Case Study Format

Kingdom of Saudi Arabia ‫المملكة العربية السعودية‬
Ministry of Higher Education ‫وزارة التعليم العالي‬

University of Tabuk ‫جامعة تبوك‬
Faculty of Applied Medical Sciences ‫كلية العلوم الطبية التطبيقية‬
Department of Nursing ‫قسم التمريض‬
CASE STUDY FORMAT
I. Introduction:
a. short definition of the case
- Scenario: a 19 year old male came to the ER of King Fahad hospital at 9:34am with a complaint of
abdominal and right shoulder pain for 3 days. He localized the pain to his epigastric area and state that it
radiates to his right upper quadrant. He notes that it became markedly worse after eating dinner last night.
- We choose this case because its common here is Saudi Arabia related to the life style of people here and
as a professional nurses we have to encourage the people about healthy life style in order to minimize
much of problems and one of them is Gallbladder stones.
Gallbladder stones : are small stones, usually made of cholesterol, that form in the gallbladder. It becomes
trapped in an opening (duct) inside the gallbladder, it can trigger a sudden, intense abdominal pain.
-Symptoms of gallstones: sudden and rapidly pain in the abdomen
nausea and vomiting -right shoulder pain -jaundice- -fever or chills
b. background of the study: statistics (incidence and prevalence)
in recent studies between 2016 July and 2019 October Saudi Arabia indicates high prevalence and
incidence a 2291 of patients with gallstones (1143 males and 1148 females). Age range was 40–70
years with a mean of 70.4% [standard deviation (SD) = 55.2] years .52.7% were Saudi citizens. 65% were
female. And 35% male. And 30.6% of patients are under 40 year. 52.5% had diabetes mellitus. 22.4% with
chronic diarrhea.
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II. Patient/Case Presentation

a. assessment:
1- The patient skin and eyes look yellow.
2-The patient have pain in the upper right quadrant of the abdomen ((pain scale:8/10))
3-The patient reports pain in right shoulder and back. ((5/10))
4- Vomiting
5- Abdominal disturbances such as: gases and heartburn.
6- General decrease in appetite
7- Vital sign: T-37.1 RR – 20 BP- 115/60 P- 110 Pain ((8/10))
b. demographics:
Age: 19Y ((25/1/2002)) - Nationality: Saudi and he lives in Tabuk
c. lifestyle:
plays football in weekend- Nonsmoker-Unhealthy diet-Under weight ((BMI-17.6))
d. family history:
No family history of related diseases
e. Medical History:
b.1. past history: no history of illness
b.2. present history: Cholelithiasis - Jaundice
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III. Anatomy and Physiology:

Anatomy of the Gallbladder
The gallbladder is a hollow organ that sits beneath the liver and stores bile made in the liver. In adults, the
gallbladder measures approximately eight centimeters (3.1 in) in length and four centimeters (1.6 in) in
diameter when fully distended.
An illustration of the gallbladder from Gray's Anatomy with with its sections labeled: fundus, body, and
neck.
The gallbladder, labeled: An illustration of the gallbladder from Gray’s Anatomy with each section labeled.
The gallbladder is divided into three sections:
The fundus.
The body.
The neck.
The neck tapers and connects to the biliary tree via the cystic duct, which then joins the common hepatic
duct to become the common bile duct. At the neck of the gallbladder is a mucosal fold where gallstones
commonly get stuck.
Layers of the Gallbladder
There are several different layers of the gallbladder: the mucosa ( epithelium and lamina propria), the
muscularis, the perimuscular, and the serosa.
The epithelium is a thin sheet of cells that is closest to the inside of the gallbladder.
The lamina propria is a thin layer of loose connective tissue, which together with the epithelium, forms the
mucosa.
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The muscularis is a layer of smooth muscular tissue that helps the gallbladder contract and squirt its bile
into the bile duct.
The perimuscular (meaning around the muscle) is a fibrous connective tissue layer that surrounds the
muscularis.
The serosa is a smooth membrane that is the outer covering of the gallbladder.(2)
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Pathophysiology:
Cholelithiasis and Biliary Colic
Cholelithiasis is the term for gallstones in the gallbladder. The stones form as a result of imbalances in the
constituents of bile and in situations of biliary stasis, which is a state where bile is not flowing. Gallstones
are usually classified as cholesterol stones or pigmented stones. Cholesterol stones account for
approximately 80% of stones. They are most often associated with the risk factors remembered by the 4
F’s: female, fat, fertile, and forty. This means that estrogen, obesity, multiparity, and advancing age are all
risk factors. Pigmented stones are broken down into brown and black stones. The black stones are
composed of calcium bilirubinate and are more likely to be seen on radiography. These stones are often
secondary to pathologies that cause hemolysis, which is red blood cell (RBC) breakdown. The metabolized
heme from RBCs causes the increased concentration of bilirubin in bile. Brown stones occur secondary to
infection. While gallstones are normally asymptomatic, a person affected by cholelithiasis may experience
something called biliary colic if a stone becomes lodged in the cystic duct. Biliary colic is characterized by
right upper quadrant pain in response to fatty meals, as the lipids stimulate the secretion of CCK which
causes painful contractions against the stone. (3)
Choledocholithiasis occurs when a gallstone becomes lodged in the common bile duct. The effects of the
lodged stone and subsequent changes in laboratory values are determined by the stone’s location. If the
stone has not traveled far, liver enzymes such as ALP, GGT, AST/ALT, and bilirubin are likely to be
elevated. If the stone has traveled far enough to reach the pancreas, amylase and lipase will become
elevated as a result of pancreatitis.
Brown pigment stones:

Brown pigment stones are formed in bile infected with enteric bacteria that elaborate hydrolytic enzymes:
beta-glucuronidase, phospholipase A, and conjugated bile acid hydrolase. The resulting anions of bilirubin
and fatty acids form insoluble calcium salts, and they are related to juxtapapillary duodenal diverticula and
are the predominant type of de novo common bile duct stones.
Brown pigment stones are composed of calcium salts of unconjugated bilirubin with small amounts of
cholesterol and protein. These stones are often located in bile ducts causing obstruction and are usually
found in conditions where there is infected bile, the obstruction will cause Jaundice.(4)
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Jaundice
You can get jaundice if a gallstone passes out of the gallbladder into the bile duct and blocks the flow of
bile.
Symptoms of jaundice include:
• yellowing of the skin and eyes
• dark brown urine
• pale stools
• itching
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IV. Medical Management l Interventions
a. Medications:
Medication Dose Description Route frequency 1\24 1\26 28/1
Omeprazole 40mg To prevent the heartburn Iv OD Heartburn Heartburn No signs of

decreased decreased heartburn sen
by 50% by 80%
Flagyl 50mg treat the symptoms of Iv TID Vomiting Only nauseaNo experienc
bacterial infections of the and nausea nausea or vo
,stomach, liver
Phenobarbital 30 mg To decrease the plasma IV OD 57.66 Dc to 45.10 Dc to 13.19

bilirubin level in the
.patient
Adol 1g to relieve moderate to Iv BID Pain scale 8 Pain scale 5 Pain is relive
.severe pain out of 10 out of 10
b. Medical interventions:
Laparoscopic gallbladder surgery (cholecystectomy) removes the gallbladder and gallstones through
several small cuts (incisions) in the abdomen. The surgeon inflates your abdomen with air or carbon
dioxide in order to see clearly.
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c. Diagnostic and laboratory tests:

1- Ultrasound scan
-Gallstones can usually be confirmed using an ultrasound scan, which uses high-frequency sound waves to
create an image of the inside of the body.
2- MRI scan
~An MRI scan may be carried out to look for gallstones in the bile ducts.
~This type of scan uses strong magnetic fields and radio waves to produce detailed images of the inside of
the body.
3- Cholangiography
~A cholangiography uses a dye that shows up on X-rays. The dye may be injected into your bloodstream or
directly into your bile ducts during surgery, or by using an endoscope passed through your mouth.
4- CT scan
~A CT scan may be carried out to look for any complications of gallstones, such as acute pancreatitis.
~In this type of scan, a series of X-rays are taken from many different angles.
Nursing care plane:
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Assessment Nursing Goal Interventions Rationale Evaluati

Diagnosis
Subjective Cues: Risk for Goal Statement: Independent: Fully Met:

infection
The patient related After the nursing 1 - Observe the sign of 1 – the patient may have After 35 mi
stated ((the to intervention the infection and inflammation. already an infection and that of interven
wound is itching surgery. patient will identify will worsen the condition. the patient
me and he smells the methods of verbalizes t
a foul smell from preventing 2- Teach the patient on how 2- provides knowledge and wound care
the wound )) infection and home he taking the medications understanding for the patient. methods an
care methods. and how to decrees the risk medication
Objective Cues: for infection. manageme
Objectives:
Wound drainage
3- to prevent the infections
Long Term 3- Wound and skin care.
The dressing sems from happing
Objectives: Partially Me
dirty
4- Encourage adequate 4- will make the immune
after 5 hours of After 5 hou
dietary and fluid intake of system strong and prevent the
nursing interventio
3000ml per day. infection.
intervention the patient infe
Vital signs:
patient will be free risk decrea
Dependent:
T-37.1 from sign of
infection. 5- administer flagyl 50mg IV 5- antibiotic to kill the bacteria.
RR – 20 TID
Short Term
BP- 115/60 Objectives 6- Take wound culture. 6- to determine presences of
bacteria.
P- 110 After 35 minutes of
Unmet:
nursing
intervention the Collaborative:
patient will
7- Teach the family of the 7- To help the patient.
verbalize the
patients wound care.
understanding in
methods of
preventing the
infection.
Assessment Nursing Goal Interventions Rationale Evaluation
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Diagnosis
Subjective Cues: Acute pain Goal Independent: Fully Met:
The patient stated related to Statement: 1 - Monitor the vital sign. 1 – Pain effects the -After 3 hours of
(( I have pain in the surgery. After the vital sign and change nursing
right of my nursing it. intervention the
stomach)) intervention 2- Evaluate pain 2-Provides patient pain scale
the patient regularly (every 2 hrs information about will be decreased to
will be noting characteristics, need for or 4/10.
relieved location, and intensity effectiveness of - After 1 hour of
from pain. (0–10 scale). interventions. nursing
Objective Cues: intervention the
Grimaces. 3-Encourage use of 3- Relieves muscle patent pain scale
Protecting the body relaxation techniques: and emotional will decrease to
part. deep-breathing tension; enhances 6/10.
Vital sign: Objectives: exercises, guided sense of control and
T: 37.1 Long Term imagery, visualization, may improve coping
RR: 20 Objectives: music. abilities.
BP: 115/60 After 3
P: 110 hours of Partially Met:
Pain: ((8/10)) nursing 4- Change the patient 4- May relieve pain
intervention position. and enhance
the patient circulation. Unmet:
pain scale
will be
decreased to Dependent:
4/10 5- Administer adol 1g iv 5- To relieve the
Bid pain.
Short Term
Objectives Collaborative:
After 1 hour 6- Teach the family 6- To prevent anxiety
of nursing about pain relieve and stress coming
intervention measure and prevent. from the family and
the patent prevent elevation of
pain scale pain.
will decrease
to 6 /10
V. Conclusion & Recommendation:
DON-FAMS
In conclusion Cholelithiasis is the term for gallstones in the gallbladder. The stones form as a result of
imbalances in the constituents of bile and in situations of biliary stasis, which is a state where bile is not
flowing. Gallstones are usually classified as cholesterol stones or pigmented stones.
So that the patient came with symptoms such AS localized the pain to his epigastric area and state that it
radiates to his right upper quadrant. He notes that it became markedly worse after eating dinner last night.
So we did intervintions post operative such as Observe the sign of infection and inflammation, - Wound and
skin care. And we did for acute pain such as Encourage use of relaxation techniques: deep-breathing
exercises, guided imagery, visualization, and Change the patient position.
Recommendations for prevention of gallstones
Eat more foods that are high in fiber, such as fruits, vegetables, beans, and peas.
whole grains, including brown rice, oats, and whole wheat bread.
Eat fewer refined carbohydrates and less sugar.
Eat healthy fats, like fish oil and olive oil, to help your gallbladder contract and empty on a regular basis.
Avoid unhealthy fats, like those often found in desserts and fried foods.
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VI. References:
2-https://courses.lumenlearning.com/boundless-ap/chapter/the-gallbladder/
3-
https://www.ncbi.nlm.nih.gov/books/NBK482488/#:~:text=The%20stones%20form%20as%20a,for
%20approximately%2080%25%20of%20stones
4-
https://www.hopkinsmedicine.org/gastroenterology_hepatology/_pdfs/pancreas_biliary_tract/gallstone_dise
ase.pdf
5- https://www.niddk.nih.gov/health-information/digestive-diseases/gallstones/eating-diet-nutrition
DON-FAMS
MADE BY:
NAME Number
1 Emad salman Alamri 391004040
2 Khalid Hassan Alrasasimah 371002956
3 Sultan Nasser Alaedi 391003145
4 Abdulaziz Fayez Alamri 391008436
5 Raed Mohammed Alshehri 391008833
6 Abdullah Sulaiman Alatawi 391003141
7 Meshal Ayid Albalwi 381009267
8 Mohsen Suliman Alatawi 391007836
DON-FAMS

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Kingdom of Saudi Arabia ‫المملكة العربية السعودية‬

Ministry of Higher Education ‫وزارة التعليم العالي‬

CASE STUDY FORMAT

-Symptoms of gallstones: sudden and rapidly pain in the abdomen

nausea and vomiting -right shoulder pain -jaundice- -fever or chills

b. background of the study: statistics (incidence and prevalence)

II. Patient/Case Presentation

1- The patient skin and eyes look yellow.

3-The patient reports pain in right shoulder and back. ((5/10))

5- Abdominal disturbances such as: gases and heartburn.

6- General decrease in appetite

7- Vital sign: T-37.1 RR – 20 BP- 115/60 P- 110 Pain ((8/10))

Age: 19Y ((25/1/2002)) - Nationality: Saudi and he lives in Tabuk

plays football in weekend- Nonsmoker-Unhealthy diet-Under weight ((BMI-17.6))

No family history of related diseases

b.1. past history: no history of illness

b.2. present history: Cholelithiasis - Jaundice

III. Anatomy and Physiology:

The gallbladder is divided into three sections:

Layers of the Gallbladder

Brown pigment stones:

Symptoms of jaundice include:

• yellowing of the skin and eyes

• dark brown urine

IV. Medical Management l Interventions

Medication Dose Description Route frequency 1\24 1\26 28/1

Omeprazole 40mg To prevent the heartburn Iv OD Heartburn Heartburn No signs of

Phenobarbital 30 mg To decrease the plasma IV OD 57.66 Dc to 45.10 Dc to 13.19

c. Diagnostic and laboratory tests:

Nursing care plane:

Assessment Nursing Goal Interventions Rationale Evaluati

Subjective Cues: Risk for Goal Statement: Independent: Fully Met:

Assessment Nursing Goal Interventions Rationale Evaluation

V. Conclusion & Recommendation:

Recommendations for prevention of gallstones

Eat fewer refined carbohydrates and less sugar.

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