Acute Cholecystitis | Patient Case Study

Treatment of Acute Cholecystitis

In this paper, I am going to talk about a patient I had the chance to assess in the clinical area. I spent one day with this patient where I gave him some of his medications and did a head to toe assessment on him. In this paper, I am going to illustrate briefly his demographics, his chief complaint, his past health history, and I am going to focus on the medication he is taking.

GG is a 49-year-old High school teacher of Mexican descent.  He has been admitted to the hospital because of his acute pain in his abdomen and back. When discussing his health history, patient states that he has hypertension and gout. The patient reported no having any prior episodes of pain in his abdomen and his posterior right side. He reported having sudden sharp pain in those areas and cramping. Patient stated he quit smoking two years ago, denies the use of recreational smoke and drinks occasionally, specifically two beers on weekends. He is 5 feet 8 inches tall and weighs 205 pounds; his oral temperature is 99.8, pulse 72, respirations 18, blood pressure 150/82; On physical examination, his abdomen was tender to palpation.

Furthermore, he presented redness, swelling, and tenderness in the metatarsophalangeal joint of the first toe of the right foot. He had a fever has demonstrated by his high temperature, and his labs were abnormal; specifically, his white blood cell count was above average, specifically 12000 units. After this finding, the provider ordered a computed tomography (CT) scan of his abdomen, and the results showed acute cholecystitis. Therefore, the provider ordered two antibiotics to eliminate the infection and pain medications to reduce the patient’s pain.

The patient is currently receiving the following medications: Rocephin (Ceftriaxone) 2 grams intravenous every 24 hours combined with Flagyl (Metronidazole) 500 mg intravenous every 8 hours to get rid of the infection. Tylenol (Acetaminophen) 1000mg orally as needed every 6 hours for his pain combined with Motrin (Ibuprofen) 600mg orally as needed every 6 hours for his pain. On top of this medication’s patient can receive Oxycodone 5 mg orally every 4 hours for his pain if Tylenol and Motrin do not work. The patient had the following home medications, Zyloprim (Allopurinol) 100 mg orally every 12 hours to treat the patient’s gout and Micardis (Telmisartan) 80 mg orally once a day to treat his hypertension.

One of the medications I am going to focus on is an antibiotic GG is currently taking. Specifically, metronidazole. This antibiotic is in the nitroimidazoles family and is used in the treatment of anaerobic infections, in this case for intra-abdominal infections, and it is usually used in conjunction with a cephalosporin, in this case, in fact, it is used together with Ceftriaxone. Its action is to disrupt DNA and protein synthesis in a susceptible organism, and its effect is to kill bacteria. This antibiotic is absorbed about 80% after oral administration and 100% via intravenous. As far as distribution, it is widely distributed into most tissues and fluids. It crosses the placenta and enters fetal circulation rapidly and enters breast milk in concentrations equal to plasma levels. Metrodinazodole is partially metabolized by the liver, partly excreted through urine and a minimal part in the feces (McCuistion, Yeager, Winton, & DiMaggio, 2018, pg.371).

Metronidazole side effects regarding the central nervous system are dizziness, headaches, and with intravenous administration encephalopathy and aseptic meningitis. For the gastrointestinal tract, the most common side effects are abdominal pain, nausea, dry mouth, and vomiting. Regarding the skin, it can cause rashes, urticaria, and skin irritation in general. Three adverse effects that need to be monitored for this drug are seizures, Stevens-Johnson syndrome, and superinfection. Some contraindications for this medicine are hypersensitivity and first-trimester pregnancy, on top of that, it should be used with caution when breastfeeding. Some precautions to have when using this drug are in cases of severe hepatic impairment, history of blood dycriasis, and when receiving corticosteroids. As far as interactions, this drug should not me took at the same time with cimetidine because it could decrease metabolism. Not to be taken with rifampin, which could increase metabolism and reduce effectiveness. Avoid taking it together with warfarin or lithium due to its increased effects of these medications. Furthermore, avoid taking with alcohol this could cause confusion and psychosis ((Vallerand & Sanoski, 2018, p.850).

The administration of this medication can be oral, topical, vaginal, and intravenous like in our case.  The maximum dose to be given intravenous is 4 grams in one day for adults, GG is currently taking 500 mg three times a day. Therefore, his dose is within the safe dose. There are no accu- checks with this medication. As far as labs in order to assess the efficacy of the antibiotics we would check his blood results to see if the white blood cells are going down meaning that the infection is diminishing, also we want to check renal and liver function since this specific antibiotic since it can cause liver and renal problems (Vallerand & Sanoski, 2018, p.850).

In the case of GG, this medication is prescribed to cure the infection in his cholecystic. Since his cholecystic is infected, the provider orders this antibiotic to eradicate the bacteria and kill the infection.  The provider could have chosen a different class of antibiotics such as Aminopenicillins like amoxicillin, which is excreted unchanged in the bile. In patients with normal biliary function, the concentration of amoxicillin is three times higher in bile than in plasma.  For example, the biliary level of ceftriaxone is 28 to 45 times higher than the plasma concentration. The bile concentration remains high even in patients with obstruction of the gallbladder. The combination of ciprofloxacin with metronidazole may be an alternative to amoxicillin/clavulanic acid in patients with mild or moderate ACC and no risk factors for resistance. In this case, the provider preferred a combination of ciprofloxacin and metronidazole. In acute cholecystitis, metronidazole is prescribed in conjunction with other antibiotics; nitroimidazole derivatives are assigned in addition to the antibiotic base suspected mixed aerobic-anaerobic infection as we can see in this specific case metronidazole has been prescribed together with ceftriaxone to increase its action (Fucks, Cossé, & Régimbeau, 2003, para.11).

When giving metronidazole, we need to assess the patient for infections, by checking his vital signs, and appearance of wounds if any, sputum, urine, and stool for infection. Also, we need to check blood; specifically, the white blood cells count at the beginning and during the therapy. Then we need to monitor intake and output and daily weight, especially for patients on sodium restriction. Another essential thing to do is to check the patient periodically for rash due to the possibility of Steven-Johnson syndrome, which is an adverse effect of this medication. Potential nursing diagnoses with this medication can be a risk for infection and diarrhea. When giving this medication the patient needs to be taught to avoid intake of alcoholic beverages, inform patient that the medicine can cause an unpleasant metallic taste and that it can cause dizziness, therefore avoid tasks that require alertness and not be alarmed if urine turns dark. Very important is to notify the provider if a rash occurs.  Lastly, the desired outcomes of this medication are the resolution of signs and symptoms of infection (Vallerand & Sanoski, 2018, p.852).

As we already discussed, metronidazole is better to be avoided in the first trimester of pregnancy, Metronidazole crosses the placental barrier, and its effects on the human fetal are not known.  Safety and effectiveness in pediatric patients have not been established. In elderly geriatric patients, monitoring for metronidazole associated adverse events is recommended, especially for decreased liver function in geriatric patients can result in increased concentrations of metronidazole that may necessitate adjustment of metronidazole dosage (Vallerand & Sanoski, 2018, p.851).

The other medication I am going to focus on is an anti-inflammatory GG is currently taking. Specifically, Ibuprofen. This medication is a nonsteroidal antiinflammation agent (NSAID)and is used to decrease pain and inflammation. Its action is to inhibit prostaglandin synthesis. This antibiotic is absorbed about 80% after oral administration and 100% via intravenous. As far as distribution, it is widely distributed into most tissues and fluids; however, it does not enter breast milk in significative amounts. Ibuprofen is mostly metabolized by the liver and excreted through the kidneys in a small amount ((Vallerand & Sanoski, 2018, p.666).

Ibuprofen side effects regarding the central nervous system are Drowsiness, dizziness, headache, confusion, insomnia. For the gastrointestinal tract, the most common side effects are gastric distress, nausea, vomiting. It can also cause blurred vision, edema, and tinnitus. Some adverse effects that need to be monitored for this drug are myocardial infarctions, various types of dermatitis, Stevens-Johnson syndrome, and gastrointestinal bleeding. Some contraindications for this medicine are hypersensitivity, active gastrointestinal bleeding, and ulcers. Should be used cautiously with patients that have had a coronary heart bypass. Some precautions to have when using this drug are in cases of severe renal impairment since it can cause nephrotoxicity history and with cardiovascular diseases.  As far as interactions, this drug should be avoided when taking warfarin sound, it can Increase bleeding, and with some foods like garlic and herbal supplements such as ginger, gingko, and ginseng. Increased effects with phenytoin, sulfonamides, warfarin, cephalosporins, and decreased effect with aspirin (Vallerand & Sanoski, 2018, p.667).

The administration of this medication can be oral as in our case and intravenous. The maximum dose to be given orally to adults is 3 grams, GG is currently taking 600 mg three times a day. Therefore, his dose is within the safe dose. There are no accu- checks with this medication. Regarding labs, it is critical to check blood urea nitrogen (BUN), creatinine, complete blood count (CBC), and liver function (Vallerand & Sanoski, 2018, p.668).

In the case of GG, this medication is given to decrease the patient’s pain due to his infection. Ibuprofen is a non-steroidal anti-inflammatory drug with anti-inflammatory, analgesic, and antipyretic activity. More in detail, ibuprofen can perform these activities by inhibiting cyclooxygenase (COX). Ibuprofen works by inhibiting COX-2 consequentially preventing the synthesis of prostaglandins responsible for fever, inflammation, and pain. However, it is crucial to point out that ibuprofen is not selective for COX-2; therefore, it is also able to inhibit COX-1. This latter inhibition is at the origin of some of the side effects typical of all non-selective NSAIDs such as gastrointestinal side effects (McCuistion, Yeager, Winton, & DiMaggio, 2018, pg. 311).

Before giving this ibuprofen, we need to obtain a drug and herbal history and report any possible drug-drug or herb-drug interactions. After we have given the medication, we need to assess for GI distress and peripheral edema, which are common side effects of NSAIDs. Report to the provider immediately if the patient has GI discomfort since this is one of the adverse effects of this medication. We need to access for asthma and urticaria as well. Observe the patient for bleeding gums, petechiae, ecchymoses, or black tarry stools. When giving this medication, we need to check labs, specifically, if BUN is elevated, creatine levels and urine output. Since this is a pain medication, we have to re-assess the pain prior and 1-2 hours following noting the type, location, and intensity. When teaching the patient about the medication, we will advise the patient to avoid alcohol when taking NSAIDs.  Moreover, we would recommend the patient to consult the doctor if visual disturbances, tinnitus, or rashes appear. Potential nursing diagnoses with this medication can be acute pain. Lastly, the desired outcomes of this medication are decreased in the severity of pain (Vallerand & Sanoski, 2018, p.669).

Ibuprofen is better to be avoided after 30 weeks’ gestation because it may cause premature closure of fetal ductus arteriosis.  We need to be careful when using it with our older population since it can increase the risk of adverse reactions secondary to age-related and drug interactions, also need to be closely monitored for decreases in renal and liver function. As far as infant’s safety has not been established for infants under six months (McCuistion, Yeager, Winton, & DiMaggio, 2018, pg. 314).

We looked at the patient’s problem and the treatment he had to cure his acute cholecystitis. We talked about his medications, in particular about antibiotic metronidazole and pain medication, ibuprofen. We discussed in depth the mechanism of action, nursing assessment and lifespan considerations of this medication and the rationale that the provider used to prescribe this medication which helped the patient get better and get discharged from the hospital.

References

• Electronic Health Record
• Fuks, D., Cossé, C., & Régimbeau, J.-M. (2013). Antibiotic therapy in acute calculous cholecystitis. Journal of Visceral Surgery, 150(1), 3–8. https://doi-org.dax.lib.unf.edu/10.1016/j.jviscsurg.2013.01.004
• McCuistion, L.E., Yeager, J.J., Winton, M.B., & DiMaggio, K.  (2018).
  
  Pharmacology: A patient-centered nursing process approach
  
  (9
  
  ^th
  
  ed.). Philadelphia, PA: Saunders.
• Vallerand, A.H., & Sanoski, C.A. (2018).
  
  Davis’s drug guide for nurses
  
  (16
  
  ^th
  
  ed.). Philadelphia, PA: Davis.

Appendix A

Pharmacology Patient Profile

Demographic Data

Pt. Initials

GG

Date of Birth

02/20/1970

Age

49

Race

Latino

Gender

Male

Admitting Diagnosis

Acute cholecystitis

Concurrent Diagnoses

Acute cholecystitis

Occupation

High school teacher

Members of Household

2

Military Service

x  No Yes

If yes, complete information under Military Service on the next page

Admission Date

06/18/2019

DatesAssessed

06/19/2019

Patient Health History

Reason for Admission

Mid back pain and abdomen pain

Past or family History of problems in the Following Categories:

O = Negative   X = PositiveU = Unknown	Past	Family	SPECIFICS ABOUT ALL POSITIVES
1.   Stroke/Hypertension	X	O	Patient has hypertension
2.   Heart Disease	O	O
3 .   Diabetes	O	X	Patient’s father has type II diabetes
4 .   Cancer	O	O
5.   Lung Disease	O	X	Patient’s mother has emphysema
6.   Blood Disorders	O	O
7.   Neurological Disorders	O	O
8.   Gall Bladder/LiverDisorder	O	O
9.   Kidney Disorder	O	O
10.  GI Disorder	O	O
11.  Skin Disorder	O	O
12.  MusculoskeletalDisorder	X	X	Patient has gout. Patient’s mother suffers from osteoporosis.
13.  Psychiatric Disorder	O	X	Patient’s brother suffers from depression.
14.  Endocrine Disorder	O	O
15.  Infectious Disease	O	O
16.  Hospitalization/Surgery	X		Patient had one surgery. He had appendectomy.

Current Medications

List ALL Medications this patient is taking, giving the entire physician’s order (i.e. Demerol 50 mg IM every 4 hours PRN pain)

Zyloprim 100 mg PO q12 hTelmisartan 80 mg PO daily Ceftriaxone 2 g IV q24 h Metronidazole 500 mg IV q8 h Acetaminophen 1000mg IV q4 h PRN pain Ibuprofen 600mg PO q6 h PRN pain Oxycodone 5mg PO q4h  PRN pain if Acetaminophen/Ibuprofen do not work

T obacco	X No YesType :		Amount:
			Stopped (date):	01/04/2017
Alcohol	No     X YesType: Beer		Amount:	2 beers on weekends
			Stopped (date):
Drugs	X  No Yes     Type:		Amount:
			Stopped (date):

Military Service		X  No Yes, Current Yes, Former
Branch of Military
When and Where Served
What do/did you do in the service?
How has military service affected you?
Did you see combat, enemy fire, or casualties?							No Yes
Were you or a buddy wounded, injured, or hospitalized?							No Yes
Were you a prisoner of war?							No Yes
Exposure concerns?	Chemical (pollution, solvents, etc.)
	Biological (infectious disease)
	Physical (radiation, heat, vibration, noise, etc.)
	When was the exposure?
	Where was the exposure?
	How long was the exposure?
	How concerned are you about the exposure?

Stress Reactions/AdjustmentProblems: With respect to your military service, have you
Had nightmares about it or thought about it when you did not want to?	No Yes
Tried hard not to think about it or went out of your way to avoid situations that reminded you of it?	No Yes
Found yourself constantly on guard, watchful, or easily startled?	No Yes
Felt numb or detached from others, activities, or your surroundings?	No Yes

Physical Assessment

Height	68 inches	Weight	200 lbs	BMI	31.2	% DBW
Temperature	39.1	Pulse	96	Respirations	18	BP	136/72

O = normal     X = abnormalNA = not assessed		COMMENTS (describe your findings)
General Appearance	O	Oriented x4, appropriate grooming, good mood, cooperative appears older than stated age 49.
Skin	O	Warm, dry, intact skin
Head and Neck	O	Head: Normocephalic, no lumps, no lesions, no tenderness, no trauma.Neck: Symmetric, supple with full ROM, no pain.
Cardiovascular	O	Heart sounds normal, no murmurs
Chest/Lungs	O	Lungs sound clear and equal
Abdomen	X	Extreme tenderness to palpation, unable to palpate or percuss due to tenderness.
Musculoskeletal	X	Body joints within normal limits with exception of joints of both ankles and feet.  Redness, swelling and tenderness in the metarsophalangeal joint of first toe of right foot. Unable to dorsiflex and extend both feet.

Appendix B

Medication Worksheet

Student Name	Bernardini Alessio			Date	07/05/2019	Patient Initials	GG
Medication Name & Classification		Dose, Frequency & Route	Mechanism of Action		Major & Common Side Effects	Rationale for this Patient	Nursing Considerations
ZyloprimClass: Antigout agents		100 mg orally every 12 hours	Zyloprim is approximately 90% absorbed from the gastrointestinal tract		Ankle, knee, or great toe joint pain stiffness or swelling, rash	Lower serum and urinary uric acid level	Watch for skin rashes and monitor serum uric acid
Telmisartan, MicardisClass: Angiotensin receptor blockers		80 mg orally once a day	Hepatic via conjugation to inactive metabolites		Back pain, sinusitis, and diarrhea	Management of hypertension	Monitor blood pressure; electrolytes, serum creatinine, BUN
CeftriaxoneClass: cephalosporins		2 g IV q 24 hours	Inhibit bacterial cell-wall synthesis, bactericidal		Anaphylaxis, superinfectionHeadache, dysgeusia, GI distress Clostridium difficile -associated diarrhea Increased bleeding, seizures Nephrotoxicity Stevens-Johnson syndrome	Treat the infection	Culture the infected area before cephalosporin therapy is started.Tell patient to report signs of superinfection. Observe for hypersensitivity reactions. .
MetronidazoleClass:		500 mg IV q 8 hours	Disrupts DNA and protein syntheses in bacteria and protozoa		Anaphylaxis, superinfectionHeadache, dizziness, insomnia, weakness Dry mouth, dysgeusia, GI distress Tongue/tooth discoloration Peripheral neuropathy, seizures Stevens-Johnson syndrome	Treat the infection	Tell patient to report signs of rashes because of the risk for Stevens-Johnson syndromeObserve for hypersensitivity reactions. .
AcetaminophenClass: nonsteroidal ant inflammatory		1000mg PO every 6 hours PRN pain	Inhibits prostaglandin synthesis		Rash, headache, insomniaToxic effects Hepatotoxicity, renal failure Thrombocytopenia Hemolytic anemia Agranulocytosis Leukopenia, neutropenia	Management of pain	Check liver enzyme tests for abnormalities.Check serum acetaminophen level if toxicity is suspected.
IbuprofenClass: nonsteroidal ant inflammatory		600mg PO every 6 hours PRN pain	Inhibits prostaglandin synthesis		Drowsiness, dizziness, headache, confusion, insomnia, dreams, blurred vision, edema, gastric distress and bleeding, tinnitus, dysrhythmias and nephrotoxicity	Management of pain	Observe the patient for bleeding gums, petechiae, ecchymoses, or black tarry stools andreport if patient has GI discomfort.
OxycodoneClass: opioid analgesic		5mg PO every 6 hours PRN pain	Act on CNSSuppress pain impulses		Drowsiness, confusion, depression, blurred vision.GI distress,psychological dependence Respiratory depression	Management of moderate pain	Monitor vital signs frequently to detect respiratory changes.Check for pupil changes and reaction.