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Nursing Case study Solved

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  1. Pathophysiology of acute cholecystitis in Maree and current treatment options


Acute cholecystitis is an inflammatory disease that takes place in the gallbladder.  Gutt et al. (2013) pinpointed the involvement of the factors as microorganism infections, motility disorders, ischemia, allergic reaction, direct chemical injury and collagen disease. The incidence of the disease is higher among people of the age group 50 and above as compared to that in the people of age below 50 years. There are several risk factors associated with the disease of acute cholecystitis identified in studies. AIDS is a major risk factor for this disease (Kimura et al. 2007).

However, in most cases it is seen that gallstones form the main factor for the incidence of acute cholecystitis in patients. A gallstone obstructs the neck or the cystic duct of the gallbladder resulting in an increase in the pressure. The degree and duration of the obstruction determine the progression of the disease (Winkelman et al. 2013). Complete obstruction of the tube for a long duration of time results in the development of acute cholecystitis in the patient. With a lack of immediate treatment, the disease gets more serious, and the complications increase.

A higher risk of acute cholecystitis is evident in people leading a sedentary lifestyle and those who are overweight or obese. It is also higher in certain ethnic groups of people as Chinese, Italians and Jewish. Rapid weight loss and diet, very low amount of physical activity, consumption of oral contraceptives and obesity are the modifiable factors contributing to the disease. The non-modifiable factors include genetic predisposition, ethnicity, age, estrogen levels and gender (Hartwig & Büchler, 2014). The patient in the given case depicts the factors as obese with a BMI of 37, age 45 and estrogen levels low.

Treatment options-

Depending on the severity of the disease, the relevant treatment procedures can be conducted on the patients suffering from acute cholecystitis. Complicated conditions of the disease require surgical approach for treatment. Unstable conditioned patients may be treated with percutaneous transhepatic cholecystostomy drainage. Infection risk in the disease is managed with antibiotics. As stated by Zerem (2012), cholecystectomy or replacement of a drainage device is a widely used therapy for treating cholecystitis. In general the patients admitted to health care settings with cholecystitis are restricted from any kind of oral diet. However, the patients depicting the uncomplicated status of the disease are allowed for liquid or low-fat diet.

The pharmacological treatments for acute cholecystitis involve the use of cefuroxime (200-250mg twice/day), ciprofloxacin (500mg once/day), and levofloxacin (500mg once/day) in combination with metronidazole (500mg thrice /day) in initial stage. Other non-steroidal anti-inflammatory drugs can also be prescribed for treating the disease. These include diclofenac (50mg twice or thrice/day), indomethacin (25-50mg twice or thrice/day) (George Longstreth, 2015). For moderate stage, the same drugs can be used at a lesser time intervals (in gaps of 12 hours, 8 hours and such) intravenously in place of orally as prescribed in an earlier stage. The patients in severe stages are prescribed with higher doses of the drug at a more close frequency.

  1. PACU discharge criteria components

Post Anaesthetic Care Unit (PACU) is mainly used for the immediate recovery of the postoperative patient. The Aldrete Scale works to evaluate the status of the patient for her ability to be discharged from the PACU setting (DeWitt et al. 2012). The main factors considered for a patient to determine the state of the patient to be able to be discharged from PACU or not include the assessment of the vital signs, pain, oxygen saturation, blood loss and level of consciousness. There are other variables too that can be assessed to determine the discharge ability of the patient from PACU. These include BP, pulse, respiratory rate (RR), laboratory value, anxiety, Oral intake, temperature, urine output and psychomotor (Andy Ng & Vickers, 2013).

The four main components of the PACU discharge criteria, as identified in the Aldrete scale, include Consciousness, Circulation (BP), Respiration and activity. Considering the patient in this case study Maree, the 45 years old women admitted to the emergency department of the hospital the vitals depicts essential information. The data regarding the four main components of the discharge criteria for the patient include the following information:

Circulation- The BP of the patient is recorded at 110/70. It indicates a normal BP for the patient as the normal BP range is less than 120 for the systolic and less than 80 for the diastolic value. However, it is a value on the verge of hypertension BP. Therefore, Maree can be discharged from the PACU by providing the patient with relevant guidelines for maintenance of her BP at the normal level.

Respiration- The RR of the patient Maree is seen to be 12. The normal range for RR is 12-28 (Thayer et al. 2012). Maree thus shows a normal rate of breathing. However, it is at just the initial value of normal RR. The patient, therefore, needs to keep a strict check on her activities and diet relating to the breathing. Hence, Maree is considered to be able to discharge from the PACU.

Consciousness- Maree was unconscious in the Post anesthesia Recovery Unit (PARU). After a time gap of 40 minutes, she depicted a drowsy status. However, the patient was easy to rouse. The presence of nausea complaints from the patient is a concerning factor restricting her discharge from the PACU. However, the next day Maree informed that her problem regarding nausea is resolved. Therefore, it ensures the meeting of the criteria of consciousness for discharging the patient from the PACU.

Activity- Although Maree depicted strong reluctance towards movement, she seemed capable of movement the next day after taking the light diet and fluid. The patient revealed a complaint of abdominal pain after 4 hours of surgery. However, the next day the patient showed an interest in activity through her comment that she needs to pick up her children from her parent’s house. It, therefore, indicates the ability of the patient to be discharged from the PACU.

  1. Discharge plan supporting the patient

As opined by Shepperd et al. (2013), discharge planning is very important for a patient regarding the health as well as the proper resource utilization of the hospital. The discharge plan helps in reduction of the length of stay at the hospital for the patient, pressure on the hospital beds and emergency readmissions. The reduction in error and unnecessary delays are facilitated through the support provided by the healthcare professionals regarding the discharge of the patient. Holland & Bowles (2012) identified the efficiency of the discharge plan support to increase the throughput of the hospital in case the inpatient beds is a bottleneck thereby reducing the referral to treatment lines.

There are certain major key elements that the discharge plan for the patient needs to consider irrespective of the fact that the patient receives emergency or elective care service. These elements include specification of a date or time of discharge initially at the earliest. Identification of the type of needs a patient has (complex or simple) comes next. Identification of the needs and procedures to meet them is the next planning that needs to be executed essentially to ensure that the discharge is fruitful. Lastly, the clinical criteria to be met by the patient for discharge needs to be determined.

As per the view put forward by Nosbusch, Weiss & Bobay (2011), the discharge planning initiated from the pre-operative assessment enable to aware the patients and others about the necessary arrangements and steps to be taken after discharge. Prior (48 hours before) coordination and checking of the availability of resources and other essential things for the discharge of the patient is important. Considering the case of Maree, it is vital that an adult accompanies her during her discharge. It can be any reliable person among her friends or colleagues. The Providence of the supply of medicines for her disease condition maintenance is highly important (Hesselink et al. 2012). While discharging the patient, the discharge nurse need to provide her with sufficient knowledge regarding how important it is to collect the medicines and maintain the timely intake of the drugs as per the prescription by the doctor. It will ensure constant pharmacological treatment maintenance of the patient’s health at home. Patients depict a lack of adherence to the drug therapy after discharge. It results in the increase in the complication of the disease and deterioration of the health status of the patients.

Correct documentation of the home address and contact number of the patient is also necessary (Mor & Besdine, 2011). It enables the nurse to maintain the regular health checkups at the correct time thereby ensuring the maintenance of a healthy status of the patient. Since, Maree stays alone with her two children in primary school; she reveals the need for a nurse or companion with her for all time to take care of her. Being estranged from her husband, she is prone to feel lonely and may distract from having a balanced diet timely. Therefore, the presence of a nurse with her will ensure the consumption of the right food at the right time for Maree facilitating her fast and effective recovery.


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