CHOLECYSTITIS Nellie Mugmoora a 39 year old

CHOLECYSTITIS Nellie Mugmoora a 39 year old female of Australian Aboriginal heritage has a recent history of right upper quadrant pain with guarding, and nausea. Nellie has a past medical history of appendicectomy; gall stones diagnosed 12 months ago and 3 children to natural childbirth Current medications include: nil Allergies: Nil Weight: 92 kg Height: 167cm Diet: low fat Her GP had suspected cholecystitis and placed her on a low fat diet, rest and antibiotic therapy. However after 2-3 days there was minimal improvement. On the last day Nellie developed vomiting and drank only low volumes of oral fluids. Nellie is admitted to a large general teaching hospital with laparoscopic surgical services. On admission your assessment reveals the following: Temperature: 38.6 Celsius Pulse: 118 b/min (regular) B.P. 110/70 mmHg Respirations: 18 / min SaO2: 98% on room air Abdominal examination: right upper quadrant constant pain 7 out of 10 on movement. Nil palpable gall bladder. Bowel sounds present. Mild jaundice observed. Respiratory examination: All lung fields clear on auscultation CVS examination: Peripheries warm, pedal pulses present. The medical officer orders the following investigations; urea and electrolytes, full blood count & Hb, APTT, INR, Platelet Count, blood cultures, liver function tests, pregnancy testing, mid stream urine (MSU) Blood results: Na: 138 K: 3.6 Urea: 6.0 mmol/L Creatinine: 0.08 mmol/L Hb: 122 WCC: 12 Platelets: 200 INR: 1.0 APTT: 28 seconds BSL: 5.6 Pregnancy test: NAD Urinalysis: S.G: 1025 pH: 5.5 Ketones -nil Sugar -nil Protein -nil Chest X Ray (CXR) – clear and normal Abdominal x ray (AXR) – ? cholelithiasis, otherwise nil significant The Medical Officer primary diagnosis for the patient is acute cholecystitis. The patient is prescribed nil by mouth (NBM), rest in bed, antiemetics, antibiotics, analgesia, IV fluids and other general care. Medications Prescribed by the Dr are: Metoclopramide 10mg IV TDS prn Meropenem 1G 8hlry IV Tramadol 50 mg IV TDS prn Intravenous (IV) therapy prescribed by the Dr includes: Normal Saline 1 litre with 20 mmol KCL 8/24 rate Normal Saline 1 litre 10/24 rate Normal Saline 1 litre 12/24 rate Nellie is admitted to the ward for 24 hours for RIB, vital sign monitoring and general care. The MSU on microscopy, culture and sensitivity (MC&S) results indicate nil bacteria. The blood culture results on MC&S indicate nil bacteria. She is placed on a fluid balance chart (FBC). Initially Nellie’s urine output is 30-40mls per hour. After 8 hrs her urine output increases to 40-50mls per hour. The next day Nellie has not responded to treatment and has an ultrasound of her abdomen. The results indicate gall bladder wall thickening and gall stones are present. See YouTube Video of ultrasound of Acute Cholecystitis She is booked for operating theatre (OT) and has blood cross matched for the procedure. Nellie has a laparoscopic cholecystectomy the next day. The laparoscopic surgery is successful and with nil complications. Nellie returns to ward (RTW) on nil per oral (NPO), IV therapy of normal saline at 80mls/hr, RIB overnight and on a PCA of IV fentanyl on a standard protocol of 1 hrly PCA observations overnight. On day three Nellie’s vital signs are: Temperature 37.2 degrees Celsius Pulse 98 /min regular Respiration 16/min Oxygen saturation 99 % on 2 l/min via NP. Blood Pressure 120/75 Abdominal assessment: Abdominal pain is nil out of 10 on rest and 1 out of 10 on movement. Nellie is commenced on ice and sips of water and then progresses to light diet, then normal diet. Her urine output is 50-60mls/hr. She stabilises and is discharged to home two days later for follow up by her G.P. regarding surgical recovery. Nellie is discharged to home on oral analgesia panadol 1g every 6 hours. Questions 1) How does the aeitology and pathophysiology of the the case study relate to the clinical manifestation of the patient in case study. 2) Identify abnormalities in the case study. Describe and explain the reasons for abnormalities in sentences. Describe in full the specific focused nursing assessment that is related o the case study. 3) How does clinical manifestation relate to the therapeutic management strategies of the patient. The therapeutic management strategies include nursing assessments, and interventions, and the medical assessments and investigations.

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