PURBANCHAL

UNIVERSITY
NATIONAL ACADEMY FOR
MEDICAL SCIENCES
OLD BANESHWOR, KTM

CASE STUDY ON CHOLELITHIASIS

SUBMITTED TO:
SUBMITTED BY:

MADAM SUMNIMA OLI

PRABITA SHRESTHA

MADAM SHARMILA MAHARJAN ROLL NO: 13

BSN 2 ND YEAR

8 TH BATCH

Date of Submission: 2071/07/13

1
 ACKNOWLEDGEMENT

I would like to express my greatest gratitude to the people who

have helped and supported me throughout my case study. I am grateful
to my teacher for her continuous support for the case study, from initial
advice and contacts in the early stages of conceptual inception and
through ongoing advice and encouragement to this day.

A special thank of mine goes to my colleagues who helped me in

completing the case study and they exchanged their interesting ideas,
thoughts & made this case study easy and accurate.

Last but not the least; I would like to pay my sincere thanks to
patient and patient party for providing every information and support
with such a co-operation without which this case study would not be
possible. I wish to thank my parents for their undivided support and
interest who inspired me and encouraged me to go my own way, without
whom I would be unable to complete my case study. I want to thank my
friends who appreciated me for my work and motivated me and finally to
God who made all the things possible.

- Prabita Shrestha

2
CONTENTS:
S CONTENTS PAGE NO.
N
1 Background 4
2 Objectives of case study 5
3 History taking 6-8
4 Physical examination 9-15
5 Developmental need and task 16
6 Cholelithiasis
 Anatomy and physiology 16-17
 Introduction 17-18
 Aetiology 18
 Pathophysiology 19-20
 Clinical features 21
 Investigations 21
 Findings of investigations 22-23
 Medical management 23
 Surgical management 23-24
 Medicines used in the 24-30
patient 30-33
 Nursing management
7 Summary of client daily progress 33-34
in the hospital
8 Diversional therapies 34
9 Nursing theory 34-35
1 Nursing care plan 36-42
0
1 Discharge planning 43
1
1 Experiences and summary 43-44
2
1 References 45
3
3
BACKGROUND:
As a practical requirement of BSc nursing curriculum under practicum of
Medical Surgical Nursing-I, we were required to do one month of
practicum in the particular hospital. Thus, we had been brought for
practical at Kathmandu Model Hospital, Bagbazar, Kathmandu. During
this practicum periods, we had to select three cases for the case study in
medical unit and in surgical unit and I have selected 1st case of
symptomatic cholelithiasis at surgical ward. This kind of the research
work as well as paper writing and presentation in front of the learned
audience is a part and partial of the course. Hence I selected that case to
study deeply to gain comprehensive knowledge of the disease to provide
holistic care to the patient.

4
OBJECTIVES OF STUDY:
General objectives:

At the end of this case study I will be able to give the complete care to the patient of
symptomatic cholelithiasis according to the need of the patient and help her for the
fast and good recovery and promotion of health in the later life.

Specific objectives:

At the end of this study I will be able to;

 Take significant history of the critical patient relevant to the disease.

 Do through physical examination of the patient.
 Identify developmental need and task of the patient.
 Identify different developmental milestone and dimension of the patient.
 Identify the nursing need of the patient.
 Provide holistic nursing care to patient and application of the appropriate
theory.
 Provide health education based on needs of the patient for the prevention of
complication, promotion and maintenance of health.
 Provide supportive education to the family members for the promotion of
health, prevention of disease, technique of identification of minor and major
illness.
 Provide discharge teaching, plan and provide accordingly.
 Maintenance of therapeutic relationship with patient and family members.
 Describe the treatment plan and schedule, home care and self-care concepts to
the family members.
 Evaluation of care provided to the patient.
5
  Explain to the family about the importance of follow up visit and continuation of
the treatment for the healthy living.

History taking
1. Demographic data:

Date of interview: 2014/07/20

Client’s name: Uma KC

Age: 66 years

Sex: Female

Address: Permanent= Sarlahi

Temporary= Dillibazar

Religion: Hinduism

Education: Illiterate

Occupation:

Marital status: Widowed

Date of admission: 2014/07/20

IPN: 55

Bed no: 402

Ward: Surgical ‘C’

Provisional diagnosis: Symptomatic cholelithiasis

Information obtained from: Patient and her daughter

2. Chief complain: “Indigestion since 2 years”

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 “Abdominal pain at lower region before 1-2 months ago”

“Loss of appetite”

3. History of present illness:

According to the patient, she was apparently well 2 years back. Then, she
gradually developed indigestion of food. She gave the history of 2 years of
indigestion and history of abdominal pain at lower region of abdomen (i.e.
hypogastric region) before 1-2 months ago. She hadn’t taken any medicine for
abdominal pain. Then, she had developed anorexia and diarrhea due to indigestion of
food. She had developed nausea on forceful intake of food. She had water brash and
indigestion was aggravated on fatty meal intake. So, she came to Kathmandu Model
Hospital for the regular check up on 214/07/20 and was provisionally diagnosed as
symptomatic cholelithiasis. She was admitted to the hospital on 2014/07/20.

4. Past medical history:

Yes
Childhood NoYes No
illness/Diseases
Measles 
Mumps 
In adulthood illness, she has a history of Pulmonary Whooping cough 
Tuberculosis 18 years ago. For which she has taken Polio 
ATT for 9 months. Rheumatic fever 
She has a history of gastritis 12 years ago. TB 
a) Allergies = Patient do not have any allergies with Malnutrition 
food, drugs, environment and others. Pneumonia 
b) Medication = She had not taken any medicine at
Others 
home.
c) Past surgical illness = Patient was operated for Adultho
Cataract in 2071/03/03 in Tilganga Eye Hospital, od
Tilganga, KTM. illness
5. Family history:
High BP 
Type of family = Joint family
Heart disease 
Family tree:
Father’s family TB 
Mother’s family Diabetes 
Filariasis 
Malaria 
Cancer 
Asthma 
Allergies 
Others 

55 72 69 68 66 60
Keys:-

Female =

Male =

Patient =

Dead =

No any significant family history as all the relatives of my patient died naturally due
to the old age. But his brother is suffering from DM & hypertension.

Family history of hereditary diseases:-

Diseases Mother’s family

Father’s family
High BP  ×
Diabetes  ×
Cancer × ×
Arthritis × ×
Blood disorder × ×
Cardiovascular problem × ×
Asthma × ×
TB × ×
Psychiatric illness × ×
Others × ×

Personal history:-

A. Place of birth:- Home

B. Childhood immunization:- Yes
C. Personal habits:-
My patient used to smoke before 15-20 years ago.

Cultural Background & practices:-

 Ethnic group: Chettri

 Belief about health and illness: She believes that health is everything and said
that disease attacked her due to her negligence of food habits.
 Health practices: She follows modern health practices.
 Food practices: She is non-vegetarian.

PHYSICAL EXAMINATION
8
1) Record of vital signs and Anthropometric measurement:
Value Weig Heig T P R BP
ht ht
Client’s 75 kg 58 97 F 74 beats/min 26 breathes/min 90/60mm of hg
value cm
Normal 97.6 60-100 15-20 120/80mm of
value F beats/min breathes/min hg
BMI= Weight in kg =75 = 222.9 = obesity

Height (in m2) 582

2) Head to toe examination:

General Appearance:
S Examination Normal Data Abnormal Data Patient’s Findings
N
a. Gait Walk straight Limp His gate was straight
b. General state Cheerful, active Sad, tired, weak Cheerful, weak and
of health and appears appearance appears healthy
healthy
c. Stature, note Very short stature in
the general turner’s syndrome renal
bodily disease, hypo pituitary
proportions (dwarfism), long limps in
and look for Marfan’s syndrome
any
deformities
d. Nutritional Appears well Obese or thin, Appears well
status nourished generalized fat in simple nourished
obesity, truncal fat with
relatively thin limbs in
Cushing’s syndrome
e. Behavior Appropriate Unusual behavior, Appropriate reaction
reaction to the unexpected shaking, to the situation;
situation movements restlessness coperative
f. Cleanliness Good hygiene, Dirty clothes, poorly Good hygiene, clean
clean clothing, well groomed clothing, well
groomed groomed
g. Speech (listen Audible voice Fast speech of Audible voice and
for pace of hyperthyroidism, lack of understandable
speech and its spontaneity in speech
pitch clarity depression, asthma.
and Slow, thick, hoarse voice
spontaneity) of myxedema
9
 Skin:
S Examination Normal Data Abnormal Data Patient’s Findings
N
Inspect the
a. skin The color varying Pallor due to anemia, The color varying
The color. Note from black, brown peripheral cyanosis from black, brown or
the color or fair depending includes anxiety, cold fair depending upon
change all over upon the genetic exposure & venous the genetic factor
the body or in factor obstruction. Central
a localized cyanosis include lungs
area disease, congenital
heart disease
b. Any patches or Skin free of lesions Skin patches, lesion or Skin free of lesions or
lesions or any or abrasions itching present abrasions
evidence if
itching as
shown by
scratching
c. Edema No edema Edema No Edema
d. Excessive No excessive Dryness in No excessive
sweating or moisture or hypothyroidism, oiliness moisture or dryness
dehydration dryness in acne
e. Hair Clean, smooth & Loss of hair, dirty hair, Clean, smooth & dry
distribution, dry hair, color of change in hair, e.g.: fine hair, white color of
color, hair varying from hair in hyperthyroidism hair depending upon
cleanliness black, brown & coarse hair in old age
white depending hypothyroidism
upon genetic
factor, no color
change in the hair
f. The evidence No bleeding, Bleeding, bruising or No bleeding, bruising
of injury bruising or laceration of skin or laceration of skin
laceration of skin
Palpitation
g. Temperature: Warm skin even Generalized warmth in Warm skin even
Feel it with the temperature fever, hyperthyroidism & temperature
back of finger. coolness in
hypothyroidism, local
warmth in inflammation
h. Texture: Feel Smooth, soft skin Roughness in Smooth, soft skin
the skin for hypothyroidism
smoothness
i. Edema: press Quickly depression Depression recovers Quickly depression
10
 the skin with recovers slowly recovers
index & middle
finger & then
leave &
watches the
depression
j. Dehydration: Elastic skin: the Comes back to its Comes back to its
Dehydrated skin quickly comes previous state slowly previous state slowly
skin loses its back to its previous due to his old age.
elasticity, state
check the
elasticity of
skin by
pinching the
skin just below
the clauide in
adults & the
abdomen skin
in children

Lymph node:
S Examination Normal data Abnormal data Patient’s Findings
N
Inspection
a. Redness/enlarge Lymph nodes not Enlargement & redness Lymph nodes not
ment of lymph visible , no redness of lymph nodes visible , no redness
nodes
Palpitation
b. Enlargement and Lymph nodes are Hard, fixed nodes. Lymph nodes are not
tenderness not palpable & Suggest malignancy palpable &
tenderness tenderness
Head:
S Examination Normal data Abnormal data Patient’s Findings
N
Inspection
Scalp:
a. Scaliness, lumps No lumps or other Redness & scaling in No lumps or other
or other lesions lesions seborrnelc dermatitis, lesions
psoriasis. Enlarged skull
in hydrocephalus

11
 Skull
b. General size and No any Hydrocephalous No any deformities,
contour of the deformities, lumps Deformities, lumps and lumps and
skull. Note any and tenderness in tenderness present in tenderness in skull.
deformities, skull. skull.
lumps or
tenderness
Face
c. Involuntary Uniform One side of the face Uniform movement
movement, movement of moves differently from of sides of face, no
edema & masses sides of face, no other side edema & masses.
edema & masses Presence of lump on
forehead due to fall
from window 15
years ago.
Palpation
d. Swelling, No swelling, Swelling, tenderness No swelling,
tenderness and tenderness & and depression tenderness &
depression depression depression
Eyes:
S Examination Normal data Abnormal data Patient’s Findings
N
Inspection:
a. Eyebrow, -Equal distribution -Absent or abnormally -Equal distribution in
eyelashes, in both sides distribution both sides
eyelids, swelling, -No infection, sty -Present infection sty -No infection, sty
conjunctiva, -No swelling, -No swelling, redness
sclera cornea, redness
pupils reaction
to light, visual
fields
b. Accommodation -No bulges -Present swelling, -No bulges
of eyes, visual -Dark pink in color, redness or lesions -Dark pink in color,
problems, use of no redness, -Bulging, staring or no redness,
power lenses paleness, sunken eyes discharge, foreign
discharge, foreign -Pale palpebral body
body conjunctiva indicate -Normal sclera and
-White in color anemia & redness pupil
with few small indicate conjunctivitis -As the torch
blood vessels -Yellow sclera indicates approaches the eye,
-Transparent, no jaundice the pupils constricts
abrasion or white -Cloudy appearance & as the torch is

12
 spot abrasions or white removed the pupils
-Pupils are round & spots dilate
uniform in size & - Irregular size or shape -Poor visual acuity
shape of pupils and uses power
-As the torch -Pupil remain lenses for short &
approaches the constricted even after long sightedness.
eye, the pupils the torch is removed -Lack of
constricts & as the -White, cloudy lens accommodation and
torch is removed extra ocular
the pupils dilate movement due to
- Transparent blurred vision
Ear:
S Examination Normal data Abnormal data Patient’s Findings
N
a. Shape, size, -The top of the pinna -The top of the pinna -The top of the pinna
location, lumps meets or crosses the does not meet meets or crosses the
or masses, eye -Dump or lesion eye
discharge, -No lumps or lesions -Clear blood or yellow -No lumps or lesions
redness, -Smoot rounded discharge, redness, -Smoot rounded
hearing test by outline mass, foreign body, outline
weber & Rinne -No discharge, excessive cerument -No discharge,
test redness, mass or present redness, mass or
foreign body, slight -Perforation, lesion, foreign body, slight
cerument present bulging cerument present
-No perforation, -No perforation,
 Weber test: lesion bulging lesion bulging
-Sound is heard in -Sound is heard in
the midline or equal the midline or equal
 Rinne test: to both ear to both ear
-The sound is heard, -The sound is heard,
longer through air longer through air
than through bore than through bore
SN Examination Normal data Abnormal data Patient’s
Findings
a. Location, size, -Centrally located -Deviated in location -Centrally located
nasal flaring, -Nostrils are uniform -Asymmetrical in size -Nostrils are uniform i
injury, any in size and do not and do not flaring, size and do not flare.
foreign bodies, flare. nostrils. -No polyp or deviation
discharge, -No polyp or -Presence of polyp or -Dark pink mucou
bleeding, deviation. deviation. membrane, n
smelling -Dark pink mucous -Red swollen mucosa of discharge or foreig
membrane, no acute rhinitis, pale bodies.

13
 discharge or foreign mucosa of allergic
bodies. rhinitis.
Nose:
Mouth:
S Examination Normal data Abnormal data Patient’s Findings
N
a. Color and -Pink, moist and -Lips bluish in color, -Pink, moist and
condition of intact skin, no bluish cracks, or ulcers intact skin, no bluish
lips, missing discoloration, cracks present. discoloration, cracks
teeth and ulcers. and ulcers.

b. Hare lips, sore -Symmetrical pink -Asymmetrical, red or -Symmetrical pink

on gums, cleft moist, papillae and pale, dry, papillae or moist, papillae and
palate, sore midline fissure fissure absent. midline fissure
on tongue, present. -Difficulty in swallowing. present.
dental carrier, -No difficulty in -Breath odor of alcohol, -No difficulty in
condition of swallowing. acetone in diabetes swallowing.
oral hygiene, -Neither foul odor mellitus, pulmonary -Presence of foul odor
smell and nor smell. infection.
examination
of different
taste buds
Throat and neck:
S Examination Normal data Abnormal data Patient’s Findings
N
a. Pain, swelling, -No difficulty in -Difficulty in -No difficulty in
difficulty on swallowing. swallowing swallowing.
swallowing -No titling of head. -Titling of head. -No titling of head.
b. Change in -No masses, scars. -A scar of post thyroid -No masses, scars.
voice, -Thyroid gland not surgery may be the -Thyroid gland not
respiratory visible and enlarged. clue to unsuspected visible and enlarged.
c. problems. -No stiffness, swelling hypothyroidism. -No stiffness, swelling
Cough, blood -No tight of neck -Enlarged thyroid -No tight of neck
in sputum, muscles and no gland. muscles and no
condition of tenderness along the -Stiffness and swelling. tenderness along the
thyroid gland, neck. -Muscle tightening, neck.
tenderness, tenderness along the
lumps, neck spine lump along the
rigidity, spine.
enlargement
of tonsils.
Chest (lung & heart):
14
S Examination Normal data Abnormal data Patient’s Findings
N
a. Shape and -Lateral diameter -Barrel shaped chest -Lateral diameter
size masses, (side to side) is wider (increase anterio- (side to side) is wider
lumps, pain than the anterio- posterior diameter) than the anterio-
posterior (front to due to pulmonary posterior (front to
back) diameter emphydema back) diameter
-Funnel shaped chest
characterized by a
depression in the lower
portion of the sternum
-Pigeon chest: sternum
is displaced anteriorly
& increasing anterio-
posterior diameter
b. Auscultate -Breathe sound are -Absent or decreased -Breathe sound are
breathe heard in all area of breathe sound heard in all area of
sounds the lungs - Prolonged expiration the lungs
-Inspiration longer -Inspiration longer
than expiration -Rales, rhonchi, than expiration
-No sales, rhonchi wheezing sounds, -Wheezing sound
wheezing sound pleural rub, crepitation
present
b. Heart -No enlargement -Enlargement -No enlargement
-Clear and regular -Decreased or in -Clear and regular
heart rate between audible heart sounds heart rate between
60-80beats/min. No irregular or missed 60-80beats/min. No
murmur sound heart beats. Heart rate murmur sound
present less than 60 or more present
than 80 beats/min.
Murmur sound present.
Gastro-Intestinal:
S Examination Normal data Abnormal data Patient’s Findings
N
a. Shape, size, -Round or flat and -Irregular in shape, -Round or flat and
swelling shape, no scare, abdominal scar, shape, no scare,
distended visible blood vessels. swelling & abdomen & visible blood vessels.
blood vessels distended blood
bowel sound, -Bowel sound present vessels. -Bowel sound present
hepatomegaly in all area (producing -High pitch tinkling in all area (producing
, every 5-15 sec) sound absence of every 5-15 sec)
splenomegaly, -No abdominal bowel sound -I did not palpate the

15
 tenderness masses & tenderness -Abdominal masses & abdomen due to her
-Spleen is not tender surgical incision.
palpable no
enlargement -Spleen enlarged &
tenderness on tender
palpation
-Kidney are not
palpable & tender -Kidney enlarged &
tender
Musculoskeletal system:
S Examination Normal data Abnormal data Patient’s Findings
N
a. Presence of -No bone or joint -Presence of bone -Presence of knee
bone, deformity, no deformity, joint joint pain
b. deformities, redness, swelling of deformity, joint -Limited movement
joint pain joint, no muscle redness or swelling, of joint, sign of pain
c. Joint swelling, wasting muscle wasting when moving the
muscle -Limited movement of joint
wasting, joint -Able to move joints joint, sign of pain when -Spine is in the
deformity freely no sign of pain moving the joint midline, spine slightly
Muscle while moving joint -Lateral deviated of curved out from the
weakness, -Spine is in the spine, increased neck & gradually
fracture midline, spine slightly curvature of spine, curving inward at
placement & curved out from the increased curvature of waist
curvature of neck & gradually spine, decreased spinal
spine, curving inward at mobility in
adduction, waist osteoarthritis
abduction
d. Reflexes:
Knee jerk -Normal extension of -Abnormal extension of -Normal extension of
reflex leg leg leg
Biceps and -Normal slight flexion -Abnormal slight -Normal slight flexion
triceps reflex and extension of flexion and extension and extension of
Planter reflex elbow of elbow elbow
-Normal -Abnormal -Normal

Mental health:
S Examination Normal data Abnormal data Patient’s Findings
N
a. Loss of -No irritation -Irritation -No Irritation
b. irritability -No sleeplessness -Sleeplessness -Sleeplessness
`c Sleeplessness -Fearless -Fearness -Fearness

16
. Fearness

Nervous system:
S Examination Normal data Abnormal data Patient’s Findings
N
a. Muscle -Equal strength in -Muscular weakness -Equal strength in
strength, both hands and ,no in one or both hand both hands and ,no
sensation, co- muscle weakness and feet muscle weakness
ordination of -Feels light brush -Loss of sensation to -Co-ordinated
movement, cotton equally on light brush movement
headache, both sides of his body
fainting, -Co-ordinated
paralysis, movement -Uncoordinated
speech, touch movement

Genital Anus:
S Examination Normal data Abnormal data
N
a. Irritation on anus, crack, -No irritation, fissure, -Presence of anal irritation,
urethral discharge, lumps cracks or enlarged blood anal fissure, enlarged blood
vessels in the anus vessels
-Labia of the same color & -Red or swollen labia
size no redness or swelling
of the labia.
-No redness or discharge -Redness at urethra
at the urethra

Abnormal findings:
1. Nutritional status was diminished due to anorexia.
2. She has lump on forehead due to fall from window 15 years ago.
3. Dyspnea
4. Visual acuity is abnormal. She has short-sightedness and long-sightedness.
5. Foul odor was present from mouth.
6. She has difficulty on walking and joint pain.

17
 Development need and task
As the age of my patient is 66 years old, she comes under the older adulthood. In
older adulthood, different physiological changes and psychosocial changes occur.
Physical needs of older adulthood are:
S According to the book According to my patient
N
1 Adaptation to chronic illness My patient has no any history of chronic illness.
So, adaptation to chronic illness is absent.
2 Adaptation to sensory Present as my patient have shortsightedness
/perceptive losses and long sightedness and she uses glasses with
power for adaptation.

Developmental tasks of older adults are:

S According to the book According to my patient

N
1 Adjusting to decreasing health Present as she had the concept that at older age
and physical strength. illness occurs and physical strength decreases.
2 Adjusting to reduce or fixed Absent as she have no retired life.
income.
3 Adjusting to death of a Present as she have adjusted after the death of
spouse. spouse.
4 Accepting oneself as an Present as she thinks that she have become old,
ageing person. so disease attacked her.
5 Maintaining satisfactory living Present as she is maintaining and living satisfied
arrangement. life with her family members.
6 Realigning relationship with Present as she is living happily with her family
adult children. member.
7 Finding meaning in life. Present as she told that life is everything.

DISEASE PORTION
CHOLELITHIASIS
ANATOMY AND PHYSIOLOGY OF GALL BLADDER:

Gallbladder is a muscular organ that serves as a reservoir for bile, present in most
vertebrates. In humans, it is a pear-shaped membranous sac on the undersurface of
the right lobe of the liver just below the lower ribs. It is generally about 7.5 cm (about
3 in) long and 2.5 cm (1 in) in diameter at its thickest part; it has a capacity varying
18
from 1 to 1.5 fluid ounces. The body (corpus) and neck (collum) of the gallbladder
extend
backward, upward, and to the left. The wide end (fundus) points downward and
forward, sometimes extending slightly
beyond the edge of the liver. Structurally, the gallbladder consists of an outer
peritoneal coat (tunica serosa); a middle coat of fibrous tissue and unstriped muscle
(tunica muscularis); and an inner mucous membrane coat (tunica mucosa).
The function of the gallbladder is to store bile, secreted by the liver and
transmitted from that organ via the cystic and hepatic ducts, until it is needed in the
digestive process. The gallbladder, when functioning normally, empties through the
biliary ducts into the duodenum to aid digestion by promoting peristalsis
and absorption, preventing putrefaction, and emulsifying fat. Digestion of fat occurs
mainly in the small intestine, by pancreatic enzymes called lipases. The purpose of
bile is to; help the lipases to work, by emulsifying fat into smaller droplets to increase
access for the enzymes, enable intake of fat, including fat-soluble vitamins: Vitamin
A, D, E, and K, rid the body of surpluses and metabolic wastes cholesterol and
bilirubin.

CHOLELITHIASIS:
1) Introduction:

Cholelithiasis is the process of stone formation in the gall bladder.

Cholecystitis is an inflammation of the gall bladder which can be acute and
chronic and usually precipitated by gall stone impacted in the cystic duct, causing
distension of the gall bladder. Stone are made up of cholesterol, calcium
19
bilirubinate, or a mixture caused by changes in the bile composition. Gall stones
can develop in the common bile duct, cystic duct, hepatic duct, small bile duct
and pancreatic duct. Crystals can also form in the submucosa of the gall bladder
causing widespread inflammation.

Cholelithiasis is one of the very common health problems in Nepal and all
over the world. It is four times more common in women than in men. It occurs
frequently in middle ages or in old age group. It is the most common disorder of
the biliary tract. It is more common in obese person, those who have diabetes
mellitus and other endocrine problem.

2) Aetiology :
 Hereditary
 Diet pattern – especially excessive fatty consumption
 Obese person may be due to impaired fact metabolism
 Birth control period-alters hormone levels
 Multiple pregnancy
 Inflammation of biliary tract
20
  Stagnant bile in gall bladder

3) Pathophysiology:

Gallstones are composed of cholesterol, bile salts, calcium, bilirubin and

proteins. However, the exact cause of gallstone formation is not clearly
understood. There are 3 specific factors which appear to contribute to the
formation of gall stones.

metabolic inflammation of
disorders biliary stasis
biliary system

increased
serum causing bile
bile stagnates constituents
cholesterol in gall bladder altered

leading to
bilirub calciu excessive inflammed gall
cholester m absorption of bladder mucosa
ol stones in
stone water absorbs more of
stones
s bile acids
causing
precipitation of
salts resulting in
reduced
forms mixed solubility of
stones of various cholesterol
sizes

21
 CHOLELITHIASIS

increased bile calcium

cholesterol bilirubinate

precipitate irritation of combines with stearic

irritation of out of the acid, lecithin and
gall bladder gall
bile bladder palmitic acid

Obstructi forms small Injur

Decreased Bile
on surface contractile y
pigment salts
crystals into gall
function
changes stone
Distensi Increase bladder mucosal
Right Release of Bile Increase Bacteri Abnorm
al al fat
on d
intraduct
upper
surface
quadrant
inflammat
ory
accumul
ates in
d serum
bilirubin prolifer depositi
Blood
flow & increased pain
al mediators
Increase
liver ation on

mucousBiliary enlargespermeabil
to
lymph Gall
atic Decreas
Tea bladde Anorexi
ed bile
draina
ge is secretioncolic grossly visible
ity of
flow
colore
d
r duct
infecti
a,
nausea/
compr
omise stones
Fluid, protein & Decreas urine on vomitin
cells enter in ed vit. K g,

impaired interstial space absorpti

on
Ruptur
flatulen
ce,
Mucosal
gall bladder
ischaem severalEdem
a
e of
gall
diarrhea
ia
stones bladde
, fat
Necrosi
s develop Perinonitis 22
Cholecysti
tis
 4) Clinical features:

SN According to the book According to my patient

1 Acute abdominal pain in right Abdominal pain was on hypogastric
hypochondric region. region before 1-2 months ago.
2 Tachycardia Absent as the pulse rate was 68
beats/min.
3 Diaphoresis Present
4 Nausea / vomiting Nausea was present after the forceful
intake of food.
5 Chills and rigor Absent
6 Jaundice Absent
7 Stool will be clay colored due to loss of Absent
urobilinogen.
8 Dyspepsia Present as patient said that indigestion
occurs after the intake of fatty meal.
9 Bilirubin will be excreted in urine. Absent as bilirubin was found in urine
R/E and M/E.
10 Sometimes a sausage – shaped mass Absent
may be felt when abdomen is
palpated.

5) Investigations:

SN According to the book According to my patient

1 Blood for Present as the result was:
TC, DC, ESR, Hb% TC= 6900 /cumm
DC: Neutrophil= 74%
Lymphocytes=26%
ESR= not done
Hb%= 11.7%
2 Abdominal plain X-ray Absent
3 USG Present as in USG, mild fatty liver and
cholelithiasis (multiple) was found.
4 CT Scan of Hepatobiliary system Absent
5 Cholecystography Absent
6 Cholescintigraphy Absent
7 Endoscopic retrograde Absent
cholangiopacreatography
8 Percutaneous transhepatic cholangiography Absent

23
 6. Findings of Investigations:

SN Finding rate Normal rate

1 Hematology:
Hb 11.7gm/dl 12 – 16 gm/dl
WBC
TC 6,900/cumm 4,000 – 11,000 /cumm

DC
Neutrophil 74% 40 – 75%
Lymphocytes 26% 25 – 40%
Platelets 157,000 /cumm 150,000 – 400,000 /cumm
Blood group / Rh B +ve

2 Biochemistry
Glucose random 5.4 mmol/l 3.5 – 7.8 mmol/l
3 RFT / KFT
Blood urea 4.2 mmol/l 2.5 – 7.5 mmol/l
Serum creatinine 67 µmol/l 40 – 110 µmol/l
Na 143 mEq/l 135 – 145 mEq/l
K 4.3 mEq/l 4.3 mEq/l
4 LFT
Total bilirubin 22 µmol/l 3 – 21 µmol/l
Direct bilirubin 6 µmol/l 0 - 6 µmol/l
Serum alkaline phosphate 117 U/L 38 – 126 U/L
SGPT 59 U/L 13 – 79 U/L
SGOT 64 U/L 15 – 46 U/L
5 Immunology
Rapid card
HIV Non-reactive
HBsAg Non-reactive
Anti HCV Non-reactive
6 Urine R/E M/E
Physical examination
Color Light yellow
Appearance Clear
Chemical examination
pH Acidic
24
 Sugar -
Protein -
Microscopic examination
WBC 10-15
RBC 0-2
Epithelial cell Plenty
Crystal Nil
Cast Nil
7 Urine C/S
No growth in 48 hours at 37C incubation period.
8 USG (In 14th July)
Abdomen and pelvic 1) Mild fatty liver
2) Cholelithiasis (multiple)

7. Medical management:

SN According to the book According to my patient

1

Nutritional and supportive therapy My patient was encouraged for bed rest.
Rest, IV fluids, NG suction, analgesic IV fluids: Inj Normal saline II pint and inj
and antibiotic agents. Dextrose 5% II pint was given.
Diet Low fat diet and liquid diet was given.
2

Pharmacological therapy Not given

Not given
Ursodeoxycholic acid (UDCA)
Chenodeoxycholic acid (CDCA)
3 Non-surgical removal of gallstones Absent

8. Surgical management:

SN According to the book According to my patient

1 Cholecystectomy, open or laparoscopic Laparoscopic Cholecystectomy was done in
2014/07/20.
2 Intraoperative cholangiography and Absent
choledochoscopy
3 Placement of a T tube in the common bile duct to Absent
decompress the biliary tree and allow access into
the biliary tree postoperatively.

I. Cholecystectomy:

25
 Cholecystectomy is the surgical removal of the gallbladder. It is a common treatment
of symptomatic gallstones and other gallbladder conditions. Surgical options include
the standard procedure, called laparoscopic cholecystectomy, and an older more
invasive procedure, called open cholecystectomy. Its indications are:
cholecystitis, biliary colic, risk factors for gall bladder cancer, and pancreatitis caused
by gall stones. The most serious complication of cholecystectomy is damage to the
common bile duct. This occurs in about 0.25% of cases.

II. Intraoperative cholangiography and choledochoscopy :

Intraoperative cholangiography is an examination of the bile ducts following
administration of a radiopaque contrast medium during operation. Choledochoscopy
is the direct visualization of the biliary tract with an endoscope through a t-tube or
incision into the common bile duct. Small calculi can be removed from the common
bile duct during this procedure.

III. Placement of a T-tube:

In this procedure, T tube is placed in the common bile duct to decompress the biliary
tree and allow access into the biliary tree postoperatively.

26
 MEDICINES USED IN MY PATIENT:
A. Tab. Cefixime 200mg BD
 Trade name: Cefixime, suprax
 Generic name: Cephalosporin
 Classification: Antibiotic
 Mechanism of action:
It is a third generation cephalosporin. The bactericidal action
of cephalosporin is due to the inhibition of cell wall synthesis. It binds to one of
the penicillin binding proteins (PBPs) which inhibit the final transpeptidation
step of the peptidoglycan synthesis in the bacterial cell wall, thus inhibiting
biosynthesis and arresting cell wall assembly resulting in bacterial cell death.

 Route:
Oral route

 Preparation:
 Powder for Suspension
 Tablet, Chewable
 Tablet
 Capsule

 Doses:
200-400 mg/day PO in single daily dose or divided q12hr
 Pharmacokinetics:
 Absorption:
Bioavailability: 40-50%
 Distribution:

27
 Distributed widely throughout body and reaches therapeutic concentration
in most tissues and body fluids, including synovial, pericardial, pleural, and
peritoneal; bile, sputum, and urine; bone, myocardium, gallbladder, skin, and
soft tissue
 Half-life: 3-4 hour
 Excretion: Urine (50% as unchanged drug), feces (10%)

 Indications:

 Cefixime treats infections of the:

Ear: Otitis caused by Haemophilus influenzae, Moraxella

catarrhalis and Streptococcus pyogenes.
Sinuses: Sinusitis.
Throat: Tonsillitis, pharyngitis caused by Streptococcus pyogenes.
Chest and lungs: Bronchitis, pneumonia caused by Streptococcus
pneumoniae and Haemophilus influenzae.

 Typhoid fever

 Acute bronchitis and acute exacerbations of chronic bronchitis

 Uncomplicated gonorrhea

 Uncomplicated urinary tract infections

 Contraindications:

Hypersensitivity to cephalosporin class of antibiotics

 Side effects:

 Most Common - Diarrhea, loose or frequent stools, abdominal pain, nausea,

stomach upset and flatulence.
 Hypersensitivity - Skin rashes, hives, fever, itching and facial swelling.
 Liver - Elevated liver enzymes level, jaundice and liver inflammation.
 Genitourinary - Transient elevations in BUN or creatinine levels and kidney
failure.
 Central Nervous System- Headache, dizziness and seizures.
 Blood - Decrease in blood cell counts.
 Other - Genital itching, vaginal inflammation/fungal infection and skin
disorders.

 Nursing considerations:
28
  Use cefixime cautiously in patients with impaired renal function or a history
of GI disease, especially colitis. Also use drug cautiously in patients who are
hypersensitive to penicillin because cross-sensitivity has occurred in about
10% of such patients.
 Be aware that allergic reaction may occur a few days after therapy starts.
 Assess bowel pattern daily; severe diarrhea may indicate
pseudomembranous colitis.
 Assess for signs of super infection, such as perineal itching, fever, malaise,
redness, and pain, rash and cough or sputum changes.
Patient teaching:
 Instruct patient to complete the prescribed course of therapy.
 Tell patient to immediately report severe diarrhea o prescriber.
 Inform patient that yogurt and buttermilk can help maintain intestinal flora
and decrease diarrhea.
 Teach patient to recognize and report signs of super infection.

B. Tab. Pantop 40mg BD

 Trade name: Pantop, Protonix
 Generic name: Pantoprazole
 Classification: Proton pump inhibitors
 Mechanism of action:
Pantoprazole is a proton pump inhibitor drug that binds to H+/K+-exchanging
ATPase (proton pump) in gastric parietal cells, resulting in blockage of acid
secretion

 Route:
Oral route
Intravenous route

 Preparation:
Tablet—20, 40 mg;
Powder for injection—40 mg/vial

 Doses:
40 mg PO qDay for 8-16 weeks
 Pharmacokinetics:
 Absorption:

Bioavailability: 77%

29
  Metabolized extensively by hepatic

 Elimination

Half-life: 1 hour

Excretion: Urine (71%); feces (18%)

 Indications:
 Peptic ulcer
 Duodenal ulcer
 Gastric ulcer
 Erosive esophagitis associated with GERD
 Zollinger-Ellison Syndrome
 Gastroesophageal reflux disease

 Contraindications:
Hypersensitivity to pantoprazole or other proton pump inhibitors (PPIs)

 Side-effects:
 Gastrointestinal: Abdominal pain, diarrhea, flatulence
 Neurologic: Headache
 Gastrointestinal: atrophic gastritis, clostridum difficile diarrhea
 Hematologic: thrombocytopenia
 Immunologic: Stevens-Johnson syndrome, toxic epidermal necrolysis
 Musculoskeletal: Muscle disorders, bone fracture and infection, Clostridium
difficile, osteoporosis-related, hip fracture
 Renal: Interstitial nephritis (rare)

 Nursing considerations:

 Assessment:

o History: Hypersensitivity to any proton pump inhibitor or any drug

components; pregnancy; lactation

o Physical: Skin lesions; urinary output, abdominal examination; respiratory

auscultation
30
  Interventions:

o Administer once or twice a day. Caution patient to swallow tablets whole; not
to cut, chew, or crush them.

o WARNING: Arrange for further evaluation of patient after 4 weeks of therapy

for gastroreflux disorders. Symptomatic improvement does not rule out
gastric cancer; gastric cancer did occur in preclinical studies.

o Maintain supportive treatment as appropriate for underlying problem.

o Switch patients on IV therapy to oral dosage as soon as possible.

o Provide additional comfort measures to alleviate discomfort from GI effects

and headache.

 Teaching:

o Take the drug once or twice a day. Swallow the tablets whole—do not chew,
cut, or crush them.

o Arrange to have regular medical follow-up care while you are using this drug.

o Maintain all of the usual activities and restrictions that apply to your
condition. If this becomes difficult, consult with your nurse or physician.

o You may experience these side effects: Dizziness (avoid driving a car or
performing hazardous tasks); headache; nausea, vomiting, diarrhea, cough

o Report severe headache, worsening of symptoms, fever, chills, blurred vision,

and periorbital pain.

C. Tab. Voveron 75mg BD

 Trade name: aclonac, cataflam, voltren
 Generic name: diclofenac
 Classification: Non-steroidal anti-inflammatory drug (NSAID)
 Mechanism of action:
Inhibits cyclooxygenase (COX)-1 and COX-2, thereby inhibiting prostaglandin
synthesis

31
 May also inhibit neutrophil aggregation/activation, inhibit chemotaxis, decrease
proinflammatory cytokine level, and alter lymphocyte activity.
 Route:
 Oral route
 Topical route
 Intramuscular route
 Rectal route
 Intravenous route
 Preparation:
 Oral - tablets, dispersible tablets or capsules.
 Injection.
 Suppositories
 Gel.
 Doses:
Adult: 100 - 150 mg / day in 2 - 3 divided doses
 Pharmacokinetics:

 Absorption

~100% absorbed

Bioavailability: 50-60%

 Distribution

Protein bound: 99-99.8%

 Metabolized in liver

 Elimination

Half-life: 1.2-2 hours

Excretion: Urine (50-70%), feces (30-35%)

 Indications:
 Rheumatoid arthritis
 Osteoarthritis

32
  Ankylosing spondylitis
 Dysmenorrhea
 Mild to moderate acute pain
 Acute migraine
 Contraindications:
 Porphyria
 Active peptic ulceration
 Hypersensitivity including hypersensitivity to other NSAIDs or aspirin.
Cautions
 Severe renal disease
 Severe hepatic disease
 History of peptic ulceration.
 Breastfeeding.
 Older people.
 Coagulation problems.
 Side-effects:
 Gastrointestinal problems including ulceration.
 Hypersensitivity reactions.
 Headache.
 Dizziness.
 Depression.
 Drowsiness.
 Sleeping problems.
 Hearing disturbance.
 Photosensitivity.
 Hematuria.
 Fluid retention.
 Raised blood pressure.
 Papillary necrosis.
 Hepatic damage.
 Alveolitis.
 Pulmonary eosinophilia.
 Pancreatitis
 Nursing considerations:
 Evaluate therapeutic response by assessing pain, joint stiffness, joint
swelling and mobility.
 Assess any worsening of asthma in appropriate patients.
 Regular full dosage has both lasting analgesic and anti-inflammatory effects,
making it useful for continuous pain associated with inflammation.
 Nurses should refer to manufacturer’s summary of product characteristics
and to appropriate local guidelines.
Patient teaching
33
  Onset of pain relief is about one hour depending on route of administration. l
Full anti-inflammatory effect may take up to three weeks.
 Take oral preparations with food and keep alcohol consumption low to
decrease risk of stomach irritation.
 If using as a long-term treatment for arthritis, consult the prescribing
professional before stopping it.
 Do not take any other NSAIDs.

9) Nursing management:
a. Pre-operative management:

SN According to the book According to my patient

1 Remove all jewelry and hand over them Removed all jewelry and hand over them
to the relatives. Remove lipstick and nail to the relatives.
polish.
2 Shave the area to be operated. After Shaved the area to be operated. After
shaving ask the patient wear clean shaving asked the patient wear clean
clothes. clothes.
3 Reassure the patient to prevent anxiety Reassured the patient to prevent anxiety
and fear of operation. and fear of operation.
4 Note allergies according to institutional No any allergies were found.
policy.
5 Take and record the vital signs, assess Taken and recorded the vital signs, all vital
and report the abnormalities for elevated signs were normal.
temperature.
6 Take the written consent. Taken the written consent.
7 Check for the carry out any special No any special orders were ordered.
orders, such as administering
enema/starting IV line, record pervious
recording, inserting NG tube, giving
medications.
8 Keep the patient at NPO for the last 8 Kept the patient at NPO for the last 8
hours. hours from 12 AM.
9 Ask the patient to void; measure and Asked the patient to void.
record the amount of urine.
10 Remove all hair clips and comb hair and Removed all hair clips and combed hair
cover it with cap. and covered it with cap.
11 Remove all prosthesis like dentures, eye No any prosthesis was found.
glasses, partial plates and contact lenses
and store them safely.
12 If the patient is wearing hearing aid, Absent as patient do not have any hearing
notify the OT nurse. Leave it in a place so problem.
that operating room personnel know it is
34
 there and can communicate with the
client.
13 Inform patient about the pre-operation Informed patient about the pre-operation
holding area and give the location of the holding area and gave the location of the
waiting room for support person. waiting room for support person.
14 Fill out the pre-op checklist and tick the Filled out the pre-op checklist and ticked
tasks performed for patient. the tasks performed for patient.
15 Sent the patient to OT room along with Sent the patient to OT room along with
patient chart, operation chart, ECG, X-ray, patient chart, operation chart,
investigation reports, drugs and needed investigation reports, drugs and needed
items and handover to OT nurse. items and handover to OT nurse.
16 Record and report: departure of the Recorded and reported: departure of the
patient’s time, medication given, note if patient’s time, medication given, note if
the patient’s belongings were handover the patient’s belongings were handover to
to patient’s relatives. patient’s relatives.

b. Post-operative management:
SN According to the book According to my patient
1 Receive the patient in a warm comfortable Present as I received the patient in a
bed. warm, wrinkle free bed with the help of
other health assistants.
2 Position the patient in supine with face Positioned the patient in supine with face
turned to one side. turned to one side.
3 Attach the supportive equipment such as Attached the oxygen 4 liter, inj. Ringer
oxygen, IV infusion, catheter, etc. Lactate 500 ml was infused at 1:15 PM, Inj.
Metron 100 mg was infused in IV site.
Urobag was hanged in proper place.
4 Assess the level of consciousness and Assessed the level of consciousness. The
orientation to time, place and person. patient was semi-conscious.
Assess ability to move extremities.
5 Assess vital signs every ½ hourly, 2-4 Assessed the vital signs in 15 minutes
hours depending upon the improvement interval for 3 times and then every 4
in the condition of the patient then every hourly.
4 hourly.
6 Check IV infusion rate frequently. Checked IV infusion rate frequently and
maintained as prescribed.
7 Give medicine according to the doctor’s Medicines were given according to the
instruction and record in an appropriate doctor’s instruction and recorded in an
place. appropriate place.
8 Avoid noise and bright light in the ward. Present as noise was avoided by keeping
visitors out and light was turned off.
9 Encourage foot and leg exercise as soon Present as soon as I reached at my
as possible within 24 hours. morning duty, I encouraged the patient to

35
 move her foot and legs.
10 Give mouth care every 4 hourly. I gave oral care in the morning.
11 Ambulation on the 1st post-op day. Present as I assisted the patient for
ambulation on the 1st post-operative day.
12 Encourage bladder and bowel movement. I encouraged the patient to take liquid and
soft diet to enhance bowel and bladder
movement. Normal bladder pattern was
returned.
13 Provide steam inhalation. Absent
14 Watch for wound soakage. I watched for wound soakage immediately
after reaching the hospital.
15 Record the client’s time of arrival and all Recorded the client’s time of arrival and all
assessment record, intake output assessment record, intake output including
including any oral fluid, IV fluid as well as any oral fluid, IV fluid as well as drainage,
drainage, voiding and emesis. voiding and emesis.

c. Care in Surgical ward:

SN According to the book According to my patient

1 Receive the patient in warm, comfortable Received the patient at 4:30 PM from post-
bed. operative ward by the staff sisters.
2 IV fluids should be continued. As my patient was taking liquid and soft
diet, IV fluid was stopped.
3 Administer medicine according to the Tab. Cefixime 200mg BD
doctor’s advice. Tab. Pantop 40mg BD
Tab. Voveron 75mg BD was given.
4 Ambulate the patient. I ambulated the patient as I reached in my
morning duty.
5 Provide stem inhalation and encourage Absent
deep breathing and coughing exercises.
6 Watch for wound soakage. I watched for wound soakage and there
was no any soakage present at wound
site.
7 Provide routine care depending upon the I provided hair care, back care and
patient’s condition. assisted for oral care and skin care.
8 Discharge the patient the day after if Discharged the patient on 3rd post-
everything goes well. operative day (2014/07/23) at 3:00 pm as
everything was normal.

10) Summary of client’s daily progress in the hospital:-

DATE: 2014/07/20 OT DAY

36
As the patient was conscious and vital signs were stable before the OT procedure.
Pre-operative care was given and then she was transferred to the OT with all
documents. In OT procedure, general anesthesia was given and patient was
positioned in reverse tredelenberg and incision was done in 4 parts in abdomen and
with the help of laparoscope, the gall bladder was cut off and multiple greenish
colored stones are found, largest measuring 5×5 cm. The patient was transferred to
post-operative ward.
In post-operative ward, patient’s general condition seems poor as she
was semi-conscious and vital signs were taken. IV fluid was continued, no any
soakage and bleeding in surgical incision site, NPO till 6 hours then sips of liquid was
planned to be given.

T P R BP SPO2
96F 90 beats/min 22 110/70mm of 97%
breathes/min Hg
DATE: 2014/07/21 1ST POST-OP DAY
Patient’s general condition seems fair. Patient is conscious & well oriented to person,
place & time. Vitals are monitored & recorded. No any soakage & bleeding in surgical
incision site. Patient was in soft diet. Bladder habit was normal. Patient was
complaining about headache & dyspnea. So, oxygen was administered at 4liter by
mask.

T P R BP SPO2
98.8F 84 beats/min 22 80/50mm of 85%
breathes/min Hg
Date: 2014/7/12 2ND POST-OP DAY
Patient’s general condition seems fair. Patient is conscious & fully oriented to person,
place & time. Vitals are monitored & recorded. No any soakage & bleeding in surgical
incision site. Patient was in soft diet. Bladder habit was normal. Oxygen was
administered at 1liter.

T P R BP SPO2
97F 74 beats/min 26 90/60mm of 96%
breathes/min Hg
DATE: 2014/07/23 3RD POST-OP DAY

37
 Patient’s general condition seems fair. Patient is conscious and fully oriented to
person, place and time. Vitals are monitored and normal. Oxygen saturation was
stable. So, oxygen was not administered. Bladder habit was normal. No any chief
complain.

1
T P R BP SPO2
84 beats/min 22 110/70mm of 93% 1)
97F
breathes/min Hg
DIVERSIONAL THERAPIES:
Diversional therapies are the therapies or treatment used to divert the mind of
patient away from the disease conditions & problems causing discomfort to the
patient.
I carried out the following diversional therapies for my patient:
1) Individual therapies: I talked a lot with the patient and encouraged her to express
her feeling of anxiety related to operation procedure. I asked her about her brief
introduction, her family members and her likes and dislikes.
2) Group therapies: I explained the patient about other patients who have already
gone through the same procedure. In the post-operative ward, I introduced her with
other patients gone through the surgery.
3) Nutritional therapy: I encouraged the patient to take nutritious food and excessive
water and semi-solid diet.
4) Physical therapy: Since, it was OT case of cholecystectomy; I encouraged her to
walk and assisted her to walk around the ward. I gave head massage for relieving
headache. I gave her back care.

12) Application of appropriate nursing theory:

OREM’S SELF CARE DEFICIT THEORY
According to Orem, “Nursing has its special concern; the individual’s need for self-
care action and the provision and management of it on a continuous basis in order to
sustain life and health, recover from disease or injury and cope with their effects.
“Orem developed her general theory of nursing in 3 related parts which are:
i. Self-care
ii. Self-care deficit
iii. Self-care system
Self-care deficit:
38
 As my patient was gone through the surgical incision, she can’t take care
of herself. So, she was unable to meet her own self-care requisites like maintenance
of air, water, food, elimination, etc. resulting a “self-care deficit”. As a nurse, it was
my job to determine these deficits and define a support modality.
The theory of self-care deficit is the care of Orem’s general theory of nursing
because it delineates when nursing is needed. Deflect arises when agency cannot
meet self-care requisites. Nurses meet the requisites by following these five methods
of helping identified Orem:
1) Acting for or doing for another
2) Giving another
3) Supporting another
4) Providing an environmental that promotes personal development in relation to
becoming able to meet present or future demands for action
5) Teaching another.
Nursing system theory:-
There are three classifications of nursing system to meet the self-care
requisites of the patient. These systems are:-
a) Wholly compensatory system
b) Partly compensatory system
c) Supportive-educative system.
As my patient was unable to perform some self-care activities because she was post-
operative patient; I used partially compensatory system and supportive educative
system.
Partly compensatory system:-
 I performed some self-care measures like assisted for mouth wash, oral care
and dress change.
 Administered oxygen due to low oxygen saturation.
 Ambulated the patient.
 Maintained the drainage of catheter for urine output.
 Encouraged the patient to take fluid and food.
Supportive educative system:-
 Encouraged the patient for ambition
 Accomplish self-care
 Regulated the exercise & development of self-care agency.

39
 13) NURSING CARE PLAN:
Problems in my patient:
 Pain
 Imbalanced fluid volume
 Imbalanced nutrition
 Lack of knowledge

Nursing Priorities

 Relieve pain and promote rest.

 Maintain fluid and electrolyte balance.
 Prevent complications.
 Provide information about disease process, prognosis, and treatment
needs.

Nursing diagnosis:

1. Acute pain related to surgical incision.

2. Risk for deficient fluid volume related to medically restricted intake.
3. Risk for Imbalanced Nutrition related to impaired fat digestion due to
obstruction of bile flow
4. Deficient Knowledge related to lack of knowledge.

1. Acute pain related to surgical incision.

Assessm Nursin Nursing Planning Implementa Rationale Evaluati

ent g goal tion on
diagno
sis

40
Subjectiv Acute Pain will Observe and Observed Goal was
Assists in
e data: pain be document and fully met
differentiating cause
The related relieved. location, documented as pain
of pain, and provides
patient to severity, and location, was
information about
said, “I surgical character of severity, and relieved
disease
have a incision pain (e.g., character of after
progression/resolutio
pain at steady, pain (e.g., giving
n, development of
incision intermittent, steady, inj.
complications, and
site.” colicky). intermittent, Voveron
effectiveness of
Objective colicky). 75mg.
interventions.
data: The
patient
Noted Severe pain not
seems Note response
response to relieved by routine
irritated to medication,
medication. measures may
and felt and report to
indicate developing
tendernes physician if
complications/need
s around pain is not
for further
the being relieved.
intervention.
surgical
Promote bed Promoted Bed rest in low-
incision
rest, allowing bed rest, Fowler’s position
site.
patient to allowing reduces intra-
assume patient to abdominal pressure;
position of assume however, patient will
comfort. position of naturally assume
comfort. least painful
position.

Use soft/cotton Used Reduces

linens; oil back soft/cotton irritation/dryness of
care, linens; oil the skin and itching
cool/moist back care, sensation.

41
 cool/moist
compresses as
compresses
indicated.
as indicated.

Encourage use Encouraged

Promotes rest,
of relaxation use of
redirects attention,
techniques, relaxation
may enhance
e.g., guided techniques,
coping.
imagery, e.g., deep-
visualization, breathing
deep-breathing exercises.
exercises. Provided
Provide diversional
diversional activities.
activities.

Removes gastric
Maintain NPO Maintain NPO
secretions that
status; status till 6
stimulate release of
insert/maintain hours.
cholecystokinin and
NG suction as
gallbladder
indicated.
contractions.

Administer Administered Relieves reflex

medications as medications spasm/smooth
indicated as indicated. muscle contraction
and assists with pain
management.
Promotes rest and
relaxes smooth
muscle, relieving
pain. Given to

42
 reduce severe pain.

2. Risk for deficient fluid volume related to medically restricted intake.

Assessm Nursin Nursing Planning Implementa Rationale Evaluati

ent g goal tion on
diagno
sis

Objective Risk for Patient Maintain Goal was

Maintained
data: The deficien will accurate Provides information fully met
accurate
patient t fluid demonstr record of I&O, about fluid as
record of I&O.
volume ate noting output status/circulating patient
Assessed
related adequate less than volume and has
skin/mucous
to fluid intake, replacement needs. stable
membranes,
medical balance increased urine vital
peripheral
ly evidence specific signs,
pulses, and
restrict d by gravity. Assess good
capillary
ed stable skin/mucous skin
refill.
intake. vital membranes, turgor
signs, peripheral after
moist pulses, and performi
mucous capillary refill. ng oral
membran hygiene.
Monitor for Monitored for Prolonged vomiting,
43
 es, good signs/symptom
signs/sympto gastric aspiration,
skin s of
ms of and restricted oral
turgor, increased/conti
increased/con intake can lead to
capillary nued nausea
tinued deficits in sodium,
refill, or vomiting,
nausea or potassium, and
individual abdominal
vomiting, chloride.
ly cramps,
abdominal
appropria absent bowel
cramps,
te urinary sounds,
absent bowel
output, depressed
sounds,
absence respirations.
depressed
of
respirations.
vomiting.

Perform
Performed Decreases dryness of
frequent oral
frequent oral oral mucous
hygiene; apply
hygiene. membranes; reduces
lubricants.
risk of oral bleeding.

Keep patient Kept patient Decreases GI

NPO as NPO as secretions and
necessary. necessary. motility.

Insert NG tube, Inserted NG

To rest the GI Tract
connect to tube, connect
suction, and to suction,
maintain and maintain
patency as patency as
indicated. indicated.
3. Risk for Imbalanced Nutrition related to impaired fat digestion due to
obstruction of bile flow

Assessm Nursing Nursing Planning Implementa Rationale Evaluat

ent diagnos goal tion on
44
 is

Risk for Patient Weighed as Monitors Goal was

Weigh as
Imbalan will indicated. effectiveness of fully me
indicated.
ced demonstr dietary plan. after
Nutrition ate increasin
related progressi g her
Consulted
to on activities
with patient
impaired toward Consult with
about
fat desired patient about Involving patient in
likes/dislikes,
digestio weight likes/dislikes, planning enables
foods that
n due to gain or foods that patient to have a
cause
obstructi maintain cause distress, sense of control and
distress and
on of weight as and preferred encourages eating.
preferred
bile flow individual meal schedule.
meal
ly
schedule.
appropria
Provide a
te Provided a
pleasant Useful in promoting
pleasant
atmosphere at appetite/reducing
atmosphere
mealtime; nausea.
at mealtime;
remove
remove
noxious stimuli.
noxious
stimuli.

Provide oral Provided oral A clean mouth

hygiene before hygiene enhances appetite.
meals. before meals.

Ambulate and Ambulated Helpful in expulsion

increase and increased of flatus, reduction of
activity as activity as abdominal
tolerated. tolerated. distension.
45
 Contributes to overall
recovery and sense
of well-being and
decreases possibility
of secondary
problems related to
immobility

Consult with Consulted Useful in establishing

dietitian as with dietitian individual nutritional
indicated. as indicated. needs and most
appropriate route.

Advance diet Advance diet

as tolerated, as tolerated,
usually low-fat, usually low-
and high-fiber. fat, and high-
Restrict gas- fiber.
producing Restricted Meets nutritional
foods (e.g., gas- requirements while
onions, producing minimizing
cabbage, foods stimulation of the
popcorn) and gallbladder.
foods/fluids
high in fats
(e.g., butter,
fried foods,
nuts).
4. Deficient Knowledge related to lack of knowledge.

Assessm Nursin Nursing Planning Implementa Rationale Evaluat

ent g goal tion on
diagno
sis
46
Subjective Provided Information can Goal was
Deficien Patient Provide
data: The t will explanations decrease anxiety, fully met
explanations
patient Knowle verbalize of/reasons for thereby reducing after
dge understa of/reasons for
said, “I do test sympathetic explainin
related nding of test procedures
not know to lack disease procedures stimulation. g her
and
about my of process, and about
knowle prognosis preparation
disease preparation disease
dge as , and needed.
condition. evidenc potential needed. process.
” e by complica
Review disease Reviewed Provides knowledge
questio tions.
Objective
ns; process. disease base from which
data: request Discuss process. patient can make
for
hospitalization Discussed informed choices.
informa
tion. and hospitalizatio Effective
prospective n and communication and
treatment as prospective support at this time
indicated. treatment as can diminish anxiety
Encourage indicated. and promote healing.
questions, Encouraged
expression of questions,
concern. expression of
concern.

Review drug Review drug Gallstones often

regimen, regimen, recur, necessitating
possible side possible side long-term therapy.
effects. effects. Note: Women of
childbearing age
should be counseled
regarding birth
control to prevent
pregnancy and risk
of fetal hepatic
47
 damage.

Instruct patient Instructed

Prevents/limits
to avoid patient to
recurrence of
food/fluids high avoid
gallbladder attacks.
in fats, gas food/fluids
producers (e.g. high in fats,
Onions, gas
carbonated producers.
beverages), or
gastric irritants
(e.g., spicy
foods, caffeine,
citrus).

Promotes flow of bile

Recommend Recommende
and general
resting in semi- d resting in
relaxation during
Fowler’s semi-Fowler’s
initial digestive
position after position after
process.
meals. meals.

Suggest Suggested
patient limit patient limit Promotes gas
gum chewing, gum chewing, formation, which can
sucking on sucking on increase gastric
straw/hard straw/hard distension/discomfort
candy, or candy, or .
smoking. smoking.
48
14) DISCHARGE PLANNING AND HEALTH TEACHING INCLUDING FOLLOW UP:
On 2014/07/23, at 3:00 PM, my patient got discharged from the hospital. I
explained my patient about the time of discharge. I told her including her visitors
the following things:
 Diet: I told her to take regular diet, digestible diet, and exclude the oily and
spicy food from diet strictly for 1 week. Encouraged her to avoid fatty and
salty foods and encouraged her to increase fluid intake.
 Exercise and physical activity: I told her to walk in the morning and
evening. I told her to do deep breathing and coughing exercise. I told her
to resume her physical activities. Encouraged her to take adequate rest as
well.
 Pain management: I gave a teaching about pain relieving measures for the
relieve of pain at incision site.
 Medicine: I explained her with her visitors to take medicine at time and at
right dose.
 Follow up: I told her to come to the hospital after 7 days in OPD. And if any
emergency condition comes, then immediately visit in emergency
department.

15) Experience and learning:

Case study is a very good method of learning nursing practice as well as the related
diseases in depth. It gives the comprehensive study of one selected patient with
books in real situation.

I learned in detail about cholelithiasis, its causes, stages, pathophysiology, sign and
symptoms, test, management and prognosis too.

I also get to learn about my patient and her family, their environment, health and
family background which helped me to provide nursing care.

It also helped me to grow my skill for professional growth. So, this case study helped
me to gain knowledge by observation, findings and conclusion.

During case study I learned the following things:

 I had the opportunity to see the patient suffering from the disease and able to
know his experiences during the diseased period.
 Learned about disease in depth along with its causes, symptoms, stages and
management.
 Learned to take detailed past and present history which helps to find out the
genetic origin.

49
  Learned to evaluate progress of the patient through maintenance of daily
report.
 Helped me to enhance knowledge regarding documentation with the help of
different activities.
 I knew that many theoretical things are not applicable in the practical life.
 Learned about the different rules and policy of that hospital.
 Participated in different treatment modalities.
 Develop knowledge and skills about individual and family therapy.

16) Conclusion and summary of client case study:

A 66 year old woman called Uma K.C who had been experiencing
abdominal pain, indigestion, loss of appetite and nausea on forceful intake. After
going to the doctors; a number of tests were carried out. Mrs. Uma K.C was
diagnosed to having Symptomatic cholelithiasis. Cholelithiasis is the process of
stone formation in the gall bladder. She had to go for a laparoscopic
cholecystectomy because of her cholelithiasis. A Laparoscopic cholecystectomy
is when the gall bladder is removed through “a small incision which is made at
the naval and a thin tube carrying the video camera is inserted”.

After the operation, she had the complain of pain at surgical incision for
several days which was normal. She recovered very fast after the medical and
nursing management. She was very happy with the given care.

On 2014/07/23, at 3:00 PM, she got discharged from the hospital as

everything was going well. She received the discharge teaching and went home
happily.

50
References:
1. Lippincott, Manual Of Nursing Practice, 8th Edition, Page
No. : 709-712
2. Lippincott, Atlas Of Pathophysiology, 2nd Edition, Page No.
: 162-163
3. HLMC, Textbook of Adult Nursing, 1st Edition, Page No. : 7-
9, Page No. : 97-100
4. Brunner and Suddarth’s, Medical-Surgical Nursing, 10th
Edition, Page No. :1115-1119
5. Rai Lalita, Nursing Concept And Theories, 2 nd Edition,
Page No. : 190-198
6. Dr. Sudeep K. Yadav, A Book On Pathophysiology, 2 nd
Edition, Page No. : 130-135
7. Giri M. Essential Fundamentals of Nursing, 1st Edition,
Page No. : 89-118
8. Pathak S. Devkota R. Fundamentals of Nursing, 2010
Edition, Page No. : 60-75

51