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 95 beats per minute, respirations 20 breaths per minute, blood pressure 109/83 mmHg, and pulse oximetry 99 percent on room air. Natasha rates her pain at 3 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 Nastasha 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.

Natasha: Please don’t press down on my stomach, I feel like I’m going to 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 of bile that has hardened, build up inside the gallbladder, causing irritation of the mucosa lining its walls. This also causes pressure in the gallbladder to increase, leading to wall distension and inflammation.

Nurse Sandy then reviews the electronic health record, or EHR, 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 PRN dose of ondansetron since yesterday.

Nurse Sandy Nathasha 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 RN Mark, and together they choose a priority hypothesis of nausea.

Then, they generate solutions to address Natasha’s nausea that will include pharmacologic and nonpharmacologic interventions; and they establish the expected outcome that after intervening, Natasha will report decreased nausea within thirty minutes.

Nurse Sandy then takes action to implement these solutions.

Nurse Sandy gathers supplies and re-enters Nastasha’s room.