Definition of a Nursing Diagnosis, Exams of Nursing

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CASE STUDY ON CHOLELITHIASIS SUBMITTED TO:- SUBMITTED BY:- SUBMITTED ON:- IDENTIFICATION DATA Client’s name : Mrs. Soudamini Bisoi Age : 45 years Sex : Female IP No : 893742115 Date of admission 1 10/12/2023 Ward 7 Bed no. 204 Education : Graduation Occupation : Housewife Marital status : Married Religion : Hinduism Address : At/po- Jagatsinghpur, Dist: - Chatra Provisional diagnosis: Cholelithiasis, Hypothyroidism lL Presenting Chief Complaints: The patient complaints for — * = Abdominal pain since Imonth (Abdominal pain was aggravated from 7 days) ® Spread below the right shoulder or to the back abdominal ° Nausea Ih. History of Present Illness Mrs. Soudamini Bisoi came to Gastro OPD, IMS & SUM Hospital due to abdominal pain and Nausea on date (10/12/2023) after checkup in OPD my patient was admitted to Ward-7at 01: 10pm. Ill. Past medical history Mrs. Soudamini Bisoi is having Hypothyroidism and taking Tab. Thyroxine 75mg. IV. Past surgical History Mrs. Soudamini Bisoi doesn’t have any past surgical history. Vv. Family History Likes / dislikes: He likes all kinds of vegetables &fish. Any change in the dietary pattern: Avoidance of irritant foods, fried, fast food and balance diet is advice. Vv. Vital Signs: 5.NO Vital Sign Normal Value Patient's Value 1. Temperature 98.6 F 97.6F 2. Pulse 60 - 80 Beats/M 82 Beats/M 3. Respiration 14 - 20 Breath/M 22 Breath/M 4. Blood Pressure 120/80 mmHg, 135/80 mmHg Vi Visual Analogue Scale: The pain score of my patient is (4 - 5) and the pain is radiating from left upper limb to left lower limb. 0 1 2 3 a 5 6 5 8 9 1 — ~ (alm e@\ (00) (66) (eo c) 9) @) (22) ) 8) S) No pain Mild, anneying © Nagging. —Distressing. Intense, Worst possible, pala uncomfortable, miserable dreadful, uabrarsble, (roublevome pin horrible pain excrutiating pain pain PHYSICAL EXAMINATION 41. GENERAL APPEARANCE * LEVEL OFCONSCIOUSNESS — : Conscious and response to all my questions * ORIENTATION : Oriented to time and person and oriented to place * SKIN COLOUR : Brown * MOOD Alert * ACTIVITY : Active but doctor order to take bed rest * BODY BUILD : Obese * NOURISHMENT : Well nourished * SPEECH : Clear 2. ANTHROPOMETRIC MEASUREMENT * WEIGHT 145 kg * HEIGHT 2159cm * BODY MASS INDEX =: 63.4kg/m? 3. HEAD TO FOOT EXAMINATION L HEAD ® SHAPE — : Normocephalic * SCALP Clean * HAIR : My patient having black hair and distributed all over the scalp. * FACE : My patient doesn't have any puffiness or swelling in face. ® SUBJECTIVE SYMPTOMS : Nocomplaints IL EYES © = ~EYEBROWS © : Hair are equally distributed and both eyes brows are symmetric ® EYELASHES — : Eyelashes are clean and equally distributed *® EYELIDS : Normal * PUPILLARY REFLEX: Reacting to light * PUPIL SIZE : Round * SCLERA : White © CONJUNCTIVA =: Normal © CORNEAL REFLEX : Present * VISSION : Normal ® EVEMOVEMENT : Conjugate eye movement ‘@ USE OF GLASSES/CONTACT LENSES : My patient is not using any type of glasses/ contact lens. ® SUBJECTIVE SYMPTOMS : Nocomplaints TH EARS ¢ USEOFHEARING AIDS :No EAR CANAL : Both the canals are clean * TYMPANIC MEMBRANE — : Normal * HEARING : Weber test is done and my patient can hear in both the ears * MOUTH TEETH TONGUE ORAL ULCER ABDOMEN PERISTALSIS NUTITIONAL ROUTE BOWEL OPENED APPETITE PERCUSSION INGUINAL LYMPH NODE LIVER SPLEEN KIDENY * BOWEL SOUND ® PERIANAL SKIN INTEGRITY * SUBJECTIVE SYMPTOMS xX. GENITOURINARY SYSTEM * URINATION * URINE * GENITALIA ® SUBJECTIVE SYMPTOMS Xi. INTEGUMENTARY SYSTEM °® SKIN COLOUR TEXTURE TURGOR HYDRATION TEMPERATURE DISCOLOURATION CYANOSIS ® PERIPHERIES * ~ICTERUS * —LESIONS/MASSES * =~ SUBJECTIVE SYMPTOMS XiL. MUSCULOSKELETAL SYSTEM ® POSTURAL CURVES ® MUSCLE TONE * UPPER EXTRIMITIES @ SYMMETRY @ MUSCLE STENGTH eevee ee eevee ee eoeee . Clean Clean : Clean : Absent : Slightly enlarge : Present : Oral feeding Present : Normal : Presence of Air : No nodes are present : Normal in size : Normal in size : Normalin size : Present : Intact : Nocomplain : Self Voiding : No sediments are present 1 No discharge or edema is present : No complain i Intact : Brown : Normal : Normal : No lesions/ masses are present : No complaint = Normal : Normal : Upper extremities are symmetrical : Weakness @ RANGE OF MOTION : Possible BICEPS REFLEX TRICEPS REFLEX OEDEMA JOINTS DEFORMITY eeoode = ~LOWEREXTERMITIES oO HHH HHS SYMMETRY MUSCLE STRENGTH RANGE OF MOTION OEDEMA JOINTS DEFORMITY GAIT VARICOSE VEINS DEPENDENCY LEVEL Normal : Normal : Absent : NO.complaint : Absent : Lower extremities are symmetrical : Normal : Possible : Absent : No Tenderness : Absent : Normal : Absent : Independent SUBJECTIVE SYMPTOMS: Nocomplaint CHOLELITHIASIS Super saturation of bile with cholesterol Formation of precipitates Gall stones (Cholelithiasis) SLNQ | ACCORDINGTO BOOK ACCORDING TO PATIENT 1 Pain in the middle or right upper abdomen. Spread Pain inthe middle or right below the right shoulder or to the back abdominal upper abdomen. symptoms that occur within minutes after a meal. Nausea 2. Abdominal swelling, distengjon or bloating 3. Abdominal Tenderness. t Vomiting 4, Clay colored stools 5. Nausea Loss of appetite 6. Vomiting 7. Loss of appetite 8. Low grade fever and chills 9. Sweating DIAGNOSTIC EVALUATION (ACCORDING TO BOOK) ® Physical examination ® Historycollection * Abdominal ultrasound *® Endoscopy * Blood test ACCORDING TO PATIENT * History was collected and known that my patient having the history of Gall bladder stone(Cholelithiasis) and due to fasting for long time. * Physical examination-on palpation abdomen is slightly enlarged and pain present, Endoscopy: Upper GI Endoscopy- Duodenal scar; Duodenal submucosal Lesion. * Abdominal ultrasound-Normal in shape and size multiple calculi and echogenic sludge filling up the entire lumen of gall bladder largest calculus measuring 11.6mm wall thickness. INVESTIGATION | PATIENT'S VALUE | NORMAL | INTERPRETATION Complete blood count Blood studies Haemoglobin Total Red blood cell count PCV MCV MCH Platelets Total WBC different count Neutrophil Lymphocytes Eosinophil Monocytes Basophils ESR Routine az Investigation RBS Hbaic Blood urea S. creatinine S. sodium 5. potassium 5S. Chloride PT control INR 2 ABG PH PCO2 PO2 HCco3 Urine test (on in ERREP"P SUbRREREEREEE "EEE (LEUEEL CURLEY] FERRE ERP ERLE Gar Fray ACCORDING TO BOOK Non pharmacological measure- Promote bed rest. Ensure hydration. Low fat diet. Eat high fiber foods. Do not skip food. Pharmacological management. Antiemetics(To prevent or supress vomiting) Proton pump inhibitor(Supresses gastric secretion) Gallstone Dissolving Drugs(Dissolve in bile with the help of bile salts)-Ursodeoxycholic Acid and Chenodeoxycholic Acid Analgesic(To reduce pain) NSAID(Relieve pain, inflammation and fever)- Diclofenac Anticholinergic-Hyoscine Antibiotic(Cephalosporins) Third generation-Cetixime Surgical management- 1. Laparoscopic cholecystectomy 2. Opencholecystectomy ACCORDING TO PATIENT * Complete bed rest. * Eat high fiber diet ¢ Ensure hydration Tab. ondansetron (8mg) SOS Tab. Pantoprazole (40mg) OD Tab. Tapentadol Extended release (Tapal-ER) 50mg sos Tab. Taxim-o (200mg) BD Laparoscopic cholecystectomy NUTRITIONAL PLAN- Calories- 1600kcl /day Protein- 1gm /kg/bodyweight Fibers-30-35gms Carbohydrate-160gm Fluids- 1.5lit/day PROGRESS NOTE SL.N DATE NURSE’S NOTES ie] 1. 20.12.2023 Patient was conscious and Pain. The patient had semi fowler position and medication as ordered. Bp- 120/80mmhg Pulse 82/min RR-26/min Temp-98.4F $po2-100% in room air Patient maintained urination and BP. Advice Ultrasound and Endoscopy 2: 21.12.2023 Today patient is conscious .generalised weakness. BP-130/80mmhg PR-80/min Temp-98.4F $PQ2-98% Advice for CBC,LFT,RFT,13,T4 and TSH Administrate IV Fluid. 3. 22.12.2023 The patient is conscious, oriented. His vitals are stable. Nat= 128meq/I K+= 3.9meq/I CL-44meq/| HGT-134me/dl ABG Value PH-7.38 PCO2-40mmhg Po2-89mmhg Hco3-23.01mmol/L Nat-142meq/L K+ -3.4meq/L Cl-48meaq/l HGT-124mg/dl patient had abdomen pain, assess the location, severity(O-10 scale) and character of pain. Eat inadequate diet ,she was thirsty demanded more orally fluids Elimination Patient was self void ,no bowel movement, since two days Moving: Able to move self in bed without support. Dressing and undressing appropriately: she was dressed independently. Avoiding dangers and injury to others: she was conscious and orientated and able to follow the instruction regarding safety. vw v vVvwv » Communication: she was able to express self clearly. Hear and saw clearly. NURSING DIAGNOSIS:- * Acute pain related to obstruction of gall stone in gall bladder as evidenced by patient’s verbalization and facial expression. * Imbalanced Nutrition less than body requirements related to Loss of appetite as evidenced by weakness. * Risk for deficient volume related to vomiting as evidenced by hypotension * Anxiety related to change in health status as evidenced by insomnia and irritability. * Deficient knowledge related to disease condition as evidenced by asking frequent question. ‘ASSESSMEN | NURSING [| GOAL IMPLEMENTATIO | RATIONALE | EVALUATIO T DIAGNOSIS N N Based on Virginia Henderson’s Theory Subjective Acute pain | Patient Assess the -monitored To identify Patient pain data: related to will be cause ,locati | location, duration, | type and was Patient says obstruction | relief on and intensity of pain, | severity of relieved . that feel pain | of gall abdomina | severity of by using 0 to 10 pain. She feel in abdomen, stones in lpain and | pain scale in pain scale. comfort. indigestion, gall bladder | decreased aggravated as in pain -Monitored blood pain after a evidenced scale . pressure, pulse heavy meal by patient Monitor vital | and respiration. -To obtain from 6-7 days | verbalizatio signs baseline nand facial -Provide data. expression. comfortable i Provide position by lying | - To feel Tenderness and comfortable | on left lateral comfort. tigid abdomen Position position. Tight upper quacrantand -Administered facial Analaési E nalgesic as per expression ‘4 . VAS-4-5 doctor’s advice- To relieve Administere | Diclofenac. pain d Analgesic Imbalanced | Patient Assess the Checked To collect Patient’s Subjective, nutrition nutritional } nutritional nutritional status the baseline nutritional data: less _ than | status will | status and data status was Patient says body be needs of the improved as that feel requirement | improved | patient evidenced by weakness, related to increase indigestion loss of Assess the Checked weight- | To identify weight and nausea appetite as weight and 45 KG BMI Objective evidenced BMI BMI-63.4kg/m2 data: by Advice for To prevent Abdominal ‘weakness healthy diet | Advice for healthy | indigestion pain score diet like high-fiber increased, food and avoid fat Weight diet decreased BMI- underweight Encourage Rest for 6-7 hours patient for To easily bed rest AdministeredIV | digestion fluid like NS, DNS and RL as Administere | per doctor’s order dV fluid To improve As per hydration disease by asking the significant understandin | care frequent disease others in g Management Objective question condition | teaching. data: Asking Advice Advice to eat high | To know the frequent regarding fiber food and good question food. avoid fat food nutrition Educate the | Educate the disease disease condition condition its causes, sign To gain and symptoms, knowledge complicationand | regarding the treatment disease condition HEALTH EDUCATION- DIET- - Advice do not skip meals. - Advice to intake sufficient water. - Advice to eat high- fibre diet. - Avoid high spicy and fatty food. - vital signs and weight regularly. Management of disease condition - Teach the patient and family members about cause , effects, treatment, prognosis and complication of cholelithiasis. - Teach the patient to recognize and report complication like pain , weakness, nausea and vomiting, - Advice to avoid stress and strain. - Advice the family members for provide home care to the patient. - Teach relaxation techniques i.e like watching TV ,reading newspaper, 562-meditation. - Do regular exercise to maintain healthy weight. - Teach the family members about support the patient psychologically and physically - Teach them about sign and symptoms of disease and complication ,if any occur then immediately consult with physician. Medicati Teach the patient and family member about time and frequency of taking medication. Teach the family members for skip of drug may induce serious complication. - Teach about side effects of medication. - Advice to complete the course of medication. Follow up- - — Instruct the patient to review for re-checkup as a prescribed. - Advise that if any side effects occur then report to the physician. - Advice for regular CBC, TSH, T3 and T4. CONCLUSION Cholelithiasis is the medical name of hard deposits(gallstone) that may form in the gall bladder. Gall stone usually form from the solid constituents of bile and may be as a grain of sand or as large as a golf ball. Cholelithiasis is the presence of gall stones, which are solidification that form in the biliary tract, usually in the gallbladder. Predisposing factor of cholelithiasis 4F’S Fat, Forty, Female and Fertile. Early detection of symptoms and prompt management is necessary to prevent the further complications and prevent the patient from life threatening condition. BIBLIOGRAPHY * BRUNNER & SIDDHARTH’S. TEXTBOOK OF MEDICAL SURGICAL NURSING; 11™ EDI; NEW DELHI: REED ELSEVIER. - (P) LTD PAGE NO-562-568 * TRIPATHY KD.ESSENTIAL OF MEDICAL PHARMACOLOGY; SEVENTH EDITION; JAYPEE BROTHERS MEDICAL PUBLISHERS (P) LTD. PAGE NO-661- 671 * LEWIS TEXTBOOK OF MEDICAL SURGICAL NURSING ;NINTH EDITION ;NEW DELHI; ELSEVIER P- 1106-1120