Question

Concept Map - Choledocholithiasis Mr. Tony Burk is a 60y/o retiree admitted to your unit from the emergency room. Upon arrival, you note that he is trembling and nearly doubled over with severe abdominal pain. The patient states that he has had severe upper right quadrant pain that radiates to his back, and he is more comfortable walking bent forward than lying down in bed. He admits to having bouts of abdominal pain in the past month but "none as bad as this". He states he feels only slightly nauseated but has experienced but has experienced nausea and vomiting during previous episodes. He states that he experienced this latest episode after eating fish and chips at a fast food restaurant. His daughter insisted he go to the hospital and has accompanied him to the floor. Assessment findings are: AAO X 3 and moves all extremities well. Moves restlessly and continuously; complains of notable fatigue. Heart sounds clear bilaterally in both anterior and posterior chest. Heart sounds clear without adventitious sounds, heart rate regular, all pulses +3 bilaterally. Abdominal guarding noted with exquisite tenderness to light palpation over the right side, especially the upper right quadrant. He has sharp respiratory arrest with palpation of the upper right quadrant. Patient reports light colored stools over the past week. Voids medium amber urine; denies pain or discomfort with voiding. Skin and sclera are slightly jaundiced. Vital signs on admission are: B/P 164/100, P 132, R 26, and T. 99.4

Answer 1

Cholelithiasis (Gall stones) characterized by deposition of cholesterol or excess hardened bilirubin in the gall bladder. Gall bladder is responsible to hold digestive fluid inform of bile and is released into small intestine. The most common symptom is sudden and severe abdominal pain radiating to the shoulder accompanied by nausea and vomiting.

Nursing Diagnosis:

1) Acute pain related to inflammatory process and obstruction of bile flow as evidenced by waves of pain and guarding of abdomen by the patient.

Nursing interventions:

- Assess for the location and severity of pain (0-10) and the nature of pain (colicky,intermittent). Encourage patient to stay calm and assume position that relieves pain. Control environmental stimulants that increases pain. Maintain nil per oral or NG suction to remove excess gastric secretions that in turn release cholecystokinin and the gall bladder contractions. Administer medications sedatives, anticholinergics to reduce reflex spasm, antibiotics to treat underlying infection.

Desired outcome : Patient report relief of pain.

2) Risk for imbalanced nutrition less than body requirements related to impairment in fat digestion secondary to obstruction of bile flow.

Nursing interventions:

- Plan nutritional assessment to identify the risk of imbalanced nutrition. Maintain weight chart to check any fluctuations in weight. Plan food chart based on patient likes and dislikes. Provide pleasant atmosphere at meal time. Abdominal assessment to identify dissension. Recommend low fat diet,fiber rich diet and restrict foods that induce gas production like onions,cabbage and fried foods. Administer supplementary bile salts to promote digestion and absorption of fats. Initiate parental fluid therapy to compensate the nutritional requirement.

Desired outcome: Patient reports desired weight gain and relief of symptoms :nausea and vomiting.