable experience to them. The exposure had been an avenue for further development and enhancement of their skills and capabilities in rendering care and promoting holistic wellness to their clients. It reminded them again that nursing profession entails a deep sense of responsibility and challenging tasks.
During the synthesis of this case study, the student nurses has identified and understood the causative factors of cholelithiasis, its signs and symptoms, clinical manifestations, diagnostic studies, medical, pharmacological and nursing interventions through obtaining cues and health history in conjunction to the disease process. They underwent extensive research in order to comprehensively understand her condition. Upon learning her case, it challenged and motivated them to work hard to provide the appropriate and effective nursing intervention and care.
Moreover, eating salty and fatty foods is the most common cause of having gallbladder stones, cholecystitis are secondary from cholelithiasis. Cholecystitis occurs when a stone blocks the cystic duct, which carries bile from the gallbladder. Predisposing factors can include heredity, age, sex and race. With the presented factors that cannot already be modified, one has to take action towards preventing the disease to happen. The only one who can help yourself is you alone. With the proper knowledge about the nature of the disease as well as its preventive measures along with responsibility and sense of will, one can surely direct himself away from the complications.
Our gallbladder is not to be taken for granted. There have been reports that mortality can be as high as 15% for immunocompromised patients.

VI.
R E C O M M E N D A T I O N
For those students who will study cholelithiasis as their case, the researchers suggest that they should know the different causes of the said condition and understand its pathology and how the signs and symptoms manifested. All information from the patient is important because it is a big help for them in accomplishing the study. Nursing history is one of the important information about your patient because you would know how the patient acquired the illness through their lifestyle, family history of illness and the like.
The researchers recommend that awareness and action should be present, through this occurrence of certain disease which is cholelithiasis can be prevented. Thus, healthier lifestyle and habits are encouraged.
VII.
B I B L I O G R A P H Y
BOOKS
* Schnell, J., et al. (2003). Davis’s Comprehensive Handbook of Laboratory and Diagnostic Tests with Nursing Implications. E.A. Davis Company

* Munden, J., et.al. (2007). Lippincott Manual of Nursing Practice Series Diagnostic Tests. Lippincott Williams and Wilkins

* Munden, J., et.al. (2005). Professional Guide to Diagnostic Tests. Lippincott Williams and Wilkins

* Ignatavicius, D., et.al. (2001). Medical-Surgical Nursing: Critical Thinking for Collaborative Care. 5th edition. Elsevier Saunders

* Gould, H., et.al. (2008). Anderson’s Pathology. 10th edition. USA: Mosby

* Porth, C., (2007). Essentials of Pathophysiology: Concepts of Altered Health States. 2nd edition. Lippincott Williams & Wilkins

* Fauci A. et al. Harrison’s Principles of Internal Medicine. 16th edition. USA: The McGraw-Hill Companies

* White, L., et.al. (2003). Medical-Surgical Nursing: An Integrated Approach. Delmar Publishers
INTERNET SOURCES
* https://tspace.library.utoronto.ca/handle/1807/6305
* http://en.wikipedia.org/wiki/Liver
* http://en.wikipedia.org/wiki/Cystic_duct
* http://www.gallbladderattack.com/gallbladder.shtml
Case Study: Cholelithiasis Page 2