Care plan 2

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Pathophysiology Chart Summary EDITING AND REWRITING

Patient’s main cause and risk factors to develop the gallstones her gender, age, history of illness. Gallbladder disease common in women over the age 40. Patient is 50 years old and has hypothyroidism.  Gall stone formation is increased in patients with hypothyroidism disease, Hypothyroidism is a when thyroid gland is unable to produce thyroid hormones. In hyperthyroidism, the lack of thyroxine has various complications. Thyroid hormones have different effect on cholesterol and fatty acid metabolism in the liver. Hypothyroidism will lead to decreased cholesterol metabolism in the live resulting bile cholesterol supersaturation causing the retention of cholesterol crystals resulting in gall stone formation. Finally, hypercholesterolemia and hypotonia caused by hypothyroidism will increase the risk of developing gall stones. In a research study conducted in 2015 found out that there is a statistical significance between female in age group more than 40 diagnosed with hypothyroidism and gall stone disease (Rassam, Najim,2018). Changes in composition of bile is the major cause of gall stone formation. The stones may stay in the gally bladder and cause inflammation or travel into the cystic duct and common bile duct. Stone can cause obstruction in ducts. Cholecystitis is the inflammation of lining of   gall bladder wall. secondary to cholestasis may show a range of symptoms. Patients symptoms were fever, severe pain, indigestion, nausea, diaphoresis, RUQ tenderness and abdominal rigidity. Moderate to severe pain. Pain attacks start after eating high fat meal or when lying down. The pain of attack usually last more than six hours. Patients will prevent pain by reducing activity that will put her increase her risk for venous thromboembolism and risk for constipation. Complication from gall stone and cholecystitis if left untreated can lead to serious complication and death. The first is gall bladder infection due accumulation of pus and bile that can progress to sepsis.   Second is gall bladder rapture and perforation will cause leakage of bile or stones in the abdominal cavity, leading to peritonitis, pelvic abscess, pneumonia. Consequently, these will lead to infection that can progress to sepsis. It a dangerous condition that needs immediate intervention (Lewis,999). Tissue death and is the other complication resulting from progressive vascular insufficiency. The other common complication is cholecysenteric fistula. Cholecytstoenteric fistula is when the gallbladder connects to the one or more surrounding gastrointestinal tract and stones ulcerates. According to a large cholecystectomy series, the incidence of CEF ranges from 0.5% to 0.9%. thought the wall (Li et al.,2017). Gallstone pancreatitis is stones from the gallbladder block the opening of the pancreas and duodenum.  The inflammation of pancreas will lead to infection resulting in pancreatic necrosis and sepsis. Cholestasis can lead to malabsorption of fat-soluble vitamins. Fat-soluble vitamins are (A, D, E and K). Vitamin A and D for bone growth, reproduction, cell division, immunity. Vitamin K has important role in blood clotting and helping in producing for bone and kidney. The lack of this vitamin will put the patient at risk for imbalanced nutrition and bleeding. In fact, patients’ plate? Anxiety and fear due to severe intermittent pain at fist then severe and severe attack are experienced. Patient expressed fair of severe pain after eating that was coming ang going for two month and got worse when she was admitted to the emergency room. Finally is Cholestits remain untreated it will progress to gallbladder cancer. According to the American Cancer Society gallbladder cancer is sometimes diagnosed after acute cholecystitis and it affects 11,000 people in United States(American Cancer Society, 2020).

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Background and Etiology EDITING DON’T CHANGE ANY INFORMATION

The patient is a Caucasian female in her fifties and does not indicate any allergies. The client has a Full Code status and presents with no history of chronic illness, trauma, or surgery. The client can carry out ADLs independently. Denies alcohol use or smoking. The patient appears her age, well dressed, neatly groomed, and has not worn any precaution armband. The client appears healthy and calm, with a blunted facial expression. The patient stays with her boyfriend, has no kids, and recently lost her job. The patient did not report any family history. Patitent s has hypothyroidism and she takes Levothyroxine (Levothyroid) 125 mcg daily.

Patient presented at the emergency department on October 15,2020. She complained of abdominal after eating solid food for the past one month. She reports that she had similar pain in the past that improved by removing lactose from her diet. Patient explained that she was seen by her primary care physician and referred for outpatient testing including ultrasound. She localized the pain to her epigastric area and stated that it radiates to her right upper quadrant. She notes that her pain got worse after eating her lunch. Patient expressed that the pain was intermittent for one month the intensity increased one day a go. She rated her pain 9/10. Her Vital signs were Her VS are BP 99/75, HR 110, RR 14, T 100.6, SpO2 98% on RA. Her CT and MRI showed cholelithiasis, gall bladder distention and borderline wall thickening. Chronic cholecystitis as well as mild dilation of intrahepatic bile duct. In addition, 2.7 cm gallstone and 5 cm stone in distal CBD with 9 mm dilatation of more proximal CBD was found. Patient was transferred to the medical surgical unit for farther monitoring and scheduled ERCP ordered for September 18,2020 and Laparoscopic cholecystectomy on September 19,2020. Patients pain was managed with Morphine 2mg IV P, PRN.

Clinical manifestation REWRITING AND EDITING

The gall bladder is a located at RUQ under the liver. The gall bladder receives bile from the liver and releases it to the small intestine. Bile is a digestive fluid useful for emulsification of lipids. Cholelithiasis is the formation of stone in the gallbladder. It is the most common biliary disorder. The stones develop when the balance of cholesterol and bile salt and calcium change.  The bile secreted by the liver is super saturated with cholesterol. Patient has hypothyroidism and . Thyroid hormones have different effect on cholesterol and fatty acid metabolism in the liver. Hypothyroidism will lead to decreased cholesterol metabolism in the live resulting bile cholesterol supersaturation causing the retention of cholesterol crystals resulting in gall stone formation. Finally, hypercholesterolemia and hypotonia caused by hypothyroidism will increase the risk of developing gall stones. The gall stones can stay in the gall bladder or migrate to the common bile duct (CBD).  Patient has 2.7 cm gallstone and 5 cm stone in distal CBD with 9 mm dilatation of more proximal CBD.  The stones can obstruction in the common bile duct, cystic duct, hepatic duct, small bile duct and pancreatic duct. When bile cannot move out it leads to cholecystitis which is the inflammation of the gallbladder.  Cholecystitis can progress to infection then sepsis.  Biliary colic is the sign and symptoms that a patient presents. Few hours after eating severe abdominal pain occurs in the RUQ, pain that radiates to the right shoulder back, tenderness, nausea, vomiting and fever. Patients experience intermittent pain at first then it escalates and persists. If left untreated Cholecystitis will cause serious complication and death. Ultrasound, endoscopic retrograde cholangiopancreatography, (ERCP) will allow visualization of gallbladder, cystic duct. Biopsy of the bile can be obtained during ERCP. Laboratory test that help diagnose Cholecystitis are increased WBCs, increased bilirubin level, increased amylase, or lipase level. Patients has increased WBCs and bilirubin.  Treatment for cholecystitis is usually focused on pain control and laparoscopic cholecystectomy. Once the gallbladder is removed, bile is not stored it flows directly into the small intestine.

Mobility and Mortality WRITING NEED CITATION FORM CDC OR REABLE SOURCE

FOCUS ON CHOLECYTITIS MORBIDITY AND MORTALITY

IN ADDITON ADD HYPOTHYROIDISM MOBILITY AND MORTALITY TRY TO CONNECT IT TO PATIENT INFORMATION

• Describes the morbidity and mortality associated with patient’s disease, citing credible source (0-4 points) (Hint: Make clear connection between each disease and other associated conditions)
• Discusses the impact of the disease on the patient’s functional health – what has been the consequence? (0-3 points)
• Takes into account unique characteristics of the patient-age-gender-race-socioeconomics (0-3 points)

Analysis REWRTING AND ADD SOME SENTENCES AT THE END

Patient was afraid of eating due to biliary colic. Even if she was getting a low-fat meal, she barely touched her meal. When we asked, she explained that she is hungry, but she fears the severe pain and nausea.  We educated her that she need needs to eat some food told her that we can give her pain medication if needed.  However, after my reading I noticed that our management was partially done. We should have removed the food from her table and then offered to her pain medication (morphine) and thirty minutes before she gets her meal and zofran for her nausea and vomiting.   “Administer antiemetic as prescribed and encourage patient to retry small amount of food after medication has had time to take effect” (Taylor et al.,2013). We   should encourage her to eat small thought the day.  We should have used an empathetic support by and helping in reviewing the menu.  The book explains that telling what he or she must eat is no guarantee that he or she will comply.  In addition, we should have educated the patient that nausea may be lessened by avoiding periods of hunger (Taylor et al.,2013).

I have learned form this situation that pain, illness and anxiety can contribute to poor nutritional intake and making ever effort to help patient is my responsibility.  For my future practice I will take additional time and attention in encouraging patients to eat and put in practice what I have learned in class. In addition, I will educate patient after resolving the problem and consult with provider to find alternative methods to meet patient’s nutritional requirements increasing patient comfort.

Describe an issue or difficulty you encountered in the delivery of care for your patient. Discuss how you resolved the difficulty and why you chose that approach. What is the evidence to support your approach (provide citation) and would you use that same approach if you encountered the issue again?

REFERENCE PLEASE EDITand add any used

American Cancer Society. (2020). Information and Resources about for Cancer: Breast, Colon, Lung, Prostate, Skin. www.cancer.org/.

Rassam Ghadhban B, Najim Abid F. The prevalence and correlation between subclinical hypothyroidism and gall stone disease in Baghdad teaching hospital. Ann Med Surg (Lond). 2018 Nov 30;37:7-10. doi: 10.1016/j.amsu.2018.11.017. PMID: 30546871; PMCID: PMC6282189.

Li, X. Y., Zhao, X., Zheng, P., Kao, X. M., Xiang, X. S., & Ji, W. (2017). Laparoscopic management of cholecystoenteric fistula: A single-center experience. The Journal of international medical research, 45(3), 1090–1097. doi.org/10.1177/0300060517699038

Doenges, M.E., Moorhouse, M.F., & Murr, A.C. (2019). Nurse’s pocketguide: Diagnoses,prioritized interventions, and ratonales (15th edition). F.A. DavisCompany