I.

INTRODUCTION
Cholecystitis is an inflammation of the gallbladder wall and nearby
abdominal lining. Cholecystitis is usually caused by a gallstone in the cystic
duct, the duct that connects the gallbladder to the hepatic duct. The
presence of gallstones in the gallbladder is called cholelithiasis. Cholelithiasis
is the pathologic state of stones or calculi within the gallbladder lumen. A
common digestive disorder worldwide, the annual overall cost of
cholelithiasis is approximately $5 billion in the United States, where 75-80%
of gallstones are of the cholesterol type, and approximately 10-25% of
gallstones are bilirubinate of either black or brown pigment. In Asia,
pigmented stones predominate, although recent studies have shown an
increase in cholesterol stones in the Far East.
Gallstones are crystalline structures formed by concretion (hardening) or
accretion (adherence of particles, accumulation) of normal or abnormal bile
constituents. According to various theories, there are four possible
explanations for stone formation. First, bile may undergo a change in
composition. Second, gallbladder stasis may lead to bile stasis. Third,
infection may predispose a person to stone formation. Fourth, genetics and
demography can affect stone formation.
Risk factors associated with development of gallstones include heredity,
Obesity, rapid weight loss, through diet or surgery, age over 60, Native
American or Mexican American racial makeup, female gender-gallbladder
disease is more common in women than in men. Women with high estrogen
levels, as a result of pregnancy, hormone replacement therapy, or the use of
birth control pills, are at particularly high risk for gallstone formation, Diet-
Very low calorie diets, prolonged fasting, and low-fiber/high-cholesterol/high-
starch diets all may contribute to gallstone formation.

Sometimes, persons with gallbladder disease have few or no symptoms.

Others, however, will eventually develop one or more of the following
symptoms; (1) Frequent bouts of indigestion, especially after eating fatty or
greasy foods, or certain vegetables such as cabbage, radishes, or pickles, (2)
Nausea and bloating (3) Attacks of sharp pains in the upper right part of the
abdomen. This pain occurs when a gallstone causes a blockage that prevents
the gallbladder from emptying (usually by obstructing the cystic duct). (4)
Jaundice (yellowing of the skin) may occur if a gallstone becomes stuck in the
common bile duct, which leads into the intestine blocking the flow of bile
from both the gallbladder and the liver. This is a serious complication and
usually requires immediate treatment.

The only treatment that cures gallbladder disease is surgical removal of

the gallbladder, called cholecystectomy. Generally, when stones are present
and causing symptoms, or when the gallbladder is infected and inflamed,
removal of the organ is usually necessary. When the gallbladder is removed,
the surgeon may examine the bile ducts, sometimes with X rays, and remove
any stones that may be lodged there. The ducts are not removed so that the
liver can continue to secrete bile into the intestine. Most patients experience
no further symptoms after cholecystectomy. However, mild residual
symptoms can occur, which can usually be controlled with a special diet and
medication.
 II. Patient’s Profile
Patient’s Name: Mr. Cholengty
Attending Physician: Dr. Espiritu
Room Number: 401 C
Age: 47
Sex: Male
Civil status: Married
Citizenship: Filipino
Religion: Roman Catholic
Address: Caroyroyan,Pili, Camarines Sur
Date Admitted: February 9, 2009
Chief Complaint: Right upper quadrant pain for several months.
During Admission: conscious, coherent, on wheel chair
Neuro Vital Signs:
Eyes: 4
Pupils’ size: L:2-3 mm R: 2-3 mm
Pupils Reactive to Light
Verbal Response: 5
Motor Response: 6
BP: 1840/100, CR: 68 bpm, RR: 20 cpm, T: 36.3

III. NURSING ASSESSMENT

A. Personal History

Mr. Cholengty is a 47 year old male, a Filipino citizen who resides at

Caroyroyan, Pili, Camarines Sur. He was born on December 2, 1962; his
religious affiliation is Roman Catholic. He is currently employed in the Air
Force of the Philippines (Philippine Army). He was admitted on MSH-Our
Lady of Perpetual Unit last February 9, 2009(Monday) with a chief
complaint of Right upper quadrant pain for several months. He also
mentioned that the severity of pain started to bother him since August
2005. When he tried to eat oily and salty foods, he experienced an
upsetting pain which decreased his appetite and feels nauseated and
vomits. He had a history of drinking alcoholic beverages and consumes 1
cigarette pack/day.
On December 23, 2009, he went to seek for medical check up and
undergone ultrasound at Plaza Medica. The findings were as follows:
Ultrasound:
** Normal liver parenchyma and intra-hepatic ducts.
** Well distended gallbladder with multiple polyps and lithiases.
**No free fluid noted
B. Family Health and Illness History

According to Mr. Cholengty that the familial disease he knows that

they have in their family was liver disease in the case of his brother. His
father died because of heart attack and her mother died of natural cause.
He also added that cholecystitis is prone to their family, because of one of
his siblings also had acquired this disease.
C. History of Past and Present Illness

This is the second time Mr. Cholengty been admitted into this hospital.
On his first admission into this hospital he had undergone fistulectomy
operation, which is almost 29 years ago. He had not experience any accident
and injuries, even though his job is prone to accident.
He was admitted into this hospital because of cholelithiases, he was admitted
last February 09, 2009. He was been diagnosed with cholelithiases with
multiple polyps two months prior to admission due to right upper quadrant
pain. He was diagnosed and surgically operated by Dr. Sales last February 10,
2009.According to Mr. Cholengty, upon admission he had undergone some
laboratory examination such as Chest X-ray, CBC,Creatinine, Sodium,
Potassium and ALT.

IV. ANATOMY AND PHYSIOLOGY

Gallbladder, muscular organ that serves as a reservoir for bile, present in

most vertebrates. In humans, it is a pear-shaped membranous sac on the
undersurface of the right lobe of the liver just below the lower ribs. It is

generally about 7.5 cm (about 3 in) long and 2.5 cm (1 in) in diameter at its
thickest part; it has a capacity varying from 1 to 1.5 fluid ounces. The body
(corpus) and neck (collum) of the gallbladder extend backward, upward, and
to the left. The wide end (fundus) points downward and forward, sometimes
extending slightly beyond the edge of the liver. Structurally, the gallbladder
consists of an outer peritoneal coat (tunica serosa); a middle coat of fibrous
tissue and unstriped muscle (tunica muscularis); and an inner mucous
membrane coat (tunica mucosa).
 The function of the gallbladder is to store bile, secreted by the liver and
transmitted from that organ via the cystic and hepatic ducts, until it is
needed in the digestive process. The gallbladder, when functioning normally,
empties through the biliary ducts into the duodenum to aid digestion by
promoting peristalsis and absorption, preventing putrefaction, and
emulsifying fat. Digestion of fat occurs mainly in the small intestine, by
pancreatic enzymes called lipases. The purpose of bile is to; help the Lipases
to Work, by emulsifying fat into smaller droplets to increase access for the
enzymes, Enable intake of fat, including fat-soluble vitamins: Vitamin A, D, E,
and K, rid the body of surpluses and metabolic wastes Cholesterol and
Bilirubin.
Risk factor
V. PATHOPHYSIOLOGY
Heredity

Obesity

Rapid Weight Loss, through diet or surgery

Age Over 60

Female Gender

Diet-Very low calorie diets, prolonged fasting, and low-fiber/high-

cholesterol/high-starch diets.

Bile must become The solute precipitate Crystals must come

supersaturated with from solution as solid together and fuse to form
cholesterol and calcium crystals stones

Gallstones

Obstruction of the cystic duct and common bile duct

Sharp pain in the right

Jaundice
part of abdomen

Distention of the gall bladder

Localized cellular
Venous and Areas of
Proliferation of irritation or
lymphatic drainage ischemia may
bacteria infiltration or both
is impaired occur
take place

Inflammation of gall bladder

CHOLECYSTITIS
 V. Medications
NAME OF CLASSIFICATION INDICATION
DRUGS/DOSAGE
ZEPTRIGEN 1gm IV q80 Antibiotic Treatment for urinary
(8AM-4PM-12MN)
tract infection.
MORPHIN SO4 0.03% sol. Analgesic and Used fro the control of
10cc per EC q 120 x 3 Antipyretic moderate to severe
doses pain and as an adjunct
(4PM-4AM) to anesthesia.
OMEPRON 40mg IV OD Antacid and Antiulcerant Active duodenal ulcer
(6AM) and GERD.
PONSTAN SF 500MG 1 Antirheumatic, Anti-
CAP TID inflammatory Analgesic For post-operative pain.
(8AM-1PM-8PM)
PARACETAMOL 500MG Analgesic and For relief of fever, minor
Q40 Antipyretic aches and pains.

VI. DIAGNOSTIC AND LABORATORY PROCEDURE

1. Complete Blood Count (CBC)

This is to determine blood components and the response to

inflammatory process and streptococcal infection.
Date Ordered: February 09, 2009
Date Result In: February 09, 2009

Results:
WBC - 9.79K/uL
NEU -5.58%
LYM -3.42%
MONO-.367%
EOS-.371%
BASO-.046%
Hemoglobin - 14.5g/dl
Hematocrit - 44.1%
Conclusion:
Complete Blood Count is within the normal range.
2. Creatinine
This is the indicator of the renal function

Date Ordered: February 09, 2009

Date Result In: February 09, 2009

Results:
84umol/L

Conclusions:
The result is within normal range based on the normal value of
58-110.
 3. Sodium
Date Ordered: February 09, 2009
Date Result In: February 09, 2009

Results:
144mmol/L
Conclusion: The result is within normal range based on the normal
value of 137-145.
4. Potassium
Date Ordered: February 09, 2009
Date Result In: February 09, 2009

Result:
4.0mmol/L
Conclusion: The result is within normal range based on the normal
value of 3.6-5.0.
5. ALT
Date Ordered: February 09, 2009
Date Result In: February 09, 2009

Result:
46 U/L
Conclusion: The result is within normal range based on the normal
value of 21-72.

6. Ultrasound
** Normal liver parenchyma and intra-hepatic ducts.
** Well distended gallbladder with multiple polyps and lithiases.
**No free fluid noted.

7. Chest X-Ray
Date Ordered: February 09, 2009
Date Result In: February 09, 2009
No active infiltrate noted nor pneumothorax seen.
The heart is not enlarged.
The right hemidiaphragm is elevated.
The left hemidiaphragm and chest bones are intact.
Impression: Consider Subdiaphragmatic lesion.
Clinical coyrrelation and further evaluation is
recommended.

GORDON’S ASSESSMENT

I. Perception and Management

 Chief Complain of: right upper quadrant pain for several months.
  understands and is aware of the presence of illness
 complies with nursing interventions

II. Other pertinent data

A. Nutrition/Metabolic
 Diet- diet is tolerated
 eats three times a day; fond of eating fatty and salty foods
 dry oral mucous membrane
 skin is dry and cool
 has vices
B. Elimination
 With Foley Catheter draining at 300-740 per shift.
 Has no bowel movement

C. Sleep/Rest
 Usually sleeps between 11-12 midnight and wakes up between 6-7
am. Awaken when pain is felt.

III. Mobility
 With regular exercise

IV. Cognitive/Perception
 Speaks Bicol, Tagalog and English
 Has abdominal discomfort

V. Activities of daily living

 Takes a bath regularly
 Brush his teeth at least three times a day

VI. Beliefs or Values

 Seldom attends mass
 Seldom reads Bible
 Roman Catholic
 Uses cell phone for communication

VII. Health Maintenance

 Follow the physician strictly

VIII. Coping /Stress Tolerance

 Smokes whenever he feels stressed.
 Ask for advice to his friends in times of problems
 Watch TV to divert his attention
 The patient’s family exhibits the desire and readiness for enhanced
health and growth in relation to the client.
 Family members move in the direction of a health-promoting and
enriching lifestyle that supports and monitors treatment programs,
and generally chooses experiences that optimize wellness.
  Significant others perform assistive and supportive behaviours with
satisfactory results.

IX. Role/ Relationship

 The patient has a good and sound relationship with her relatives who
are taking care of him.
 The patient is the second child of three.
 The patient is a graduate of Air Force of the Philippines, Philippine
Army.
 A father of 2 children.
 A husband for 17 years.

Self-Perception and Self-Concept

1. Patient’s General Appearance
 Pale palpebral conjunctiva
 Dry lips
 Drowsy
2. Emotional Aspect
 Anxious when he was hospitalized
 Can focus on questions

X. Sexuality/Reproductive
 Married

Competencies:
 Has many friends
 Alteration in physical ability
Nursing Physical Assessment
 Age: 47
 TPR: 36.7, 74bpm, 21cpm
 BP: 140/100 mmHg
 Skin pale
 Pale conjuctiva
 Facial edema
 drowsy
 Dry oral mucous membrane
 Cracked lips
 Nonproductive cough
 Abdominal pain (pain scale = 5/10)
 Decreased peristaltic sound heard upon auscultation
 Muscle twitching
 (+) Trousseaus’s sign

VII. DISCHARGE PLANNING

M - Instructed the patient to continue medication as ordered

1. Cirok 500mg/cap 2x a day (10am-10pm) for 7 days.
 2. Ponstan SF 500mg/cap 3x a day (8am-1pm-8pm) for 2 days
then as necessary.
E - Instructed the patient to do exercise as tolerated such as
walking
T - Instructed the patient to continue the medication
H - 1. Encouraged patient to increase fluid intake
2. Encouraged patient to eat foods rich in Vitamin and
Nutritious foods
3. Encourage patient to avoid salty and fatty foods
4. Encourage patient to have enough rest
O - Instructed to come back for follow-up check-up on February 20,
2009.
D - Advised the patient to a diet as tolerated but preferably
avoiding salty and
fatty foods.
 VIII. Patients Care

a. Nursing Care Plan

1. Acute Pain

Cues Nursing Scientific Objectives Nursing Rationale Evaluation

Diagnosis Explanation Intervention
s s
S “Dai naman Acute pain Due to the After 4 hours 1. Observed - Assists in
grabe ang related to presence of of nursing and document differentiating a. Pain
namamati inflammation stones in the intervention location, cause of pain, and scale of
kong kulog, and distortion gallbladder it the patient severity (0–10 provides 2/10
tama lang” as of the causes some will report scale), information about b. Facial
verbalized by gallbladder as obstruction in relieve of and character disease grimace
the client. evidenced by the cystic pain. of pain (e.g., progression/resolu s not
presence of duct which in steady, tion, noted
O stones in the turn causes a intermittent, development of c. RR-25
- pain common bile sharp acute colicky). complications, and d. BP-
scale of duct. pain on the effectiveness of 130/80
5/10 right part of 2.Positioned interventions.
- difficult the abdomen. the patient in
y in a semi -Suited position for
moving as Fowler’s. a patient having a
manifeste 3.Promoted gallbladder
d by facial bedrest, disorder.
grimaces allowing
- (+) patient to - Bedrest in low-
pallor assume Fowler’s position
- (+) position of reduces intra-
muscle comfort. abdominal
guarding pressure;
- RR- 30 however, patient
- BP- will naturally
140/90 assume least
painful position.
4. Control
environmental - Cool
temperature. surroundings aid
in minimizing
5. Encouraged dermal discomfort.
use of
relaxation - Promotes rest,
techniques, redirects
e.g., deep- attention, may
breathing enhance coping.
exercises.
Provide
diversional
activities.

6. Make time
to listen to
and maintain - Helpful in
frequent alleviating anxiety
contact with and refocusing
patient. attention,
which can relieve
7. pain.
Administered
analgesics as
indicated - Relief of pain
facilitates
cooperation with
other
therapeutic
interventions,
 2. Fluid Volume deficient

Cues Nursing Scientific Objectives Nursing Rationale Evaluation

Diagnosis Explanations Intervention
s
S Fluid Volume Because of After series of 1. Maintain - Provides Is there still the
 Deficient vomiting NI the pt. will accurate information presence of;
related to excessive maintain record of I&O, about fluid a. vomiting
vomiting losses through adequate fluid noting output status/circulati b. dry skin
O normal routes volume as less than ng c. dry mouth
- (+) occur thus evidenced by Intake, volume and d. poor skin
pallor causes Fluid moist mucous increased replacement turgor
- (+) Volume membranes urine specific needs. e. body
body Deficient and good skin gravity. weakness
weakne turgor, Assess
ss skin/mucous
- (+) membranes,
vomitin peripheral
g pulses, and
- with capillary
poor refill. - Decreases
skin dryness of oral
turgor 2. Perform mucous
- (+) dry frequent oral membranes;
skin hygiene reduces
- (+) dry risk of oral
mouth bleeding.

- Skin and
mucous
3. Provide membranes
skin and are dry, with
mouth care decreased
 elasticity,
because of
vasoconstricti
on and
reduced
intracellular
water.
- promotes
hydration.
4. Increase
fluid intake - Relieves
thirst and
5. Ascertain discomfort of
patient’s dry mucous
beverage membranes
preferences, and augments
and set up a parenteral
24- replacement.
hr schedule
for fluid
intake.
Encourage
foods with - Reduces
high nausea and
fluid content. prevents
vomiting.
6. Administer
antiemetics,
e.g.,
prochlorperazi
ne
(Compazine)
as ordered by
the physician.
Post-operative NCP
3. Knowledge Deficit

Cues Nursing Scientific Objectives Nursing Rationale Evaluation

Diagnosis Explanatio Interventions
ns
S Deficient There is this After an hour 1. Provide - Information can - Does
“pwede bang knowledge presence of of nurse- explanations decrease anxiety, the
maulit ang related to knowledge patient of/reasons for thereby reducing patient
sakit ko” as condition, deficit due to interaction test sympathetic understan
verbalized by prognosis, some the patient procedures stimulation. ds and
the patient treatment, unfamiliar will Verbalize and could
self-care, information understandin preparation recall all
and that causes g of disease needed. - Provides the
O discharge some process, knowledge base teachings
- Frequently needs confusion to prognosis, 2. Review from which given?
asking the client and potential disease patient can make - Is there
question that needs complication process/progn informed choices. a
about his to be s. osis. Discuss Effective significant
condition, discussed. hospitalization communication changes
treatment and and support that occur
and diet prospective at this time can on the
- With treatment as diminish anxiety patients
worried indicated. and promote knowledg
gaze Encourage healing. e
questions, regarding;
expression of a. disease
concern. condition
- Gallstones often b. diet
recur, c. treatment
3. Review necessitating d. medicatio
drug regimen, long-term n
possible side therapy. e. self-care
effects. needs

- Prevents/limits
4. Instruct recurrence of
patient to gallbladder
avoid attacks.
food/fluids
high in fats
(e.g.,
whole milk, ice
cream, butter,
fried foods,
nuts, gravies,
pork), gas
producers
(e.g., cabbage,
beans, onions,
carbonated
beverages), or
gastric irritants
(e.g., spicy
foods,
caffeine, - Promotes gas
citrus). formation, which
can increase
5. Suggest gastric
patient limit distension/discom
gum chewing, fort.
sucking on
straw/hard
candy, or
smoking.