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The Scene

Mr. Kasim Al-Mutar is a 49 years old male diagnosed with Cholesystisis. He presents himself to the emergency department after noticing abdominal pain in his right upper quadrant (RUQ) for 2 days along with fever and vomiting.  He is along with her daughter who is 12 years old. The readings which are provided by the previous nurse are of much concern.

1. The Person’s Situation:

We have a 49 years old man whose name is Mr. Kasim Al-Mutar.  He looks pale and has developed desiccated throat condition. His mucous membranes have dried up.  He has developed Tachycardia condition. He has severe pain in his right upper quadrant and has been requesting a drink of water. He has reported a high shoulder pain with score 7 on a scale of 10. He was last seen vomiting just 2 hours ago. The group mostly affected by Cholesystitis as a result of inflammation of gallbladder lies between 41 and 50 years. Though acute conditions are seen more commonly in women than in men yet Mr. Kasim Al-Mutar‘s age is of concern. Mr. Kasim has his daughter with him who is 12 years old. She should accompany him for the time being.

2.  Cues and Information

2(a).Current or Handed over Information

Temperature                      38.8
Blood Pressure                 100/45
Heart Rate                          126

2(b).New Information

Condition of Membrane Mucosa              Dry
Shoulder Pain                                                    7/10
Skin Color                                                            Pale
Level of thirst                                                    Patient requests for consuming water

2 (c) Related Knowledge

1. When a person’s pain is high on severity scale, on the right side:
It is a sign of peritoneal irritation which may be the case also.

2. When pain is severely localized to RUQ and is not subsiding after it had originated from epigastric region; but with no signs of gangrene:
It is a common symptom of uncomplicated Cholesystitis.

3. Possibilities of Right Upper Quadrant paint can occur from numerous other conditions. It can be a bile duct stone causing Biliary Colic or a Cholangitis which is defined as a tubular infection obstructing flow of bile from the liver to gallbladders and intestines. Abdominal pains are also witnessed from Choledochal cyst, a condition where either a part or the whole of bile duct is congenitally dilalated.     

Sometimes complications are labyrinthine when the pancreas is also involved. It can simulate any disease caused by Gallbladder or even coexist with it.

4. Various ways of diagnostic evaluation for pain in RUQ -
a) Non Imaging Tests like Liver function tests (These are done initially to be certain about Hepatobiliary disease), test for Amylase levels, Urinalysis, WBC counts & Electro-cardio diagrams.
b) Imaging Tests excluding Ultra Sound– Obtaining radiographs of abdomen and chest are fast and relatively less expensive ways to figure out pains which are intestinal and pulmonary in nature.
c) Ultrasound Imaging tests – Gallstones are very well detected by the help of ultra sound and the accuracy is more than 90% most of the time. Detection of gallstones by means of OCG has been substituted by sonography in the past.

5. Cases of symptomatic GB disease without acute Cholecytitis also exist. (Disabled world, 2017)

3. Process Information

3(a).Interpretation

“His pulse rate is high”. A normal level of pulse rate for a male person in this age group would be: 119
His maximum heart rate at normal condition would be around 171.

“His body temperature is within normal range.” The normal temperature of a human body is 37 degree Celcius.

“His diastolic pressure is low.” A normal diastolic pressure of a male around 50 lays around 80.

3(b).Discrimination

List of identified cues which are most relevant to Mr. Kasim Al-Mutar’s health status at present:

a. Blood Pressure

b. Pulse Rate

c. White Blood Count

d. Level of Bilirubin

e. Condition of Mucosa

f. Color of skin

g. Intensity of Pain

3(c).Relation

A. Mr. Kasim has low blood pressure.
B. Mr. Kasim is tachycardic.
C.  Mr. Kasim has severe shoulder pain unlike that in a typical attack related to gallbladder.

3(d). Inference

On the basis of the cues collected about Mr. Kasim’s condition, the following inferences can be made out of interpretation of the same.

Mr. Kasim Al-Mutar is:

a. Tachycardic (Medtronic, 2017)

b. Hypotensive

3(e).Prediction

90% of cases related to acute Cholecytitis includes a gall stone which blocks the bile duct or cause local inflammation. One thing to be noted is that the concerned patient has shown negligible signs of anorexia.  Treatment not done within proper time period can lead to more complications. These includes perforations which is mostly a gastrointestinal one, formation of abscess due to bacterial infection or a fistulae which is formed once the infection has already caused inflammation to an extreme degree.
Showing concern over Mr. Kasim’s present health condition, not taking suitable and well –calibrated actions at present may lead to following consequences:
A. Rupturing of Gallbladder.
B. Further it can cause Septicemia if left untreated.
(Serious bloodstream infection will further exacerbate the present condition of patient)
C. High complications on treating after rupture.
D. Body may go into a state of shock.
E. Organs may stop working.
F. There is fair chances for occurrence of death if the patient does not recovers quickly from the present condition.

4. Identified Problems/Issues

4(a).Synthesis

From the inferences and facts states above, the following diagnosis have been made in case of Mr. Kasim :

A. Acute Cholecytisis.

B. Tachycardia

C. Hypotension.

D. Dehydration.

Mr. Kasim’s condition differs from a person in normal condition in the following ways:
A. Pain preferably in upper quadrant of the abdomen.
B. Frequent reporting of vomiting and fever.
C. Conditions of Tachycardia.
D. Severity of shoulder pain on a scale of 10.
E. Concerning level of dehydration.

5. Detail of Assessment

Pain in the right upper quadrant, in many cases, leads to stimulation of hepatobiliary system and afte after, evaluating the gallbladder becomes vital. Although many patients report abdominal pain in RUQ but the causes may vary in terms of sources of infection. There are many other conditions which can cause the specified pain in GB. These includes Biliary Colic, Appendicitis, Viral & Alcoholic Hepatitis, Pancreatic inflammations and to some extent, Colitis such as diverticulitis. In some cases, upper abdominal pain is harmless because they are due to dyspepsia or gastroenteritis. But in the case of Mr. Kasim Al-Mutar, things are more inclined towards the speculated condition that he is reported to carry. Accurate imaging of GB is required to arrive at the consensus regarding the overall degree of damage caused and treatment required.

6. Actions Suggested

To improve Mr. Kasim’s condition, the following short-term goals are suggested:
A. Hepatic Iminodiacetic Acid Scan (Trowbridge, R.K. et. al. 2017)
B. Ultrasound of RUQ
C. Monitoring Mr. Kasim’s pain scores- pain which is occurring in his shoulder and which has already been rated to a high degree.
D. Maintaining his psychosocial well-being.
E. Monitoring the level of dryness of his mucus membranes. 
F. Managing desiccation that he might suffers as was observed from his condition of dehydration.

7. Evaluation of Outcomes

His cognitive status         Presently anxious as well as uncomfortable but not restless.
He may require mental encouragement.

Level of thirst                    Patient requests for drinking water

Oral Mucosa                       Still a dry mouth

Mucous Membrane        Desiccation reduced to insignificant extent.

Heart Rate                          121

Skin Color                            Pale

Blood Pressure                 100/52

Mr. Kasim Al-Muttar‘s condition has moderated but further intensive care and monitoring. The doctor has to be communicated with, more frequently, to effectively monitor his condition. His daughter is young and hasn’t yet developed the required maturity to perform quick decisions.

8. Reflection of the Process and New Learning

From the scenario, it is apparent that the conditions could have been made less critical by an early diagnosis. Frequent intake of water should be done by the patient to prevent dehydration. Oral intake is permissible for patient in case of uncomplicated Cholecystitis but it should be totally prohibited when the case is more complicated and requires surgical approach. Mr. Kasim Al-Muttar’s could have been prevented from getting deteriorated if he had been on a liquid low-fat diet from the day of reporting. (Bloom,   A.A. 2017)

It is learnt that cases of abdominal pain concerned with the upper quadrant are to be taken seriously and one has to be specific about feeding the patient. 

Optimal therapy for acute cholesystitis has not yet been defined and sometimes complications are inevitable. So clinical practices needs to be precise and at their peak to avoid any unwanted blame.

It is also learnt from previous subjects with same disease that, 75% of patients with this GB disease respond greatly to medical therapies. At the initial stage, these patients are provided with strong antibiotics, IV hydration and medications to alleviate pain symptoms. The remaining 25% have either refraction towards conservative treatment or require surgery as the last resort because of complications. Therefore an accepted approach is to perform Cholecystectomy following an acute Cholecytitis. ( Evid B.C., 2017)

Another thing to learn from the assessment is that symptoms can vary according to the age, gender or medical history of a patient and so will vary the kind of nursing assistance to be given in each case.

References List

Medtronic (2017) Tachycardia[Accessed online: http://www.medtronic.com.au/your-health/tachycardia/index.html][Accessed on:3/24/2017]

Medscape(2017) Cholecystitis[Accessed online: http://emedicine.medscape.com/article/171886-overview][Accessed on:3/24/2017]

Disabled world(2017) Common symptoms of gall bladder disease [Accessed on: https://www.disabled-world.com/artman/publish/gall-bladder.shtml] [Accessed on:3/24/2017]

Bloom  A.A.(2017) Cholecystitis [Accessed online: http://emedicine.medscape.com/article/171886-overview] [Accessed on:3/24/2017]

Evid B.C.(2017) Acute Cholecystitis [Accessed online: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2907986/] [Accessed on:3/24/2017]

Patient.Info (2017) Right Upper Quadrant Pain [Accessed online: https://patient.info/in/doctor/right-upper-quadrant-pain] [Accessed on:3/24/2017]
Trowbridge R.L., Rutkowski N.K. and Shojania K.G. (2017) Does This Patient Have Acute Cholecystitis? [Accessed online:http://www.osuem.com/downloads/resources/ama2003trowbridge806copy.pdf] [Accessed on:3/24/2017]