Case study analysis Essay Example

  • Category:
    Nursing
  • Document type:
    Case Study
  • Level:
    Undergraduate
  • Page:
    3
  • Words:
    1800

Assessment 2: Case study analysis

Assignment 2

Marking Guide – Case Study

Class Number:

Case study analysis

Introduction

One of the core elements in this case is Dorothy’s age and boy. While this has some relevance, she also weighs 86kgs with height of 169cm. Another important element related to the condition is the constant pain in the right upper quadrant (RUQ). This is coupled with nausea, abdominal pain and vomiting. Before going to bed, the patient took fish and chips which certainly were fatty foods. Other notable elements in this case are the past surgical history and medical history. The patient had total hysterectomy with bilateral salpingoopherectomy and intra-abdominal abscess complication developed as a result. Going by her medical history, she has had painful and heavy periods characterised by depression, fatigue and anaemia. She was discharged four weeks before this visit with some oral antibiotics administered. This case presents intermittent pain in the shoulders which the patient rates at 8/10. Lastly, inclusion of Morphine S/C 5-7.5mg 2 hourly, Ondansetron 4mg IV and the
intravenous therapy Normal Saline over 6 hours (1000/6) are also core elements.

Critical Questions and Rationale

Beginning with her last oral intake, Institute for Clinical Systems Improvement (2009) explains that onset symptoms associated with acute cholecystitis is fatty foods especially if such are ingested an hour or so before the pain. This is why nausea and vomiting are experienced—such are acute cholecystitis associated symptoms. The constant pain in the epigastric area (right upper quadrant) is related to the provisional diagnosis made—cholecystitis. Generally, acute cholecystitis is link with cholelithiasis (gallstone disease) characterised by right upper quadrant pain (steady and severe due to the inflamed bladder), fever and in some cases leukocytosis. Another common manifestation of acute cholecystitis is the pain to the back and right shoulder which she rates at 8/10.

Her age, weight and gender plays significant roles as far as the case is concerned. To begin with, Registered Nurses’ Association of Ontario (2010) notes that gallstones are common among women over the age of 35 years thus high chances of developing cholecystitis. Her weight also relates to the condition diagnosed. At 86kgs Dorothy is not keen with her diet thus predisposing her to cholecystitis (Siddiqui 2008).

Past surgical and medical histories are important as they relate to the development of the condition diagnosed. Beginning with the past surgery, this was done under general anaesthesia (TAH+BSO) six weeks before this visit. This was actually total hysterectomy with bilateral salpingoopherectomy. When this type of surgery is done there may be a need to remove surrounding tissues and lymph nodes. Unfortunately, injuries or infections to other organs are common postoperative complication associated with hysterectomy. In most cases, xxx explains that bladder can be perforated especially when there is entry to the anterior cul-de-sac. This explains why there were oral antibiotics when discharged. In a recent study, Glasgow & Mulvihill (2010) note that other than cholelithiasis, acute cholecystitis can be caused by the infection in the common bile duct drainage system. And this infection must have been due to the total hysterectomy with bilateral salpingoopherectomy.

An intra-abdominal abscess as noted has been included as one of the core element due to its relationship with the condition diagnosed. An intra-abdominal abscess is a collection of infected fluid or pus surrounded by inflamed tissue (in this case, probably the inflamed bladder). There are other minor causes of intra-abdominal abscess such as diverticulitis or appendicitis but this case is due to the surgery resulting to bacterial infection (probably E. coli). Wilson et al. (2008) add that abscesses shows up after two or more weeks after infection. This explains why Dorothy had the complication six weeks after operation (meaning there was infection during the surgery).

On the other hand, while assessing her medical history, reasons for painful and heavy periods vary from one person to another. Depression is as a result of psychological torture resulting from painful and heavy periods. This is why Sertraline (Zoloft) 100mg was to be administered on a daily basis—an antidepressant belonging to a class of SSRI (selective serotonin reuptake inhibitor). Fatigue and anaemia are as a result of heavy periods.

Finally, the relevance of Morphine S/C 5-7.5mg, Ondansetron 4mg IV and the
intravenous therapy Normal Saline over 6 hours (1000/6) are as follows; Morphine S/C 5-7.5mg was to control the pain especially an intra-abdominal abscess and intermittent pain in the shoulders. Ondansetron 4mg IV is relevant in this case as it was administered to control nausea and vomiting. Finally, Normal Saline over 6 hours (1000/6) was to be given to Dorothy to replace the lost electrolytes through vomiting.

Review of Current and New Knowledge

The pathophysiological process of Acute Cholecystitis begins when inflammation of the gallbladder becomes sudden and intense. This then leads to fast progression of the disease. Friedman (2009) notes that in most cases the inflammation is due to the obstruction of the bile duct (calculous cholecystitis). There are other possible causes of Acute Cholecystitis. These include motility disorders, collagen disease, allergic reactions, and ischemia among others. The obstruction further causes the gallbladder to distend resulting in edema around the gallbladder cells. As a result of this, gallbladder walls may undergo gangrene and nercrosis (gangrenous cholecystitis). When examined physically, patients may have fever and tachycardia.

As noted by Wang & Afdhal (2010), cholecystitis is common in patients with gallstones history. In as much, acalculous
cholecystitis (without gallstones) can be diagnosed. In such cases, acalculous cholecystitis will be manifested with critically ill patients who will have high mortality and morbility (Robinson et al. 2010). As noted in the case of Dorothy, acute cholecystitis is associated with pain around epigastric area and such are always steady and severe. This contrasts the typical history of pain associated with biliary colic (acute cholelithiasis) that has been known to be that colicky (intermittent) in nature with severity at the beginning and gradual relief over hours.

Ultrasound can easily visualise gallstones. However, this alone cannot confirm diagnosis of cholecystitis (Chari & Shah 2008). In case of the ultrasound, fluid surroundings or the thickened gallbladder (greater than 4-5mm) are suggestive of acute cholecystitis. If analysed from the laboratory, Dorothy may reveal elevated white blood cells count with a left shift. Since this case is uncomplicated cholecystitis (acute), health behaviours and beliefs will limit Dorothy’s case to the cystic duct and gallbladder. However, if values for cystic duct and gallbladder are elevated then complicating conditions such as choledocholithiasis or cholangitis will be considered.

Nursing management

The immediate nursing management for acute cholecystitis includes having Dorothy fast; electrolyte and fluid resuscitation and narcotic analgesia. Opioid analgesia may be required by this patient. However, if management chooses to work with narcotic analgesia such should be made effective by intramuscular injection of ketorolac usually given in the range of 30-60mg depending on the age and renal function. Since the patient is vomiting nasogastric tube placement should be considered necessary. The case study does not indicate whether Dorothy has an evidence of gastric distention or ileus. If this is diagnosed then nasogastric tube placement is equally appropriate. Institute for Clinical Systems Improvement (2009) reports that indomethacin can reverse the inflammatory changes in patients with acute cholecystitis. And when given early, indomethacin can improve gallbladder contractility. Nursing management should also consider including diclofenac as it reduces the rate of progression to acute cholecystitis in patient with symptomatic gallstones.

Since Dorothy has not manifested symptoms such as high fever, hypotension or tachycardia; commencement of intravenous antibiotics is not necessary unless the above symptoms manifests or if there will be no improvement over 12 hours under conservative management. National Institute of Diabetes and Digestive and Kidney Diseases (2012) brings an interesting dimension on the condition arguing that the favourable results of the antibiotic treatment that can reduce septic complication in Dorothy depend on adequate serum instead of tissue concentrations. This is an important research that is not only evidence-based but directly relates to the case of Dorothy. It needs to be noted that though antibiotic (Morphine S/C 5-7.5mg) has been chosen for Dorothy, this needs to considered as unique case since the choice of antibiotic depends on local experience and patterns of bacterial resistance.

Recent studies have shown that single-agent therapy coupled with an extended cephalosporin is appropriate since it is safe and relevant in coverage of most acute cholecystitis cases (Siddiqui 2008; Robinson et al. 2010). This should not be exclusively used because in high-risk or severe cases, anaerobe cover will be essential. In the event of anaerobe cover; addition of a nitroimidazole will be necessary. Research further shows that patients manifesting early uncomplicated acute cholecystitis cases it is insignificant to prolong antibiotic for more than 24 hours postoperatively. That is why nursing management recommends surgery as optimal therapy not antibiotic therapy.

Reflection/Conclusion

Studies continue to show that Acute Cholecystitis is a prevalent condition in Western populations. In as much, extensive, population-based analyses are needed to ascertain rates and outcomes of complications especially rates of biliary injuries. Furthermore, from the literature materials reviewed, more data are essential to guide in determining the most effective use of antibiotics when handling Acute Cholecystitis. Generally, early laparoscopic cholecystectomy (LC) remains to be the most preferred method for treating this condition. And for optimal and effective management of Acute Cholecystitis cooperation between radiologist, gastroenterologist and surgeon remains to be the best.

Referencing

Chari RS, & Shah SA., 2008, Biliary system. In: Townsend CM, Beauchamp RD, Evers BM, Mattox KL, eds. Sabiston Textbook of Surgery. 18th ed. St. Louis, Mo: WB Saunders.

Friedman, LS. 2009, Liver, biliary tract and pancreas. In L.M. Tierney, S.J. McPhee & M.A.

Papadakis (Eds.) Current medical diagnosis and treatment (44th ed.). New York: McGraw-Hill.

Glasgow, RE, Mulvihill, SJ, 2010, Treatment of gallstone disease. In: Feldman M, Friedman LS, Brandt LJ, eds.Sleisenger & Fordtran’s Gastrointestinal and Liver Disease. 9th ed. Philadelphia, Pa: Saunders Elsevier.

http://guidelines.gov/summary/summary.aspx?doc_id=9624, Viewed 5 September 2013Preoperative evaluation. Institute for Clinical Systems Improvement (ICSI), 2009,

Institute for Clinical Systems Improvement (ICSI), 2009, Assessment and management of acute pain. Viewed 5 September 2013, http://guidelines.gov/summary/summary.aspx?doc_id=9009

National Institute of Diabetes and Digestive and Kidney Diseases, 2012. Viewed 5 September 2013, http://digestive.niddk.nih.gov/ddiseases/pubs/gallstones/index.aspx .

Registered Nurses’ Association of Ontario, 2010, Nursing best practice guideline: Assessment and management of pain. Toronto: RNAO.

Robinson, TN., Biffl, WL., Moore, EE., Heimbach, JK., Calkins, CM. & Burch, J., 2010, Routine preoperative laboratory analyses are unnecessary before elective laparoscopic cholecystectomy. Surgical Endoscopy 17(3), 438-441.

Siddiqui T., 2008, Early versus delayed laparoscopic cholecystectomy for acute cholecystitis: a meta-analysis of randomized clinical trials. Am J Surg.195:40-47.

Wang, DH, & Afdhal NH., 2010, Gallstone disease. In: Feldman M, Friedman LS, Brandt LJ, eds. Sleisenger & Fordtran’s Gastrointestinal and Liver Disease. 9th ed. Philadelphia, Pa: Saunders Elsevier.

Wilson, B., Shannon, M., Shields, K. & Stang, C. 2008, Prentice Hall nurse’s drug guide. Upper Saddle River, NJ: Prentice Hall.