Question

Scenario: D.J. is a 50-year-old female presenting at the ER with jaundice, upper abdominal pain, nausea, vomiting. The pain had a sudden onset and has lasted for a couple of days. She also mentioned itching in her palms and bilateral legs. Upon abdominal examination, the MD assessed liver enlargement via palpation and percussion. A Nasogastric tube was inserted and connected to low intermittent suction with 300ml of brown, clear liquid returning on insertion. The patient is NPO except for medication administration. The patient continues to complain of a colicky, cramping abdominal pain radiating to RUQ where it then radiates to her back. She currently rates her pain a “7”.

Past Medical History: hypertension, Type 1 Diabetes Mellitus, and denies the use of alcohol

1.) Assessment

2.) NANDA Diagnosis

3.) Pathophysiology

4.) Medical diagnosis

5.) Nursing diagnosis

6.) Goals/Expected Outcome (Include Time Frame):

7.) Nursing intervention and rationale of nursing intervention.

8.) Goals/Expected Outcome (Include Time Frame)

Answer 1

1.Nursing assessment :

Integumentary system-assess skin color,scelera and micois membranes.

Circulatory system-assess for capillary refill and peripheral pulses

Assess for any unusual bleeding,epistaxis,petechiae or melena,vomiting and nausea.

Gastrointestinal system:assess for abdominal distension,frequent pain,tenderness or bloating,type of pain,location of pain and severity of pain,Assess for murphy's sign.

Other underlying disease if present

2 nursing diagnosis according to NANDA

Acute pain related to inflammatory process as evidenced by cholecystitis.

Risk for imbalanced nutrition related to dietary restrictions and pain

3.pathophysiology:Acute cholecystitis is caused by an obstruction of the cystic duct,leading to distension of the gallbladder.As gallbladder become distended,blood flow compromised and it cause ischemia and necrosis of mucosal membrane.Pressure on the gallnladder increases,the organ become enlarge and wall thickens.

The gallbladder can become infected by various microorganisms including those that are gas forming.cholecystitis also can lead to gallstone pancteatitis if stones dislodge down to the sphincter of oddi and are not cleared,thus blocking the pancteatic duct.

4.medical diagnosis:

Biliary ultrasound:reveals calculi or bile duct obstruction.

Oral cholecystography:method for viaualising general appearance and function of gall bladder including any filling defects or structural defects.

Cholecystograms for chronic cholecystitis

Abdominal x ray films

Serum bilirubin and amylase:elevated or not.

Serum lover enzymes,prothrombin levels,ultrasonography.