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home / study / science / nursing / nursing questions and answers / case study: gall bladder john smith is a 65-year-old retiree who is admitted to your unit from ... Question: Case Study: Gall bladder John Smith is a 65-year-old retiree who is admit... Case Study: Gall bladder John Smith is a 65-year-old retiree who is admitted to your unit from the emergency department (Ed). On arrival, you note that he is trembling and nearly doubled over with severe abdominal pain. John indicates that he has severe pain in the right upper quadrant (RUQ) of his abdomen that radiates through to his mid back as a deep, sharp, boring pain. He is more comfortable walking or sitting bent forward rather than lying flat in bed. He admits to having had several similar bouts of abdominal pain in the last month, but "none as bad as this." He feels nauseated but has not vomited, although he did vomit a week ago with a similar episode. John experienced an acute onset of pain after eating fried fish and chips at a fast-food restaurant earlier today. He is not happy to be in the hospital and is grumpy that his daughter insisted on taking him to the emergency department for evaluation. After orienting him to the room, you perform your physical assessment. The findings are as follows: He is awake, alert, and oriented × 3, and he moves all extremities well. He is restless, constantly shifting his position, and complains of fatigue. Breath sounds are clear to auscultation. Heart sounds are clear and crisp, with no murmur or rub noted and with a regular rate and rhythm. Abdomen is flat, slightly rigid, and very tender to palpation throughout, especially in the RUQ; bowel sounds are present. He reports having light-colored stools for 1 week. The patient voids dark amber urine but denies dysuria. skin and sclera are jaundiced. Admission vital signs are blood pressure 164/100, pulse of 132 beats/min, respiration 26 breaths/min, temperature of 100° F (37.8° C), spo2 96% on 2 L of oxygen by nasal cannula. Preoperative Laboratory Test Results WBC 11,900/mm3 Hgb 14.3 g/dL Hct 43% Platelets 250,000/mm3 ALT 200 units/L AST 260 units/L ALP 450 units/L Total bilirubin 4.8 mg/dL PT/INR 11.5 sec/1.0 Amylase 50 units/L Lipase 23 units/L Urinalysis Negative What organs are located in the RUQ of the abdomen? (Start thinking about what organ is involved based on his chief complaint) What does a positive Murphy’s sign indicate when a health care provider performs deep palpation? Which lab results are abnormal, and what do they reflect? Which other data in the assessment are consistent with common bile duct obstruction? Explain the pathophysiologic changes that can cause these signs and symptoms associated with common bile duct obstruction. Clay colored stools Dark urine Steatorrhea Jaundice Pain with fatty food intake The patient’s abdominal ultrasound reveals several stones in the common bile duct and gallbladder. He is admitted to the medical-surgical unit and placed on nothing by mouth (NPO) status and scheduled to undergo endoscopic retrograde cholangiopancreatography (ERCP) that afternoon. Explain the rational for the treatment of acute cholecystitits with the following interventions. NPO with possible NG suction Antibiotics (which route) Antispasmodics Define ERCP and indication for it based on this patient’s status. Which results are abnormal, and what do they reflect? The patient then undergoes ERCP and the stones and bile are released, but imaging indicates a stone is still within the cystic duct and gallbladder. A surgeon was consulted and a laparoscopic cholecystectomy was ordered. List four to five preoperative orders that will likely need to be done before the patient goes to surgery. If he had a laparoscopic cholecystectomy, which discharge instruction would the nurse advise the patient: (explain the rational for the correct choice). Keep the incision areas clean and dry for at least a week Report he need to take pain medication for shoulder pain Report any bile-colored or purulent drainage from the incisions Expect some postoperative nausea and vomiting for a few days
Explanation / Answer
the right upper quadrant consists of Liver,Gallbladder,Duodenum,Pancreas,colon and stomach. Murphy sign is detected during an abdominal examination.if it is positive it means that the patient is suffering from cholecystitis. THe normal value of ALT =.7-55,AST=.8-48,ALP=.45-115,Bilirubin=0.1-1.2mg/dl,PT 9.5 -13.8sec but the lab values for liver function test is increased in Mr John smith indicates the presence of liver disease.Amylase level 23-85u/l indicate the presence of pancreatitis. Gallstones are usually silent ,producing no pain and with only mid gastrointestinal problems.The patients with gall bladder disease may ypically experience two types of symptoms due to the disease of gallbladder and other due to obstruction of the bilepassages by a gall stone.The patient experiences fulness,abdominal distension,and vague pain in the right upper quadrant of the abdomen.this distress is often exhibited after eating a meal rich in fried or fatty foods.Mr john also experienced similar symptoms especially after taking fried fish and chips.Jaundiced skin is a symptomwhich occurs in few patients with gall bladder disease ,with obstruction of the common bile duct.The colour of the urine will be very dark. There are two types of gallstones,those composed predominantly of the pigment and those composed primarily of cholesterol.The risk for developing such stones is increased in patients with cirrhosis,hemolysis,and infections of the biliary tract.Pigment stones cannot be removed dissolved and has to be removed surgically.Cholesterol is insoluble in water and it is a constituent of bile .Its solubility depends on the bileacids and lecithin in bile.In gall-stone prone patients bile acid synthesis is decreasedand increased chlesteril synthesis in the liver,resulting in bile supersaturated with cholesterol,which percipitates out to form stones. ERCP is Endoscopic Retrograde Cholangiopancreatography permis direct visualization of structures that previously could be seen only during laparotomy.Fluroscopy and multiple x-rays are used during ERCP to evaluate the presence and location of ductal stones.Before the procedure nurse observes the client for signs of respiratory and central nervous system depression ,hypotension ,oversedation and vomiting.Since the patient is having fever ,measures will be taken to lower the fever and after that conduc ERCP. Antibiotic agents are prescribed to minimize the risk of sepsis and septic shock. Administration of Vitamin k if the Prothrombin level is low .Administer IV Glucose with protein hydrolysate supplements to aid wound healing and help prevent liver damage.Explain to the patient about the importance of deep breathing excercises and frequent turning.The patient is also informed about the drainage tubes,nasogastric tubes which might be required during the immediate postoperative period. Expect some post operative nausea and vomiting for a few days as recovering from open gallbladder removal often takes several days 4-8 weeks to recover and these symptoms are quite natural during this time.
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