Case Study–Title: Cholelithiasis/Cholecystitis and Open Cholecystectomy
Scenario: A 60-year-old obese female is being seen in her primary care provider’s office with a possible history of gallstones and now with a possible diagnosis of cholecystitis. Her daily medications include Zestril (lisinopril) for a 5-year history of hypertension and a multivitamin. When asked about exercise and diet, the patient reports that she eats mostly fast food and spends most of the day in her recliner watching TV. The patient reports that in the past month she has had progressively worse indigestion and upper right quadrant pain that occurs a few hours after meals and is especially severe when she goes to bed. Additionally, the pain has started to radiate to the right shoulder. Using a pain intensity scale, the patient reports it to be 6/10 to 8/10. The pain subsides after a few hours, but the patient reports that her right upper quadrant always feels tender.
1. NGN Item Type: Extended Drag and Drop
Place an X (or drag and drop) to indicate which patient assessment findings require follow-up by the nurse at this time.
| Assessment Finding | Assessment Finding That Requires Follow-Up |
| Right upper quadrant tenderness | |
| Patient is obese. | |
| Dark amber colored urine | |
| Patient oral temperature = 100.4°F (38°C) | |
| Patient reports that she urinates 4-5 times per day. |
Rationale for the above choices:
Cognitive Skill: Recognize Cues
2. NGN Item Type: Extended Response
Which nursing assessment findings support the patient’s probable diagnosis of cholecystitis? Select all that apply.
_____ A. Jaundice
_____ B. Pain is worse after meals and when lying down
_____ C. BP 160/82
_____ D. Patient reports indigestion
_____ E. Abdomen is soft and non-distended
_____ F. Intermittent right shoulder pain
_____ G. WBC count 12000/mm3
Rationale for the above choices:
Cognitive Skill: Analyze Cues
Scenario: A 60-year-old obese female with a history of cholelithiasis and hypertension who saw her primary health care provider 1 day ago for worsening intermittent right upper quadrant pain and indigestion has now been admitted into the hospital for a diagnosis of acute cholecystitis. She now reports constant abdominal pain that radiates to her right shoulder. Using the pain intensity scale, the patient rates the pain 9/10. She also states that she has been nauseous for the past 24 hours and has not been able to eat or drink without vomiting. She now has a nasogastric tube for gastric decompression that is connected to low intermittent suction. She also has an IV of 5% Dextrose and 0.45% normal saline infusing at 125 mL/hour in her right basilic vein. The admitting nurse is planning care for the patient.
1. NGN Item Type: Cloze
Choose the most likely options for the information missing from the statements below by selecting from the list of options provided.
Based on the patient’s current condition, the nurse recognizes that the patient’s priority needs will be to prevent ____________, __________, and __________.
| Options |
| Infection |
| Pain |
| Inadequate diet |
| Hypotension |
| Fluid and electrolyte imbalance |
| Cardiac dysrhythmias |
| Wound dehiscence |
Rationale:
Cognitive Skill: Prioritize Hypotheses
2. NGN Item Type: Extended Drag and Drop
Use an X (or drag and drop) to indicate which actions listed in the left column would be included in the plan of care for this patient.
| Nursing Actions | Relevant Nursing Actions |
| Prepare to administer antibiotics. | |
| Obtain urine specimen for culture and sensitivity. | |
| Monitor intake and output. | |
| Monitor serum electrolytes. | |
| Collaborate with dietician to provide low fat diet. | |
| Frequently assess patient pain level. |
Rationale:
Cognitive Skill: Generate Solutions
Scenario: This morning the patient had an open cholecystectomy this morning for acute cholecystitis and returned to the nursing unit from the post anesthesia care unit (PACU) 4 hours ago. She is now awake but drowsy. Using the pain intensity scale, she reports that the pain medication she received 1 hour ago decreased her pain level from an 8/10 to 4/10. She has a T tube draining a moderate amount of bile. The dressing on her right upper quadrant is clean and dry. Vital signs are temperature 98.9◦ (37.2◦ C), pulse 88 bpm, respirations 16 per minute, BP 118/72 mmHg. She will be started on a clear liquid diet this evening.
NGN Item Type: Matrix
Use an X for the nursing actions listed below that are Indicated (appropriate or necessary), Contraindicated (could be harmful), or Nonessential (makes no difference or not necessary) for the patient’s care at this time. Only one selection can be made for each nursing action.
| Nursing Action | Indicated | Contraindicated | Nonessential |
| Administer analgesic before planned patient activity. | |||
| Clamp T tube to prevent loss of bile. | |||
| Assess patient’s serum glucose level daily. | |||
| Encourage the use of the incentive spirometer. | |||
| Maintain patient on bedrest in supine position. |
Rationale for the above choices:
Cognitive Skill: Take Action
Scenario: The patient was discharged on the 5th postoperative day 2 weeks ago. She is now at the surgery clinic for follow-up care. Her T tube was discontinued before discharge and there is now a small dressing over the insertion site, which is clean and dry. Her right upper quadrant surgical wound is clean and dry and open to air. Stitches are intact. She reports that she is following the discharge instructions the nurse provided her before she left the hospital. The patient has gained 5 pounds and she reports that she continues to eat fast food since it requires less effort than to prepare her own meals. She reports that she is not on a weight reduction program at this time. Although the patient reports that she does not have pain during her interview, she reports that she takes 2 Percocet tablets every 4 hours while she is awake and that she will need the prescription to be refilled.
NGN Item Type: Highlighting/Enhanced Hot Spot
Rationale for the above choices:
Cognitive Skill: Evaluate Outcomes
Copyright © 2023 by Elsevier, Inc. All rights reserved.
Copyright © 2023 by Elsevier, Inc. All rights reserved
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