THE ARAB AMERICAN UNIVERSITR

FACULTY OF ALLIED MEDICAL SCIENCE

DEPARTMENT OF NURSING
CASE STUDY
Student Name: Mona Amal Jbareen
ID: 21410843
Date: 21/12/2015
Hospital: Rafidia Surgical Hospital
Instructor Name: Salah

Introduction:
The patient (A.A) is a 53-year-old man, from
Nablus, Muslim, married since 25 years, have four
sons and two daughters, he works in the electricity
.company
He Is admitted to the hospital with abdominal pain
in the right upper quadrant, center of abdomen
.just below breastbone, and in the right shoulder
His pulse rate, Blood pressure and temperature
.were with in normal range
.The patient had been hospitalized 3 months
:Pathophysiology
The process of gallstone formation is referred to as
cholelithiasis. It is generally a slow process, and
usually causes no pain or other symptoms. The
majority of gallstones are either the cholesterol or
mixed type. Gallstones can range in size from a
few millimeters to several centimeters in diameter.
About 70% of gallstones are formed from
cholesterol. Pigment stones (black or brown) are
also very common and account for the remaining
30% of stones. Patients can have a mixture of the
two gallstone types.
Cholesterol Stones
Gallstones may develop when there is too much
cholesterol in the bile secreted by your liver. Bile
usually dissolves or breaks down cholesterol.
However, if the liver makes more cholesterol than
bile can dissolve, hard stones may develop.
Bilirubin

Bilirubin is a chemical produced when the liver

destroys old red blood cells. Some conditions, such
as cirrhosis of the liver and certain blood disorders,
cause the liver to produce more bilirubin than it
should. Stones form when the gallbladder cannot
break down the excess bilirubin. These hard
substances are also called pigmented stones.
Concentrated Bile
The gallbladder needs to empty bile to be healthy
and function properly. If it fails to empty its bile
content, the bile becomes overly concentrated,
which causes stones to form.
Pathophysiology (Clinical picture)
clinical
picture:
signs &
symptoms
Abdominal
Pain

Rational for
clinical
picture

medial surgicl
treatment

Due process laparoscopic

that have
cholecystecto
undergone my

Rational

removal of the
gallbladder a small
pearshaped sac that is
located directly beneath
the liver in the upper
right side of the
abdomen. The
gallbladder's main
function is to store bile,
which is produced by the
liver, and to release it as
needed for digestion. the
gallbladder's function is
important, but it is not
an essential organ.

biliary colic

occurs
laparoscopic
when the
cholecystecto
extrahepati my
c ductscystic,
(hepatic
duct or
common
bile duct)
are
suddenly
blocked by
.a gallstone

to removal of the
gallbladder. It is a
common treatment of
symptomatic gallstones
and other gallbladder
.conditions

Assessment:
Demographic Data:
Patient Initials: A.A
Occupation: worker in the electricity company
Religion: Muslim
Age: 53 years old
Gender: Male
Marital status: married
Date of Patient Admission: 05.12.2015
Time: 09:48
History:
Chief complaint: the patient told me she complain
of pain in the right upper quadrants of the
abdomen.
Past Medical history : the patient told me :

began to suffer from this pain of about 3 months.

after this she went to the Rafidia Surgical
Hospital , ultrasound examination was done .And
knew the cause of the disease.
Past surgical history: No past surgical history.
Allergies:
food: the patient told me that she doesn't have
allergies to any type of food.
Medication: the patient told me that she doesn't
have allergies to any type of medication.
Smoking: the patient told me : she isnt smoker.
General Data:
Vital signs
1. Body temperature: Temp: 37 C /Normal /
obtained axillary ( the normal average between
36.5-37.4)
2. Respiratory: Respiration: 18 breath/min, the
normal average (12-20)16 breath/min.
3. Pulse: 95 beat/min (the normal average (60100)80 beat/min
4. B/P: 110/70 MMHG, obtained from the left hand,
and in normal range, the normal average of systole
(110-135), and the normal average of diastole (6580).
5. Height: The patient told me that he is 159 cm.
6. Weight: The patient told me that he is 80 kg.

* The BMI IS 31.6 / Normal weight = 18.524.9 /

Underweight = <18.5/ Overweight = 2529.9 /
Obesity = BMI of 30 or greater
General Appearance :
1. Skin color: light brown/ by inspection.
2. Level of consciousness: completely oriented/ by
inspection.
3. Posture & position: able to walk but with help by
another person.
4. Physical deformities: he hasnt any deformities.
5. motility :
Gait: by inspection/ has upright posture and
steady gait, and spinal column is straight.
Involuntary movements: by inspection/ he
doesnt has any involuntary movement.
Use of assistive device: by inspection/ he
needed help , and need an assistive device.
6. Facial expression: by inspection/ his facial
expression was smiley .
7. Mood & affect: by inspection / good mood,
respond to us very well.
8. Personal hygiene: by inspection/ its clean, with
help from her family.
9. Speech: comprehensive word, clear sound.
Medical Diagnosis:
Etiology, signs,
symptoms

Definition

Medical
Diagnosi

signs and
symptoms may
result, such as:
*Sudden and
rapidly
intensifying pain
in the upper right
portion of your
abdomen *
Sudden and
rapidly
intensifying pain
in the center of
your abdomen,
just below your
breastbone * Back
pain between
your shoulder
blades *Pain in
your right
shoulder.

little pebbles that develop

inside the gallbladder-a
small, pear-shaped organ
located on the right side of
your upper abdomen. The
gallbladder stores and
releases bile, a liquid that
helps digest fats. If the bile
contains too much
cholesterol or waste
products, it can harden into
gallstones. If the tubes
(ducts) carrying bile are
blocked by gallstones, the
gallbladder may become
swollen and painful.

s
G.B.S
gallbladd
er stone

Systems Include
Neurovasclar system:
1. Reflexes: the patient is relaxed and the joint is
flexed appropriately.
2. Level of consciousness: normal.

3. Speech: the patient can express himself.

4. Coordination and general balance: he walks
across the room, turns, and walks back.
5. Appearance and behavior: appropriate.
6. Eye-opening response: spontaneously.
7. Motor response: obeys.
8. Verbal response: oriented.
musculoskeletal system:
1. Temporal mandible joint for tenderness: by
inspection the joint and palpation each joint for
tenderness no swelling , no tendernrss, and joient
more smoothly.
2. Upper extremities (ROM & muscle strength): by
deep palpation strength muscle.
a. Shoulder: by palpation strength muscle and
equal strength on each body side.
b. Elbow: by palpation strength muscle and equal
strength on each body side.
c. Wrist and carpals: by palpation strength muscle
and equal strength on each body side.
3. Lower extremities:
a. Hip: client raises one leg at a time while I
attempt to hold it down/ painful due process that
have undergone.
b. Knee: client spreads his legs against my
resistance, strength muscle.

c. Ankle & foot: the pt attempt to flex the foot

again resists, strength muscle.
Cardiovascular System :
1. Auscultate the carotid artery: no sound hear on
auscultate.
2. Palpate the apical impulse: apical pulsation can
be felt by palpation.
3. Percussion sound: by percussion dull sounds are,
normally heard over dense area such as heart.
4. Auscultation listens for s1 & s2 (rate &rhythm ):
by auscultation s1 and s2 can be heard at all
anatomic site.
Respiratory system:
1. Shape of chest: by inspection/ anteroposterior to
transverse diameter is 1:2 , chest symmetrical.
2. Skin condition: by inspection / light brown,
uniform with the color of body.
3. Symmetric expansion of the lung: by inspection /
full symmetric expansion during breathing.
4. Auscultation of breath sound: the thorax
vesicular and bronchovesicular breath sound very
normal.
5. Respiratory rate &rhythm: normal breath and it
is silent.

Skin:
1. Color: by inspection / light pink, uniform color.
2. Moisture: the skin is very moisture.
3. Texture: smooth skin and warm.
4. Thickness: by palpation & inspection the pt is
normal thickness of skin/ thin skin is 0.5 mm/ thick
skin is up to 6 mm in palms and soles.
5. Edema: patient doesnt has any edema her skin
is uniform with no edema.
6. Turgor: when pinched , skin springs back to
previous state.
7. Hygiene: by inspection / its clean.
8. Lesions & rashes: by inspection/ patient doesnt
has any lesions & rashes.
Urinary System:
1. urinary habits: the patient told me: he is
accustom to urinate when he wake up.
2. color: the patient told me : light yellow color.
3. frequency:
the patient told me: he is voiding more than 3
times per day.
4. urgency: the patient told me : he can control
himself to doesnt go to the bathroom
immediately .
5. burning: the patient told me : he doesnt has any
burning.

Gastrointestinal System:
1.Contour: by inspection/ the contour is rounded.
2.Color & skin condition (abdomen): by inspection /
light brown color and uniform, no lesion.
3.Umbilicus (hernia, discharge): by inspection he
has'nt discharge , after dressing for the site of
operation.
4.Bowel sound: the pt didnt eat for a week so he
doesnt has a bowel sound.
5. rectum:
a. bowl habits: the patient told me: he defecate at
least 3 times a weak.
b. sphincter control: the patient told me: he can to
control herself .
c. Incontinency: the patient told me he doesnt has
facial incontinency.
d. Hemorrhoid: the patient told me he has no
hemorrhoid.
e. Fissures: the patient told me he has no fissures.
Hematology:
There are leukocytosis with a "left" shift, and
elevations in the amylase and lipase levels in the
pancreatitis. And elevations of hepatic
transaminases and alkaline phosphatase.

:Endocrine
.Rate of growth: normal .1
.Heat or cold intolerance: normal .2
.Changes in glove, shoe, or ring sizes: no change .3
.Sweating or flushing: normal .4
.Weight changes: no changes, in average .5
Abnormal pigmentations: There is no .6
.appearance of pigmentation
.Change in skin texture: no change .7
.Impotence: no impotence .8
Dryness of skin and hair: no dryness, no loss of .9
body hair or hirsutism (people with endocrine
problems often have either hirsutism or loss of
.body hair)

Pain:
The most common symptom of gallstones is pain in
the stomach area or in the upper right part of the
belly, under the ribs.
The pain start suddenly in the center of the upper
belly (epigastric area) and spread to the right
upper back orshoulder blade area. It was hard to

the patient to get comfortable. Moving around does

not make the pain go away. Continuous pain for 1
to 5 hours.
The patient prevent the pain from taking normal or
deep breaths.
The pain begin at night and was severe enough to
wake he. and occur after meals
Psychological/ social:
Sleep: the patient was unable to sleep enough due
to her conifinement.
The patient is cooperating even in pain he is awae
of her current condiotion.
And give appropriate solution to problem he
encounter in life. She Knows how to manage stress
by diverting her attention to others.
Self Care Ability
Activity
Eating/ Drinking
Bathing
Toileting
Ambulating

Independent

Assistive

Dependent

Refrences:
1. From Wikipedia.
2. Nursing care plane .
3. Clinical Pharmacology for Nurses john Trounce

Notes
Medication:
(list all treatment: refer to chart, medication sheet,
krdex)
Nursing Expected Side
Implicati Efeects
ons
nausea,
vomiting,
sedation,
dizziness,
diaphoresis,
urinary
retention and
constipation
Avoid
Swelling,
skipping
redness, pain,
doses or
or soreness at
not
the injection site
completin may occur. This
g the full medication may
course of also
therapy.
infrequently
cause loss of
appetite,
nausea,
vomiting,
diarrhea,
irritability, or
headache.

Indication
for My
Patient
for the
treatment of
moderate to
severe pain.

Dosage
and
Rout
75 mg /
IM

Drugs and
Classificat
ion
Pethidine

prevent
infections
that are
proven or
strongly
suspected
to be
caused by
bacteria.

750 mg / ZINACEF
IV
(cefuroxim
e)

This
medicatio
n may be
taken
with food
or a full
glass of
water or
milk to
prevent
stomach
upset.

Diarrhea
,dizziness or
lightheadedness
, headache loss
of appetite,
nausea or
vomiting.

is an
1500/
antibiotic
Tablet
effective
against
anaerobic
bacteria and
certain
parasites.

metronidaz
ole
(Flaggy)

Lab Work:
Date

Lab Test

Normal
Values

Current
Values

Nursing
Interpretatio
n

05/12/2015

WBC
Hgb
Hct
Platelets
Glucose
BUN
Creatinine
Na
K
Ca
RBC
MCV

4.8-10.8
16_12
47_37
450_140
120_60
23_4
1.3_0.6
145_135
5_3.5
4.5-5.5
5.40_4.20
97_80

K/UL 9.6
g/dl 12.1
36.9
k/ul 287
mg/dl 91.6
mg/dl 14
mg/dl 0.4
140mEq/L
3.6mEq/L
1.29mEq/L
M/ul 4.65
Fl 79.4

Normal
Normal
Normal
Normal
Normal
Normal
Low
Normal
Normal
Low
Normal
Normal

Date

Lab Test

Normal
Values

Current
Values

Nursing
Interpretatio
n

06/12/2015

WBC

4.8-10.8

K/UL 14.4

Hight

Hgb
Hct
Platelets
Glucose
BUN
Creatinine
Na
K
Ca
RBC
MCV

16_12
47_37
450_140
120_60
23_4
1.3_0.6
145_135
5_3.5
4.5-5.5
5.40_4.20
97_80

g/dl 11.2
34.6
k/ul 270
mg/dl 91.6

Low
Low
Normal
Normal

mg/dl 14
mg/dl 0.4
140mEq/L
3.6mEq/L
1.29mEq/L

Normal
Low
Normal
Normal
Low

M/ul 4.35
Fl 79.6

Normal
Normal

PIE (Plan, Intervention, Evaluation):

Evaluation

Rational

Implementation

Planing&
Goal

After 8 hours of
nursing
interventions,
the patient will
verbalize relief or
control of pain.

Helps evaluate
degree of
discomfort and
may reveal
developing
complications.
Reduction of
anxiety or fear that
can promote
relaxation and
comfort.
Reduces muscle
tension, promotes
relaxation, and
may enhance
coping
abilities.Requiring

INDEPENDENT
Assess pain,
notinglocation,
characteristics,
intensity (0-10
scale). Encourage
patient to verbalize
concerns. Active
listen these concerns
and provide support
by acceptance,
remaining with
patient and giving
appropriate
information.
Provide comfort
measure like back

After 8
hours of
nursing
intervention
s, the
patient will
verbalize
relief or
control of
pain.

Nursin
g
Diagno
sis
Acute
pain

after 8 hours of
nursing
interventions the
patient was able
verbalize
understanding of
therapeutic
needs .

prompt Medical
intervention.
Relieves pain,
Enhances comfort
and promotes rest.

rub or deep
breathing exercises.

provides
knowledge base on
which patient can
make informed
choices. *
promotes
independence in
care and reduces
risk of
complication. *
during initial 6
mounths after
surgery, low fat
diet limits need for
bile and reduces
discomfort
assosiated with
inadequate
digestion of fat. *
minimizes the risk
of pancreatic
involvement.*
intestines require
time to adjust to
stimulus of
continuous output
of bile. * indicators
of obstruction of
bile flow or altered
digestion, requiring
further evaluation
and intervention. *
resumption of

independent:- *
review disease
process, surgical
procedure or
prognosis. *
demonstrate care of
incisions or dressing
or drains. *
emphasize
importance low fat
diet, eating small
frequent
meals,gradual
reintroduction of
foods or fluids
containing fats over
4 to 6 mounth
period. * discuss
avoiding or limiting
use of alcoholic
beverages. * inform
patient that loose
stools may occur for
several mounths. *
identify signs and
symptoms requiring
notification of
healthcare provider
like dark urine ,
jaundiced color of
eyes or skin, clay
colored stools. *
review activity

after 8
hours of
intervention
s the
patient will
verbalize
understandi
ng oh
therapeutic
needs.

knowle
dge
deficie
nt
regard
ing
conditi
on and
self
care
relate
d to
inform
ation
misint
erpret
ation

usual activities is
normally
accomplished
within 4-5 weeks.

relaxed and
report anxiety is
reduced to a
manageable
level * showing
problem- solving
skills *
demonstrate
healthy ways to
deal with and
express anxiety.

limitations depending
on individual
situation.

assess level of
anxiety * assisst
client ti identify
anxiety and begin to
deal with problems .

after 6 hour
of nursing
intervention
the patient
will:
showing
problem
-solving
skills *
demonstrat
e healthy
ways to
deal with
and express
anxiety*
appear
relaxed and
the level of
anxiety is
reduced to
manageabl
e level.

Anxiet
y

Feeding Tubes:
The patient eat orally, not applied any
feeding tubes.
Dates:
Date admission: 5/12/2015, Time- 09:48.
Date of operation: 7/12/2015, Time- 12:48.
Date of discharge: 9/12/2015.