Case study - Acute cholecystitis: Nursing

Nurse. Sandy works on a medical surgical unit and is caring for Natasha, a 40 year old female with a history of obesity who's been diagnosed with acute cholecystitis and is awaiting surgical intervention in collaboration with the registered nurse, RN Mark.

Nurse, Sandy goes through the steps of the clinical judgment measurement model to make clinical decisions about Natasha's care by recognizing and analyzing cues, prioritizing hypotheses, generating solutions taking action and evaluating outcomes.

First, nurse, Sandy recognizes important cues including Natasha's vital signs which are temperature 98.9 °F or 37.1 °C. Heart rate of 95 BPM respirations, 20 breaths per minute BP, 10 9/83 millimeters of mercury and pulse oximetry.

99% on room air. Natasha rates her pain at three on the pain scale.

She sees that Natasha is holding an emesis bag which contains a small amount of emesis. Nurse Sandy also notices that Natasha has IV fluids infusing into her peripheral IV nurse Sandy auscultates, Natasha's abdomen and notes active bowel sounds in all quadrants which is consistent with RN Mark's assessment.

However, upon palpation, Natasha grimaces and puts her hand over her mouth. Please don't press down on my stomach.

I feel like I'm gonna throw up again. Nurse Sandy provides Natasha with a fresh emesis bag and rubs her back as she vomits afterwards.

Nurse Sandy analyzes these cues. She understands that cholecystitis refers to inflammation of the gallbladder, which is a small pear shaped organ located beneath the liver in patients with acute cholecystitis, bile or gallstones, which are made up of bile that is hardened, build up inside the gallbladder causing irritation of the mucosal lining its walls.

This also causes pressure in the gallbladder to increase, leading to wall distention and inflammation. Nurse Sandy then reviews the electronic health record or E hr and notes that Natasha initially presented to the emergency department with right upper quadrant pain and vomiting that occurred hours after eating fried chicken for dinner.

She also notes that Natasha is taking oral contraceptives which nurse Sandy recalls increases the risk for developing cholecystitis.

Additionally, nurse Sandy sees that two hours ago, RN Mark gave Natasha a dose of morphine sulfate IV but she has not received her P RN dose of Odansetron.

Since yesterday. Natasha needs effective management of nausea while she awaits her procedure.

Now, using the information she's gathered along with Natasha's medical history. Nurse Sandy reports her findings to our and Mark and together they choose a priority hypothesis of nausea, then they generate solutions to address Natasha's nausea that will include pharmacologic and non pharmacologic interventions and they established the expected outcome that after intervening Natasha will report decreased nausea within 30 minutes.

Nurse Sandy then takes action to implement these solutions. Nurse Sandy gathers supplies and reenter Natasha's room.

Hi, Natasha. I have a medication called Odansetron to help with your nausea.

It goes underneath your tongue and dissolves. Oh, yeah, I remember I had that in the emergency department and it really helped nurse Sandy then administers the Odansetron according to the principles of safe medication administration.

Ok. It appears you have some fluids infusing through your IV.

So you don't get dehydrated. I also have a cold compress for your forehead.

Do you think that would feel good? Yes, that would be nice.

Ok. I placed the call bell right next to you.

Don't hesitate to call me if you need anything. Thank you Sandy assists Natasha to a comfortable position and leaves the room to document her interventions.

30 minutes later, nurse Sandy enters Natasha's room to evaluate the outcome of her actions. She takes Natasha's vital signs and reassesses her pain.

Her temperature is 98.6 °F or at 37.0 °C. Heart rate is 88 BPM.

Respirations are 16 breaths per minute. BP is 1 12/68 millimeters of mercury and oxygen saturation is 99% on room air.

Her pain rating is at three on a 0 to 10 scale. Natasha is currently resting and tells nurse Sandy that she no longer feels nauseated.

Nurse, Sandy gently presses down Natasha's abdomen and notes she can tolerate palpation without vomiting. Since Natasha's nausea is under control, nurse, Sandy will continue to monitor her as she prepares for her procedure.

All right. As a quick recap, nurse, Sandy recognized and analyzed cues related to Natasha's cholecystitis.

And in collaboration with RN Mark prioritized hypotheses and generated solutions to address her nausea. Nurse, Sandy and RN Mark then implemented pharmacologic and nonpharmacologic measures to address Natasha's nausea and evaluated her outcome by comparing them to the expected outcome since Natasha's nausea had improved.

They determined that the plan of care was successful.