John Smith  is a 65-year-old retiree who is admitted to your unit from the emergency department (Ed). On arrival, you note that he is trembling and nearly doubled over with severe abdominal pain. John indicates that he has severe pain in the right upper quadrant (RUQ) of his abdomen that radiates through to his mid back as a deep, sharp, boring pain. He is more comfortable walking or sitting bent forward rather than lying flat 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 nauseated but has not vomited, although he did vomit a week ago with a similar episode. John experienced an acute onset of pain after eating fried fish and chips at a fast-food restaurant earlier today. He is not happy to be in the hospital and is grumpy that his daughter insisted on taking him to the emergency department for evaluation. 

After orienting him to the room, you perform your physical assessment. The findings are as follows: He is awake, alert, and oriented × 3, and he moves all extremities well. He is restless, constantly shifting his position, and complains of fatigue. Breath sounds are clear to auscultation. Heart sounds are clear and crisp, with no murmur or rub noted and with a regular rate and rhythm. Abdomen is flat, slightly rigid, and very tender to palpation throughout, especially in the RUQ; bowel sounds are present. He reports having light-colored stools for 1 week. The patient voids dark amber urine but denies dysuria. skin and sclera are jaundiced. 

Admission vital signs are blood pressure 164/100, pulse of 132 beats/min, respiration 26 breaths/min, temperature of 100° F (37.8° C), spo2 96% on 2 L of oxygen by nasal cannula.

Preoperative Laboratory Test Results 

·       WBC 11,900/mm3 

·       Hgb 14.3?g/dL 

·       Hct 43% 

·       Platelets 250,000/mm3 

·       ALT 200?units/L 

·       AST 260?units/L 

·       ALP 450?units/L 

·       Total?bilirubin 4.8?mg/dL 

·       PT/INR 11.5?sec/1.0 

·       Amylase 50?units/L 

·       Lipase 23?units/L 

·       Urinalysis Negative

1.     What organs are located in the RUQ of the abdomen? (Start thinking about what organ is involved based on his chief complaint)

2.     What does a positive Murphy’s sign indicate when a health care provider performs deep palpation?

3.     Which lab results are abnormal, and what do they reflect?

4.     Which other data in the assessment are consistent with common bile duct obstruction?

5.     Explain the pathophysiologic changes that can cause these signs and symptoms associated with common bile duct obstruction.

A.    Clay colored stools

B.    Dark urine

C.    Steatorrhea

D.    Jaundice

E.    Pain with fatty food intake

The patient’s abdominal ultrasound reveals several stones in the common bile duct and gallbladder. He is admitted to the medical-surgical unit and placed on nothing by mouth (NPO) status and scheduled to undergo endoscopic retrograde cholangiopancreatography (ERCP) that afternoon.

6.     Explain the rational for the treatment of acute cholecystitits with the following interventions.

A.    NPO with possible NG suction

B.    Antibiotics (which route)

C.    Antispasmodics

7.     Define ERCP and indication for it based on this patient’s status.

8.     Which results are abnormal, and what do they reflect?

The patient then undergoes ERCP and the stones and bile are released, but imaging indicates a stone is still within the cystic duct and gallbladder. A surgeon was consulted and a laparoscopic cholecystectomy was ordered. 

9.     List four to five preoperative orders that will likely need to be done before the patient goes to surgery.

10.  If he had a laparoscopic cholecystectomy, which discharge instruction would the nurse advise the patient: (explain the rational for the correct choice). 

a.     Keep the incision areas clean and dry for at least a week

b.     Report he need to take pain medication for shoulder pain

c.     Report any bile-colored or purulent drainage from the incisions

d.     Expect some postoperative nausea and vomiting for a few days

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