I.

Introduction

A gallstone is a stone formed within the gallbladder out of bile components. The term cholelithiasis
may refer to the presence of stones in the gallbladder or to the diseases caused by gallstones. Most people
with gallstones (about 80%) never have symptoms. In 14% of those with gallstones, a crampy pain in the
right upper part of the abdomen, known as biliary colic, occurs each year. Complications of gallstones
include inflammation of the gallbladder, inflammation of the pancreas, and liver inflammation. Symptoms
of these complications may include pain of more than five hours duration, fever, yellowish skin, vomiting,
or tea-color urine.

Risk factors for gallstones include birth control pills, pregnancy, a family history of gallstones,
obesity, diabetes, liver disease, or rapid weight loss. Gallstones are formed in the gallbladder, typically
from either cholesterol or bilirubin. Gallstones may be suspected based on symptoms. Diagnosis is then
typically confirmed by ultrasound. Complications may be detected on blood tests.

Prevention is by maintaining a healthy weight and eating a proper diet. If there are no symptoms,
treatment is usually not needed. In those who are having gallbladder attacks surgery to remove the
gallbladder is typically recommended. This can be either done through several small incisions or through
a single larger incision. Surgery is typically done under general anesthesia. In those who are unable to
have surgery, medication to try to dissolve the stones or shock wave lithotripsy may be tried.

In the developed world, 1015% of adults have gallstones. Rates in many parts of Africa, however,
are as low as 3%. Gallbladder and biliary related diseases occurred in about 104 million people (1.6%) in
2013 and they resulted in 106,000 deaths. Women more commonly have stones than men and they occur
more commonly after the age of 40. Certain ethnic groups have gallstones more often than others. For
example, 48% of American Indians have gallstones. Once the gallbladder is removed, outcomes are
generally good. In the Philippines, thousands of new cases are diagnosed each year and cholecystectomy
(the surgical removal of the gallbladder), is one of the most common abdominal operations done locally.

Signs and Symptoms

Gallstones may be asymptomatic, even for years. These gallstones are called "silent stones" and do
not require treatment. The size and number of gallstones present does not appear to influence whether or
not people are symptomatic or asymptomatic. A characteristic symptom of gallstones is a gallstone attack,
in which a person may experience colicky pain in the upper-right side of the abdomen, often accompanied
by nausea and vomiting, that steadily increases for approximately 30 minutes to several hours. A person
may also experience referred pain between the shoulder blades or below the right shoulder. These
symptoms may resemble those of a "kidney stone attack". Often, attacks occur after a particularly fatty
meal and almost always happen at night, and after drinking.

In addition to pain, nausea, and vomiting, a person may experience a fever. If the stones block the
duct and cause bilirubin to leak into the bloodstream and surrounding tissue, there may also be jaundice
and itching. This can also lead to confusion. If this is the case, the liver enzymes are likely to be raised.
II. Objectives

General Objective:

The general objective of the case study is to gain the comprehensive knowledge about the disease
process and also to gain Practical experience working with a patient having cholelithiasis and to give
holistic patient care according to their need.

Specific Objectives:

Knowledge:
Plan on how to treat patients condition regarding to this kind of case.
Improve the use of the nursing process that would include assessment, diagnosis, planning,
implementation and evaluation into a more useful and more effective in doing the patients
nursing care plan.

Skills:
Assess the condition of the patient by establishing rapport, gathering all vital information and
determining clients past and present health history. Perform physical assessment on clients
condition to attain baseline data.
Develop an independent and collaborative work, together with the medical health team members.
Prioritize things which are essential in assessing and developing proper interventions in treating
or alleviating the illness.
Perform nursing interventions in an accurate and sequential manner.

Attitude:
Apply the core and fundamental systematic approach of the nursing profession in promoting
health unto the clients.
Apply virtues or positive traits as a health care provider, to think and act in ways that are good
and to do what is morally right.
XII. DISCHARGE PLAN

Medication:

Instruct the client to continue medication as prescribe by the physician.

Discuss to the patient the significant effects of the drug that hes going to take
and if not follow rightly.

Exercise:

Advise light exercises at least 15 to 30 minutes per day like stretching or walking
slowly and carefully seek assistance for safety measures if needed.
Advise patient to do light daily activities which aides in achieving and
maintaining an optimum level of wellness and heath.
Encourage the patient to get at least 6-8 hours of sleep every night and has naps
even an hour every afternoon.

Treatment:

Advise the patient to comply prescribed medications as directed.

Advise patient to follow doctors order about the lifestyle changes and eating

hobbies.

Health Teaching:

Provide information regarding about the current situation of the disease.

Provide personal hygiene information to avoid infection
Instruct client about the information about the drugs.
Provide Information that will help enhances the lifestyle of the patient.

Out-Patient:

Instruct the client to call her Doctor if client experiences nausea and are
vomiting, urine is dark, and clay-colored bowel movements.
Emphasize the importance and benefits of the following scheduled dates of
check-up
Instruct the patient to report any unusualities seen as soon as possible.
 Diet:

Encourage patient to eat nutritious and healthy foods including fruits and
vegetables, 100% whole grains, lean meats and fish, and low-fat dairy products.
Try to stay away from foods high in fats and salt

A healthy balanced diet consists of:

Plenty of fruit and vegetables. Aim to have at least five portions each day.
Plenty of starchy carbohydrates. Examples include bread, rice, cereals, pasta, potatoes, chapattis and
plantain. Choose wholegrain varieties when possible.
Some milk and dairy products (2-3 portions per day). Choose low-fat dairy products.
Some meat, fish, eggs and alternatives such as beans and pulses.
Limited amounts of foods high in fats and sugars. Limit saturated fat that is found in animal products,
such as butter, ghee, cheese, meat, cakes, biscuits and pastries. Replace these with unsaturated fats found
in vegetable oils, such as sunflower, rapeseed and olive oil, avocados, nuts and seeds.
Make sure your diet is high in fiber. This can be found in beans, pulses, fruit and vegetables, oats, and
whole wheat products, such as bread, pasta and rice.
Drink plenty of fluid - at least two liters daily, such as water or herbal teas.
XIII. EVALUATION

In this case study, we were able to assess the client properly and gain baseline data by building rapport
with the client and the patients significant others. We have formulated the correct diagnosis based from
the thorough assessment done to the client. The objectives set by the group were achieved. And base from
this case, we were able to plan the actions that are to be arranged. We have been able to give the
appropriate nursing interventions with efficiency. Health teaching was also discussed to the patient about
the things and habits to be avoided. We identified cholelithiasis means its cause and effect, systems and
parts of the body that might be affected and also the treatment of this illness. Including the laboratories,
diagnostics and its implications to the clients condition which may help our group and also the patient to
be knowledgeable in this case that we may possibly encounter again.