Reference no: EM133709332
Scenario Patient with gall bladder disease and choledocholithiasis
T.B., a 60-year-old retiree, is admitted to your unit from the ED. Upon arrival you note that he is trembling and nearly doubled-over with severe abdominal pain. T.B. indicates that he has severe RUQ (right upper quadrant) pain that radiates to his back, and he is more comfortable walking bent forward than lying in bed. He admits to having had several similar bouts of abdominal pain in the last month but "none as bad as this." He feels slightly nauseated but has experienced N/V during previous episodes. T.B. experienced an acute onset after eating fish and chips at a fast-food restaurant. His daughter insisted on taking him to the hospital. Assessment findings are an AAO x 3 man of medium build who MAEW (moves all extremities well). Moves restlessly and continually, c/o of notable fatigue. Breath sounds clear throughout, anterior and posterior. Heart sounds clear without adventitious sounds, heart rate regular, all pulses 3+ bilat. Bowel sounds audible, abdominal guarding noted with exquisite tenderness to light palpation over R side, especially RUQ. Has sharp inspiratory arrest with palpation of the RUQ. Reports lightcolored stools x 1 wk. Voids medium amber urine per urinal without difficulty. Skin and sclera slightly jaundiced. Admit VS are 164/100, 132, 26, 37.46, 36° C.
1. What structures are located in the RUQ of the abdomen?
2. Which of the above organs are palpable in the RUQ? Abdominal ultrasound demonstrates several retained stones in the common bile duct. T.B. is admitted to your floor and is scheduled for an open cholecystectomy in the AM.
3. Given T.B.'s diagnosis, what laboratory values would be important to evaluate?
4. List four preop preparations that need to be done.
5. T.B. is medicated with morphine 5 mg IM q4h for pain. He reports that, on a scale of 1 to 10, his pain has decreased from 10 to 4 in 1 hour. What else could be done for T.B.'s pain?
6. What data charted in the assessment are consistent with common bile duct obstruction?.
7. At 2330, T.B. spikes a temperature to 38.6° C (tympanic). He is started on a broad spectrum antibiotic: Imipenem/cilastatin 500 mg IV q6h (check renal function-must be dose-adjusted or there is an increased risk for seizure). What, if anything, needs to be done before the antibiotic is begun?
8. T.B. undergoes a cholecystectomy. Why is a T-tube drain installed during common bile duct surgery? The first day after surgery, the drainage should have a small amount of bloody drainage. This soon changes to dark green (bile-colored) drainage. Initially the Ttube drains approximately 500 ml per day then gradually decreases. The second day postop, you enter T.B.'s room. You note a small amount of bile drainage on his gown and a moderate amount on the abdominal dressing. When you remove the tape to change the dressing, you note that T.B.'s skin is blistered and reddened.
9. In order to protect the blistered area from further damage, you apply a hydrocolloid dressing, such as DuoDERM, HydraPad, Restore, or Ultec to the damaged skin. What are the benefits of this type of dressing?
10. T.B. recovers uneventfully and will be discharged with his T-tube still in place. What does he need to know about this drain?
11. What other discharge teaching does he need?
12. Most gall bladder surgeries today are done laparoscopically versus and open cholecystectomy. Discuss the reasons why some are done though a laparoscopic cholecystectomy versus an open cholecystectomy.