Complete Cholelithiasis Case Analysis
Complete Cholelithiasis Case Analysis
Complete Cholelithiasis Case Analysis
ON
CHOLELITHIASIS S/P CHOLECYSTECTOMY
Prepared by:
BSN 3B (Group 1)
Allyssa Anastacio
December 2021
i. Introduction
Cholelithiasis or commonly known as Gallstones, are hardened deposits of
digestive fluid that can form in the gallbladder. The gallbladder is a tiny organ located
underneath the liver and it holds a digestive fluid known as bile that is released into your
small intestine (Tanaja J. et. al., 2021). Gallstones were claimed to be more common in
women (Female, Fertile, Fat, Fair, and Forty) while for men, ages 60 plus and some risk
factors for gallstones are related to diet, while other factors are not as controllable.
Uncontrollable risk factors are things like age, race, sex, and family history.
in a duct and causes a blockage, the resulting signs and symptoms may include:
Sudden and rapidly intensifying pain in the upper right or center portion of your
abdomen and just below your breastbone, back pain between your shoulder blades,
and pain in right shoulder (Gallstone pain may last several minutes to a few hours) and
nausea or vomiting.
ii. Objectives
The goal of this study is to gain knowledge and to give the appropriate care and
nursing management to the patients who have had an open cholecystectomy using the
Specific Objectives
Cognitive
To analyze all the data given by the patient to make appropriate nursing
management.
Psychomotor
To develop an appropriate nursing care plan to the patient who have had an
open cholecystectomy.
Affective
The study presented is about the patient who have had a successful open
cholecystectomy. This study will guide the nursing students to know how to do
postoperative care of Open Cholecystectomy. The information collected for the study is
limited to the patient's data, medical records, and information provided by the patient
through online interview but still, the patient’s confidentiality will be prioritized. I develop
and design the appropriate nursing care plan and management for the patient based on
the information gathered.
I. Personal Data
A. Demographic Profile
Name: R.L.
Address: P52-16 14th 17th st. VAB, Pasay City
Age: 60 years old
Sex: Male
Civil Status: Single
Religion: Roman Catholic
Birthday: October 22, 1965
Birthplace: Danao Panglao, Bohol
Educational Attainment: Grade 3
Occupation: Construction
Hospital: Our Lady of Peace Hospital
Room and Bed No.: SP-01
Case No.: 21-55998
Attending Physician: Dr. Rolando G. Baria, Dr. Ferdinand C. Distor
Chief Complaint: Pain in right upper quadrant (RUQ)
Medical Diagnosis: Calculous Cholecystitis
Because of this on January 12, 2021, the patient decides to seek medical advice
with the physician. Then the patient had ultrasound (Cholelithiasis) and cbc test (all are
normal findings). The physician advises him to take Ursofalk and Ursodeoxycholic acid
or ursodiol to see if the gallstones will be gone.
But after a months of taking the medication (Ursofalk and Ursodeoxycholic acid
or Ursodiol), the patient returns to the doctor and reports no difference in his symptoms.
As a result, on July 13, 2021, the patient had another ultrasound, which still revealed
Cholelithiasis, therefore the specialist has already advised him to undergo surgery
because the drugs have had no impact on him and the gallstones were bigger than
before.
He began to have pain in his lower back when he was sitting and standing one
month prior to his diagnosis. However, once the patient is able to walk, the pain
subsides. The patient had a cbc taken on November 24, 2021, and the results were
completely normal, but an ultrasound revealed a pleural effusion, necessitating
thoracentesis.
Prior for open cholecystectomy on November 26, 2021, patient was given a
dextrose. November 28, 2021 the patient was discharge from the hospital and was
given medication of Cefuroxime 500mg (1tab, 2x a day) and Mefenamic acid 500MG
(1cp, 4x a day) as need for pain.
The patient did not have the usual childhood diseases such as measles and
chicken pox and stated he has no known food or drug allergies. He also has no history
of injuries or any accidents, no trauma and his mental health is good. But at the age of
49, the patient had a chicken pox. He has no history in injuries or any accidents, no
trauma and his mental health is good.
LEGENDS
C. Family Medical History
Alive
Male
Female
Gallstones
Pleural Effusion
Father Mother
Unknown
D. Sociocultural History
The patient is 2nd among his 2 siblings, He easily have conversation w/ anybody.
He is easy to be with. The patient usually was the one who provides financially for him
and his live-in partner. Sometimes, her wife also contributes to their financial by doing
sideline by doing laundry to their neighbors. Mrs. A.P is residing permanently at Pasay
City for more than 10 years with his live-in partner. Their house is made with mixed
cement/concrete and has 1 floor, 3 bedrooms, 1 main door, 1 window, and 1 bathroom
near the kitchen.
Their water source is Maynilad and their electricity source is Meralco. Their
garbage waste is always collected every day. The patient’s house is 10-minute walk
away from the nearest church and uses jeepneys and tricycle as their transportation
when going to the hospital.
The patient urinates 8–10 The patient urinates still There are no
Elimination Pattern times a day, with yellow urinates 8–10 times a day, changes in patient’s
urine and no discomfort. with yellow urine and no elimination pattern.
Brown color in feces and discomfort. Brown color in
defecates twice a day feces and defecates twice
with no discomfort. a day with no discomfort.
The patient sees himself Since the gallstones were The patient's self-
Self-Perception/ Self a healthy man though he removed and his meal perception pattern
Concept Pattern already knew about his plan was changed, the improved since his
condition and a good patient perceives himself gallstones were
partner to his live-in to be healthier. removed.
partner.
The patient has never The patient still has never Patient’s values and
Values-Beliefs Pattern been involved in any been involved in any beliefs pattern had
religious activities. He religious activities. He still been improved.
only attends church every only attends church every
Sunday and continue to Sunday and his faith to
trust in God and the God increases, since the
power of prayer in their operation to him was
lives. success and was been
paid with the help of other
people.
IV. Concept Mapping
- Final Diagnosis
- Risk factors
- Pathophysiology
Cholesterol
- Nursing Diagnosis Enlarged Gallbladder
gallstones are
(8.0 x 3.0 cm)
- Medication formed
- Serious conditions
- Intervention
Temporary More persistent
- Diagnostic Test
obstruction of obstruction of cystic
the cystic duct duct
Independent:
Noon
- ½ cup steamed rice
- 1 cup fresh spinach
- Sweet Potatoes
-1 pc of Boiled Fish
Dinner
- 1 cup of cereal
-1 medium apple
- Instruct patient to
make a note every meal
of what she ate by
writing it down on a piece
of paper.
Collaborative: