Presentation on cholelithiasis

CHOLELITHIASIS

1. CASE PRESENTATION ON  CHOLELITHIASIS BY  Arushi negi M.sc. nursing 1st year

2. Marital status: Married Religion: H indu Date of admission:26/12/2021 Date of discharge: - Diagnosis: Cholelithiasis Surgery (if any): L aparascopic cholecystectomy Date of Surgery: 28-12-2021 Date of interview :03-01-2022 Doctor In-charge: Dr. J.P singh Informant : Patient herself.

3. History of Illness: Chief complaints : patient was having pain in abdomen since last 12 days. History of fever 4-5 days At present :Patient is well , and have pain at surgical site. Present medical history : My patient was having epigastric pain since last 12 days so she visited a nearby clinic at her residence who recommended an ultrasound in which she was diagnosed with cholelithiasis. She was recommended to go for higher facility for which she chose Lal Bahadur Shastri Hospital

4. Past medical history:  Patient is diagnosed with diabetes since last 15 years and was taking treatment from her nearby clinic.She has now stopped taking medications . Past surgical history: Patient has undrgone hernioplasty 5 years back for hiatal hernia nearby in a facility near  her house.

5. FAMILY HISTORY S. No . Name of family members   Age sex Occupation Relation of family Member to patient   Education   Health status   1. Omi devi 67y F House wife Self 3rd Unhealthy 2. Ramprakash 70 y M Farmer Husband 5th Healthy 3. Indrajeet 45 y M Pvt job Son BA Healthy 4. Sushila 40 y F House wife Daughter in law 10th Healthy 5. Rahul 20 y M Student Grandson BBA Healthy 6. Rakesh 18 y M Student Grandson 12th Healthy 7. Monika 44 y F House wife Daughter 12th Healthy 8. Rajeev 46 y M Pvt job Son in law Polytech Healthy 9. Shikha 16 y F Student Granddaughter 10th Healthy

6. FAMILY TREE: Female Male

7. Personal History: No smoking and alchol consumption history. Menstrual history:  Patient attained menarche at the age of 14 yrs , and menopause at 50 yrs ,  She didn’t undergo any checkups during her pregnancy. Had normal vaginal delivery. Dietary habits: She consumes non vegetarian diet. Elimination pattern : She has constipation problem.

8. PHYSICAL EXAMINATION GENERAL APPERANCE: Body build - Endomorph Height- 151 cm Weight- 95 kg Vital signs Temperature - 98.7 F Pulse: 85 b/m Respiration: 18 b/m B.P: 124/96 mmHg

9. Colour of skin: normal Head: Shape and size of skull: well rounded Scalp: free from any lices Face: sagging of skin due to old age Eyes: no abnormality detected.  Eye brow and eyelid: hair evenly distributed , symmetrical Conjunctiva: no abnormality detected. Sclera: slight yellow  in color

10. Ear: External ear: symmetrical Hearing problem: no abnormality detected. Nose: External nares: straight and uniform Mouth and pharynx: Mouth: lips are pink in color Teeth: no discoloration , lacks 3 teeth Tongue: normal

11. Neck: Thyroid gland: no abnormality detected Lymph node: normal Range of motion : No abnormalities. Chest: Breath sounds:  no abnormality detected Lungs: clear

12. Abdomen: Inspection: scars of laproscopic cholecystectomy . Auscultation: no abnormality detected. Palpation: pain on touch Extremities: Upper: no abnormalities Lower: no abnormalities Back: no bed sores.

13. LAB INVESTIGATION: LFT : Bilirubin - 3 mg/dl (0.1-1.2 mg/dl) Direct -0.5 mg/dl (0.0-0.2 mg/dl ) SGPT - 42 IU/L( 5-40 ) SGOT - 41 IU/L(5-40)

14. MEDICATIONS: In my patient: VANCOMYCIN METRONIDAZOLE CIPLOXACIN PANTOPRAZOLE PARACETAMOL MONOCEFTRIAXONE NORMAL SALINE

15. METRONIDAZOLE CHEMICAL NAME DOSE /ROUTE ACTION INDICATION CONTRA-INDICATION SIDE EFFECT NURSING RESPONSIBILITIES METRO NIDA ZOLE TRADE NAME - METROGYL DRUG CLASS - ANTIBIOTICS Adults—500 or 750 milligrams (mg) 3 times a day for 5 to 10 days. Children—Dose is based on body weight and must be determined by your doctor. The dose is usually 35 to 50 milligrams (mg) per kilogram (kg) of body weight per day, divided into 3 doses, for 10 days. Metronidazole interacts with the microbial DNA to break its strand and helical structure leading to inhibition of protein synthesis, degradation, and cell death. Anaerobic bacterial infections.  Amoebiasis  Bacterial vaginosis Trichomoniasis  H. pylori eradication associated with peptic ulcer disease. Acute dental infections. Prophylaxis of post-op anaerobic bacterial infections Hypersensitivity to metronidazole and other nitroimidazoles. Concomitant use with disulfiram within the last 14 days. Coadministration with alcohol or propylene glycol containing products during or 3 days after therapy discontinuation. Pregnancy during the 1st trimester in the treatment of trichomoniasis. Severe neurological disturbances, encephalopathy, convulsive seizures, aseptic meningitis, peripheral and optic neuropathy, paraesthesia; superinfection (e.g. fungal or bacterial superinfection, C. difficile-associated diarrhoea. Blood and lymphatic system disorders: Leucopenia, neutropenia. Cardiac disorders: Chest pain, tachycardia. Ear and labyrinth disorders: Tinnitu Avoid use unless necessary. Metronidazole may be carcinogenic. Administer oral doses with food. report the adverse effects to the physicians.

16. VANCOMYCIN CHEMICAL NAME DOSE /ROUTE ACTION INDICATION CONTRA-INDICATION SIDE EFFECT NURSING RESPONSIBILITIES VANCOMYCIN HYDROCHLORIDE TRADE NAME - VANCOMYCIN DRUG CLASS - GLYCOPEPTIDE ANTIBIOTICS ADULT - 125MG /ORAL 500MG / IV 6 HRLY PEDIA : 40MG/KG /IV BACTERIOCIDAL AND BACTERIOSTATIC IN ACTION ACTS BY INTERFERING WITH CELL MEMBRANES SYNTHESIS IN MULTIPLYING ORGANISMS IN LIFE THREATNING INFECTIONS. IN CLOSTRIDIUM DIFFICILE COLITIS HYPERSENSITIVITY TO VANCOMYCIN PREVIOUS HEARING LOSS USE OF OTOTOXIC OR NEPHROTOXIC AGENTS CNS: Dizziness, nausea Body as a whole: Serious allergic reactions (anaphylactoidreactions) CV: Low blood pressure Respi: Wheezing GI: Indigestion Endo: Hives or itching, Red Man syndrome (due to repid infusion of Vancomycin 1. Administering vancomycin include ensuring a patent IV line, 2. Planning for administration of the preoperative dose as much as two hours before the initial incision is made. 3. Including information about the dose and timing of preoperative vancomycin administration in the surgical time out. 4. Report the adverse effect to physician.

17. DISEASE CONDITION

18. ANATOMY AND PHYSIOLOGY OF GALL BLADDER

19.  Urobilinogen is either excreted in the feces or returned to the portal circulation. If the flow of bile is impeded , bilirubin does not enter the intestine. As a result, blood levels of bilirubin increase resulting increased renal excretion of urobilinogen and decreased excretion in the stool. These changes produce many of the signs and symptoms seen in gallbladder disorders.

20. DEFINTION: Cholelithiasis referes to c alculi, or gallstones, usually form in the gallbladder from the solid constituents of bile; they vary greatly in size, shape, and composition . If gall stones migrate into ducts of biliary tract it is known as choledocholithiasis.

21. TYPES OF GALL STONES :

22. ETIOLOGY:

23. RISK FACTORS

24. PATHOPHYSIOLOGY:

25. CLINICAL MANIFESTATIONS Gallstones may be silent, producing no pain and only mild Gl symptoms. Pain and Biliary Colic  If a gallstone obstructs the cystic duct, the gallbladder becomes distended, inflamed, and eventually infected (acute cholecystitis).  The patient may have biliary colic with excruciating upper right abdominal pain that radiates to the back or right shoulder.  Murphy’s sign - indicator of gall bladder inflammation ( acute pancreatitis ) pain on deep breath when finger on under the liver border at the bottom of the rib cage.

26. Jaundice Found in patient usually with obstruction of the common bile duct.  The bile is absorbed by the blood and gives the skin and mucous membranes a yellow color.  Changes in Urine and Stool Color The excretion of the bile pigments by the kidneys gives the urine a very dark color.  The feces, no longer colored with bile pigments, are grayish (like putty) or clay colored.

27. Vitamin Deficiency Obstruction of bile flow interferes with absorption of the fat soluble vitamins A, D, E, and K. Patients may exhibit deficiencies of these vitamins if biliary obstruction has been prolonged. ( bleeding because of vitamin K )

28. Patient Picture In my patient pain in abdomen, and changes in urine color was observed by patient during the initial stages.

29. DIAGNOSTIC TESTS: Abdominal X-Ray Ultrasonography Radionuclide Imaging or Cholescintigraphy a radioactive agent is administered intravenously (IV). The biliary tract is then scanned, and images of the gallbladder and biliary tract are obtained.

30. Cholescintigraphy

31. Cholecystography An iodide containing contrast is administered 10 to 12 hours before the x-ray study. The normal gallbladder fills with this radiopaque substance. If gallstones are present, they appear as shadows on the x-ray film.

32. Endoscopic Retrograde Cholangiopancreatography ERCP permits direct visualization of structures This procedure examines the hepatobiliary system via a side-viewing flexible fiberoptic endoscope inserted through the esophagus to the descending duodenum .

33. Percutaneous transhepatic cholangiography It invovles injection of dye directly into biliary tract and x-rays are done,

34. Patient Picture In my patient ultrasound was done which identified cholelithiasis of size 45 × 40 × 35 mm. CBC , LFT , KFT was also done.

35. MANAGEMENT: Medical Management: Nutritional and Supportive Therapy The diet immediately after an episode is usually low-fat liquids. These can include powdered supplements high in protein and carbohydrate Cooked fruits, rice or tapioca, non gas -forming vegetables, bread, coffee, or tea may be added as tolerated. The patient should avoid eggs, cream, fried foods, cheese, rich dressings, and alcohol.

36. Pharmacologic Therapy Ursodeoxycholic acid and chenodeoxycholic acid have been used to dissolve small gallstones . It acts by inhibiting the synthesis and secretion of cholesterol, thereby desaturating bile. Six to 12 months of therapy is required in many patients to dissolve stones, and monitoring of the patient for recurrence of symptoms or the occurrence of side effects is required during this time.

37. Nonsurgical Removal of Gallstones Dissolving Gallstones To dissolve gallstones by infusion of a solvent ( mono- octanoin or methy tertiary butyl ether ) into the gallbladder. The solvent can be infused through the following routes: through a tube or catheter inserted percutaneously directly into the gallbladder, through a tube or drain inserted through a T-tube tract to dissolve stones not removed at the time of surgery, endoscopically with ERCP; transnasal biliary catheter.

38. Intracorporeal Lithotripsy A laser pulse is directed under fluoroscopic guidance with the use of devices that can distinguish between stones and tissue. The laser pulse produces rapid expansion and disintegration of plasma on the stone surface, resulting in a mechanical shock wave. Repeated procedures may be necessary because of stone size, local anatomy, bleeding, or technical difficulty.

39. Extracorporeal Shock Wave Lithotripsy Lithotripsy which is a noninvasive procedure, uses repeated shock waves directed at the gallstones in the gallbladder or common tripsy , bile duct to fragment the stones. The waves are transmitted to the body through a fluid-filled bag or by immersing the patient in a water bath. After the stones are gradually broken up, the stone fragments can be spontaneously passed from the gallbladder or common bile duct, removed by endoscopy, or dissolved with oral bile acid or solvents.

40. Surgical Management: Laparoscopic Cholecystectomy Laparoscopic cholecystectomy is performed through a small incision or puncture made through the abdominal wall at the umbilicus. The fiberoptic scope is inserted through the small umbilical incision. Several additional punctures or small incisions are made in the abdominal wall to introduce other surgical instruments into the operative field. A camera attached to the laparoscope permits the surgeon to view the intra-abdominal field and biliary system on a television monitor.

41. The cystic artery is dissected free and clipped. The gallbladder is separated from the hepatic bed and removed from the abdominal cavity after bile and small stones are aspirated. Stone forceps also can be used to remove or crush larger stones.

42. Cholecystectomy Gallbladder is removed through an abdominal incision after the cystic duct and artery are ligated. A drain is placed close to the gallbladder bed and brought out through a puncture wound if there is a bile leak.

43. Small-Incision Cholecystectomy A surgical procedure in which the gallbladder is removed through a small abdominal incision.. If  needed, the surgical incision is extended to remove larger gallbladder stones. Drains may or may not be used. The short length hospital stay has been identified as a major advantage of this type of procedure .

44. Percutaneous Cholecystostomy Under local anesthesia, a fine needle is inserted through the abdominal wall and live edge into the gallbladder under the guidance of ultrasound or computed tomography (CT). Bile is aspirated to ensure adequate placement of the needle, and a catheter is inserted into the gallbladder to decompress the biliary tract.

45. Patient Picture IN MY PATIENT LAPROSCOPIC CHOLECYSTECTOMY WAS DONE ON 28/12/2021

46. Complications: Chronic cholecystitis Acute cholecystitis Choledococholithiasis Gallstone pancreatitis Gallstone ileus Perforation of gall bladder Gallbladder carcinoma

47. Nursing Management: ASSESSMENT NURSING DIAGNOSIS GOAL INTERVENTION IMPLEMENTATION EVALUATION subjective data - mujhe pet me dard hota hai objective data - facial expression acute pain and discomfort related to surgical incision. to reduce pain assess the pain score. promote bed rest provide pillows around incision to relieve pain. encourage relaxation techniques such as deep breathing. encourage walking and using heat pad to ease discomfort. provide analgesics. pain score assed as 3/10 bed rest is promoted extra pillow provided for comfort deep breathing promoted. patient encouraged to walk. patient has slight reduction in pain as 2/10 according to pain score.

48. ASSESSMENT NURSING DIAGNOSIS GOAL INTERVENTION IMPLEMENTATION EVALUATION subjective data - pt told , “mujhe khana khane ka man nahi krta.” objective data - weakness of patient to perform activity. loss of muscle tone imbalanced nutrition :less than body requirements related to inadequate bile secretion. to provide optimal nutritional intake. asess the patient’s nutritional status. encourage patient to have diet rich in carbohydrates and protein and low in fats. encorage patient to follow this diet even after getting discharge for 4-6 weeks. encorage to gradually add the fat to the diet. assess the elimination pattern. patient nutritional status assessed as inadequate. patient was encouraged to eat protein rich food such as daal and low fat food such as oily food. patient enocurage to follow the diet. elimination pattern recorded as patient is having constipation. patient’s nutritional satus is same. patient promises to follow the diet.

49. ASSESSMENT NURSING DIAGNOSIS GOAL INTERVENTION IMPLEMENTATION EVALUATION subjective data - patient told, “ mujhe kuch samajh nahi aa raha hai. objective data - patient looks anxious. deficient knowledge about self care activities related to incision care and dietary medication. to provide knowledge regarding self care routines. asess the knowledge level of patient. educate patient about the medication and their action. educate about the symptoms to report such as jaundice, dark urine , pruritis. edcuate about care of wound. clear all the doubts encourage questioning. knowledge level assessed as low. educated patient about the medication. patient educated about symptoms to look for. patient is educated about wound care. all the doubts were cleared. patient ‘s knowledge has been enhanced.

50. ASSESSMENT NURSING DIAGNOSIS GOAL INTERVENTION IMPLEMENTATION EVALUATION subjective data - mujhe surgery ki jagh par khujli krne ka man krta hai objective data - surgical site is slight red. risk for infection related to surgical site to reduce chances of infection. Assess the condition of surgical site. monitor any signs of infection maintain strict asepsis technique while wound dressing. perform hand hygiene . educate client about precautionary measures. surgical site assessed as free from infection. no signs of infection witnessed. aseptic technique followed for dressing. hand hygiene performed. health education provided. Risk for infection reduced.

51. ASSESSMENT NURSING DIAGNOSIS GOAL INTERVENTION IMPLEMENTATION EVALUATION subjective data - mujhe chalte samay dard hota hai objective data - pain while walking. Impaired physical mobility related to pain at surgical site. to improve physical mobility assess the level of physical mobility. \ assess the barriers for mobility. assess the strength to perform ROM .evaluate need for assitive devices. educate to walk around a little . level of physical mobility is moderate. pain is the barrier for mobility. patient has weakness to perform ROM. no need for assistive devices. patient was encouraged for little walking like going to washroom with the help of family member. patient ‘s physical mobility is still same

52. NURSE’S NOTES

53. Progress notes : Patient is well, general condition is fair . Vitals checked and charted. T- 98.7 F P- 85 b/m R- 18 b/m B.P- 126/84 mmHg All due medications given Health education provided.

54. HEALTH EDUCATION :

55. SUMMARY : Today we dealt with case presntation on cholelithiasis, my patient’s condition, about disease condition, cholelithiasis, risk factors, etiology, clinical manifestations, pathophysiology, lab diagnostics, medcial management, surgical management, nursing process, health education on follow up care.

56. CONCLUSION Calculi, or gallstones, usually form in the gallbladder from the solid constituents of bile; they vary greatly in size, shape, and composition . They are uncommon in children and young adults but become more prevalent with increasing age. If gall stones migrate into ducts of biliary tract it is known as choledocholithiasis.

57. Bibliography: Hinkle Janice L. and Cheever H. Kerry , Brunner and suddhart’s textbook of medical surgical nursing , volume 2 , 13th edition,2014, wolters lkluwer(india) private ltd. pg no - 1391-1401. Patient details from patient file and through data collected on interview basis.