Mrs. Omi Devi, a 67-year-old female, presented with abdominal pain for 12 days and was diagnosed with cholelithiasis after an ultrasound revealed gallstones. She has a history of diabetes and hernia surgery. On physical examination, she had pain in her abdomen on palpation at the site of her recent laparoscopic cholecystectomy. Her lab tests showed elevated bilirubin levels. She is being treated medically with antibiotics and pain medications and was advised dietary and lifestyle modifications to manage her condition.

1. CASE PRESENTATION
ON
CHOLELITHIASIS
BY ARUSHI NEGI
M.SC. NURSING 1ST YEAR

2. Identification Data:
• Client name: Mrs. Omi devi
• Age/sex: - 67 years / Female
• Father/spouse name: Mr. Ram meher
• Hospital registration number: 22030
• Ward: Surgery ward
• Bed No.- 45
• Address: Village sher, Panipat , Haryana
• Education: 3rd
• Occupation: House wife

3. Marital status: Married
Religion: Hindu
Date of admission:26/12/2021
Date of discharge: -
Diagnosis: Cholelithiasis
Surgery (if any): Laparascopic cholecystectomy
Date of Surgery: 28-12-2021
Date of interview :03-01-2022
Doctor In-charge: Dr. J.P singh
Informant : Patient herself.

4. History of Illness:
Chief complaints: patient was having pain in abdomen since
last 12 days.
History of fever 4-5 days
At present :Patient is well , and have pain at surgical site.
 Present medical history:
My patient was having epigastric pain since last 12 days so she
visited a nearby clinic at her residence who recommended an
ultrasound in which she was diagnosed with cholelithiasis. She
was recommended to go for higher facility for which she chose
Lal Bahadur Shastri Hospital

5. Past medical history:
Patient is diagnosed with diabetes since last 15 years and
was taking treatment from her nearby clinic.She has now
stopped taking medications .
Past surgical history:
Patient has undrgone hernioplasty 5 years back for hiatal
hernia nearby in a facility near her house.

6. FAMILY HISTORY
S. No . Name of
family
members
Age sex Occupation Relation of
family
Member to
patient
Education Health
status
1. Omi devi 67y F House wife Self 3rd Unhealthy
2. Ramprakash 70 y M Farmer Husband 5th Healthy
3. Indrajeet 45 y M Pvt job Son BA Healthy
4. Sushila 40 y F House wife Daughter in
law
10th Healthy
5. Rahul 20 y M Student Grandson BBA Healthy
6. Rakesh 18 y M Student Grandson 12th Healthy
7. Monika 44 y F House wife Daughter 12th Healthy
8. Rajeev 46 y M Pvt job Son in law Polytech Healthy
9. Shikha 16 y F Student Granddaught
er
10th Healthy

7. FAMILY TREE:
Female
Male

8.  Personal History:
No smoking and alchol consumption history.
 Menstrual history:
Patient attained menarche at the age of 14 yrs , and
menopause at 50 yrs,
She didn’t undergo any checkups during her pregnancy.
Had normal vaginal delivery.
 Dietary habits:
She consumes non vegetarian diet.
 Elimination pattern : She has constipation

9. PHYSICAL EXAMINATION
GENERALAPPERANCE:
 Body build - Endomorph
 Height- 151 cm
 Weight- 95 kg
Vital signs
 Temperature - 98.7 F
 Pulse: 85 b/m
 Respiration: 18 b/m
 B.P: 124/96 mmHg

10. Colour of skin: normal
Head:
Shape and size of skull: well rounded
Scalp: free from any lices
Face: sagging of skin due to old age
Eyes: no abnormality detected.
 Eye brow and eyelid: hair evenly distributed ,
symmetrical
Conjunctiva: no abnormality detected.
Sclera: slight yellow in color

11. Ear:
External ear: symmetrical
Hearing problem: no abnormality detected.
Nose:
External nares: straight and uniform
Mouth and pharynx:
Mouth: lips are pink in color
Teeth: no discoloration , lacks 3 teeth
Tongue: normal

12. Neck:
Thyroid gland: no abnormality detected
Lymph node: normal
Range of motion: No abnormalities.
Chest:
Breath sounds: no abnormality detected
Lungs: clear

13. Abdomen:
Inspection: scars of laproscopic cholecystectomy .
Auscultation: no abnormality detected.
Palpation: pain on touch
Extremities:
Upper: no abnormalities
Lower: no abnormalities
Back: no bed sores.

14. LAB INVESTIGATION:
LFT :
Bilirubin - 3 mg/dl
(0.1-1.2 mg/dl)
Direct -0.5 mg/dl
(0.0-0.2 mg/dl )
SGPT - 42 IU/L(
5-40 )
SGOT - 41
IU/L(5-40)

15. MEDICATIONS:
In my patient:
 VANCOMYCIN
 METRONIDAZOLE
 CIPLOXACIN
 PANTOPRAZOLE
 PARACETAMOL
 MONOCEFTRIAXONE
 NORMAL SALINE

16. METRONIDAZOLE
CHEMICAL
NAME
DOSE /ROUTE ACTION INDICATION CONTRA-
INDICATION
SIDE EFFECT NURSING
RESPONSIBILITI
ES
METRO NIDA
ZOLE
TRADE NAME -
METROGYL
DRUG CLASS -
ANTIBIOTICS
Adults—500 or 750
milligrams (mg) 3
times a day for 5 to
10 days.
Children—Dose is
based on body
weight and must be
determined by your
doctor. The dose is
usually 35 to 50
milligrams (mg) per
kilogram (kg) of
body weight per day,
divided into 3 doses,
for 10 days.
Metronidazole
interacts with the
microbial DNA to
break its strand and
helical structure
leading to inhibition
of protein synthesis,
degradation, and
cell death.
• Anaerobic
bacterial
infections.
• Amoebiasis
Bacterial
vaginosis
Trichomoniasis
• H. pylori
eradication
associated with
peptic ulcer
disease. Acute
dental infections.
• Prophylaxis of
post-op
anaerobic
bacterial
infections
• Hypersensitivity
to metronidazole
and other
nitroimidazoles.
• Concomitant
use with
disulfiram within
the last 14 days.
• Coadministratio
n with alcohol
or propylene
glycol
containing
products during
or 3 days after
therapy
discontinuation.
• Pregnancy
during the 1st
trimester in the
treatment of
trichomoniasis.
Severe neurological
disturbances,
encephalopathy,
convulsive seizures,
aseptic meningitis,
peripheral and optic
neuropathy,
paraesthesia;
superinfection (e.g.
fungal or bacterial
superinfection,
C. difficile-
associated diarrhoea.
Blood and
lymphatic system
disorders:
Leucopenia,
neutropenia. Cardiac
disorders: Chest
pain, tachycardia.
Ear and labyrinth
disorders: Tinnitu
Avoid use unless
necessary.
Metronidazole may
be carcinogenic.
Administer oral
doses with food.
report the adverse
effects to the
physicians.

17. VANCOMYCIN
CHEMICAL
NAME
DOSE /ROUTE ACTION INDICATION CONTRA-
INDICATION
SIDE EFFECT NURSING
RESPONSIBILITI
ES
VANCOMYCIN
HYDROCHLORID
E
TRADE NAME -
VANCOMYCIN
DRUG CLASS -
GLYCOPEPTIDE
ANTIBIOTICS
ADULT - 125MG
/ORAL
500MG / IV 6
HRLY
PEDIA : 40MG/KG
/IV
BACTERIOCIDAL
AND
BACTERIOSTATIC
IN ACTION
ACTS BY
INTERFERING
WITH CELL
MEMBRANES
SYNTHESIS IN
MULTIPLYING
ORGANISMS
IN LIFE
THREATNING
INFECTIONS.
IN CLOSTRIDIUM
DIFFICILE
COLITIS
HYPERSENSITIVI
TY TO
VANCOMYCIN
PREVIOUS
HEARING LOSS
USE OF
OTOTOXIC OR
NEPHROTOXIC
AGENTS
CNS: Dizziness,
nausea
Body as a whole:
Serious allergic
reactions
(anaphylactoidreacti
ons)
CV: Low blood
pressure
Respi: Wheezing
GI: Indigestion
Endo: Hives or
itching, Red Man
syndrome (due to
repid infusion of
Vancomycin
1. Administering
vancomycin include
ensuring a patent IV
line,
2. Planning for
administration of the
preoperative dose as
much as two hours
before the initial
incision is made.
3. Including
information about
the dose and timing
of preoperative
vancomycin
administration in the
surgical time out.
4. Report the
adverse effect to
physician.

18. DISEASE CONDITION

19. ANATOMY AND PHYSIOLOGY OF
GALL BLADDER

20. The gallbladder, a pear-shaped, hollow, sac like organ that is 7.5 to 10
cm (3 to 4 in) long, lies in a shallow depression on the inferior surface
of the liver, to which it is attached by loose connective tissue.
The capacity of the gallbladder is 30 to 50 ml of bile.
Its wall is composed largely of smooth muscle. The gallbladder is
connected to the common duct by the cystic duct .
Functions as a storage depot for bile.

21. Bile is composed of water and electrolytes along with
significant amounts of lecithin, fatty acids, cholesterol,
bilirubin, and bile salts.
The bile salts, together with cholesterol, assist in
emulsification of fats
Approximately half of the bilirubin is a
component of bile. It is converted into
urobilinogen, which is a highly soluble
substance.

22.  Urobilinogen is either excreted in the feces or returned
to the portal circulation.
If the flow of bile is impeded , bilirubin does not enter
the intestine.
As a result, blood levels of bilirubin increase resulting
increased renal excretion of urobilinogen and decreased
excretion in the stool.
These changes produce many of the signs and
symptoms seen in gallbladder disorders.

23. DEFINTION:
Cholelithiasis referes to calculi, or gallstones,
usually form in the gallbladder from the solid
constituents of bile; they vary greatly in size, shape,
and composition .
If gall stones migrate into ducts of biliary tract it is
known as choledocholithiasis.

24. TYPES OF GALL STONES :
Cholestrol stones
those composed pre
dominantly of cholesterol. If
excessive cholestrol is present
and insufficient bile acid is
secreted , bile becomes
supersaturated with cholestrol
and results in cholestrol
stones.
Pigment stones
probably form when
unconjugated
pigments in the bile
precipitate to form
stones.
Mixed stones
combination of
cholestrol and
pigment stones.

25. ETIOLOGY:
Excessive amounts of
cholesterol
Increased body weight and
older age with increased
cholesterol in the bile.
Bile contains too much
bilirubin

26. RISK FACTORS
Family
history Obesity
Women, especially
those who have
had multiple
pregnancies
Women of Native
American or U.S.
southwestern
Hispanic ethnicityy
Frequent
changes in
weight
Rapid weight
loss
Treatment with high
estrogen therapy
Cystic fibrosis
Diabetes

27. PATHOPHYSIOLOGY:
Decreased bile acid synthesis or incomplete and infrequent
emptying of gall bladder may cause the bile to become
overconcentrated.
Increased cholestrol synthesis in the liver
Super saturation of bile with cholestrol
Formation of precipitates
Gall stones( cholelithiasis)

28. CLINICAL MANIFESTATIONS
Gallstones may be silent, producing no pain and only mild Gl symptoms.
Pain and Biliary Colic
 If a gallstone obstructs the cystic duct, the gallbladder becomes distended,
inflamed, and eventually infected (acute cholecystitis).
 The patient may have biliary colic with excruciating upper right abdominal
pain that radiates to the back or right shoulder.
 Murphy’s sign - indicator of gall bladder inflammation ( acute pancreatitis
) pain on deep breath when finger on under the liver border at the bottom of
the rib cage.

30. Jaundice
 Found in patient usually with obstruction of the common
bile duct.
 The bile is absorbed by the blood and gives the skin and
mucous membranes a yellow color.
Changes in Urine and Stool Color
 The excretion of the bile pigments by the kidneys gives the urine a very
dark color.
 The feces, no longer colored with bile pigments, are grayish (like putty) or
clay colored.

31. Vitamin Deficiency
 Obstruction of bile flow interferes with
absorption of the fat soluble vitamins
A, D, E, and K.
 Patients may exhibit deficiencies of
these vitamins if biliary obstruction has
been prolonged. ( bleeding because of
vitamin K )

32. Patient Picture
In my patient pain in abdomen, and changes
in urine color was observed by patient during
the initial stages.

33. DIAGNOSTIC TESTS:
Abdominal X-Ray
Ultrasonography
Radionuclide Imaging or Cholescintigraphy
a radioactive agent is administered
intravenously (IV). The biliary tract is then
scanned, and images of the gallbladder and
biliary tract are obtained.

34. Cholescintigraphy

35. Cholecystography
 An iodide containing contrast is administered 10 to 12 hours
before the x-ray study.
 The normal gallbladder fills with this radiopaque substance.
If gallstones are present, they appear as shadows on the x-ray
film.

36. Endoscopic Retrograde
Cholangiopancreatography
ERCP permits direct visualization of
structures
This procedure examines the
hepatobiliary system via a side-
viewing flexible fiberoptic endoscope
inserted through the esophagus to the
descending duodenum .

37. Percutaneous
transhepatic
cholangiography
It invovles injection of
dye directly into biliary
tract and x-rays are
done,

38. Patient Picture
In my patient ultrasound was done which
identified cholelithiasis of size 45 × 40 × 35
mm.
CBC , LFT , KFT was also done.

39. MANAGEMENT:
Medical Management:
Nutritional and Supportive Therapy
 The diet immediately after an episode is usually low-fat liquids.
 These can include powdered supplements high in protein and
carbohydrate
 Cooked fruits, rice or tapioca, non gas-forming vegetables, bread,
coffee, or tea may be added as tolerated.
 The patient should avoid eggs, cream, fried foods, cheese, rich
dressings, and alcohol.

40. Pharmacologic Therapy
Ursodeoxycholic acid and chenodeoxycholic acid
have been used to dissolve small gallstones .
It acts by inhibiting the synthesis and secretion of
cholesterol, thereby desaturating bile.
Six to 12 months of therapy is required in many
patients to dissolve stones, and monitoring of the
patient for recurrence of symptoms or the occurrence
of side effects is required during this time.

41. Nonsurgical Removal of Gallstones
Dissolving Gallstones
 To dissolve gallstones by infusion of a solvent ( mono- octanoin or
methy tertiary butyl ether ) into the gallbladder.
The solvent can be infused through the following routes:
 through a tube or catheter inserted percutaneously directly into the
gallbladder,
 through a tube or drain inserted through a T-tube tract to dissolve
stones not removed at the time of surgery,
 endoscopically with ERCP;
 transnasal biliary catheter.

42. Stone Removal by Instrumentation
A catheter and instrument with a basket attached are threaded through the T-tube tract
, the basket is used to retrieve and remove the stones lodged in the common bile duct.
A second procedure involves the use of the ERCP endoscope . After the endoscope is
inserted, a cutting instrument is passed through the endoscope into the ampulla of
Vater of the common bile duct.
It may be used to cut the submucosal fibers, enlarg ing the opening, which may allow
the lodged stones to pass spontaneously into the duodenum.
Another instrument with a small basket or balloon at its tip may be inserted through the
endoscope to retrieve the stones .

43. Intracorporeal Lithotripsy
A laser pulse is directed under fluoroscopic guidance
with the use of devices that can distinguish between
stones and tissue.
The laser pulse produces rapid expansion and
disintegration of plasma on the stone surface, resulting
in a mechanical shock wave.
Repeated procedures may be necessary because of
stone size, local anatomy, bleeding, or technical
difficulty.

44. Extracorporeal Shock Wave Lithotripsy
Lithotripsy which is a noninvasive procedure, uses repeated
shock waves directed at the gallstones in the gallbladder or
common tripsy, bile duct to fragment the stones.
The waves are transmitted to the body through a fluid-filled
bag or by immersing the patient in a water bath.
After the stones are gradually broken up, the stone
fragments can be spontaneously passed from the gallbladder
or common bile duct, removed by endoscopy, or dissolved
with oral bile acid or solvents.

45. Surgical Management:
Laparoscopic Cholecystectomy
 Laparoscopic cholecystectomy is performed through a small
incision or puncture made through the abdominal wall at the
umbilicus.
 The fiberoptic scope is inserted through the small umbilical incision.
 Several additional punctures or small incisions are made in the
abdominal wall to introduce other surgical instruments into the
operative field.
 A camera attached to the laparoscope permits the surgeon to view
the intra-abdominal field and biliary system on a television monitor.

46.  The cystic artery is dissected free and clipped. The gallbladder is
separated from the hepatic bed and removed from the abdominal
cavity after bile and small stones are aspirated.
 Stone forceps also can be used to remove or crush larger stones.

47. Cholecystectomy
Gallbladder is removed
through an abdominal
incision after the cystic
duct and artery are
ligated.
A drain is placed close to
the gallbladder bed and
brought out through a
puncture wound if there
is a bile leak.

48. Small-Incision Cholecystectomy
A surgical procedure in which the gallbladder is
removed through a small abdominal incision..
If needed, the surgical incision is extended to
remove larger gallbladder stones.
Drains may or may not be used.
The short length hospital stay has been identified
as a major advantage of this type of procedure .

49. • It involves making an incision in the
common duct, usually for removal of
stones.
• After the stones have been evacuated, a
tube is usually inserted into the duct for
drainage of bile until edema subsides.
• This tube is connected to gravity
drainage tubing: the patient is monitored
closely, and a laparoscopic
cholecystectomy is planned for a future
date after acute inflammation has
resolved.
Choledochostomy

50. Percutaneous Cholecystostomy
 Under local anesthesia, a fine needle is inserted through the abdominal wall
and live edge into the gallbladder under the guidance of ultrasound or
computed tomography (CT).
 Bile is aspirated to ensure adequate placement of the needle, and a catheter
is inserted into the gallbladder to decompress the biliary tract.

51. Patient Picture
 IN MY PATIENT LAPROSCOPIC CHOLECYSTECTOMY WAS
DONE ON 28/12/2021

52. Complications:
 Chronic cholecystitis
 Acute cholecystitis
 Choledococholithiasis
 Gallstone pancreatitis
 Gallstone ileus
 Perforation of gall bladder
 Gallbladder carcinoma

53. Nursing Management:
ASSESSMENT NURSING
DIAGNOSIS
GOAL INTERVENTION IMPLEMENTATION
EVALUATION
subjective data -
mujhe pet me
dard hota hai
objective data -
facial
expression
acute pain and
discomfort related to
surgical incision.
to reduce pain assess the pain
score.
promote bed rest
provide pillows
around incision to
relieve pain.
encourage relaxation
techniques such as
deep breathing.
encourage walking
and using heat pad
to ease discomfort.
provide analgesics.
pain score assed as 3/10
bed rest is promoted
extra pillow provided
for comfort
deep breathing
promoted.
patient encouraged to
walk.
patient has slight
reduction in pain
as 2/10
according to
pain score.

54. ASSESSMENT NURSING
DIAGNOSIS
GOAL INTERVENTION IMPLEMENTATION EVALUATION
subjective data - pt
told , “mujhe khana
khane ka man nahi
krta.”
objective data -
weakness of patient
to perform activity.
loss of muscle tone
imbalanced nutrition
:less than body
requirements related
to inadequate bile
secretion.
to provide
optimal
nutritional intake.
asess the patient’s
nutritional status.
encourage patient to
have diet rich in
carbohydrates and
protein and low in
fats.
encorage patient to
follow this diet even
after getting discharge
for 4-6 weeks.
encorage to gradually
add the fat to the diet.
assess the elimination
pattern.
patient nutritional
status assessed as
inadequate.
patient was
encouraged to eat
protein rich food such
as daal and low fat
food such as oily food.
patient enocurage to
follow the diet.
elimination pattern
recorded as patient is
having constipation.
patient’s nutritional
satus is same.
patient promises to
follow the diet.

55. ASSESSMENT NURSING
DIAGNOSIS
GOAL INTERVENTION IMPLEMENTATION EVALUATION
subjective data -
patient told, “ mujhe
kuch samajh nahi aa
raha hai.
objective data -
patient looks
anxious.
deficient knowledge
about self care
activities related to
incision care and
dietary medication.
to provide
knowledge
regarding self care
routines.
asess the knowledge
level of patient.
educate patient about
the medication and
their action.
educate about the
symptoms to report
such as jaundice, dark
urine , pruritis.
edcuate about care of
wound.
clear all the doubts
encourage
questioning.
knowledge level
assessed as low.
educated patient about
the medication.
patient educated about
symptoms to look for.
patient is educated
about wound care.
all the doubts were
cleared.
patient ‘s knowledge
has been enhanced.

56. ASSESSMENT NURSING
DIAGNOSIS
GOAL INTERVENTION IMPLEMENTATION EVALUATION
subjective data -
mujhe surgery
ki jagh par
khujli krne ka
man krta hai
objective data -
surgical site is
slight red.
risk for infection
related to surgical
site
to reduce
chances of
infection.
Assess the condition
of surgical site.
monitor any signs of
infection
maintain strict
asepsis technique
while wound
dressing.
perform hand
hygiene .
educate client about
precautionary
measures.
surgical site assessed as
free from infection.
no signs of infection
witnessed.
aseptic technique
followed for dressing.
hand hygiene
performed.
health education
provided.
Risk for
infection
reduced.

57. ASSESSMEN
T
NURSING
DIAGNOSIS
GOAL INTERVENTION IMPLEMENTATION
EVALUATION
subjective data
- mujhe chalte
samay dard
hota hai
objective data -
pain while
walking.
Impaired physical
mobility related to
pain at surgical site.
to improve
physical
mobility
assess the level of
physical mobility.
assess the barriers
for mobility.
assess the strength
to perform ROM
.evaluate need for
assitive devices.
educate to walk
around a little .
level of physical
mobility is moderate.
pain is the barrier for
mobility.
patient has weakness to
perform ROM.
no need for assistive
devices.
patient was encouraged
for little walking like
going to washroom
with the help of family
member.
patient ‘s
physical
mobility is still
same

58. NURSE’S NOTES

59. Progress notes :
 Patient is well, general condition is fair . Vitals checked
and charted.
 T- 98.7 F
 P- 85 b/m
 R- 18 b/m
 B.P- 126/84 mmHg
 All due medications given
 Health education provided.

60. HEALTH EDUCATION :
• Sitting upright in bed or chair or walking may ease discomfort ,
Analgesic medication as needed and prescribed
• Report to surgeon if pain not relieved even with analgesic
Managing pain
• Light exercise ( walking ) immediately, Shower or bath after 1-2 days
,Avoid lifting heavy objects.
Resuming the
activity
• Check puncture sites daily for infection., Wash with soap and water
Caring for the
wound
• Resume normal diet
Resuming eating
• Report sign and symptoms of infection at puncture site., Report fever,
nausea , vomiting or abdominal pain.
Follow up care:

61. SUMMARY :
Today we dealt with case presntation on
cholelithiasis, my patient’s condition, about disease
condition, cholelithiasis, risk factors, etiology,
clinical manifestations, pathophysiology, lab
diagnostics, medcial management, surgical
management, nursing process, health education on
follow up care.

62. CONCLUSION
 Calculi, or gallstones, usually form in the gallbladder from
the solid constituents of bile; they vary greatly in size,
shape, and composition .
 They are uncommon in children and young adults but
become more prevalent with increasing age.
 If gall stones migrate into ducts of biliary tract it is known as
choledocholithiasis.

63. Bibliography:
 Hinkle Janice L. and Cheever H. Kerry , Brunner
and suddhart’s textbook of medical surgical nursing
, volume 2 , 13th edition,2014, wolters
lkluwer(india) private ltd. pg no - 1391-1401.
 Patient details from patient file and through data
collected on interview basis.