A Case Study 0n Ascending Cholangitis

PANPACIFIC UNIVERSITY NORTH PHILIPPINES Urdaneta City, Pangasinan

Ascending Cholangitis

CASE STUDY (Tarlac Provincial Hospital)

In Partial Fulfillment of the Requirements For General Case Presentation

Submitted by: Tarlac Group (October Rotation)

October 2009

I. PATIENT ASSESSMENT DATA BASE A.

GENERAL DATA 1. Patient’s Name: Patient XYZ 2. Address: Tarlac City, Tarlac 3. Age: 42 y/o 4. Sex: Male 5. Birth Date: May 7, 1968 6. Rank in the Family: Eldest 7. Nationality: Filipino 8. Civil Status: Married (Widower) 9. Date of Admission: October 3, 2009 10. Order of Admission: 4:04pm 11. Attending Physician: Dr. Roedel Dizon

B.

CHIEF COMPLAINT

Patient had fever and complaint of epigastric pain prompting immediately his family members to consult. The client was weak and pale in appearance and noted to have facial grimacing. Patient XYZ has been guarding the affected area, furthermore, cold clammy sweat has been observed.

C.

HISTORY OF PRESENT ILLNESS

Patient’s condition started 1 week prior to admission with epigastric pain with on and off fever. He went to Cagayan Valley Medical Center for consult on September with a diagnosis of dyspepsia. After medical interventions, patient was then discharged and apparently well. Until few hours prior to admission, patient had fever and complaint of right upper quadrant (RUQ) abdominal pain so they immediately went to Tarlac Provincial

Hospital for consult and was admitted. He has been given medications such as Dobutamine and has had his initial laboratory exams.

D.

PAST HEALTH HISTORY/STATUS

Patient had chicken pox, measles and mumps when he was a child. However, he and his watcher could not remember how old he was when he got them. He verbalized that his immunization was complete. When he was in grade one, he had a perforating eye injury that caused the blindness of his right eye. E.

FAMILY ASSESSMENT Name

Relation

Age

Sex

Occupation

Educational Attainment

Sergio Maniti

Father

63

Male

none

3rd Year High School

2nd Year High School Imelda Maniti

Mother

---

Female

---High School graduate

Shiela Bimeda

Sister

41

Female

Government Employee

Graduate of Automotive Vocational Course

4th Year Highschool Ambulance

Sergie Maniti

Brother

39

Male

Driver

High School Graduate High School Graduate

Housewife Shirly Macasiog

Sister

36

Female

Housewife Sharon Tanhueco

Sister

26

Female

Service Crew Shalee Jonnales F.

Sister

26

Female

SYSTEMS REVIEW – GORDON’S 11 FUNCTIONAL HEALTH PATTERNS ASSESSMENT 1.

Health Perception - Health Management Function

Patient XYZ had stated that being healthy is free from sickness and the absence of disease. He refers to doctors whenever he or one of his family members gets sick. He managed his health by following medical treatment being given by his health care providers. In addition, he perceived that he is not totally healthy because his right eye has been blind since on the first grade. 2.

Nutrition – Metabolic Pattern

The client eats thrice a day with adequate amount of food. He has good appetite. His usual daily menu includes meat and vegetables. He drinks 12-15 glasses of water and up to 2 cups of coffee a day. 3.

times a brownish in use laxatives 4.

Elimination Pattern He urinates 3-4 times a day with amber-colored urine. He further stated that urinating is not a problem. Defecation pattern has been reported to be seven week most occurring in the morning with a semi-solid consistency and color. No difficulty of defecating has been stated and did not have to and other stool softeners. Activity – Exercise Pattern _0_ Feeding _0_ Bathing _0_ Bed Mobility

_0_ Dressing _0_ Toileting _0_ Home Maintenance

_0_ Grooming _0_ Cooking

Legend: 0 – Full care I – Requires use of equipment II – Requires assistance or supervision from others III- Requires assistance or supervision from another equipment and a device IV – Dependent; doesn’t participate 5.

Cognitive – Perceptual Pattern Hearing: Vision:

No hearing abnormalities as state by the client His left eye functions normally and does not need to use eyeglasses when reading. Sensory Perception: No sensory perceptual abnormalities

Learning Styles: He learns upon doing it by himself. Understands more when there are illustrations 6.

Sleep – Rest Pattern He sleeps 6-8 hours a day. He does not need any relaxation techniques for him to fall asleep easily. He does not have any sleeping difficulty. When travelling, would request for the vehicle to stop if it’s already time for them to sleep. Approximately, they would sleep up to 5 hours.

they

7.

Self-Perception And Self-Concept Pattern

He does not consider himself as a burden to his Aunt’s family. He even said that he helps in their daily expenses by giving some of his earnings to them. As a patient, he said it’s normal that family members take care of him especially he doesn’t have a family of his own. He considers himself as simple and hardworking person. At work, he is the one who cooks for the whole crew. He said he is good in cooking. He is also a good mechanic though he wasn’t able to learn how to drive. He said, he is too afraid to drive. 8. Role – Relationship Pattern He is a good brother and a good son to his parents. He had proven being a responsible family member when he decided to work immediately for them after from high school. He is in good terms with his Aunt’s family.

graduating

At work, he is a dependable co-worker. He said, whenever a co-worker needs help, he tries to help him. When conflict arises, he initiates to resolve it immediately. 9.

Sexuality – Reproductive Pattern

He said he is still sexually active, though he does not practice safe sex. He admits that he doesn’t want to use condom. He practices withdrawal method. He is of the circumstances of not practicing safe sex but he said it’s a matter of whatever will happen to him like acquiring sexually transmitted infections.

aware fate 10.

Coping – Stress Tolerance Pattern When he has problems, he solves it by himself. He does not bother other family members to help him solve it especially if it is manageable. Sometimes, he drinks alcohol to cope from his problem.

11.

guidance

G.

Value – Belief Pattern He is a Catholic. He would go to church if there is time. He still believes that God would help him to solve his problems. He prays to ask for assistance and especially when they are travelling.

Heredo-Familial Illness Father (TB, HPN)

Patient XYZ (Ascending Cholangitis)

2nd Child

3rd Child

Mother (Diabetes)

4th Child

5th Child

6th Child

7th Child

H.

DEVELOPMENTAL HISTORY Theorist

Erik Erikson’s Psychosocial Theory

Age 40 – 65 y/o Generativity vs. Stagnation

James Fowler’s Stages of Faith Development

for both male and female

for both male and female

Conjunctive Faith Stage (mid-life)

I.

Sex

Patient Description The patient did not have a child of his own. He was not able to fulfill his role as a parent. He wanted to have a child but unfortunately his wife died. He said he had no luck but was contented with his immediate family. It seems that he is being passive and feels lack of purpose and productivity. The patient verbalized that it is better that he had no family so he could work and travel without worrying about them when he’s away. He added that he don’t have future plans to have his own family. I observed that this might be contradictory to what he really wants. He also said that he wanted to have his own child, therefore, it seems he only want to confine himself to the reality that he might not be able to have his own family at this stage of his life.

PHYSICAL ASSESSMENT A. General Survey

Oxygen

Patient XYZ was awake, lying on bed, conscious and coherent, and weak in appearance. A nasogastric tube was inserted at the right nares aseptically. inhalation was given regulated @ 3 LPM. An IVF of DsW + 2 ampules of

Dobutamine was connecting to a

infused at his right hand as venoclisis. An IFC has been inserted urine bag inplace.

B. Vital Signs

BP: T : RR: CR:

1st Day 110/80 mm Hg 39.6 °C 32 bpm 100 bpm

2nd Day 120/80 mm Hg 37.8 °C 30 bpm 98 bpm

3rd Day 110/90 mm Hg 37.7 °C 28 bpm 95 bpm

C. Regional Exams

Area Assessed

Techniques Used

Findings

Skin > color

inspection

> texture > temperature > moisture

palpation palpation palpation

dark-skinned with hyperpigmentations rough and dry warm to touch dry

Nails > color of nailbed > texture > shape > nail base

inspection palpation inspection inspection

pink, not clean slightly rough convex curvature firm

Hair > color > distribution > moisture > texture

inspection inspection inspection inspection

black evenly distributed oily fine

Eyes > eyebrows

inspection

> eyelashes > ability to blink

inspection inspection

> ocular movement > sclera > pupils

inspection inspection inspection

symmetrically aligned, equal movement slightly straight blinks voluntarily eyes move freely (both) icteric (jaundice) round, reactive to light, constricts briefly (L eye)

Nose > symmetry, shape, size and color > mucosa color > nasal septum > sinuses

inspection inspection inspection palpation

Mouth and Throat > lips

inspection

> sublingual area > tongue > teeth

inspection inspection inspection

symmetrical, smooth, tan pinkish oval and symmetrical nares not tender

slightly brown, symmetrical, dry, icteric (jaundice) pinkish, dry 19 teeth, with dental caries

> throat

Cardiovascular > heart rate > heart sounds Thorax and Lungs > symmetry > respiratory rate > breathing pattern > lung/breath sounds Abdomen > contour > texture > frequency and character

inspection palpation

no swelling noted no pain when palpated

auscultation auscultation

100 bpm clear

inspection inspection inspection

symmetrical 32 bpm, tachypneic rapid and shallow

auscultation

vesicular

inspection palpation

globular mild tenderness on right upper quadrant soft gurgling sound

auscultation

Upper Extremities > skin color > size

inspection inspection

> symmetry

inspection

Lower Extremities

dark-skinned equal and appropriate for his body symmetrical

> skin color > size

inspection inspection

> symmetry

inspection

Neurologic > level of consciousness

interview inspection,

> behavior and appearance

interview

> mood and affect

inspection, interview inspection, interview

>thought process

II.

dark-skinned equal and appropriate for his body symmetrical

responds quickly but he needs to ask again the question poor eye contact, does not pay attention to questions and tells his sister to answer quite irritable blunted affect there are questions that pertains to him that he cannot recall

PERSONAL/ SOCIAL HISTORY The patient drinks 2 cups of coffee everyday. He could consume a pack of cigarette in one day. He started smoking when he was 25 years old. He can drink 1 bottle of Ginebra almost each day and he drinks more when he is with his co-workers and friends. He spends more time travelling because of the nature of his work. They deliver religious icons and images from Northern Luzon to Central Visayas region. His last travel was in Cagayan. There was limited time for him to socialize or to attend family gatherings.

He is the eldest child in their family. He was only a high school graduate but he decided to work immediately for his family.

III. ENVIRONMENTAL HISTORY (LIVING/NEIGHBORHOOD/CIRCUMSTANCES) The family is not well-off but they can manage to survive and meet their basic needs. He lives with his aunt’s family in a subdivision. The neighborhood is quiet and peaceful. The patient said there are no circumstances that could endanger their lives. There were no incidents of crime or illegal activities in the vicinity. There were no piggeries or poultry that could be a health hazard for them.

IV.

INTRODUCTION Ascending Cholangitis or acute cholangitis is an infection of the bile duct, usually caused by a bacteria ascending from its junction with the duodenum (first part of the small intestine. It tends to occur if the bile ducts are already partially obstructed by gallstones. In 1877, Charcot described cholangitis as a triad of findings of right upper quadrant (RUQ) pain, fever, and jaundice. The Reynolds pentad adds mental status changes and sepsis to the triad. A spectrum of cholangitis exists, ranging from mild symptoms to fulminant overwhelming sepsis. With septic shock, the diagnosis can be missed in up to 25% of patients. Consider cholangitis in any patient who appears septic, especially in patients who are elderly, jaundiced, or who have abdominal pain. A history of abdominal pain or symptoms of gallbladder colic may be a clue to the diagnosis. Cholangitis can be life-threatening and is regarded as a medical emergency. Characteristic symptoms include jaundice, fever, abdominal pain, and in severe cases, low blood pressure and confusion. Initial treatment with intravenous fluids and antibiotics, but there is often an underlying problem (such as gallstones or narrowing in the bile duct) for

which further tests and treatments may be necessary, usually in the form of endoscopy to relieve obstruction of the bile duct. Bile duct obstruction, which is usually present in acute cholangitis is generally due to gallstones. 10-30% of cases, however, are due to other caused as benign stricturing (narrowing of the bile duct without an underlying tumor), postoperative damage or an altered structure of the bile ducts such as narrowing at the site of an anastomosis (surgical connection) and various tumors (cancer of the bile duct, gallbladder cancer, cancer of the ampulla of Vater, pancreatic cancer or cancer of the duodenum). Cholangitis may also complicate medical procedures involving the bile duct, especially ERCP. To prevent this, it is recommended that those undergoing ERCP for any indication receive prophylactic (preventive) antibiotics.

VI.

ANATOMY AND PHYSIOLOGY

Anatomy of the Biliary System: The biliary system consists of the organs and ducts (bile ducts, gallbladder, and associated structures) that are involved in the production and transportation of bile. The transportation of bile follows this sequence: 1. When the liver cells secrete bile, it is collected by a system of ducts that flow from the liver through the right and left hepatic ducts. 2. These ducts ultimately drain into the common hepatic duct.

3. The common hepatic duct then joins with the cystic duct from the gallbladder to form the common bile duct, which runs from the liver to the duodenum (the first section of the small intestine). 4. However, not all bile runs directly into the duodenum. About 50 percent of the bile produced by the liver is first stored in the gallbladder, a pear-shaped organ located directly below the liver. 5. Then, when food is eaten, the gallbladder contracts and releases stored bile into the duodenum to help break down the fats. Functions of the Biliary System: The biliary system's main function includes the following: •

to drain waste products from the liver into the duodenum

•

to help in digestion with the controlled release of bile

Bile is the greenish-yellow fluid (consisting of waste products, cholesterol, and bile salts) that is secreted by the liver cells to perform two primary functions, including the following: •

to carry away waste

•

to break down fats during digestion

VIII. LABORATORY AND DIAGNOSTIC EXAMINATIONS Date: October 3, 2009 Prothrombin Time (PT) Patient’s Time 17.1 seconds (done twice)

Normal Values 10-14 seconds

Significance prolonged PT my suggest hepatic disease, deficiencies in fibrinogen, prothrombin, Vit K or

factors V, VII, or X Activated Partial Thromboplastin Time (APTT) Patient’s Time 52.1 seconds (done twice)

Normal Values 26 - 36 seconds

Significance prolonged APPT my suggest deficiencies in coagulation factors (Vit. K)

Date: October 5, 2009 Blood Chemistry

Results

Normal Values

Significance

BUN

6.89 mmol/L

2.9 – 8.2 mmol/L

within normal range

Creatinine

176.8 µmol/L

53 -106 µmol/L

an increase may suggest renal disease

Hepatic Enzymes SGOT/AST

Results 7.1 U/L

Date: October 6, 2009

Normal Values 8 – 33 U/L

Significance low levels suggests lack of Vitamin B6

Whole Abdominal Ultrasound R Mid-hepatic Length L Mid-hepatic Length Common Bile Duct Main Portal Vein Spleen R Kidney L Kidney Prostate Gland • • • • • • • •

= = = = = = = =

17.9 cm 12.4 cm 1.5 cm 1.3 cm 8.7 x 3.8 cm 10.2 x 4.9 x 4.7 cm 10.6 x 5.1 x 5.3 cm 2.5 x 2.9 x 3.1 cm (11.6 gms)

The liver is enlarged without focal lesion. Common bile duct and intrahepatic ducts are dilated. Extrahepatic portions of the common bile duct are obscured by bowel gas. Markedly distended gallbladder is noted Gallbladder is adequately distended without intraluminal echoes or wall thickening Pancreas cannot be properly evaluated due to presence of bowel gas Spleen is unremarkable Both kidneys are within normal size configuration, parenchymal echopattern, and cortical thickness. No focal lesion, ectasis, or lithiasis noted Prostate gland is normal in size without calcifications Urinary bladder is underfilled with note of foley catheter

Impression: Hepatomegaly with biliary obstruction Markedly distended gallbladder vs. bowel loop Underfilled urinary bladder

Date: October 7, 2009

Blood Chemistry Total Bilirubin

Results 47.5

Direct Bilirubin

17

Normal Values 2 - 21 mmol/L

<5 µmol/L

Significance increased values may suggest hepatitis, biliary stricture

increased values may suggest biliary obstruction

(B1) increased values may suggest hepatic damage Indirect Bilirubin

Electrolytes Sodium

Potassium

30.5

Results 152.4 mmol/L

2.90 mmol/L

2 – 17 µmol/L

Normal Values 136 - 142 mmol/L

3.8 – 5.0 mmol/L

Significance increased values may suggest impaired renal function

decreased values may suggest gastrointestinal and renal disorders

Chloride

Hematology

121.7 mg/L

Results

95 – 103 mg/L

Normal Values

Blood Type

Type O+

WBC

17.6 G/L

4.1 – 10.9 G/L

RBC

3.68 T/L

4.2 – 6.30 T/L

increased values may suggest severe dehydration or complete renal shutdown

Significance

-increased values may suggest infection -decreased values may suggest anemia -decreased values may suggest

HGB

112 g/L

120 – 180 g/L

anemia, recent hemorrhage or fluid retention -decreased values may suggest anemia, hemodilution

HCT

360 L/L

370 – 510 L/L -decreased values may suggest

Platelet

66 g/L

140 – 440 G/L

immune disorders, Vit B12 deficiencies

XI.

DRUG STUDY Generic Name: Cefuroxime Dosage: 750 mg IVP q 8° Indication: it is used as an anti-infective agent for urinary tract infections and severe infections

Mechanism of Action Inhibits bacterial cell wall synthesis, rendering cell wall osmotically unstable, leading to cell death

Side Effects diarrhea, nausea and vomiting, gas or heartburn

Generic Name: Metronidazole Dosage: 500 mg IV infusion q 8°

Contraindications Hypersensitivity to cephalosporins and related antibiotics; pregnancy (category B), lactation

Adverse Reactions Allergic reactions like skin rash, itching or hives, swelling of the face, lips or tongue, dark urine, difficulty of breathing, irregular heartbeat or chest pain, seizures, unusual bleeding or bruising, white patches or sores inside the mouth

Nursing Considerations •

Determine history of hypersensitivi ty reactions to cephalosporins , penicillins, and history of allergies, particularly to drugs,

•

Inspect IM and IV injection sites frequently for signs of phlebitis.

•

Monitor I&O rates and pattern:

•

Monitor for bleeding

Indications: It is used for the treatment of serious infection caused by susceptible anaerobic bacteria in intra-abdominal infections, skin infections, gynecologic infections, septicemia, and for preoperative postoperative prophylaxis Mechanism of Action

Side Effects

Contraindications

Adverse Reactions

It binds to bacterial and protozoal DNA to cause loss of helical structure, strand breakage, inhibition of nucleic acid synthesis and cell death.

GI discomfort, anorexia, nausea, furred tongue, dry mouth and unpleasant metallic taste, headache, less frequently vomiting, diarrhea, weakness, dizziness and darkening of the urine. Watery (tearing) eyes if applied near to eye area, transient redness and mild dryness.

Blood dyscrasias. Active CNS diseases. Hypersensitivity to imidazole. Tuberculosis to mucous membranes and certain viral conditions. 1st trimester of pregnancy. Lactation. Children. Leukopenia. Peripheral neuropathy (long term therapy). Psychiatric disorders.

Convulsive seizures; peripheral neuropathy; rash, pruritus. Burning and skin irritation

Nursing Considerations •

•

•

Obtain baseline information on patient’s infection: fever, wound characteristics, WBC count (>100,000mm3) and regularly assess during treatment. Assess for allergic reactions: rash , urticaria, pruritus. Monitor renal function: urine output, inputoutput ration, polyuria,dysuria , pyuria, BUN and creatinine. Decreasing

and

•

•

output and increasing BUN, creatinine may indicate nephrotoxicity. Monitor bowel pattern, discontinue drug if severe diarrhea occurs. Assess for over growth of infection: peripheral itching, fever malaise, redness, swelling, drainage, rash and change in cough/sputum.

Generic Name: Paracetamol Dosage: 300mg IVP q 4° for temp ≥ 38.5 °C Indication: To relieve mild to moderate pain due to things such as headache, muscle and joint pain, backache and period pains. It is also used to bring down a high temperature. Mechanism of Action

Side Effects

Contraindications

Adverse Reactions

Decrease fever by inhibiting the effect of pyrogens of the hypothalamic heat regulating centers by a hypothalaminc action leading to sweating nd vasodilation relieves pain by inhibiting prostagalandin synthesis in CNS does not have inflammatory action because of its minimal effect

Side effects are rare with paracetamol when it is taken at the recommended doses.

Hypersensitivity to acetaminophen or phenacetin; use with alcohol.

Skin rashes, blood disorders and acute inflammation of the pancreas have occasionally occurred in people taking the drug on a regular basis for a long time. One advantage of paracetamol over aspirin and NSAIDs is that it doesn't irritate the stomach or causing it to bleed, potential Side effects of aspirin and NSAIDs.

Nursing Considerations •

•

•

Assess patients fever or pain: type of pain, location, intensity, duration, temperature, diaphoresis Assess allergic reactions: rash, urticaria; if this occur, drug may have to discontinued Assess hepatotoxicity; dark urine, claycolored stools, yellowing of skin and sclera; itching, abdominal pain, fever, diarrhea if patient is on

long term therapy. •

•

•

Monitor liver and renal function. AST, ALT bilirubin, protime, BUN, CREA Check input and output ratio; decreasing output may indicate renal failures (long-term therapy) Assess for chronic poisoning: rapid, weak pulse; dyspnea: cold, clammy extremities; report immediately to prescriber

Generic Name: Pantoprazole Dosage: 80 mg IV infusion Indications: Gastric acid pump inhibitor Mechanism of Action

Side Effects

Contraindications

Adverse Reactions

Inhibits both basal and stimulated gastric secretions by suppressing the final step in acids production, through the inhibition of the proton pump by binding to and inhibiting hydrogenpotassium adenosine triphosphatase, the enzyme system located at the secretory surface of the gastric

Headache, diarrhea, abdominal pain, rash

Hypersensitivity. Moderate to severe hepatic or renal dysfunction.

Insomnia, flatulence, hyperglycemia

Nursing Considerations •

•

•

•

•

Assess for underlying condition before therapy and regularly thereafter to monitor drug effectiveness. Assess GI symptoms: epigastric/abdomina l pain, bleeding and anorexia. Monitor for possible druginduced adverse reactions Monitor hepatic enzymes: AST, ALT, alkaline phosphatase during treatment Assess patient and family’s knowledge

parietal cell.

on drug therapy.

Generic: Vitamin K/ Phytomenadione Dosage: 1 amp IVP q 8° Indication: Used in the treatment and prevention of hemorrhage associated with Vitamin K deficiency Mechanism of Action

Side Effects

Synthetic analog of Vit. K w/c is essential to hepatic synthesis of blood clotting factors II, VII, IX, X.

Hypotension, cyanosis, headache, dizziness, rash. Anaphylactoid reactions; pain, swelling

Contraindications Pronounced allergic diathesis. Infants<1 yr.

Adverse Reactions Urticaria. Hyperbilirubinemia including kernicterus. In newborns. death after IV injection. Pruritic erythematous plaques at IM injection site.

Nursing Considerations •

•

•

•

Assess for patients condition before therapy and regularly thereafter to monitor drug effectiveness. Assess for bleeding: bruising, hematouria, black- tarry stools and hematemesis. Monitor for possible drug- induced adverse reactions Assess patient and family’s knowledge on

drug therapy

X.

Identified Problems According to Priority 1. Ineffective breathing pattern related to decreased lung expansion secondary to liver enlargement

2. Acute pain related to ductal spasm secondary to biliary duct obstruction 3. Hyperthermia related to presence of disease process

XI. NURSING CARE PLAN Assessment

Nursing Diagnosis

S> “hinahabol ko ang aking hininga” as verbalized by the client O> - rapid and shallow breathing -nasal flaring noted -use of accessory muscles

Vital Signs:

Ineffective breathing pattern related to decreased lung expansion secondary to liver enlargement

Scientific Background

Goals

The liver is located immediately below the diaphragm which is the major muscle of respiration. Upon enlargement of the liver, it compresses the diaphragm upward thus decreasing lung expansion during inspiration resulting to rapid and

After 2-3 hours of rendering proper nursing intervention , the client will demonstrate easier respiration and respiratory rate will decrease from 32 bpm to 22 bpm

Interventions

> assess and monitor vital signs

> monitor respiratory status

> place client in sitting/high fowler’s position

> provide adequate ventilation

Rationale

> serve as baseline data

> to note for worsening of tachypnea

> it allows good lung excursion and chest expansion

> to facilitate effective breathing

Evaluation

Goal partially met. After 3 hours of rendering proper nursing intervention, the client demonstrated easier respiration and respiratory rate decreased from 32 bpm to 25 bpm

RR: 32 bpm BP: 110/80 mm Hg

shallow breathing pattern

> ensure O2 delivery system is applied to the patient

CR: 100 bpm T: 39.6°C

> refer to physician accordingly during tachyneic episodes

> so that appropriate amount of oxygen is continuously delivered

> to assess respiratory status

> explain effects of wearing restrictive clothing

> teach patient appropriate breathing techniques by demonstration emphasizing slow inhalation,

> use of tight or restrictive clothing compromises respiratory excursion

> appropriate breathing techniques are important in maintaining

holding end inspiration for a few seconds and passive inhalation

adequate gas exchange

Assessment

Nursing Diagnosis

S> “masakit ang tiyan ko” as verbalized by the client

O> - facial grimace - with guarding behavior noted - restlessness - pale and weak in appearance - rated pain as 6/10 in a pain scale of 1-10; 1 as the

Acute pain related to ductal spasm secondary to biliary duct obstruction

Scientific Background

Goals

As the biliary duct becomes obstructed, the pressure within the bile duct increases thus producing involuntary contraction usually accompanied by pain that may last from seconds to minutes

After 4 hours of rendering proper

Interventions

> monitor vital signs

nursing intervention , the patient’s level of pain of 7/10 will subside to 3/10

> perform a comprehensive assessment of pain to include location, onset/ duration, quality, severity and precipitating factors

Rationale

Evaluation

> to monitor any changes from the previous to present data. Serve as baseline data

Goal partially met. After 4 hours of rendering proper nursing intervention, the patient’s level of pain subsided from 7/10 to 4/10

> to assess etiology/ contributing factors

lowest and 10 as the highest

> determine possible pathophysiolog ical causes of pain

Vital Signs: BP: 110/80 mm Hg

> to assess precipitating factors

> perform pain assessment each time pain occurs

RR: 32 bpm CR: 100 bpm T: 39.6°C

> provide comfort measures

> provide calm and quiet environment

> administer analgesics as indicated

> instruct the patient to report pain

> to rule out worsening of underlying condition

> to provide nonpharmacological pain management

> to prevent anxiety

> to maintain acceptable level of pain

> explain cause of pain, if known

> instruct the patient to evaluate and report effectiveness of measures used

> so that immediate relief measures may be instituted

> this will contribute to patient’s understanding to his condition

> it will determine if measures used were not effective to facilitate better interventions

Assessment

Nursing Diagnosis

S> “sobrang init ko” as verbalized by the patient

O> - febrile (39.6 °C) - flushed skin - warm to touch -diaphoretic > pale and weak in appearance

Hyperthermia related to disease process

Scientific Background

Goals

During inflammation or infection, the area of infection or infection phagocyte releases endogenous pyrogens (fevercausing substance). These will act as receptors in the hypothalamus to cause upward alteration of its temperature set point

After 1-2 hours of rendering proper

Interventions

> monitor vital signs

nursing intervention , the patient’s temperature will subside from 39.6°C to 37°C or maintain body temperature within normal range (36.5°C – 37.5°C)

> remove excess clothes or blanket

> perform TSB

Rationale

Evaluation

> to monitor any changes from the previous to present data. Serve as baseline data

Goal met. After 1-2 hours of rendering proper nursing intervention, the patient’s temperature subsided from 39.6°C to 37.5°C.

> to promote heat loss through evaporation

> TSB opens the skin pores therefore facilitating conduction and evaporation of heat from a warm surface to a cool surface

Vital Signs: > to reduce metabolic

BP:

demands

110/80 mm Hg RR: 32 bpm

> to support circulating volume and tissue

CR: 100 bpm T: 39.6°C > provide adequate rest

> administer fluid an electrolyte replacement

> administer medications as indicated

> explain temperature measurements

perfusion

> to treat underlying cause

> this will provide patients knowledge how to assess their temperature; this will provide information on how to prevent or control temperatures especially when they were already

and all treatments

discharged

> provide information regarding normal temperature and control > discuss precipitating factors and preventive measures

XII. ONGOING APPRAISAL October 8, 2009 Patient XYZ’s condition has improved. He is not experiencing abdominal pain. His NGT and IFC were removed. He is already allowed to have general liquids on his diet. Patient is with ongoing Pantoprazole drip. October 9, 2009 The patient is allowed to Medications are still continued.

have

soft

diet.

Pantoprazole

drip

was

discontinued.

October 10, 2009 Patient is requested to have another abdominal ultrasound to confirm obstruction. If confirmed, the patient may be transferred to surgery ward. October 11, 2009

bile

duct

The patient is not experiencing abdominal pain, fever and shortness of breath. The patient is still for abdominal ultrasound. October 12, 2009 The patient may be transferred to regular ward. The patient is still for abdominal ultrasound for confirmation of common bile duct obstruction. XIII. DISCHARGE PLAN M – Medicine - advise patient to continue his prescribed medicines E – Environment and Exercise - maintain a quiet environment to promote relaxation - provide clean and comfortable environment - encourage walking everyday T – Treatment - continue home medications - advise patient to take multivitamins for increased immunity - teach patient about wound care H – Health Teachings - provide oral and written instructions about wound care, activity, diet recommendations, medications, and follow-ups O – Out-Patient Follow-Up - patient will be advised to go back to the hospital in a specific date to have a follow-up check-up after discharge D – Diet and Danger Signs - encourage patient to increase protein intake for tissue repair

- advise patient and family members to immediately consult if the patient is experiencing any likely symptoms, or changes that may occur when the patient is at home. VII. PATHOPHYSIOLOGY (Ascending Cholangitis) Biliary tract obstruction (gall stone, neoplasm, or stricture) (Main Factor of Pathogenesis) Elevated Intraluminal Pressure

Walls of biliary tract become distended Occlusion of lymphatic channels then the venous return and arterial supply to the biliary tract becomes undermined Reduced blood supply to the biliary tract

Diminished host antibacterial defenses

Immune System Dysfunction

Decreased oxygenation Walls of biliary tract starts to break Bacteria gain access to the biliary tree

Bacteria start to multiply

Bacteremia

Invasion of bacteria (E.coli 27%, Klebsiella species 16%, Enterococcus species 15%,Sreptococcus species 8%, Enterobacter species 7%, Pseudomonas aeruginosa 7% Retrograde ascend from duodenum or from portal venous blood to the hepatic ducts, biliary canaliculi, hepatic veins and perihepatic lymphatics Charcot’s triad:fever, RUQ pain,jaundice Reynold’s pentad:altered mental status, hypotension,RUQ pain, fever and jaundice Unclassical signs:pruritus, malaise and tacycardia