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I. INTRODUCTION Cholecystitis is an inflammation of the gallbladder wall nearby abdominal lining. Cholecystitis is usually caused by a gallstone in the cystic duct that connects the gallbladder to the gallbladder to the hepatic duct. The presence of gallstone in the gallbladder is called cholelithiasis. Risk factors associated with development of gallstone include heredity, obesity, rapid weight loss, through diet or surgery, age over 60, Native American or Mexican American racial makeup, female gender-gallbladder disease is more common in women than in men. Some common risk factor that leads to the developmental of cholecystitis are the 4s- Female, Fat, Fertile and Forty. Women with high estrogen levels, as a result of pregnancy, hormone replacement therapy, or the use birth control pills, are at particularly high risk for gallstone formation. Very low calorie diets, prolonged fasting, and low-fiber/high-cholesterol/ high-starch diets all may contribute to gallstone formation. Sometimes, persons with gallbladder disease have few or no symptoms. Others, however, will eventually develop one or more of the following symptoms; (1) frequent bouts of indigestion, especially after eating fatty or greasy foods, or certain vegetables such as cabbage, radishes, or pickles, (2) nausea and bloating (3) attacks of sharp pains in the upper right part of the abdomen. This pain occurs when a gallstone causes a blockage tht prevents the gallbladder from emptying (usually by obstructing the cystic duct). (4) Jaundice (yellowing of the skin) may occur if a gallstone becomes stuck in the common bile duct, which leads into intestine blocking the flow of bile from both gallbladder and the liver. This is a serious complication and usually requires

immediate treatment. The only treatment that cures gallbladder disease is a surgical removal of the gallbladder, called cholecystectomy. Generally, when stones are present and causing symptoms, or when the gallbladder is infected and inflamed, removal of the organ is usually necessary. When the gallbladder is removed, the surgeon may examine the bile ducts, sometime with x-rays, and removal of any stones that may lodge there. The ducts are not removed so that the liver can continue to secrete bile into the intestine. Most patients experience no further symptoms can occur, which can usually be controlled with a special diet and medication. About 95% of people with acute cholecystitis have gallstone (calculous cholecystitis ) and 5% lack gallstone (acalculous cholecystitis). The incidence of acute cholecystitis among people with gallstone is unknown. Of people admitted to hospital for biliary tract disease, 20% have acute cholecystitis. The number of cholecystectomies carried out for acute cholecystitis increased from the mid 1890s to the early 1990s, especially in older people. Acute calculous cholecystitis is three times more common in women that in men up to the age of 50 years, and is about 1.5 times more common in women in men thereaftee. The group NMC-4 was assigned in the FLC ward for 7am-3pm shift at Notre Dame de Chartres Hospital last September 2-4, 8-10 2011 under the supervision Ms. Andrea Bayo. During our shift we were able to handle patients with different cases. One of many cases we encountered is the Cholecystitis, in which our patient was diagnosed to have.

Our group chose the case Cholecystitis because it is interesting, caught our attention and less common unlike other cases. We also chose this case to be able to deepen our understanding about cholecystitis and also learn from the pathophysiology and management and intervention to the patient with cholecystitis. Cholecystitis is a serious situation which can cause death when disregarded or untreated or right intervention is not given to the patient.

II-PATIENTS PROFILE

A. Biographical Data Name: Age: Birthday: Nationality: Religion: Gender: Civil Status: Address: Occupation: Ward: Date of Admission: Time of Admission: Chief Complaint: Admitting Diagnosis: Operation Performed: Final Diagnosis: Patient X 54 years old April 06, 1957 Filipino Anglican Female Married Acupan Virac,Itogon Benguet Housewife Father Louis Chauvet (FLC) September 1, 2011 10:18am For Gallstone Femoral, Upper Right Quadrant pain Acute cholecystitis Open Cholecystectomy Cholelithiasis / Cholecystitis

B. Medical History B1. History of Present Illness Last July 2011 while patient x was busy gardening on their field. She felt dizzy and then she collapsed. But after a few minutes she was awake for being collapsed, she went home and told to her husband the incident. They decided to take her to Baguio General Hospital And Medical Center for consultation, and the physician told them that she is suffering, from acute cholecystitis the patient has been scheduled for surgery but was delayed. But on September 2, 2011 the patient was scheduled to undergo open cholecystectomy to be performed by Dr. Romeo Conception. Upon assessment, the patient was conscious and coherent. B2. Past Medical History The patient suffered from common illnesses such as cough and colds but did not seek any consultation. She practiced self-medications such as intake of paracetamol for headache and ascorbic acid. Patient was no known allergies to food and drugs. B3. Family History Hypertension runs in the family in the paternal side and her sister suffered from cholecystitis, but did not undergo surgery since pharmacologic approach was utilized.

B4. Social and Environmental The patient is a housewife with 8 children. She has a good relationship with her family and friends. She doesnt smoke and drink alcohol. She is non-smoker and onalcoholic beverage drinker. The patients house is permanent. It is located in the mountain. Spring is their main source of water. The patients usual diet consist of salty foods and she usually eats lunch with sauces like bagoong and patis, vinegar, soy and alamang which serves as precipitating factors for the existing condition. B5. Obstetric and Gynecological History, Surgical History The patient has 8 children (G8P8(8-0-0-8)). The 7 children were delivered via Normal Spontaneous Delivery and the last child was born via Caesarian Section delivery.

III. GORDONS 11 FUNCTIONAL HEALTH PATTERN 1. Health-Perception Health-Management Pattern The patient suffered from common illnesses such as cough and colds but did not seek any consultation; she practiced self-medications such as intake of paracetamol for headache. It was July 2011 when she was diagnosed of cholecystitis and on September 2, 2011 she undergone operation for her disease. Patient X is a non smoker- non alcoholic beverage drinker. 2. Nutritional-Metabolic Pattern During assessment the patient is on NPO as ordered by the doctor as preparation for surgery. Prior to hospitalization she was able to eat her normal diet and able to drink 6 to 8 glass of water. The patients fluid intake during the shift is 600-900cc. She receives an IVF if D5NR 1L regulated at 41 to 42 gtts/min to run for 8 hours infusing well on the left hand and followed by an IVF of D5NM 1L regulated at 41 42 gtts/min to run for 8 hours. Patient consumed a total IVF of 1000cc that day. 3. Elimination Pattern The patient urinated 400cc during the shift. Urine is yellow in color. She defecates once a day, Stool is soft in consistency and brownish in color. During the 24 hours shift, patient was able to urinate approximately 1200cc

4. Activity-Exercise Pattern The patietn mve slowly in ved due to her present condition, She needs assistance when doing such movements because of her body weakness and pain on her incision site. She is able to extend and flex her extremities. Patient Xs pulse rate ranges from 60 0 beats per minute. The patients blood pressure was taken on her right arm in a lying position; her blood pressure ranges from 130/80 to 120-80 mmHg. 5. Sleep-Rest Pattern Patient was able to sleep well. She lies in her bed most of the time in order for her to be comfortable and rested. The patient was able to sleep 6 to 8 hours a day. But she was disturbed when the nurse goes to her room to check her vital signs and when she was given a medication. 6. Cognitive-Perceptual Pattern The Patients ears re symmetrical. It is free from lesions, she is able to hear and respond to the questions being asked. Her eyes are symmetrical. It is free from inflammation, crusting and masses. The cornea is moist, shiny, clear and pale conjunctiva. She was able to see things shown to her

She gives information with regard to her feeling toward her health condition. She is oriented to time and aware of the place where she is and the people around her. During the interview she complains of pain on her incision site. 7. Self-Perception Self-Concept Pattern The patient verbalized that before the operation that she was nervous. She also verbalized that she can no longer do the activities that she able to do when she was not operated. 8. Role-Relationship Pattern Patient X is living with her husband and children. She has a good relationship with her family. Her children were able to provide their necessities. 9. Sexuality-Reproductive Pattern Patient X is no longer active in her sexual life because of her age. The patient has 8 children (G8P8(8-0-0-8)). The 7 children were delivered via Normal Spontaneous Delivery and the last child was born via Caesarian Section delivery. 10. Coping-Stress Tolerance Pattern Patient X verbalized that she shares her problems to her family. they are always there to support her whenever she has problem.

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11. Value-Belief Pattern Patient X is happily married and affiliated to the Anglican Church. She verbalized that they attend to their church every Sunday.

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IV. ANATOMY AND PHYSIOLOGY

Gallbladder, 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 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,

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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.

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V. PATHOPHYSIOLOGY The term cholecystitis refers to inflammation of the gallbladder. Both acute and chronic cholecystitis are associated with cholelithiasis. Acute cholecystitis associated with complete or partial obstruction. It is believe that the cause of inflammation is by chemical irritation from the concentrated bile along with mucosal swelling and ischemia resulting from venous congestion and lymphatic statis. Bacterial infection may arise secondary to the ischemia and chemical reaction. The bacteria reach the injured gallbladder through the blood,bile ducts or from adjacent organ, most common pathogen staphylococci and enterococci. Since the wall of gallbladder is the most vulnerable to ishemia this could results to mucosal necrosis and may lead to gangrenous changes and perforation of the gallbladder. Chronic cholecystitis results from repeated episodes of acute cholecystitis or chronic irritation of the gallbladder by stones (cholelithiasis).

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o o o o o Heredity Obesity surgery Female Gender fiber/high-cholesterol/high-starch diets.

Bile must become supersaturated with cholesterol and calcium

The solute precipitate from solution as solid crystals

Crystals must come together and fuse to form stones

Gallstones

Obstruction of the cystic duct and common bile duct

Sharp pain in the right part of abdomen

Jaundice

Acute pain related to inflammation and distortion of the gallbladder

Distention of the gall bladder

Impaired skin integrity related yellow discoloration of the skin

Venous and lymphatic drainage is impaired

Proliferation of bacteria and enterococci

Chronic irritation of the gallbladder by stones

Areas of ischemia may occur

Inflammation of gall bladder Fever and abnormal increase of WBC (Hyperthermia related to bacterial process as manifested by increase WBC)

CHOLECYSTITIS

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VI. MANAGEMENT OF CARE A. Laboratory Tests and Interpretations Hematology September 1, 2011 Test WBC RBC Hemoglobin Hematocrit Platelet Neutrophils lymphocytis monocyte eosinophils MCV MCH MCHC Result 6.7 x 10 3/ul 4.62 13.2 0.401% 271 50 46 0.00 0.04 86.8um 28.6 32.9 Interpretation: As show in the table above, that the Hematocrit had decrease. This implies that the low hematocrit values could be a result of anemia and chronic infection; since cholecystitis is a infection chronic this could be an indicator of low hematocrit count. Furthermore the other Blood test results are in normal range (Brunner and Suddarths . Medical Surgical in Nursing 12th Edition). Normal values 4.0 10.0 3.5 5.5 mill/mm3 12 16 g/dl 36.1-44.3% 150, 000 350, 000ml 54%-62% 25%-30% 0-800/uL 0-450/uL 76-100um 27-32pg/cell 32-36g/dL Interpretation Normal Normal Normal Decreased Decreased Normal Normal Normal Normal Normal Normal Normal

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