seminar on cholelithiasis BY SANJANA AAGATE

PRESENTED BY SANJANA AAGATE.

1. CASE PRESENTATION ON CHOLELITHIASIS Sanjana Aagate. M.sc nursing

2. DEMOGRAPHIC DATA Name : Mrs. Rukmini Santosh Patil. Age : 65 yea r Sex : Female Address : Aeroli Religion : Hindu Education : Illiterate Marital status : Married Income : 40,000 Occupation : House wife Ward : SICU Date of admission : 18/3/2024 IP No : 291648 Diagnosis : Cholelithiasis Surgery: Laproscopic Cholecystectomy

3. CHIEF COMPLAINTS 65 yr old, Mrs. Rukmini patil female patient is residing at aeroli came to casualty on 18/03/2024 with the complaints of - 5 days ago 2 episodes of fever, Yellowish discoloration of skin, Itching all over body, 3 episode of vomiting yesterday, Whitish coloration of stool, Generated pain in abdomen According to these signs and symptoms Doctor advised to do CT SCAN, in report there was ‘Gall stone appear as single within gallbladder and is densely calcified’. As per report surgeon advised to do surgery ‘Cholecystectomy’ immediately as the patient has colic pain.

4. Sr no Name of the member Age Sex Relationship with family Marital status Education Occupation Health status 1 Santosh Patil. 69 Male Husband Married Illiterate Farmer Healthy   2 Rukmini Patil. 65 Female Self Married Illiterate House wife Cholelithiasis 3 Karan Patil. 40 Male Son Married Graduate Company Healthy 4 Madhuri Patil. 35 Female Daughter in law Married HSC House wife Healthy 5 Suman Patil. 17 Female Grand Daughter Unmarried 11th Student Healthy 6 Arpit Patil. 14 Female Grand son Unmarried 8 th Student Healthy FAMILY HISTORY:

5. PRESENT MEDICAL HISTORY: Patient has medical history of Diabetes mellitus, Hypertension. Tab. telma 40, Tab. Tenegliptine hydrochloride PRESENT SURGICAL HISTORY: Patients cholecystectomy done.

6. PAST MEDICAL HISTORY Past illness : Hypertension since 3 years, Diabetes Mellitus since 4 years Childhood illness : Nothing significant Allergies : Not allergic to food and drugs Injuries : No any Hospitalization : Not any Other major illness : Nothing significant Immunization : Not completed in childhood Medication : Tab. telma 40, Tab. Tenegliptine hydrochloride

7. PAST SURGICAL HISTORY: Surgeries: Appendectomy 5 years back tubectomy 20 years back Hospitalization: for appendectomy and tubectomy

8. PERSONAL HISTORY Habit : not having any bad habit. Diet : Sh e eats non veg and veg both , 3 meals per day Social interaction : She is social with neighbour and family members Sleeping pattern : Her sleeping pattern is normal sleeps for 7-8 hours a day continuous sleep.

9. ELIMINATION PATTERN : Her bowel pattern is not normal sometimes constipation occurs, whitish colouration of stool, altered bowel pattern was present since 1 month.

10. ENVIRONMENTAL HISTORY Mrs. Rukmini is residing in her own house. It is a flat system having electricity connection, it is ventilated room. They are using tap water supply for drinking and cooking purpose. They are practicing close waste disposal method. Good toilet facility is also available there .

11. SOCIO ECONOMIC HISTORY Client is a member of middle class family and son is the earning member of the family. Monthly income is 40,000/- only. Their living standard is moderate . She is having good relationship with family members and friends .  

12. SR NO. VITAL SIGNS PATIENT VALUE NORMAL VALUE INFERENCE 1 Temperature 98.7 F 98.6 F Normal 2 Pulse 88 b/m 70-80 b/m Normal 3 Respiration 28 b/m 16-20 b/m Increased 4 Blood pressure 150/60 mm of Hg 120/80 mm of Hg Increased 5 Pain 7 0 – No pain Severe pain

13. PHYSICAL EXAMINATION GENERAL OBSERVATION Body Built: Medium Posture: Erect Personal appearance: Poor hygiene GCS: 15

14. ABDOMEN INSPECTIO N : Abdominal wall bulges during inspiration and falls during expiration, Drain present in right upper quadrant to drain the waste bile or blood. Dressing present at drain site and other than that four small dressings of Tegaderm are present on abdomen. PALPATION : tenderness present PERCUSION : Normal, bladder dullness not found, gaseous Distention present AUSCULTATION : Bowel sound is normal. Abdominal Girth: 101 cm

15. SR. NO. INVESTIGATION NAME PATIENT VALUE NORMAL VALUE INFERENCE   Hemoglobin 9.7 gm/dl   13-18 gm/dl Low level 3.  Platelets 236000mm3   150000-450000 mm3 Normal 6.  SGOT   230 U/L   5-40 U/L Increased 7.  SGPT   78 U/L   5-40 U/L Increased 8.  Direct Bilirubin   0.7 mg/dl   0.1-0.4 mg/dl Increased 9.  Creatinine   1.32mg/dl   0.5-1.5 mg/dl Normal 10.  HIV 1 &11 HbsAg Anti Hcv   Non reactive   Normal

16. ANATOMY AND PHYSIOLOGY

17. The gallbladder is a  pear-shaped organ located within the right hypochondrial region of the abdomen .  It is located directly below the liver .  The primary function of the gallbladder is to  concentrate and store bile which is produced by the liver .  About 50% of the bile produced by the liver is first stored in the gallbladder .  When food is in the duodenum, bile flows readily from the liver and gallbladder into the duodenum to help break down the fats .

18. DISEASE CONDITION

19. CHOLELITHIASIS DEFINITION: Cholelithiasis, commonly known as gallstones, is a condition characterized by the formation of solid particles, or stones, in the gallbladder. These stones can vary in size and composition, ranging from small, sand-like particles to larger, pebble-sized formations.

20. Step Description 1. Gallstone Formation - Imbalance in bile components (cholesterol, bile salts, bilirubin)<br>- Supersaturation of bile with cholesterol or bilirubin 2. Nucleation - Precipitation of cholesterol or bilirubin to form solid crystals in bile 3. Growth - Crystals aggregate and grow into gallstones, varying in size and composition (cholesterol, pigment) 4. Stasis - Reduced gallbladder motility or obstruction of bile flow leads to stagnation and concentration of bile, promoting stone growth 5. Inflammation - Gallstones may cause irritation, inflammation, and injury to the gallbladder wall (cholecystitis) or bile ducts<br>- Inflammation may lead to further complications such as infection or pancreatitis 6. Complications - Obstruction of the bile ducts (choledocholithiasis) leading to jaundice, pancreatitis, or cholangitis<br>- Gallstone ileus (obstruction of the small intestine) due to migration of large stones<br>- Empyema or gangrene of the gallbladder in severe cases 7. Chronic Cholecystitis - Recurrent inflammation and irritation of the gallbladder due to chronic presence of gallstones PATHOPHYSIOLOGY:

21. BOOK PICTURE PATIENT PICTURE Imbalance in bile composition: An imbalance in the components of bile, such as cholesterol, bilirubin, and bile salts, can lead to the formation of gallstones. Gallbladder motility issues: Problems with the contraction and emptying of the gallbladder can contribute to the formation of gallstones. Genetic predisposition Obesity Certain medications: Diabetes, liver cirrhosis, medications for blood disorders. Formation of dense calcified gallstone.          Gallstone seen near cystic duct. No genetic history Client has medications continuous for diabetes and hypertension ETIOLOGY

22. BOOK PICTURE PATIENT PICTURE Gall stones: Cholesterol stones: It occurs because of secretion of abnormal bile by the liver Pigment stones: This is the result of bacterial and parasitic infection in biliary tree. types: Black pigment stones found in gallbladder. Earthy brown pigment stone found in common bile duct. 3. Biliary sludge: It means the bile is in a gel form and contains numerous crystals of calcium bilirubinate and cholesterol and glycoprotein.           Dense calcified gall stone present in Gall bladder, i.e it is biliary sludge. TYPES OF GALL STONE:

23. BOOK PICTURE PATIENT PICTURE Pain: pain in the upper right abdomen or between the shoulder blades. Nausea and vomiting: experience nausea and vomiting, after consuming fatty foods. Jaundice: If a gallstone blocks the bile duct, it can lead to jaundice Stool: Whitish or grayish discolouration . Fever and chills Client had colic pain acute in onset, and gradually it gets increased, severe at right upper quadrant. Nausea and vomiting present Gallstone blocked the bile duct. Whitish discolouration of stool. Mild Fever present.   CLINICAL MANIFESTATION :

24. BOOK PICTURE PATIENT PICTURE Cholecystitis Choledocholithiasis Pancreatitis Cholangitis Gallstone ileus No any complication            COMPLICATIONS :

25. BOOK PICTURE PATIENT PICTURE Medical history, Physical examination, CT scan, MRI, Plain X-RAY Ultrasonography Blood tests Oral cholecystography Medical History. Physical Examination CT SCAN 2 D ECHO X-RAY   Blood examination shows increased SGOT and SGPT level and direct bilirubin level due to inflammation and infection present in gall bladder. DIGNOSTIC EVALUATION

26. BOOK PICTURE PATIENT PICTURE Assessment Medical management: Non-surgical management: Medications: Medical dissolution of gallstones by oral chenodeoxycholic acid and ursodeoxycholic acid. Contact dissolution therapy attempted via percutaneous catheters placed in ERCP. Extracorporeal shock-wave lithotripsy to dissolve gallstone fragments. Endoscopic sphincterotomy is attempted at ERCP. Surgery: cholecystectomy Endoscopic procedures: ERCP Laproscopic Cholecystectomy done. MEDICAL MANAGEMENT:

27. NURSING DIAGNOSIS Imbalanced nutrition: less than body requirements related to NBM status secondary to surgery as evidenced by client’s verbalization. Risk for Infection related to malnutrition and cholecystectomy surgery. Surgical site pain related to post operative surgery cholecystectomy. Risk for Impaired Skin Integrity related to imbalanced nutritional status. Activity intolerance related to disturbed physical functioning as evidenced by decreased movement due to presence of drain. Knowledge deficit related to lack of information about medication and diet as evidenced by verbal report. Risk of infection related to drain from surgical site. Administration of spirometry exercise related to avoidance of collapse of lung.

28. DATE MEDICATION DIET TIME NURSES RESPONSIBILITY SIGN 19/3/24 Inj. piptaz 2.25gm Inj. pcm 1gm Inj. pan 40mg Inj. emset 4mg Inj. tramadol Tab. Telma 40 mg Tab. Ivabrad Syp . Lactulose Inj. HAI as per HGT Patient kept on Nil by mouth.           8am         8.30am 9am   10am 11am 11.30 am   11:45am 12pm     Administration of medication is done. Patient is not showing any adverse reaction. History collection is done. Physical examination done. Drain emptying done was 50ml, amount of drain reducing. Abdominal girth checked and recorded, 102cm. HGT checked and recorded RT aspiration continuous. Record and reporting done. Surgical site care done by monitoring surgical dressing, any leakage or pus collection present or not. SANJANA NURSES NOTES:

29. HEALTH EDUCATION: Maintaining healthy weight. Eating balanced diet. Avoiding rapid weight loss. Staying hydrated.

30. BIBLIOGRAPHY: Adult health medical surgical nursing, by Dr. Joginder vati , prabhajot kaur , lakhwinder kaur , Lotus publisher first edition 2022. Lippincot manual of Nursing practice, 10 th edition wolters Kluwer health 2014. Mosby drug guide for nursing students 11 th edition publishing service manager. Pat Joiner. Brunner and suddharth , medical surgical. https://m.net med.com.

31. SUMMARY Here, I summarize my case presentations as, it includes; Client’s demographic data, history collection, physical examination, anatomy and physiology of affected part, disease condition, investigation reports, nursing diagnosis, nurses notes and health education.