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Comprehensive Case StudyBethany LeonardCedar Crest CollegeAbstractThis paper studies the case of a hospitalized patient who is recovering from a cholecystectomy. The patient is at risk for post-operative complications including infection, blood clots, adverse reactions to medication, and decreased coping due to stressors. This paper discusses the patient’s treatments and interventions which minimize the patient’s health risks. The pathophysiology of cholecystitis is discussed. Head to toe assessments of the patient are described and values are given for vital signs. Abnormal lab values are listed and discussed. The patient’s medications are listed with rationales and nursing implications given for each drug. Three nursing diagnoses are laid out with interventions, implementations, and evaluations described for each one. Evidence-based rationales are presented for all interventions. The patient’s responses to the treatments are documented.Keywords: Inpatient, cholecystitis, cholecystectomy, surgery, post-operative, complications, risks, infection, DVT, prophylaxis, antibiotics, nursing diagnoses, interventions, rationales, evaluation, outcomesComprehensive Case StudyA 68-yr-old male was admitted to the hospital two days ago with the diagnosis of cholecystitis. The patient (pt.) underwent a cholecystectomy and is now less than 24 hours post-operative. The pt. reported having occasional gallbladder pain in the past but states, “It was never bad enough to come to the hospital until this time.” The pt. describes having upper abdominal pain for several days that worsened in intensity until a trip to the emergency room became necessary, as the pt. was vomiting and could not eat or drink. Pt. is observed holding right upper quadrant (RUQ) of abdomen when recalling the pain from the inflamed gallbladder.PathophysiologyCholecystitis is an acute inflammation of the gallbladder which can occur due to blockage of the cystic duct by a gallstone (National Institute of Health [NIH], 2015). The buildup of bile causes swelling and irritation in the gallbladder, potentially leading to infection or rupture if unresolved. A tumor of the gallbladder, although rare, can also cause cholecystitis (NIH, 2015). Risk factors such as diabetes and obesity may increase the likelihood of developing cholecystitis. The irritation within the gallbladder causes severe upper abdominal pain. The pt. may also experience nausea and vomiting, fever, clay-colored stools, or jaundice. Prompt identification of the problem can lead to improved pt. outcomes.HistoryThe pt. has a past medical history of chronic heart failure (CHF), atrial fibrillation (A-fib), and chronic kidney disease (CKD) stage two. Pt. has a past diagnosis of hyponatremia which is now resolved. The pt. has experienced a prior fracture of the right shin which was surgically repaired, as well as a broken index finger on the left hand; both are now healed. Several years ago the pt. was admitted to the hospital with severe sepsis and spent three months in the intensive care unit (ICU) before making a full recovery.Nursing AssessmentPt. is a full code and has no known allergies. Pt. is 70” tall and weighs 102.7 kg.Vital SignsThe pt.’s vital signs remained within normal limits throughout the shift. Pulse oxygen levels were slightly low but the doctor’s orders were to apply oxygen at 2 Liters if oxygen saturation fell below 90%, which did not occur. Pt. rated pain as 0/10 throughout entire shift.TimeTemperatureHeart RateResp. RateBlood Pres.SpO2Pain081099.0 F7120114/7192%0/10110099.7 F7016129/7292%0/10153598.9 F7916117/7191%0/10HEENTPt.’s head is symmetrical and shows no signs of trauma. Hair is fine and balding. Ears are symmetrical and color is normal with no erythema, drainage, or swelling. Mild cerumen is visible bilaterally. Hearing is intact and pt. responds to verbal cues appropriately. Eyes are symmetrical; pupils are equal, round, reactive to light and accommodation. Sclerae are white and clear with no swelling or drainage. Eye movement is intact and symmetrical bilaterally. Nose is symmetrical with no redness or drainage. No sores or polyps are noted; septum is inline and intact. Pt.’s oral mucosa is pink and moist with no visible abrasions. Pt. has no teeth and states, “My dentures are at home.” When asked if someone to bring the dentures to the hospital, the pt. stated, “No, I don’t want them. I can’t use them right now since I can’t eat anyway. And I can eat fine without them.”NeurologicalUpon entering the room the pt.’s eyes open spontaneously. The pt. is alert and oriented to person, place, time, and event but responds slowly and appears lethargic. The pt. states, “I’m feeling a little tired.” Pt. obeys verbal commands and speech is appropriate. Pupillary reaction is brisk with symmetrical accommodation. Pt. moves upper and lower limbs upon request; movement is weak. The pt.’s affect is calm and cooperative.CardiovascularPt.’s heart rate is regular with S1 and S2 sounds present. Pt. is hooked up to cardiac telemetry to monitor heart rate and rhythm continuously. Radial pulses are +3 bilaterally and pedal pulses are +2 bilaterally. No edema is present. Capillary refill is <3 seconds on all four extremities. Pt.’s skin is warm and dry with an appropriate, even coloring.RespiratoryPt. is on room air. Respirations are regular and lung sounds are clear in all lobes. Pt. has thin amount of green/yellow sputum and a cough. Cough is triggered by deep breathing. Pt. denies shortness of breath and shows no signs of respiratory distress.GastrointestinalPt. has four small laparoscopic incisions on middle and right upper quadrant of abdomen. Edges of incisions are approximated and held closed by Dermabond – adhesive glue. Abdomen is slightly distended, round, soft, and tender near surgical site. Pt. reports some belching, flatulence, and feeling bloated from the gas. Bowel sounds are present in all four quadrants. Pt. has not had a bowel movement since admission to the hospital two days ago. Pt. is still on a clear liquids diet following surgery. Pt. consumed jello and apple juice in the morning and reports no nausea or abdominal discomfort following intake.GenitourinaryPt. has a Foley catheter inserted yesterday afternoon following surgery. Catheter is draining clear yellow urine that is free of odor. Catheter is size 16 French and has 5 ml of fluid in the balloon. Insertion site shows no signs of infection such as drainage, erythema, swelling, or pain (as reported by pt.).MusculoskeletalPt. reports a slight weakness of the extremities since being hospitalized but no joint pain. Arm strength is 4/5 bilaterally and leg strength is 3/5 bilaterally. Pt. can perform active assisted range of motion. Pt.’s ambulates with a one-person assist due to overall weakness and potential for hypotension. Pt.’s gait is steady and developmentally appropriate. Pt. ambulates upright at a slow but regular pace with no assistive devices.Mental HealthPt.’s behavior is appropriate for the situation. Pt.’s stressors include hospitalization, surgery, and family death. Pt. has downcast eyes when talking about past life circumstances. Tears come to the pt.’s eyes when discussing loss of loved ones. Pt. appears to be coping well and describes support systems in place such as work and a sister. Pt. utilizes verbal and nonverbal communication and maintains appropriate eye contact. Pt.’s reactions are consistent and pt. uses self-assertion to discuss needs.IntegumentaryAside from laparoscopic wound sites on abdomen, pt.’s skin is clean, dry, and intact. Skin color is pale pink and is warm to the touch. No rashes, lesions, or ecchymoses are present. Pt. is able to ambulate with supervision and move independently in bed. Pt. has a Braden score of 19, indicating low risk for skin breakdown.Vascular AccessPt. has two peripheral IVs. The line in the dorsal left hand is a 20 gauge IV which is capped. The line in the right forearm is a 16 gauge IV which has continuous D5W-1/2 NS infusing at a rate of 100 ml/hr. Both IV sites remained free of erythema, drainage, swelling, or pain (as reported by the pt.) throughout entire shift. Dressings remained clean, dry, and intact.Diagnostic TestsPt. had a chest x-ray done two days ago upon hospital admission. Results showed no acute cardiopulmonary disease or other abnormalities. An abdominal ultrasound showed thickening of the gallbladder wall and extra fluid buildup, signifying cholecystitis. Surgical removal of the gallbladder was indicated.LabsThe pt.’s abnormal labs were as follows:DateLabResultReference RangeSignify6/16Albumin2.83.5-4.7Low6/16Calcium8.48.5-10.1Low6/16Creatinine1.240.53-1.20HighAll other laboratory values were within normal limits. While albumin can sometimes be low due to malnutrition or kidney and liver problems, the likely cause for the pt. is a post-operative acute inflammatory response (Peralta & Rubery, 2015). The slightly low calcium could be partly due to the pt.’s decreased intake over the past few days. Decreased calcium has been found to be associated with lower albumin levels following surgery as a result of hemodilution caused by physiological saline (Lepage et al., 1999). Elevated creatinine indicates poor kidney function (Davis, 2015). The pt. has CKD, which could be a contributing factor for the high creatinine.MedicationsMedicationDoseRouteTimeTherapeutic ClassRationaleRN ImplicationsCefazolin(Ancef)1 gIV pushQ8HAntibioticInfectionPush over 3-5 min. Observe for signs/symptoms of anaphylaxis.Metronidazole(Flagyl)500 mgIVPBQ8HAntibioticInfectionCompatibility with D5W-1/2 NS unknown; hang with new primary tube. Monitor for rash and signs of Stevens-Johnson syndrome. Heparin(Porcine)5,000 unitsSCQ12HAnticoagulantDVT prophylaxis; Treatment of A-fib.Rotate injection site. Monitor for signs of bleeding or hemorrhage. Monitor platelet count every 3-5 days.D5W-1/2 NS100 ml/hrIVContinuousFluidsHydrationCheck IV site Q1H to ensure fluids are infusing properly and to watch for signs of infiltration.Benzocaine-menthol (Cepacol)15 mgLozengeQ2H PRNTopical anestheticSore throatEnsure pt. has intact gag reflex before giving lozenge.Morphine1-2mgIVQ2H PRNNarcoticMod-Severe PainMonitor for respiratory depression. Evaluate drug effectiveness by re-assessing pain level after administration.Ondansetron(Zofran)4 mgIVQ8H PRNAntiemeticNausea & vomitingMonitor nausea, vomiting, abdominal distention, and bowel sounds. Monitor ECG if pt. has hypokalemia or hypomagnesemia.Oxycodone-acetaminophen(Percocet)1-2tab (5-325 mg)POQ4H PRNNarcoticMod-Severe painMonitor BP, pulse, and respirations. Drug should not be taken broken, crushed, or chewed. Evaluate drug effectiveness by re-assessing pain level after administration.All drug information and nursing implications taken from Vallerand, Sanoski, & Deglin (2013).Treatments & TherapiesPt. is receiving treatments including sequential compression devices (SCDs), incentive spirometry, regular turning and repositioning, ambulation as tolerated, fluids, and medications for deep vein thrombosis (DVT) prophylaxis, infection, and pain. Pt. is encouraged to cough and deep breathe.Stressors according to Neuman SystemPt.’s intrapersonal stressors include loss of loved ones and the accompanying grief, and personal health problems both past, present, and chronic. Pt. has recovered from multiple broken bones and a past bout with sepsis, and is now recovering from the current cholecystectomy. Pt.’s extrapersonal stressors include managing work as a transportation driver for the Amish throughout his illness and financial management with hospital bills. Pt. did not express any interpersonal stressors.Nursing Diagnoses, Interventions, Plans, & EvaluationsDiagnosis #1: Risk for infection R/T abdominal incision sites.InterventionRationaleImplementationEvaluationAssess the pt.’s incision site every 4 hours for signs of infection (redness, warmth, swelling, drainage, increased pain). Assess pt.’s temperature every 4 hours.Assessment allows for care plan modification and interventions, as needed (Ralph & Taylor, 2008, p. 245). Increased temperature after surgery may signal wound infection (Ralph & Taylor, 2008, p. 176).Pt. was assessed at 0810, 1100, and 1535. Pt. remained free of fever or any signs of infection.Pt. denied pain at the incision site while at rest, and reported only momentary twinges of pain while rising to ambulate. Pt. reported no chills or perceived temp changes.Wash hands before and after contact with the pt. or any object contaminated with blood or body fluids.Hand washing is the most effective means for preventing microbial transmission (Ralph & Taylor, 2008, p. 180).Student nurse washed hands before and after all pt. contact and after contact with any bodily fluids.Pt. remained free of any signs of infection or new onset of illness.Administer antibiotics as ordered.Antibiotics can decrease incidence and severity of wound infection (Ralph & Taylor, 2008, p. 180).Pt. received prescribed antibiotics as ordered throughout shift.Pt. currently displays no signs of infection; antibiotics had the desired effect.Keep surgical wound covered with appropriate sterile dressing.Dressing the wound helps prevent wound contamination and subsequent infection (Ralph & Taylor, 2008, p. 180).Pt.’s wound remained covered with dermabond dressing and small clear tape during shift.The dressings were dry and intact throughout shift; wound remained free of any signs of infection.Teach pt. to wash hands before and after meals and after using the toilet or urinal.Hand washing prevents spread of pathogens to other objects, to food, and to the pt. (Ralph & Taylor, 2008, p. 176).Pt. utilized the bathroom sink and bedside hand sanitizer to wash hands before and after eating. Toileting not carried out due to indwelling catheter.Pt.’s hands remained free of visible soiling and pt. remained free of all signs of infection.Diagnosis #2: Tissue perfusion, risk for ineffective peripheral R/T pt. being post-operative / post-anesthesia and having limited mobility for several days.InterventionRationaleImplementationEvaluationAssess pt.’s legs for signs of DVT, including erythema, swelling, edema, leg pain, and hot to the touch.These signs indicate a DVT, which is a medical emergency (Treas & Wilkinson, 2014, p. 1367-1368).Student nurse assessed pt.’s legs at 0810, 1100, and 1535 and found no erythema, swelling, edema, or warmth. Pt. denies leg pain.Pt. has no signs or symptoms of DVT. Peripheral tissue perfusion intact.Maintain use of SCDs as ordered by the doctor.SCDs compress veins and promote venous return to the heart (Treas & Wilkinson, 2014, p. 1373 & 1482).Pt. used SCDs continuously when in bed.Pt. stated SCDs were not causing any discomfort. Pt. has no signs of DVT, so SCDs are carrying out purpose effectively.Have pt. work to continue increasing mobility.Increasing pt.’s activity helps prevent venous pooling and stasis and promotes venous return (Ralph & Taylor, 2008, p. 404).Pt. ambulated to and from bathroom as well as around the hall multiple times on the day of care.Pt.’s gait very slow but steady. Pt. did not stumble or falter. Pt. stated, “I’m tired” after returning to room.Monitor pt.’s I & O to ensure adequate fluid intake and to catch dehydration early.Adequate hydration keeps the blood from becoming viscous; viscous blood clots more readily (Treas & Wilkinson, 2014, p. 1373).Student nurse encouraged pt. to drink lots of water and recorded pt.’s I & O.Pt. continuously sipped on water while student nurse was in the room. I & O on day of care had a positive balance of 250, showing no dehydration.Diagnosis #3: Grieving R/T death of family member AEB pt.’s downcast expression, tears, and statement, “I’ve been through a really rough time.”InterventionRationaleImplementationEvaluationAssess for signs of grief when speaking with pt. Use therapeutic silence when appropriate as pt. expresses grief.Being aware of when the pt. is experiencing grief and using silence when appropriate conveys concern, understanding, and support (Ralph & Taylor, 2008, p. 489).Student nurse observed pt. having downcast eyes. Student nurse used silence several times while listening to pt. talk about loss.After having someone listen to his grief, the pt. was able to relate happy memories of the lost loved ones.Talk to the pt. about the stages of the grieving process and describe normal responses to grief.Understanding the grieving process enhances the pt.’s ability to cope (Ralph & Taylor, 2008, p. 489).Intervention partially carried out – student nurse told pt. it is normal to experience a variety of emotions related to grief, such as anger, sadness, and denial.Pt. nodded in agreement and said, “Thank you.” Pt. seemed validated by what student nurse said.Encourage pt. to express feelings related to the grief.Reserving feelings and holding them in can interfere with resolving grief (Treas & Wilkinson, 2014, p. 373).Student nurse sat beside pt.’s bed and took time to deeply engage in therapeutic communication so pt. would feel comfortable opening up about feelings.After some conversation, pt. opened up about grief. Pt. talked about the difficulty of missing his wife and children and the sadness of losing his whole family.Use therapeutic touch when appropriate and only if pt. seems open to it.Touch can convey caring and concern when used appropriately (Treas & Wilkinson, 2014, p. 468).Student nurse reached over and held pt.’s hand as he talked about the loss of his family.Pt. responded by squeezing student nurse’s hand, indicating the pt. found comfort in the touch.If pt. desires, request consultation with a spiritual advisor.This is a way to address the need of the pt. to find meaning in their suffering (Treas & Wilkinson, 2014, p. 377).Intervention not carried out.If pt. desires to speak with a spiritual advisor, would expect the consultation to bring comfort to the pt.ConclusionThe pt. responded positively to all interventions and remained free of signs of infection or complications on the day of care. The pt. responded well to teaching and increased his use of the incentive spirometer, coughing and deep breathing, and ambulating in the hall. Pt. will need further education and reinforcement to maintain post-operative health status and to achieve continued improvement. Respiratory monitoring is important as the pt. recently began having a scant amount of sputum. Pt. education regarding fatigue and hypotension should be reinforced as the pt.’s mobility increases. Dietary teaching regarding an intake of lower fat foods following the pt.’s cholecystectomy should be emphasized. The pt. should be able to discharge within the next few days if improvement continues.ReferencesDavis, C. P. (2015). Creatinine blood test. Retrieved from , R., Legare, G., Racicot, C., Brossard, J. H., Lapointe, R., Dagenais, M., & D’Amour, P. (1999). Hypocalcemia induced during major and minor abdominal surgery in humans. The Journal of Clinical Endocrinology & Metabolism, 84(8). 2654-2658. doi:0021-972X/99/$03.00/0National Institute of Health, Medline Plus. (2015). Acute cholecystitis. Retrieved from , R., & Rubery, B. A. (2015). Hypoalbuminemia. Retrieved from , S. S., & Taylor, C. (2008). Nursing Diagnosis Reference Manual (7th ed.). Ambler, PA: Lippincott Williams & Wilkins.Treas, L. S., & Wilkinson, J. M. (2014). Basic Nursing. Philadelphia: F. A. Davis Company.Vallerand, A. H., Sanoski, C. A., & Deglin, J. H. (2013). Davis’s drug guide for nurses (13thed.). Philadelphia, PA: F.A. Davis. ................
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