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4/23/12

OpenCHOLECYSTECTOMY


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Patients ProfileName: Balansag, Nicolas

Age: 46 years old

Sex: Male

Civil Status: MarriedReligion: Roman Catholic

Date of Admission: March 5, 2012

Room No.: 424

Complaints: right upper quadrant pain,general abdominal pain for 1 month

Diagnosis: Acute Calculous Cholecystitis


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Case Abstract

Mr. Balansag is residing at Dona RitaVillage 1C Compound, Muntinlupa

City with her wife and their 2

daughters. Patient is working as amechanic at Don Bosco School.Patient is an occasional alcoholic

drinker, a slight smoker which

consumes around 3 sticks perday.He has no known allergy to food

and drugs. Patient is known to be

hypertensive at the age of 40. His


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Patient complains of general

abdominal pain for 1 month nowand that he hasnt been able tosleep well because of the pain

felt in his right upper quadrant.He seek consult to Dr.

Macadagdag thus advised to be

admitted to Medical Centre ofMuntinlupa.


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Introduction

Cholecystectomy is the surgical removal ofthe gallbladder. Despite the development ofnon-surgical techniques, it is the mostcommon method for treating symptomatic

gallstones, although there are other reasonsfor having this surgery done. Each year morethan 500,000 Americans have gallbladdersurgery. Surgery options include the standardprocedure, called laparoscopiccholecystectomy, and an older moreinvasiveprocedure, called open cholecystectomy. Acholecystectomy is performed whenattempts to treat gallstones with ultrasound

to shatter the stones or medications to


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Gallbladder disease is cured byremoval of the gallbladder in a

procedure referred to as acholecystectomythe most commonsurgical procedure performed on the

biliary tract. A cholecystectomy isperformed to relieve thegastrointestinal distress common inpatients with acute or chroniccholecystitis (with or withoutgallstones); it also removes a sourceof recurrent sepsis. Persistent

infection in the biliary tract may


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Open cholecystectomy is a surgery in whichthe abdomen is opened to permit

cholecystectomy -- removal of the gallbladder.This operation has been employed for over 100years and is a safe and effective method fortreating symptomatic gallstones,ones that arecausing significant symptoms. At surgery,

direct visualization and palpation of thegallbladder, bile duct, cystic duct, and bloodvessels allow safe and accurate dissection andremoval of the gallbladder. Intra-operative

cholangiography has been variably used as anadjunct to this operation. The rate of commonbile duct exploration for choledocholithiasis(gallstones in the bile duct) varies from 3% in

series of patients having elective operations to21% in series that include all atients. Ma or


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Open Cholecystectomy

In open gallbladder surgery(cholecystectomy), the surgeonremoves the gallbladder through a

single, large incision in the abdomen.You will need general anesthesia, andthe surgery lasts 1 to 2 hours. Thesurgeon will make the incision either

under the border of the right rib cage orin the middle of the upper part of theabdomen (between the belly button andthe end of the breastbone).


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Definition of the Disease

Cholelithiasis is a condition in which gallstones,lodge in the neck of the gallbladder or in the

cystic duct, interfering with or totallyobstruction normal bile flow from the

gallbladder to the duodenum. Many factors,some of which aren't well understood,

contribute to the formation of gallstones. Firstis too much cholesterol.Normally, bile contains

enough bile salts and lecithin, a fattycompound to dissolve the cholesterol excretedby your liver. But if bile contains morecholesterol than can be dissolved, thecholesterol may form into crystals and

eventually into stones. Cholesterolin bile has


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If the gallbladder doesn't empty completely oroften enough, bile may become too

concentrated and contribute to the formation

of gallstones. This may occur during pregnancy.No matter what their size, shape or number,

gallstones generally fall into one of twocategories. First is cholesterol gallstones.

These gallstones, often yellow in color, arecomposed mainly of undissolved cholesterol,

although they can also have othercomponents, such as calcium and bilirubin, the

residue from the breakdown of red blood cells.About 80 percent of gallstones are cholesterolstones.Second is pigment gallstones. Thesesmall, dark brown or black stones form whenyour bile contains too much bilirubin. It's not

always clear what causes them. They tend


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Complications

Pain Peritonitis

Pancreatitis

Cholecystitis

Cholangitis

Pancreatitis

Nausea and Vomiting

Cholestasis, extrahepatic

Bile Stricture


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Signs and Symptoms Cholecystitis usually presents as a pain in

the right upper quadrant. This is usually aconstant, severe pain. The pain may befelt to 'refer' to the right flank or rightscapular region at first.

This may also present with the abovementioned pain after eating greasy or

fatty foods such as pastries, pies and friedfoods.

This is usually accompanied by a low


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More severe symptoms such as highfever, shock and jaundice indicate

the development of complicationssuch as abscess formation,perforation or ascending cholangitis.

Another complication, gallstoneileus, occurs if the gallbladderperforates and forms a fistula withthe nearby small bowel, leading to

symptoms of intestinal obstruction.

Chronic cholecystitis manifests withnon-s ecific s m toms such as


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Anatomy of the Main OrganInvolve


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GALL BLADDER


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Functions of GALLBLADDER

v The function of the gallbladder isto store bile and concentrate. Bile is

a digestive liquid continuallysecreted by the liver. The bileemulsifies fats and neutralizes acidsin partly digested food. A muscular

valve in the common bile ductopens, and the bile flows from thegallbladder into the cystic duct,

along the common bile duct, and


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Cholesterol is not very soluble, so in order toremain suspended in fluid it must be transportedwithin clusters of bile salts called micelles. If there

is an imbalance between these bile salts andcholesterol, then the bile fluid turns to sludge.

This thckened fluid consists of a mucus gelcontaining cholesterol and calcium billirubinate

If the imbalance worsens, cholesterol crystal form( a condition called supersaturation), which caneventually form galstones

Supersaturation and cholelithiasis can occur as aresult of various abormalities, although the cause isnot entirely clear. There are many events that maypromote cholelithiasis


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The gallbladder may not be able to emptynormally, so bile becomes stagnant

The cells lining the gallbladder may not be able toefficiently absorb cholesterol and fat from bile

There are high levels of billirubin. Billirubin is asubstance normally absorb cholesterol and fatfrom bile

There are high levels of billirubin. Billirubin is asubstance normally formed by the breakdown ofhemoglobin in the blood. It is removed from thebody in bile. Some experts believe billirubinmayplay an important role in formation of cholesterolgallstones

Pigment stones. Pigment stones are composed ofcalcium billirubinate or calci ied billirubin. Pi ment

Di ti d


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Diagnostic andLaboratory Tests

Ultrasonography-Gallstones are suspected inpatients with biliary colic. Abdominalultrasonography is the method of choice fordetecting gallbladder stones; sensitivity andspecificity are 95%. Ultrasonography alsoaccurately detects sludge.

CT SCAN

MRI (Magnetic Resonance Imaging )

Oral cholecystography

Hepatobiliary Nuclear Scan

Endoscopic ultrasonography accurately detects

small gallstones (< 3 mm) and may be needed if


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IMAGES of GALL STONES


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Diagnostic/ Lab test

Asymptomatic gallstones and biliarysludge are often detected incidentallywhen imaging, usually ultrasonography,is done for other reasons.

About 10 to 15% of gallstones arecalcified and visible on plain x-rays.

Elevated conjugated Bilirubin

Elevated Alkaline Phosphatase

Elevated Serum Amylase

Elevated Lipase

i i b


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Diagnostic/ Lab test


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Pathophysiolo

gy


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Drug Study


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Nursing Care Plan: Ineffective Breathing


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Assessment Nursing Diagnosis Planning Interventions Rationale Evaluation

S:O: The patientmay manifest:>tachypnea

>reluctance tocough>holding breath> DOB

Ineffectivebreathing patternr/t to pain

Short-term:After 1 hour of nursinginterventions, thepatient will

demonstrate improvedbreathing pattern.Long-term:After 4 hours ofnursing interventionthe patient willestablish effectivebreathing pattern

1. administersupplementaloxygen vianasal cannula

as ordered2. administer pain

medications asordered

3. monitor vitalsigns especiallyrespiratory rate

4. encourage/assist with deep-

breathingexercises andpursed-lipbreathing asappropriate

5. check forrestlessnessand changes inmental status

1. Maximizesavailableoxygen,especially

whileventilation isreducedbecause pain

2. to treatunderlyingcause ofrespiratoryproblem

3.

for baselinedata4. promotes

maximalventilationandoxygenation

5. may indicatehypoxia

Short-term:After 1 hour ofnursinginterventions, the

patient shall havedemonstratedimprovedbreathing pattern.Long-term:After 4 hours ofnursinginterventions, thepatient shall have

established aneffectivebreathing pattern

Nursing Care Plan: Ineffective BreathingPattern


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N i C Pl A ti it


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Assessment Nursing Diagnosis Planning Interventions Rationale Evaluation

S: O: The patient

may manifest:>tachypnea>reluctance tocough>holding breath> DOB

Ineffectivebreathing patternr/t to pain

Short-term:After 1 hour of

nursinginterventions, thepatient willdemonstrateimprovedbreathing pattern.

Long-term:

After 4 hours ofnursingintervention thepatient willestablish effectivebreathing pattern

administersupplementaloxygen via nasal

cannula asordered

administer painmedications asordered

monitor vital signsespeciallyrespiratory rateencourage/assistwith deep-

breathingexercises andpursed-lipbreathing asappropriatecheck forrestlessness andchanges in mentalstatus

Maximizesavailable oxygen,especially while

ventilation isreduced becausepainto treatunderlying causeof respiratoryproblem

for baseline data

promotesmaximalventilation andoxygenation

may indicatehypoxia

Short-term:After 1 hour of

nursinginterventions, thepatient shall havedemonstratedimprovedbreathing pattern.Long-term:

After 4 hours ofnursinginterventions, thepatient shall haveestablished aneffectivebreathing pattern

Nursing Care Plan: ActivityIntolerance


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Nursing

Diagnosis


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Acute pain and discomfort related to

surgical incision

Imbalanced nutrition less than bodyrequirements related to inadequate bile

secretionRisk for constipation related to effects

of surgery

Risk for infection related Impaired skin integrity related to

disruption of first line of defense

Activity intolerance


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Nursing

Interventions


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Relieving Pain

The location of the subcostal incision inOpen Cholecystectomy surgery

diseases likely to cause the patient toavoid turning and moving, to splint the

affected site, and to take shallowbreaths to prevent pain. Because full

exacerbation of the lings and gradually

increased activity are necessary toprevent postoperative complications,the nurse should administer analgesic

agents as prescribed to relieve pain and

promote well-being.

Improving respiratory


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Improving respiratorystatus

Patients undergoing biliary tractsurgery are prone to pulmonary

complications, as areall

abdominal incision. Thus, thenurse remind patient to take

deep breaths and coughevery

hour to expand the lungs fullyand prevent atelectasis.

I i N t iti l


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Improving NutritionalStatus

The nurse encourages the patient toeat a diet low in fats and high in

carbohydrates and proteinsespecially after surgery. At the time

of hospital discharge, these areusually no special dietary

instructions other than to maintain a

nutritious diet and avoid excessivefats. Fat restriction usually is lifted in

4-6 weeks when the biliary ducts

dilate to accommodate the volume


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Monitoring and Managing


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Monitoring and ManagingPotential Complications

Bleeding may occur as a result ofinadvertent puncture or nicking

of major bloodvessel. Post-operatively, the nurse closely

monitors vital signs and inspects

the surgicalincision and drains, ifin place, for evidence of

bleeding.

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