ATENEO DE DAVAO UNIVERSITY College of Nursing

IN PARTIAL FULFILLMENT OF OUR REQUIREMENTS IN NURSING CARE MANAGEMENT 103 RELATED LEARNING EXPERIENCE

A CASE STUDY ABOUT CHOLECYSTITIS

Presented to: MRS. GISSELLE CHARADE A. ZAMORA, R.N.

Presented by: MR. MICAH NOEL I. PERPETUA MR. JONI S. PURAY MS. MA. PRINCESS H. GCCAE SANTILLAN MS. ARNIKKA B. RUBIA MR. RIEL R. SEGURA BSN 3H GROUP 4

TABLE OF CONTENTS PART PAGE Acknowledgement. Introduction Objectives.. Patients Data. Genogram.. Family History.. Developmental Data... Physical Assessment... Complete Diagnosis Anatomy and Physiology Etiology Symptomatology.. Pathophysiology... Doctors Order.. Diagnostic Examiation.. Drug Study Procedural Report. Nursing Theories Nursing Care Plans. Discharge Planning. Prognosis.. Conclusion Recommendation. Bibliography.

Acknowledgement

The student nurses would like to express their gratitude and appreciation primarily to Mr. Police for allowing them to have his case as their study. He had been very accommodating and cooperative to them during the entire exposure. Moreover, he was also very patient with them while providing them sufficient information regarding him and his case. Furthermore, they are grateful to Anna for being supportive and also for giving them an opportunity to learn more regarding her husbands case so that they could provide effective and efficient nursing interventions. The staff nurses are also acknowledged for their kind accommodation. Their humility in sharing some of their knowledge was great help to the student nurses learning. Consequently, their efforts and assistance have made the student nurses efficient in rendering nursing care towards the valued patients. The student nurses would also like to thank Maam Gisselle Charade A. Zamora, R.N. for giving them the appropriate orientation and facilitation on their first exposure to St. Joseph. She had been very patient and understanding to them, and gave them an enjoyable and unforgettable experience that made them further appreciate the journey of our being. In addition, they would also want to express their heartfelt thanks to Sir Anselmo Lafuente, R.N., their substitute clinical instructor at St. Joseph ward at DMSF Hospital, for guiding and inspiring them with his remarkable

holistic teachings that encouraged them not only to be better nurses, but as well as better individuals. May they find the right path towards God, as he wishes them to.

The student nurses would also like to thank their respective families who have always supported and encouraged them to be confident in what they are doing; for the financial and moral support and for understanding. Thank you for the love. The group would also like to extend their gratitude to the Perpetua family for welcoming them into their home and for securing them enough provisions and moral support. And above all, they are very thankful to the Almighty Father for gracing them with His wonderful blessings. He is their ultimate strength and hope. They pray for His loving guidance as they continue their journey in their nursing careers.

INTRODUCTION The gallbladder is a small pear-shaped organ which aids in the digestive process. Its function is to store and concentrate bile - a digestive liquid continually secreted by the liver. The bile in turn emulsifies fats and neutralizes acids in partly digested food. Despite its importance in the digestion of fat, many people are unaware of their gallbladder. Fortunately enough, the gallbladder is an organ that people can live without. Perhaps, this fact contributes to the laxity of the majority. The gallbladder tends to be taken for granted ignored of the proper care and conditioning. Lifestyle together with heredity, sex, race and age are just some factors that leave a room for gallbladder complications to occur. This study is about cholecystitis. The most common cause of cholecystitis is gallstones (90% of the cases). The bile becomes concentrated in the gallbladder. This later causes irritation and is probably the leading cause of inflammation. Cholecystitis affects women more often than men and is more likely to occur after age 40. People who have a history of gallstones are at increased risk for cholecystitis. In the international level, cholecystitis has an increased prevalence among people of Scandinavian descent, Pima Indians, and Hispanic populations, whereas cholelithiasis is less common among individuals from sub-Saharan Africa and Asia. It affected 20.5 million people (1988-1994) with a mortality record of 1,077 deaths in 2002. Hospitalizations total up to 636,000 in the same year and over 500,000 have undergone cholecystectomies. In the Philippines alone, an

extrapolated prevalence of 5,073,040 people are affected by the disease last 2007. (http://digestive.niddk.nih.gov/statistics) The student nurses have chosen this case as they see it fit for the perioperative concept as the patient has had undergone open cholecystectomy. Moreover, despite the cholecystitis low incidence, they would like to give credit and to know more of the nature and function of the gallbladder. Much often this small organ is not given importance. Thus they are in a pursuit for knowledge to be able to impart it to others. Furthermore, this case is quite interesting since it does not always affect only females and elderly. It can affect everyone. It can be alarming since many people are confused and unaware of the symptoms presented. As teen-agers living in a fast-phased world and governed by schedules, they too are predisposed to lifestyle modification especially diet and food preferences which can contribute to the disease. With this study, the student nurses hope to apply their learning in taking care not only of their patients but also of themselves. As nursing students and future nurses, they would want to understand and appreciate more on what is happening to a patient with cholecystitis. Consequently, they are interested on what will be the necessary

management that will be given. Through this, they are hoping that they will be able to find the right plan of care and sound interventions, not forgetting the patients rights as a person. All in all, these will help them to become efficient nurses and better persons later on.

Objectives After 5 days of data gathering, research and analysis, the student nurses shall have devised objectives that will guide them for the proper understanding and fair interpretation of the case of their chosen patient.

GENERAL OBJECTIVES Cognitive The student nurses first main goal is to gain knowledge through the completion of the case study and to impart this learning to Mr. Police and to those directly and indirectly involve with the completion of this case. Specific Objectives under Cognitive aspect Within the 5 days span of duty, the student nurses will be able to: Gather significant data from the patients chart which includes the doctors order, laboratory exams and etc. to have complete information about the patients current condition. Research on the anatomy and physiology of the clients affected system. Research on the possible causes and also the symptoms the patient experienced that may suggest the current condition of the patient. Research and understand the disease process of the patients illness. Determine and interpret the medical management employed including laboratory and diagnostic procedures.

Identify and study the drugs prescribed to the patient which affects the patients current situation.

Psychomotor In this aspect, the student nurses goal is to apply all what they have learned during the process of completing this case study to improve nursing care that will meet Mr. Polices need for the improvement of his general welfare. Specific Objectives under Psychomotor aspect Within the 5 days span of duty, the student nurses will be able to: Conduct a thorough physical assessment and to interpret the assessment in order to give the care the patient need. Formulate nursing care plans and apply them to satisfy the patients needs and give appropriate nursing interventions. Make a discharge plan for the patient using M.E.T.H.O.D and validate the patients prognosis according to categories. Affective With the knowledge gained and through the application of this knowledge, another goal is that the student nurses will be able to empathize with the current situation of the patient and to gain some values like the value of patience and calmness which is important for a them to have in order to become better nurses in the future.

Specific Objectives under Affective aspect Within the 5 days span of duty, the student nurses will be able to: Establish rapport and therapeutic communication in order to gain information about the patient which includes the medical and family health history, expectations of his condition to him gather significant data from the patients chart and to his family and etc.; and for the betterment of nursing care. Assume the role of being the patients advocate.

PATIENTS DATA Personal Data Name: Age: Sex: Nationality: Date of Birth: Place of Birth: Civil Status: Address: Religion: Mr. Police 46 years old Male Filipino August 28, 1962 General Santos City Married Cabantian, Country Homes, Davao City Christianity (Roman Catholic) College Graduate PNP

Educational attainment: Occupation: Clinical Data Admitting Date and Time: Case Number: Ward: Room/ Bed: Attending Physician: Chief Complaint: Diagnosis: VS upon admission:

April 27, 2009 at 10:40 am 01-36-90

St. Joseph (3C) 325-5 Dr. Batucan, Wolter right upper quadrant pain Cholecystitis T/C Cholelithiasis

BP 120/90 mmHg 36.5C Sources of info:

R 28 cpm

P 109 bpm

Temp

Chart, Mr. Police himself, and his wife

GENOGRAM

Lolo A

Lola A

Lolo B

Lola B

Dad

Mo m

Ann a

Mr. Police

Sis

Stepbrod

Stepsis

BB 1 Legend:

BB 2

: Hypertensive : Unknown cause of death : Suicide : Died of childhood illness : Deceased

HEALTH HISTORY A. Family Background Mr. Police is the eldest among Mr. Dads and Mrs. Moms two children. But his younger sister died of a childhood illness at the age of three years old, he could not recall. He grew up at General Santos City where the relatives of his mother live. When Mr. Police was a first year high school, his parents got separated because of third party. He lived with his mother and Mrs. Moms live-in partner at Davao City, while his father returned to Leyte where his other relatives live. With his mothers second family, he had another two siblings, Step-brod and Step-sis. Step-brod died at the age of 18 because of suicide. He had suicide because of altered mental status due to shabu use. Today, Step-sis has her own family at Leyte. Because Mr. Police had been away from the relatives of his father, he does not know any significant disease they have or had. He doesnt also know the causes of deaths of his grandmother and grandfather on the paternal side. On the other hand, what he only knows is that the eldest sister of her mother has hypertension, and that his grandfather on the maternal side died of hypertension. Currently, Mr. Police has been married to Anna for 15 years. They met at Mandug, Davao City, where Mr. Police had been assigned at work before. The couple had difficulty conceiving a child because Anna has an obstetrical problem. She verbalized, ingon sa doctor naa man gud

daw gas-gas akoang matres. Fortunately, nine years after their marriage, they were blessed with BB 1 who is now a kindergarten student, aged six years old. Two years after, BB 2 followed.

B. Personal Background Mr. Police graduated at MATS with a 4-year degree of BS-MT. But because he couldnt find a job with the course he had, he had sixmonth training to become a policeman. Currently, he had been

assigned to San Pedro Police Station for a year already. He works 24 hours straight, then have a two-day rest. On his rest day, he stays in their house and on the evening, goes with his friends and has a drinking session. He enjoys watching TV, and sometimes does the cooking as he likes to. He is not as close as the children are to Anna. But he enjoys playing with them sometimes and taking them out on weekends. He is a barkadista as his wife, Anna, describes him. He has a set of close friends who are also policemen like him. He is a Roman Catholic, who does not always goes to Church every Sundays but is a Sto. Nio devotee. Every January, he goes back to General Santos City, to attend certain activities in celebrating Sto. Nio fiesta. Mr. Police has been a smoker since he was 20 years old. His wife said he smokes three boxes of cigarettes everyday. He has also been an alcoholic drinker since he was 13 years old. He drinks three glasses of

alcoholic drink everyday. Furthermore, he doesnt have a regular exercise. But he enjoyed boxing with his friends, as an exercise, which only lasted for six months (September 2008- February 2009). He stopped because his friends also decided to stop. With regards to his diet, he is a meat-addict, as Anna verbalized. Everyday, he eats meat, and could not sleep without eating such. He also eats lots of pulutan during their drinking sessions such as laman-loob, chicaron, and other pica-pica. Moreover, he does not eat vegetables but eats all kinds of fruits. Moreover, he has no known drug and food allergy.

C. Effects/ Expectations of Illness to Self/ Family Because of his condition, he had to undergo an operation which means he had to have a sick leave from his work. Moreover, Anna also has to watch over him and she has to leave the children under the care of her elder sister for a while. Moreover, Anna is worried of the effect of the operation to the health of her husband. But she is hoping that because of this hospitalization, he would realize that he should have a healthy control over his health, that he would cease drinking and smoking. Furthermore, Anna is also expecting that her husband would regain his strength back soon.

D. History of Past Illness Mr. Police experienced common illness such as colds, cough, and fever during his childhood. He also had chicken pox during his childhood. However, he could not recall at what age he got the disease and as well as the management of his chicken pox. Five years prior to admission (2004), he was diagnosed with diabetes with an FBS result of 7.8 mmol/dL. They were having an annual check up when he discovered that he has elevated blood sugar. He was then advised to control his diet and have a regular exercise but he was not given any maintenance drug. Moreover, he was not compliant with the doctors advice.

Two years ago (2007), he was admitted to Davao Medical Center due to loss of consciousness. Prior to that, he was experiencing

palpitations, and pain on the suboccipital area (nape) associated with headache. He had elevated blood pressure of 180/100 as he could remember during the VS taking at the emergency room. He was admitted for one day and was diagnosed with hypertension. He was then given Lopicard 5mg tab OD, as a maintenance anti-hypertensive medication. The doctor advised him to cease smoking and drinking alcohol, and as well as to avoid over fatigue. He stopped smoking, but only for two months.

E. History of Present Illness A month prior to admission, Mr. Police experienced right upper quadrant pain associated with a sense of bloatedness, without nausea and vomiting. The pain was tolerable so he did not seek medical attention yet. He said he also had an increased level of pain tolerance so he also didnt mind to take any pain relievers. Until three days prior to admission, patient had severe right upper quadrant pain, which was said to be intolerable. Moreover, when pressure is applied on the RUQ of the abdomen, pain is elicited. He had also lost his appetite because of the pain. His scleras were also slightly icteric during admission and he was positive with Murphys sign. So he sought consultation at OutPatient Department- Emergency Room at Davao Medical School

Foundation Hospital. Ultrasound revealed cholecystitis, so patient was advised admission and operation.

DEVELOPMENTAL DATA Theories Assessme nt A C H I Genital (13 years and older) E V E D Genital Energy is directed toward attaining a mature sexual relationship. This stage involves a reactivation of the pregenital impulses. These impulses are usually displaced, and the individual passes to the genital stage of maturity. An inability to resolve conflicts can result in sexual problems, such as frigidity, impotence, and the inability to have a satisfactory sexual relationship. Stages Justification Mr. Police and Anna have a Freuds Psychosexual Theory good sexual relationship. Though Mr. Police has an erection-related problem, the couple are able to maintain a healthy sexual relation with each other. Anna said that she understands that this might be due to Mr. Polices diabetes, though they sometimes do not achieve sexual satisfaction. The erectionrelated problem of Mr. Police does not damage the couples relationship. It even made the couple more mature and understanding of each others sexual needs. Furthermore, Mr. Police compensates by wooing his wife through romantic dinners and being sweet with her, even in public. Moreover, energy is directed towards his work

as a policeman, being committed to his work and as well as to his colleagues, who are also the recipient of Mr. Polices energy towards his social relationships to other people.

Stage 7: Generativity Eriksons Psychosocial Theory Stage 7: Generativity vs. Stagnation (Middle Adulthood 40-65 yrs.) A C H I E V E D vs. Stagnation The middle adult years are a time of concern for the next generation as well as involvement with family, friends, and community. Sociallyvalued work and disciplines are expressions of generativity. Simply having or wanting children does not in and of itself achieve generativity. There is a desire to make a contribution to the world. If this task is not met, stagnation results, and the person becomes selfabsorbed and obsessed with his or her own needs or regresses to an earlier level of coping. Mr. Police is able to send his child to a private school, to ensure a high standard of his educational needs. Moreover, he works alone to provide the familys financial needs. He doesnt allow his wife to work to make sure that the children receive a direct parental guidance in their growing years. Moreover, as he works as a policeman, he is satisfied with his service to the public through their protection and crime control activities. He yearns for the communitys peace and order and is achieved through his public service as a policeman.

Mr. Police said that it is Middle Adulthood Havighursts Development al Theory Middle Adulthood (40-65 yrs. old) A C H I E V E D Developmental tasks for middle adulthood include: Accepting and adjusting to physical changes Attaining and maintaining a satisfactory occupational performance Assisting children to become responsible adults Relating to ones spouse as a person Adjusting to aging parents Achieving adult social and civic responsibility normal that in his age, people get disease because they are aging. Moreover, he is able to obtain a satisfactory occupational performance, as he stayed on his job for already more than 20 years already. Though his children are still four and six years old, he teaches them values such as honour, respect, and honesty, for them to become like him, a responsible citizen of our country. In addition, Mr. Police said that he is blessed with their relationship because Anna is not just a wife to her, but also a friend, whom he could confide his problems. As his parents are also getting old, he said that he visits them at least once or twice a year. He even said that wants them to live their remaining life happy and

satisfied with it. Moreover, he has achieved social and civic responsibility through his public service as a policeman.

PHYSICAL ASSESSMENT GENERAL SURVEY At 4 pm on April 30, 2009, physical assessment was done. Mr. Police, a 46 year old Filipino male, was lying in bed, asleep; with an IVF # 3 D5NSS 1L at the level of 80 cc, regulated at 120 cc/hr, infusing well at right metacarpal vein; with epidural catheter; with Jackson Pratt drain; with slightly soaked, intact dressing at right upper quadrant of the abdomen, status post open cholecystectomy. Patient is responsive and coherent when awaken; with complain of pain at the incision site, with a pain scale of 6 out of 10. Patient was on NPO. He appeared endomorphic. Patient was in good grooming, wearing clean patients gown. Respiratory distress was not noted. Aside from that, he weighs 85 kg and stands 55 and has a body mass index of 31.18 which denotes that he belong to the obese type I which ranges from 30 34.9. VITAL SIGNS BP= 120/180 mm Hg T= 36 C SKIN Skin was warm to touch, slightly dry, rough, and with good skin turgot. Neither jaundice nor cyanosis observed. Papules on the face observed, with nevi noted on the right side of the nose. Patient was not cyanotic. No bruises or discolorations observed. No edema noted. PR= 85 bpm RR= 15 cpm

HEAD Skull size was normocephalic. Skull and face were symmetrical with an equal distribution of hair. Hair was black in color with fair amount of white and gray strands, short, dry, and fine. There was no dandruff or infestation present. No lesions, lacerations, tenderness, masses and depressions noted.

FACE The forehead was furrowed with wrinkles. Face portrayed emotions with symmetrical movements. No masses or involuntary movement. The face was round, with no edema, lesions, discolorations present. EYES Mr. Police did not use any corrective aids such as glasses or contact lenses. Eyebrows were evenly distributed and symmetrically aligned with no of flakes, scars and lesions noted. Eyelashes were evenly distributed and slightly curled outward. Lid margins were clear, lacrimal duct openings were evident at the nasal side of the upper and lower lids. Blinking reflex was present. Skin around the eyes was intact with equal movement, with no discharges and no discolorations observed. Eyelids close symmetrically. No edema seen in the periorbital region. Shiny smooth and pink palpebral conjunctiva noted. No edema or tenderness over lacrimal gland observed. Eye color was dark brown. His pupils were equal within 1-2 mm diameter in size and both have a brisk reaction to light and uniform reaction to accommodation. Small anterior polar opacification was observed on both eyes. Nystagmus, strabismus and lid lag were not evident. EARS Ears were symmetrical with same size bilaterally and color consistent with face. Pinnas were free from lesions, masses, swelling, redness, tenderness, and discharges and were in line with the eyes. External

canals were clear with no cerumen seen. No inflammation, masses, discharges and foreign bodies noted. Gross hearing acuity was good. No pain on the mastoid process was reported upon palpation. NOSE The nose was symmetrical with no deformities, skin lesions, masses present. Nasal septum is intact and in midline. No nasal flaring was observed. No discharges were present. No tenderness in his sinuses upon palpation. MOUTH Mouth was proportional and symmetrical. Lips were rust colored and were dry with no presence of ulcerations, sores or lesions. Teeth were yellowish in color with some dental caries noted. Right upper first premolar tooth was absent. Tongue was in central position and moves freely with no swelling or ulcerations observed. Gag reflex was present as evidenced by patient swallowing. Tonsils were not inflamed. Halitosis was also noted. NECK Neck was symmetrical with no masses or swelling noted. No jugular vein distention was noted. Range of motion was normal and moves easily without discomfort upon rotation, flexion, extension and hyperextension. Thyroid was not enlarged has no nodules, masses, and irregularities upon palpation. Trachea is symmetrical and in midline without deviation.

BREAST Nipples were dark brown in color, inverted and in the midline. No crusting and masses noted. Breasts were symmetrical with no edema noted. Both axilla were free of lesions rashes, and infections. Lymph nodes were not palpable. CHEST and LUNGS No thorax deformity observed. Respiratory rate was 15 cycles per minute with regular breathing pattern. Symmetrical chest expansion was observed during respiration. No use of accessory muscles during breathing observed. Chest wall was intact; no tenderness and masses noted. Uniform temperature also noted. No adventitious breath sounds heard upon auscultation. No cough present. No dyspnea, hemoptysis, hiccups noted. HEART Apical heart beat was present upon auscultation with a point of maximal impulse at the 5th intercostal space left midclavicular line; with cardiac rate of 85 beats per minute with a regular rhythm. No abnormal beats, palpitations, thrills or murmurs present upon auscultation. ABDOMEN Abdomen was slighty enlarged and globular when patient was in supine position; with slightly soaked, intact dressing on the right upper quadrant with Jackson Pratt drain. Pulsations were not visible. The

abdomen had hypoactive bowel sounds of two bowel sounds per minute. Tenderness noted on the right upper quadrant near the incision site. GENITO URINARY Unable to perform inspection in the genitourinary region. However, patient verbalized that he had not noted any discharges from his genitalia nor presence of papules or ulcerations. Patient had not yet voided since he had arrived from the OR.

BACK & EXTREMITIES Symmetrical shoulder movement observed during respiration. Spine was located at the midline with no discrepancies noted. Shoulders, arms, elbows and forearms were free from nodules, deformities and atrophy. Range of motion was not limited. Neither pallor nor bone enlargements were noted upon inspection of the upper extremities. A permanent tattoo was present on his right deltoid area, anchordesigned. Upper extremities were not edematous. Radial and brachial pulses were present. Hip joint and thighs were symmetrical with no deformities present. No edema noted at both legs. No inflammation noted in the lower extremities. Range of motion was active and not limited.

DEFINITION OF COMPLETE DIAGNOSIS CHOLECYSTITIS Cholecystitis is the inflammation of the galbladder

Source: Smeltzer, S.C., Bare, B.G. Brunner & suddarths Textbook of Mecial-Surgical Nursing 11th Edition. Cholecystitis refers to inflammation of the gallbladder and cystic duct. Source: Barbara Gould, Pathophysiology for the Health Professions, Third Edition, Saunders Elsivier Cholecystitis refers to inflammation of the gallbladder.

Source: Carol Mattson Porth, Pathophysiology, Concepts of Altered Health Sciences CHOLELITHIASIS The presence of calculi in the gallbladder

Source: Smeltzer, S.C., Bare, B.G. Brunner & suddarths Textbook of Mecial-Surgical Nursing !0th Edition. Cholelithiasis refers to formation of gallstones, which are masses of solid material or calculi that forms in the bile.

Source: Barbara Gould, Pathophysiology for the Health Professions, Third Edition, Saunders Elsivier Cholelithiasis, or gallstones, is caused by precipitation of substances contained in bile, mainly cholesterol and bilirubin. Source: Carol Mattson Porth, Pathophysiology, Concepts of Altered Health Sciences

ANATOMY AND PHYSIOLOGY HEPATOBILLARY TREE

LIVER A. Location and size of the liver- largest gland in the body, weighs approximately 1.5 kg; lies under the diaphragm; occupies most of the right hypochondrium and part of the epigastrium. B. Liver lobes and lobules- two lobes separated by the falciform ligament 1. Left lobe- forms about one sixth of the liver 2. Right lobe- forms about five sixths of the liver; divides into right lobe proper, caudate lobe, and quadrate lobe 3. Hepatic lobules- anatomical units of the liver; small branch of hepatic vein extends through the center of each lobule C. Bile ducts

1. Small bile ducts form right and left hepatic ducts 2. Right and left hepatic ducts immediately join to form one hepatic duct 3. Hepatic duct merges with cystic duct to form the common bile duct, which opens into the duodenum D. Functions of the liver 1. Glucose Metabolism -after a meal, glucose is taken up from the portal venous blood by the liver which and is converted in into glycogen

(glycogenesis),

stored

the

hepatocytes.

Glycogen is converted back to glucose (glycogenolysis) and release as needed into the blood stream to maintain normal level of the blood glucose. -glucose can be synthesized by the liver through the process gluconeogenesis 2. Ammonia Conversion -use of amino acids from protein for gluconeogenesis result in the formation of ammonia as a by product. Liver converts ammonia to urea 3. Protein Metabolism -Liver synthesizes almost all of the plasma protein including albumin, alpha and beta globulins, blood clotting factors plasma lipoproteins

4. Fat Metabolism -Fatty acid can be broken down for the production of energy and production of ketone bodies 5. Vitamin and Iron Storage -stores vitamin A, D, E, K 6. Drug Metabolism 7. Bile Formation -bile is formed by the hepatocytes -composed of water, electrolytes such as sodium,

potassium, calcium, chloride, bicarbonate, lecithin, fatty acids, cholesterol, bile salts -collected and stored in the gallbladder and emptied in the intestine when needed for digestion a. Lecithin and bile salts emulsify fats by encasing them in shells to form tiny spheres called micelles b. Sodium bicarbonate increases pH for optimum enzyme function c. Cholesterol, products of detoxification, and bile pigments (e.g. bilirubin) are wastes products excreted by the liver and eventually eliminated in the feces

GALLBLADDER

The gallbladder (or cholecyst, sometimes gall bladder) is a small organ whose function in the body is to harbor bile and aid in the digestive process. Anatomy

The cystic duct connects the gall bladder to the common hepatic duct to form the common bile duct.

The common bile romero duct then joins the pancreatic duct, and enters through the hepatopancreatic ampulla at the major duodenal papilla.

The fundus of the gallbladder is the part farthest from the duct, located by the lower border of the liver. It is at the same level as the transpyloric plane.

Microscopic anatomy The different layers of the gallbladder are as follows:

The

gallbladder

has

simple

columnar

epithelial

lining

characterized by recesses called Aschoff's recesses, which are pouches inside the lining.

Under the epithelium there is a layer of connective tissue (lamina propria).

Beneath the connective tissue is a wall of smooth muscle (muscularis externa) that contracts in response to

cholecystokinin, a peptide hormone secreted by the duodenum.

There is essentially no submucosa separating the connective tissue from serosa and adventitia.

Size and Location of the Gallbladder The gallbladder is a hollow, pear-shaped sac from 7 to 10 cm (34 inches) long and 3 cm broad at its widest point. It consists of a fundus, body and neck. It can hold 30 to 50 ml of bile. It lies on the undersurface of the livers right lobe and is attached there by areolar connective tissue. Structure of the Gallbladder Serous, muscular, and mucous layers compose the wall of the gallbladder. The mucosal lining is arranged in folds called rugae, similar in structure to those of the stomach. Function of the Gallbladder The gallbladder stores bile that enters it by way of the hepatic and cystic ducts. During this time the gallbladder concentrates bile fivefold to tenfold. Then later, when digestion occurs in the stomach and intestines, the gallbladder contracts, ejecting the concentrated bile into the duodenum. Jaundice a yellow discoloration of the skin and mucosa, results when obstruction of bile flow into the duodenum occurs. Bile is thereby denied its normal exit from the body in the feces. Instead, it is absorbed into the blood, and an excess of bile pigments with a yellow hue enters the blood and is deposited in the tissues. The gallbladder stores about 50 mL (1.7 US fluid ounces / 1.8 Imperial fluid ounces) of bile, which is released when food containing

fat

enters

the

digestive

tract,

stimulating

the

secretion

of

cholecystokinin (CCK). The bile, produced in the liver, emulsifies fats and neutralizes acids in partly digested food. After being stored in the gallbladder the bile becomes more concentrated than when it left the liver, increasing its potency and intensifying its effect on fats. Most digestion occurs in the duodenum.

BILIRUBIN PRODUCTION AND ELIMINATION Bilirubin is the substance that gives bile its color. It is formed from senescent red blood cells. In the process of degradation, the hemoglobin from the red blood cell is broken down from biliverdin, which is rapidly converted to free bilirubin thru biliverdin reductase. Free bilirubin, which is not soluble in plasma, is transported in the blood attached to plasma albumin. Even when it is bound to albumin, this bilirubin is still called free bilirubin. As it passes through the liver, free bilirubin is released from its albumin carrier molecule and moved into the hepatocytes. Inside the hepatocytes, free bilirubin is converted to conjugated bilrubin thru glucoronyl transferase, making it soluble to bile. Conjugated bilirubin is secreted as a constituents of bile, and in this form, it passes through the bile ducts into the small intestine. In the intestine, approximately one half of the bilirubin is converted into a higly soluble substance called urobilinogen by the intestinal flora. Urobilinogen is either absorbed into the portal circulation or excreted in the feces. Most of the urobilinogen that is absorbed is returned to the liver to be re-excreted into the bile. A small amount of urobilinogen, approximately 5% is absorbed into the general

circulation and then excreted by the kidneys. Usually, only a small amount of bilirubin is found in the blood; the normal level of total serum bilirubin is 0.1 to 1.2 mg/dL. Laboratory measurements of bilirubin usually measure the free and the

conjugated bilirubin as well as the total bilirubin. These are reported as the direct (conjugated) bilirubin and the indirect (unconjugated or free) bilirubin.

ETIOLOGY AND SYMPTOMATOLOGY Precipitating Factors: Factors Diet (high cholesterol, high calorie, high sodium) Present Present Rationale Increased intake of calories, refined carbohydrate, cholesterol, and saturated fats has all been postulated to cause cholesterol gallstones. Patients with cholesterol gallstones secrete a greater fraction of dietary cholesterol into bile than do normal subjects. SOURCE: Harrisons Principle of Medications and Oral Contraceptives Absent Internal Medicine, 16th Edition Hypolipidemic agents (clofibrate, gemfibrozil) that lower serum cholesterol by increasing biliary cholesterol secretion increase the risk of cholesterol gallstones by twofold to threefold. Competitive inhibitors of 3-hydroxy-3methylglutaryl coenzyme A (HMGCoA) reductase (lovastatin, simvastatin, pravastatin) decrease biliary cholesterol saturation. Estrogen therapy is associated with an increased risk of developing cholesterol gallstones. Oral contraceptive steroids increase biliary cholesterol secretion and

saturation but do not affect gallbladder motility. Source: Barbara Gould, Pathophysiology for the Health Professions, Third Edition, Saunders Total Parenteral Nutrition Absent Elsivier TPN is a powerful risk factor for gallstone formation. Gallstones from during TPN because of decreased gallbladder motility from lack of mealstimulated cholesystokinin (CKK) release, resulting in increased fasting and residual volumes. SOURCE: Harrisons Principle of Spinal Cord Injury Absent Internal Medicine, 16th Edition Patients with spinal cord injury have 10% incidence of forming gallstones within the first year after injury. This high risk, which is 20 times normal, is believed to be secondary to abnormal gallbladder motility and probably biliary hypersecretion of cholesterol from the progressive reduction in body mass. SOURCE: Harrisons Principle of Primary Biliary Cirrhosis Absent Internal Medicine, 16th Edition Patients with primary biliary cirrhosis have an increased prevalence of gallstones. Stone analysis has not

been performed, but the elevated cholesterol saturation of bile in these patients suggest that they form cholesterol stones. SOURCE: Harrisons Principle of Diabetes Mellitus Present Internal Medicine, 16th Edition Despite obesity and increased total body cholesterol synthesis and decreased gallbladder motility seen in patients with diabetes, diabetes mellitus itself does not appear to be an independent risk factor for cholesterol gallstone disease. SOURCE: Harrisons Principle of Hemolytic Syndromes Absent Internal Medicine, 16th Edition Inherited hemolytic anemia, sickle cell disease, sphericytosis, thalassemia, chronic hemolysis associated with artificial heart vavles, and malaria dramatically increase the risk of pigment stone formation because of increased biliary secretion of total bilirubin conjugates, especially bilirubin monoglucoronide, at the expense of the bilirubin diglucuronide, the predominant conjugate in healthy individuals. SOURCE: Harrisons Principle of

Internal Medicine, 16th Edition Ileal Disease, Resection, and Bypass Absent Patients with ileal dysfunction have a strikingly increased risk for developing gallstones. Gallstones develop in 3050% of patients with ileal Chrons disease; the risk correlates positively with the extent and duration of ileal dysfunction, Although ilieal disease or resection leads to cholesterol supersaturation and cholesterol stone formation in some patients , careful studies now show that most patients with ilieal dysfuncyion form black pigment, not cholesterol stones. SOURCE: Harrisons Principle of Biliary Infection Absent Internal Medicine, 16th Edition Brown pigment stones are frequently found in the intrahepatic bile ducts and are always associated with infection by colonic organisms usually E.coli, or parasitic infestation (Ascaris lumbricoides, or other helminthes). Intraductal stones developing after cholecystectomy are invariable associated with bile stasis, biliary tree infection, and/or retained suture material. SOURCE: Harrisons Principle of Internal Medicine, 16th Edition

Obesity

Present

Obesity is strongly associated with increased gallstone prevalence. The risk is proportional to the increase in total body fat. Obese people synthesize more cholesterol in both hepatic and nonhepatic tissues, transport it to the liver, and secrete more of it into the bile, leading to bile that is often greatly supersaturated with cholesterol. Source: Barbara Gould, Pathophysiology for the Health Professions, Third Edition, Saunders Elsivier Obese patients undergoing rapid weight loss (1-2% of body weight or approximately 1-2 kg/week), either by very low caloric dieting or gastric stapling, have a 25-40% chance of developing gallstones within 4 months. During rapid weight loss, biliary cholesterol saturation increases acutely as cholesterol is mobilized from adipose tissue and skin and secreted into bile. SOURCE: Harrisons Principle of Internal Medicine, 16th Edition

Rapid Weight Loss/ Fasting diets

Absent

Predisposing Factors: Factors Gender Present Absent Rationale Women have twice the risk as men of developing cholesterol gallstones because estrogen increases biliary cholesterol secretion. Before puberty this risk is negligible, and beyond menopause the increased risk disappears. Source: Barbara Gould, Pathophysiology for the Health Professions, Third Edition, Saunders Advancing Age Present Elsivier The incidence increases with age. Less than 5-6% of the population under age 40 have stones, in contrast to 25-30% of those over 80. Source: Carol Mattson Porth, Pathophysiology, Concepts of Altered Race Absent Health Sciences Prevalence highest in North American Indians, Chilean Indians, and Chilean Hispanics, greater in Northern Europe and North America than in Asia, lowest in Japan; familial disposition; hereditary aspects SOURCE: Harrisons Principle of Internal Medicine, 16th Edition

Heredity

Absent

Family history alone imparts increased risk, as do a variety of inborn errors of metabolism that lead to impaired bile salt synthesis and secretion or generate increased serum and biliary levels of cholesterol, such as defects in lipoprotein receptors (hyperlipidemia syndromes), which engender marked increases in cholesterol biosynthesis. SOURCE: Harrisons Principle of

Parity/ Pregnancy

Absent

Internal Medicine, 16th Edition Pregnancy is an independent risk factor for cholesterol gallstones. The risk increases with increasing parity, especially with more than two children. During pregnancy, elevated estrogen and progesterone levels increase biliary cholesterol secretion. Elevated progesterone also inhibits gallbladder contractility. 40% of women develop biliary sludge in their gallbladder and 12% of women form their first stones during pregnancy. SOURCE: Harrisons Principle of Internal Medicine, 16th Edition

Symptomatology Symptoms Biliary Colic/ Moderate to Severe Pain Present Present Rationale The most common symptom is in pain the right upper part of the abdomen or epigastrium. This can cause an attack of abdominal pain, called biliary colic, which: develops quickly, is severe, lasts about one to three hours before fading gradually, isn't helped by over-the-counter and isn't helped by passing wind. The pain may radiate to the back, right scapula or shoulder. The pain often begins suddenly following a meal. The pain of biliary colic is caused by the functional spasm of the cystic duct when obstructed by stones, whereas pain in acute cholecystitis is caused by inflammation of the gallbladder wall. Source: Carol Mattson Porth, Pathophysiology, Concepts of Altered Health Sciences Palpation of the abdomen frequently elicits localized tenderness in the right upper quadrant which is associated with guarding and rebound tenderness. Source: Carol Mattson Porth, Pathophysiology, Concepts of

Tenderness

Present

Murphys Sign

Present

Altered Health Sciences The patient with acute inflammation of the gallbladder might have a positive Murphys sign, which is inspiratory arrest during deep palpation in the right upper quadrant. SOURCE: Harrisons Principle of

Nausea and Vomiting

Absent

Internal Medicine, 16th Edition These signs and symptoms may accompany a gallbladder attack. Pain is usually accompanied by nausea and vomiting. Source: Barbara Gould, Pathophysiology for the Health Professions, Third Edition, Saunders Elsivier Gallstones sometimes get trapped in the neck of the gallbladder and can cause persistent pain that lasts more than several hours and is accompanied by fever, also due to the irritation and inflammation of the gallbladder wall. Fever occurs in about one third of people with acute cholecystitis. The fever tends to rise gradually to above 100.4 F (38 C) and may be accompanied by chills

Fever and chills

Absent

SOURCE: Harrisons Principle of fLoss of appetite and Anorexia Present Internal Medicine, 16th Edition The pain often begins suddenly following a large or rich meal. People tend not to eat, especially fatty or oily foods, in order not to experience that pain. Fat absorption is also impaired for the lack of bile salts, As a result, rapid loss of weight and anorexia can occur. SOURCE: Harrisons Principle of Internal Medicine, 16th Edition

Predisposing Factors: Gender Age Race Heredity Pregnancy PATHOPHYSIOLOGY

Precipitating Factors: Diet Medications and Oral Contraceptives Obesity Rapid Weight Loss Spinal Cord Injury Primary Biliary Cirrhosis Diabetes Mellitus Hemolytic Syndromes Ileal Disease, Resection and Bypass Biliary Infection Total Parenteral Nutrition

Liver cells secrete cholesterol into bile along with phospholipid in the form of unilamellar vesicles

Liver cells also secrete bile salts

Liver excrete relatively high proportion of cholesterol in the bile

Liver excrete conjugated bilirubin into bile

Invasion of bacteria

Calcium enters bile passively along with other electrolytes

Liver excrete some unconjugated bilirubin into bile

A Residual vesicles Some of the unilamellar vesicles dissolve The bacteria hydrolyze conjugated bilirubin Bacterial hydrolysis of lecithin Unconjugated Bilirubin tends to form insoluble precipitates with calcium

Formation of mixed micelles Increase in unconjugated bilirubin

Release of fatty acids

Formation of Calcium Bilirubinate

The cholesterol carrying capacity of the micelles and residual vesicles is exceeded

fatty acids forms complex with calcium

Black Pigment Gallstones

Bile is supersaturated with cholesterol

Attraction of Leukocytes

Bacteria release lytic enzyme

Formation of Calcium Bilirubinate

Formation of Crystals Nucleation of cholesterol crystals

leukocytes hydrolyze bilirubin conjugates and fatty acids

Brown Pigment Gallstones

Cholesterol Gallstones

Mixed Stones

CHOLELITHIASIS

Gallstone tries to go out of the gallbladder

Obstruction of the common bile duct by gallstones (Choledocholelithiasis)

Obstruction of the cystic duct by gallstones

Cholestasis

Release of phospholipase from the epithelium of the gallbladder Absence of Bile in the duodenum levels of bilirubin/bile pigments in the circulation

Disruption of mucous coat of the gallbladder epithelium

Prolong Cholestasis

Hydrolization of lecithin into lysolecithin

Damages mucosal cells due to detergent action of bile salts

Hepatomegaly S/S Indigestion, Vit ADEK deficiency, gray stools

Fibrosis

Liver Cirrhosis

S/S jaundice, ecteric sclera, pruritus, dark urine

Irritation of the gallbladder wall

Fibrous nodules distorts the architecture of the liver

Resistance to portal blood flow Increase pressure in hepatic portal vein Portal Hypertension

S/S Biliary Colic, Tenderness, Murphys sign, nausea and vomiting, fever, elevated wbc, anorexia

Release of prostaglandins within the gallbladder wall

ACUTE CHOLECYSTITIS

IF TREATED: Open Cholecystectomy Laparoscopic Cholecystectomy Litotripsy Ursodeoxycholicacid

IF NOT TREATED

GOOD PROGNOSIS

Bacteria invade the injured gallbladder through the blood, lymphatic or bile ducts form adjacent organs (Empyema of the gallbladder)

External surface of the gallbladder is scarred and layered by fibrinous exudates and distended

Edema, hemorrhage and suppuration of the gallbladder wall

Compression of blood vessels

Increased Intraluminal pressure

Compromised blood flow to the mucosa and lymphatic stasis

Ischemia

Ulcerations of the mucosa

Necrosis

Gangrenous Cholecystitis

Free Perforation

Localized Perforation

Adhesion to an adjacent hollow viscus (duodenum)

Pericholecystic abcess

Cholecystoenteric fistula formation

Gall stone induced intestinal obstruction (gallstone ileus); drainage of bile into adjacent organs; entry of air and bacteria into the biliary tree

As the intestine becomes congested, its ability to absorb food and fluids decreases

Cut off the blood supply to the affected portion of your intestine

Ischemia

Dehydration

Necrosis

Hypovolemia

Perforation in the intestinal wall

Hypovolemic shock Generalized Peritonitis

Sepsis S/S fever, chills, tachycardia

Septic Shock

DEATH

Liver failure

Shunting of blood into the splenic vein

Liver is unable to convert the protein byproduct ammonia into urea

Spleen enlarges to compensate decreased liver function

Blockage or increase pressure in the portal vein causes blood to backflow to the different vessels located near the esophagus and GIT

Increase pressure in peritoneal capillaries

Fluid shifting from the portal vein to the peritoneal cavity

Ammonia enters general circulation

Splenomegaly

Gastroesophageal Varices

Ascites

Morphologic changes in astrocytes S/S Asterixis Astrocytes may undergo Alzheimer type II astrocytosis

Increase in size decreases the spleens ability to function properly or loss of function

Rupture

Hypovolemia

Invasion of bacteria from the blood, or lymph or through the bowel wall

Increases in blood waste product since spleen is not able to properly destroy RBCs

Hypovolemic shock

Spontaneous Bacterial Peritonitis

Death S/S Fever, diarrhea, abdominal pain Sepsis

Astrocytes become swollen

Death S/S Thrombocytop enia, anemia, leukopenia

Septic Shock

Development of a large pale nucleus, a prominent nucleolus, and margination of chromatin

Death

HEPATIC ENCEPHALOPATHY

S/S Anorexia, Nausea, Liver tenderness, Jaundice

Cerebral edema

Increased intracranial pressure

Brain Hernation

Hepatic Coma

DEATH

Chronic Cholecystitis

Increased subepithelial and subserosal fibrosis and proliferation of lymphocytes and other chemical mediators

Extensive dystrophic calcification of the gallbladder wall (Porcelain bladder) Growth of gallbladder carcinoma Metastasize to the liver

Secondary Liver Cancer

DOCTORS ORDER Date & Order Time 04-27-09 Pls. admit under 10:40am Walter G. Batucan Rationale Dr. For proper evaluation and management and care under Dr. Batucan who is an expert on General Surgery, Liver, Gallbladder, Billiary and Pancreatic Surgery. Bile contains large amount of cholesterol that usually remains dissolved in the bile but when there is oversaturation with cholesterol, cholesterol becomes insoluble and crystallizes. Low fat diet serves as a prevention and treatment for gallstone formation. Remarks Done

Low fat diet

Done

Labs: CompleteBloodCount, PlateletCount

Blood Typing

Complete blood count Done is the determination of Hemoglobin the quantity of each 172g/dL quantity of each type RBC 5.46 of each blood cell in a X10^12/L given specimen of Hematocrit blood, often including 0.53 the amount of WBC 15.2 X hemoglobin, 10^9/L hematocrit, and the Segmentersproportion of various 0.72 white cells. LymphocytePlatelet count and 0.28 other blood Platelet 222 components that will X10^9/L help determine the underlying diagnosis. Patient is to undergo Done an invasive surgery Blood type

Urinalysis

Chest X-ray

ECG

which could lead to blood loss therefore blood typing is done before blood can be transfused on him to replace the loss blood. An indicator of health and disease, it is helpful in the detection of renal or metabolic disorders. It is an aid in diagnosing and following the course of treatment in diseases of the kidney and urinary system and in detecting disorders in other parts of the body such as metabolic or endocrinic abnormalities in which the kidneys function normally. Chest X-ray provide a good outline of the heart nad major blood vessels and ussualy can reveal a serious disease in the lungs, the adjacent spaces, and the chest wall, including the ribs. Ordered so as to check patients cadiopulmonary condition before undergoing an invasive surgery. ECG is a recording of the electrical impulses of the heart. Such test is an important indicator of how well the heart is functioning. Prior to surgery, the heart must first be checked

O+

Done Yellow; cloudy Rxn:6 Spec. gravity1.030 Glucose (-) Albumin (++ +) Pus cells 24/hpf RBC 1-2/hpf Mucus threads (+)

Done > Suggestive of an inflammatory lung disease compatible with bibasal pneumonia. Please correlate clinically.

Done Normal Sinus Rhythm

Fasting Blood Sugar

Creatinine

Uric Acid

Total Bilirubin Direct Bilirubin Indirect Bilirubin

Alkaline Phosphatase

to determine whether or not it can handle the surgery. Prior to surgery, blood glucose is to be checked to determine if the patient has a disorder in glucose metabolism mainly diabetes for healing tends to be longer if one has diabetes. Creatinine is a breakdown product of creatine phosphate in muscle, and is usually produced at a fairly constant rate by the body. It is mainly filtered by the kidney, though a small amount is actively secreted. Measuring serum creatinine is used to indicate renal function. Measurement of uric acid is most commonly in evaluation of renal failure, gout and leukemia. Evaluates impairment of the liver or hemolytic anemia. Direct and Indirect bilirubin are differentiation on why there is an increased bilirubin. Direct bilirubin is associated with liver dysfunction or blockage while Indirect bilirubin is related to destruction of red blood cells. This enzyme test is used chiefly as an

Done 6.84mmol/L

DONE 148umol/L

Done 0.497mmol/L

Done 33.3umol/L Done 7.6umol/L Done 25.7umol/L

Done 228U/L

Albumin

Attach result

index of liver and bone disease when correlated with other clinical findings. The test helps in determining if a patient has liver disease or kidney disease, or if not enough protein is being absorbed by the body. ultrasound Prior to admission patient had undergone UTZ, attaching the result in the chart allows better diagnosis and analysis for the rest of the medical team involved in his upcoming surgery.

Done 55.4

Refer accordingly 11:20am

Call doctors attention immediately once any unusuality occurs.

Done Cholecystitis with bile sludge formation and suggestive hydrophoric change. Cannot entirely rule out calculus in the cystic duct Done

04-28-09 7am

Meds: Lopicard 5mg tab OD Patient is hypertensive, c/o patients stock and was ordered to continue his maintenance medication. Please refer to Dr. Torno Prior to surgery Cadiofor Cardio-Pulmonary Pulmonary system clearance co must first be diagnosed management whether or not the patients circulatory and respiratory system can handle the surgery. Dr. Torno is an Intenist whose specialty is cardio and pulmo.

Done

Done

Pls. schedule for cholecystectomy

10am

04-28-09 12:20pm

lap Surgical removal of the gallbladder using a laparascope is indicated for acute cholecystitis. Secure consent Securing consent ensures the safety of both the medical team and the patient. It is the permission obtained from the patient that he is to undergo a surgical procedure. Anesthesiologist: Dr. Dr. Barinaga may be Eugene Barinaga the partner anesthesiologist of Dr. Batucan. Start vitamin K 10g IV Pre-operative standard OD operating procedure so as to prevent excessive bleeding during the actual surgical procedure. Follow up all lab results Lab results are not yet and attach to chart available, thus a follow up must be made in order for the doctors to correlate the findings. Start PLR iL @ KVO rate PLR an isotonic solution that resembles blood serum used as passage for the Vit. K IVTT that was ordered beforehand and for future medications. It is also used for hydration and electrolyte replacement. Anesthesiologist: Pre-op The referral was made Evaluation so as to ensure a safe Thanks for this referral and successful surgical procedure. Patient seen and Anesthesiologist made evaluated, chart review rounds to the patient

Done

Done

Done

Done

Done

Done

done

Anesthesia plans explained consequences and benefits explained

Nothing per orem temporary at 5am after breakfast

so as to establish a therapeutic relationship prior to the scheduled operation and to evaluate the patient. Explaining the pros and cons of the anesthesia allows the patient to contemplate and to have a mutual understanding with the anesthesiologist by agreeing with what anesthesia to use. To clear the digestive tract in preparation for the operation to avoid GI disturbances and reduce the possibility of vomiting and aspiration and the risk of possible bowel obstruction.

Done Accepted by patient

Done

04 -28-09 3pm

Pre-meds: Midiazolan 15mg 1tab An anti-anxiety drug, tab @ 12nn tomorrow given so as to relieve with 30cc of water. patients anxiety regarding his upcoming surgery. Resume consent for Consent is a written anesthesia understanding and a permission from the patient that allows the use of certain anesthesia in the surgical procedure that hell undergo. Reschedule OR OR schedule was not tomorrow at 7am indicated on prior orders. 7am was ordered for it was the most convenient time for patient, his medical team and the OR staffs.

Done

Done

Done

Inform OR, Dr. Barinaga

Informing Dr. Barinaga regarding the scheduled surgery allows him time to prepare and ready himself for the upcoming surgical procedure.

Done

04-28-09

IM: thank you for refer No history of cough but with rales at L>R CXR pneumonia CAP low risk HPN T/C DM2

04-28-09 5pm

10pm

Patient showed signs and symptoms of pneumonia. Patient was diagnosed with CAP low risk due to the findings above, HPN due to history of hypertension and T/C due to high serum glucose as shown in his FBS. Start Sulperazone 1.5g Given to treat IV q8 respiratory infection and also serves as preoperative prophylaxis. Continue Lopicard Patient may continue with his maintenance medication. Pls. reschedule surgery After being seen by his on Thursday internist, his surgeon then rescheduled the operation maybe due to patient having pneumonia. Anesthesiologist: Dr Change of Tozon anesthesiologist instead of Dr. Barinaga due to the rescheduling of the surgery. Schedule at 7am After rescheduling the day, OR finally gave the time for the patients surgery. Anesthesiologist aware The new anesthesiologist was

Done

Done Done

Done

Done

04-29-09 10:40am

04-29-09 1:40pm

5pm

04-30-09 12mn

made aware of the upcoming surgery for him to be prepared. For Surgery tomorrow at The scheduled 7am once cleared procedure will be carried out once the Internist cleared the patient for surgery. Cefoxitin (Monowell) Serves as pre1amp IVTT ANST now operative prophylaxis. prior to OR Kindly inform Dr. Although Sulperazone Batucan Sulperazone and Cefoxitin can serve will serve as pre-op as pre-operative antibiotic management prophyaxis, the discontinue Cefoxitin if internist chose ok with Dr. Batucan Sulperazone over Cefoxitin maybe because the former is more potent than the latter but still its the attending physicians decision on what drug to give. No absolute Surgery can now be contraindication to done after CP planned surgery CP ok clearance was done. Plan carry out above For abrupt orders implementation. For open Patient has gangrenous cholecystectomy instead gallbladder and open of lap chole cholecystectomy is indicated for such. IntraOp NPO now Patient was put on NPO for he is to undergo surgery the following day. Metoclopramide 1amp Promotes gastric IVTT at 6am emptying prior to surgery. Ranitidine 1amp IVTT at Patient was on NPO so 6am ranitidine, an H2 antagonist, was ordered because it

Done

Done Done

Done

Done

Done Done

inhibits the action of histamine at the H2 receptors of the parietal cells inhibiting gastric acid secretion. 04-30-09 To PACU PostOp For intensive monitoring after the surgery and for recovery. NPO Nothing per orem until patient passes out flatus for he still has no peristalsis and so as to avoid aspiration. VS q15 until stable, then Monitoring the vital q1 X 4hrs then q4 signs determines patients bodys reaction after he had undergone the surgery and so as for prompt intervention for any deviations in vital signs. IVF D5NSS iL at 120cc/hr To replenish fluids, nutrients and electrolytes. Meds: 1. Tramadol 50mg q6 Relief of moderate to IVTT moderately severe pain, serves also as a post operative analgesia. 2. Ketorolac 30mg q8 Short-term IVTT management (up to 5 days) of moderately severe acute pain and reduces signs and symptoms of inflammation - redness, swelling, fever, and pain. 3. Ranitidine 50mg q8 Ranitidine serves as IVTT post surgery antacid and to prevent ulcer of Done

Done

Done

Done

Done

Done

Done

4. Sulperazone 1.5g q8 IVTT Epidural anesthesia: Bupivacaine 0.25% 10cc + 0.25 MSO4 OD c/o Dr. Tozon

Morphine precaution I & O q shift

Refer accordingly 04-30-09 5pm IVFTF: D5NSS 120cc/hr iL at

which is ketorolacs adverse effect. Post operative prophylaxis Bupivacaine serves as analgesia for surgery added with magnesium sulfate so as to prevent seizue, convulsion and to lower the blood pressure. Ordered because morphine increases biliary spasm. Anesthetics and surgery affect the hormones regulating fluid and electrolyte balance (Aldosterone and ADH), placing the client at risk for decreased urine output and fluid and electrolyte imbalances. Monitoring I & O help assess fluid balance. Accurate measurement of a patient's fluid intake and output will identify those patients at risk of becoming dehydrated or overhydrated. Postoperative patients are at risk of these. Call doctors attention immediately once any unusuality occur To continue IVTT medication administration and to replenish electrolyte and fluid loss due to the surgical procedure.

Done Done

Done Done

Done Done

DIAGNOSTIC EXAMINATIONS Exam Result Reference Clinical Indication Hemoglobin is an important component of red blood cells that carries oxygen and carbon dioxide to and from tissues. The hemoglobin determination test is used to screen for diseases associated with anemia and in determining acid-base balance. The oxygen carrying capacity of the blood is also determined by the Hemoglobin -Observe the client for signs of anemia including pallor, dyspnea, chest pain, and fatigue. Care after test: Interpretatio n Above normal range. -Explain that a blood sample will be taken from the hand or arm and that the sample will be evaluated for the presence of infection or anemia in the body. Nursing Responsibility Prepare the client:

Range Hematology (April 27, 2009) Hemoglobi 172 M: 140n 170 F: 120 150 g/dL

Erythrocyt e

5.46

4.0-6.0 X10^9/L

concentration. This test is used to evaluate any type of decrease or increase in red blood cells. These changes must be interpreted in conjunction with other parameters, such as hemoglobin and/or hematocrit Measures the percentage of RBC in a blood volume. The test is performed to help diagnose blood disorders, such as polycythemia, anemia or abnormal

-Encourage Within normal range. rest periods for client experiencing fatigue related to anemia. -Evaluate clients ability to perform activities of daily living. -Refer to community health care services as Within normal range. needed if client is unable to meet basic daily needs. -Obtain a dietary consult to assist the client and family in choosing a well-balanced diet, including

Hematocrit

0.53

M: 0.40 0.60 F: 0.38 0.40

dehydration, blood transfusion decisions for severe symptomatic anemias, and the effectiveness of those Leukocyte 15.2 5.0 10.0 X10^9/L transfusions. A white blood cell count is a determination of number of WBC or leukocytes/uni t volume in a sample of venous blood. The test is used to detect infection or inflammation and leukemia, also used to help monitor the bodys response to various treatments Above normal range. An elevated number of leukocytes can result from infectious diseases (usually bacterial origin), and with trauma, surgery, or acute leukemia.

foods high in iron and vitamin B12. -Review related tests such as hemoglobin, hematocrit, reticulocyte count, RBC indices, TIBC, bone marrow and liver biopsies, and iron absorption and excretion studies.

and to monitor bone marrow function, and to determine the need for further tests, such as differential Differential Count: Segmenter count. Contains actual number of different types of leukocyte. It also evaluates the distribution and 0.72 morphology of the leukocytes. 0.45-0.65 They are the Above bodys main bacteria fighters by phagocytosis. The test is used to determine certain viral diseases, anemia, acute infections and inflammatory diseases. normal range, indicates neutrophils are found with a number of bacterial infections, inflammatory but noninfectious diseases (collagen disorders, rheumatic fever, pancreatitis),

and with malignancies Lymphocyt es 0.28 0.2-0.35 The largest group of leukocytes. Evaluate bacterial and viral infection, immune disease, leukemia, and ulcerative Platelet Count 222 150 450 X10^9/L colitis The smallest formed elements in blood that promote blood clotting after an injury. The test is performed to determine if blood clots normally, evaluate platelet production, and to diagnose and Within normal range . Within normal range.

monitor a severe increase or decrease in Blood Typing O

+

platelet count This blood test is performed to match donor blood with recipient who requires blood transfusion. Blood typing identifies the inherited antigens that compromise one of four possible blood types: A, B, AB, O.

Type O people have red blood cells with neither antigen, but produce antibodies against both types of antigens. Because of this arrangement, type O can be safely given to any person with any ABO blood type. Hence, a person with type O blood is said to be a "universal donor" but cannot receive blood except from the correspondin g O type people

Inform the patient about the purpose or significance of the test. Follow up results in the laboratory. Inform the patient the result of the test.

e Range Urinalysis (April 27, 2009) Physical Exam Color Amber Yellow

Exam

Result

Referenc

Clinical Indication

Interpretatio n

Nsg Responsibility Prepare client:

Urine specimens may vary in color from pale yellow to dark amber. The color of urine changes in many disease states due to the presence of abnormal pigment.

Amber colored urine is normal but it indicates high specific gravity and a small amount of urine. Specific gravity is above 1.020 and output less than 1L per day However, excretion of cloudy urine may not be abnormal since the change on urine pH may cause precipitation within the bladder of normal -Advise the client to wash the peri-anal area prior to collecting the specimen to avoid contamination with secretions or stool. -Inform the client that a specimen from the first -Explain that this test is to look for problems with the urine and the organs that help form it.

Appearance

Cloudy

Clear

Urine specimen may appear clear to cloudy. This helps to indicate presence of WBC, RBC, bacteria, pus, phosphates, urates and uric acid in the urine composition.

urinary constituents. Alkaline urine may appear cloudy because of the presence of phosphates, and acid urine may appear cloudy because of Reaction 6.0 4.6 - 8 It expresses the the urine as a dilute acid or base solution and measures the free hydrogen ion concentration in Specific Gravity 1.030 1.0101.035 the urine. Specific gravity is a means by which the kidneys ability to concentrate urine is Within normal range urates. Within

morning urination is preferred since it is usually concentrated and more likely to reveal abnormalities and formed substances. -Describe the procedure for collecting a clean-catch or midstream specimen if indicated

exact strength of normal range

Glucose

Negativ e

measured. Chemical Exam Negative Urine glucose test are used to detect diabetes, confirming a diagnosis of diabetes, or monitoring the effectiveness of diabetic control. Detection of protein in urine provides the basis for differential diagnosis of renal disease. Microscopic Exam Negative This is done to detect any bacteria/ infection in the genitourinary tract.

Normal

Albumin

+++

Negative

Above normal result.

Pus Cells

2-4/hpf

Above normal result, indicates patient may have an infection. Finding of more than 1 or 2 RBCs per high powered field is an

RBC

1-2/hpf

0 1/hpf

RBCs are occasionally found in the urine, but persistent findings should

be thoroughly investigated foe such indicates serious renal disease.

abnormal condition and can indicate a renal, systemic disease or trauma to the kidney. Normal

Mucus Threads

This is a common finding in urine since the entire urine system is filled with mucus.

X-ray Report (April 27, 2009) Chest PA Clinical Indication: Chest X-ray is done to diagnose pulmonary disease and diseases of the mediastinum and bony thorax. This test also gives valuable information on the condition of the heart, lungs, gastrointestinal tract and thyroid gland. Findings: Heart is within normal limit in size. There are infiltrates on both lung bases. Rest of the lung fields is clear. Lateral CP sinuses are sharp. Impression: Suggestive of an inflammatory lung disease compatible with bibasal pneumonia. Please correlate clinically. Interpretation: Chest X-ray was ordered so as to assess the patients cadio and pulmonary system prior to surgery and it was found out that aside from having cholecystitis, patient also has pneumonia which then needs an Internist to determine whether he can proceed with the scheduled surgery. Nursing Responsibilities: Explain to the patient that the chest x-ray will be used for screening, diagnosis and evaluation of change in his respiratory system. Explain the nature of the procedure to the patient Instruct the patient to remove all metal objects between his neck and chest and change to hospital gown.

Instruct the patient to take a deep breath and exhale; then he is required to take another deep breath but hold it while the picture is taken.

Tell patient that the procedure takes only a few minutes. Inform the patient regarding the result of the test.

ECG Result (April 27, 2009) Rate: 25 min PR interval: 0.10second Rhythm: Sinus QRS: 0.08second Axis: +15 QTc: 0.44seconds Position Intermediate Interpretation: Normal Sinus Rhythm >The electrical impulse is formed in the SA node and conducted normally. >This is the normal rhythm of the heart. Nursing Responsibilities: Inform patient on why and how the test is done. Tell him that this is not an invasive procedure, painless and a safe test. Place patient in a supine position in the bed or table. Prepare the skin (shave if there is excess hair) by applying contact paste or prejelled discs. Place the electrodes accurately. Inform the patient regarding the result.

Range Blood Chemistry (April 27, 2009) FBS 6.84 4.20 6.40 mmol/L

Exam

Result

Reference

Clinical Indication Fasting blood sugar test measure the amount of glucose in the blood and to detect any disorder of glucose metabolism.

Interpretation Above normal level, indicates diabetes.

Nsg Responsibility - Explain that a blood sample will be taken from the hand or arm and that the sample will be evaluating the amount of sugar present in the blood that may indicate diabetes and evaluate if metabolic derangement has resulted by the disease. -Instruct the client not to eat or drink anything, 12 hours prior to taking the

test. He can just drink water. -Administer Omeprazole 400 mg tab, 1 tab OD to suppress gastric acid secretion, preventing hyperacidity since the patient will be on NPO for 12 hours. Creatinine 148 53 97 umol/L Creatinine is a nitrogenous waste product produced during protein metabolism in muscle tissue. The test is used to determine kidney function and/or 2. Assess fluid and nutritional status of Above normal range, which indicates a decreasing kidney function, or muscle disease. 1. Explain that this test is important to help understand how well the kidneys are working.

damage.

client for clues or renal impairment and other disease causing changes in creatinine levels. 3. Continuously monitor fluid balance through daily weights and intake and output recordings. 4. Evaluate for increased fluid volume manifested by edema, decreased urine out put, neck vein distention, dyspnea and hepatomegaly

. Total Bilirubin 33.3 2.0 21.0 umol/L The measurement of bilirubin is important in evaluating liver function, and hemolytic anemia. A NORMAL level of total bilirubin reules out any significant Direct Bilirubin 7.6 0.0 3.4 umol/L impairment in the excretory function of the liver or Indirect Bilirubin 25.7 2.0 17 umol/L excessive hemolysis of red blood cells. Differentiation of bilirubin is done to determine which of the problems above is the cause of the Above normal range, may indicate obstructive jaundice of which is a result of obstruction of the common bile duct or hepatic ducts due to stones or neoplasm. Above normal range, may indicate choledocholithi asis. Above normal range, may indicate hemolytic anemia. Inform patient regarding the test result. Tell patient that 10ml venous blood is to be collected before he eats his breakfast. Explain the purpose and the procedure of the test.

elevation of total bilirubin. An in crease in indirect bilirubin is associated with hemolysis while an increase in direct bilirubin is seen as liver dysfunction or Uric Acid 0.497 0.2 0.4 umol/L blockage. Uric acid is formed from the breakdown of nucleonic acids and is an end product of purine metabolism. Measurement of uric acid is most commonly in evaluation of renal failure, gout and leukemia. Above normal range, could be associated with nitrogen retention and with increase in urea, creatinine and other nonprotein nitrogenous substances in the blood. May indicate a decreased renal function. Monitor patients intake and output so as to determine if he has a decreased Inform the patient regarding the result. Explain the purpose and the procedure of the test.

renal function. Alkaline Phosphatas e 228 64 306 U/L This enzyme test is used chiefly as an index of liver and bone disease when correlated with other clinical findings. In liver disease, the blood level rises when excretion of this enzyme is impaired as a result of obstruction in the biliary Albumin 55.4 38 51 g/L tract. This test can help determine if a patient has liver disease or kidney disease, or if the body is not absorbing enough Inform the patient regarding the result. Above normal range, may indicate renal disease. Explain the purpose and the procedure of the test. Inform the patient regarding the result. Within normal range Explain the purpose and the procedure of the test.

protein.

Ultrasound Report (04/27/09) Ultrasound Report (This report is based on sonographic findings and must be correlated clinically.) The liver is normal in size and tissue attenuation with smooth external outline. No cystic or solid parenchymal lesions demonstrated here. The intrahepatic ducts are not dilated. The width AP diameter of the common bile duct is 0.4cm. no focal lesions noted intraluminally. The gallbladder is significantly distended to 11.6cm to 4.1cm (length X AP dm) with diffusely thickened walls that measures up to 1.1cm low level echoes are seen in the dependent portion of the gallbladder. Quetionable echoes are seen in the partly obscured cystic duct. The pancreas is obscured by overlying bowel gas preluding adequate assessment. Impression: > Cholecystitis with bile sludge formation and suggestive hydrophoric change. Cannot entirely rule out calculus in the cystic duct > Sonographically normal liver and biliar ducts Interprertation: Based on the above findings (patient has gangrenous gallbladder), he then needs to undergo open cholecystectomy instead of lap cholecystectomy.

Nursing Responsibilities: Explain the purpose and the procedure of the test. Inform patient that ultrasound is a noninvasive procedure. Instruct him not to eat solid food for the 12 hours prior to exam to allow greatest dilation of the gallbladder. Inform him that water is permitted. Inform patient regarding the result. DRUG STUDY Generic Name: Amlodipine besylate Brand Name: Lopicard Classification: Calcium channel blocker;

Antianginal; Antihypertensive Mode of Action: Blocks the transport of calcium into the smooth muscle cells lining the coronary arteries and other arteries of the body. Since calcium is important in muscle contraction, blocking calcium transport relaxes artery muscles and dilates coronary arteries and other arteries of the body. By relaxing coronary arteries, amlodipine is useful in preventing chest pain (angina) resulting from coronary artery spasm. Relaxing the muscles lining the arteries of the rest of the body lowers the blood pressure, which reduces the burden on the heart as it pumps blood to the body. Reducing heart burden lessens the heart muscle's demand for oxygen, and further helps to prevent angina in patients with coronary artery disease. Dosage: Lopicard 5mg tab OD

Indication: Hypertension Contraindication: Hypersensitivity to amlodipine, impaired hepatic or renal function, sick sinus syndrome, heart block (second or third degree), lactation Side Effects: dizziness, light-headedness, headache, fatigue, edema of the lower extremities, flushing, nausea, vomiting, palpitations, stomach pain, drowsiness, muscle cramps, abdominal discomforts Adverse Effects: asthenia, arrhythmias, chest pain, yellowing of the eyes or skin, difficulty breathing Drug - Drug Interaction: Risk of congestive heart failure with betaadrenergic blockers. Increased antihypertensive effects with other antihypertensives. Possible increased serum levels and toxicity of cyclosporine if taken concurrently. Nursing Responsibilities: 1. Assess patient for contraindication. 2. Assess for baseline data. 3. Administer drug without regard to meals. 4. Monitor patients vital signs carefully while adjusting drug to therapeutic dose. 5. Instruct patient to take drug with meals if stomach upset occurs. 6. Instruct him to take drug exactly as prescribed by his physician.

7. Tell patient that he may experience some side effects brought upon by the drug. 8. Instruct him to report intolerable side effects so management can be done. 9. Instruct him to eat frequent small meals if vomiting occurs. 10. 11. Oral care if patient vomits. Instruct him to adjust lighting, noise and temperature if he

experiences headache and report if it is intolerable so that medication may be given. 12. Instruct him to report any adverse effects that he may experience.

Generic Name: Vitamin K BRAND NAME: Aqua-Mephyton CLASSIFICATION: Fat soluble vitamin MECHANISM OF ACTION: Vitamin K is essential for the hepatic synthesis of factors II, VII, IX, and X, all of which are essential for blood clotting. Vitamin K deficiency causes an increase in bleeding tendency, demonstrated by ecchymoses, epistaxis, hematuria, GI bleeding. DOSAGE: Vitamin K 10g IV OD INDICATION: Prevention of bleeding, Vitamin K malabsoption, hypoprothrombinemia CONTRAINDICATION: Hypersensitivity, severe hepatic disease, last few wk of pregnancy SIDE EFFECTS: Dizziness, flushing, transient hypotension after IV administration, rapid and weak pulse, diaphoresis, erythema, pain swelling and hematoma at injection site ADVERSE REACTION: Anaphylaxis or anaphylactoid reactions, usually after rapid IV administration DRUG INTERACTION: Cholestyramine, mineral oil: may inhibit Gi absorption of vitamin K Oral anticoagulants: decreased anticoagulant effect

 Antibiotics: may inhibit vitamin K production leading to bleeding NURSING RESPONSIBILITIES : 1. Assess for contraindication. 2. Assess for baseline data. 3. Monitor protime during treatment; monitor for bleeding, pulse and BP. 4. Teach patient not to take other supplements, unless directed by prescriber, to take this medication as directed. 5. Tell patient that he may experience side effects brought about by the drug and to report intolerable ones so as prompt interventions be done. 6. Instruct patient to report symptoms of bleeding: bruising, nosebleeds, bleack tarry stools, hematuria. 7. Stress the need for periodic lab tests to monitor coagulation level. 8. Instruct patient to report adverse effect that he may experience.

Generic Name: Midazolam HCl Brand Name: Dormicum Classification: Benzodiazepine (short-acting);Anxiolytic; CNS depressant; Anticonvulsant Mode of Action: Acts mainly at the limbic system and reticular formation; potentiates the effects of gamma amino butyric acid (GABA), an inhibitory neurotransmitter; anxiolytic and amnesia effects occur at doses below those needed to cause sedation, ataxia; has little effect on cortical function. Dosage: Midazolam 15mg 1tab tab at 12nn with 30cc of water Indication: Sedation, anxiolysis, and amnesia prior to surgery Contraindication: acute Hypersensitivity glaucoma, to benzodiazepines;psychoses, coma, acute alcoholic

marrow-angle

shock,

intoxication, pregnancy (cleft lip or palate, inguinal hernia, cardiac defects, microencephaly, pyloric stenosis have been reported when used in the first trimester; neonatal withdrawal syndrome reported in infants); neonates Side Effects: Drowsiness, dizziness, GI upset, difficulty concentrating, fatigue, nervousness, crying, dreams, hiccups, diaphoresis, incontinence, nausea, vomiting, diarrhea, constipation, dry mouth, salivation, headache, light-headedness Adverse Effects: Lethargy, apathy, disorientation, delirium, stupor, dysarthria, dystonia, tremor, rigidity, vertigo, euphoria, vivid dreams,

psychomotor

retardartion,

extrapyramidal

symptoms,

nystagmus,

bradycardia, tachycardia, urticaria, gastric disorder, jaundice, hepatic dysfunction, paresthesias, gynecomastia, bronchospam, laryngospam, drug dependence, respiratory depression, respiratory arrest

Drug Drug Interaction: Increased CNS depression with alcohol, opioids, barbiturates, other sedatives and anaesthetics. Increased respiratory depression with opiates, phenobarbital, other benzodiazepines. Plasma concentrations increased by CYP3A4 inhibitors such as cimetidine, erythromycin, clarithromycin, diltiazem, verapamil, ketoconazole and itraconazole, antiretroviral agents, quinupristin with dalfopristin. Midazolam concentration decreased by phenytoin, carbamazepine, phenobarbital, rifampicin. Halothane, thiopental requirements may be reduced during concurrent use. Nursing Responsibilities: 1. Assess patient for contraindication. 2. Assess for baseline data. 3. Monitor level of consciousness before, during and for at least 2 6hours after administration. 4. Carefully monitor VS during administration. 5. Keep patient on bed for 3hours, not to permit ambulation upon administration. 6. Teach him that the drug helps him to relax and will make him sleep, and the drug is a potent amnesiac and he will not remember what has happened on him. 7. Instruct him to take the drug exactly as prescribed. 8. Instruct him to avoid alcohol, or sleep inducing, or OTC drugs before receiving the drug. 9. Tell patient that he may experience side effects brought upon by the drug.

10.

Instruct patient to report adverse effects that he may

experience.

Generic Name: Cefoperazone Na 1 g, Sulbactam Na 0.5 g Brand Name: Sulperazone [vial] Classification: Cephalosporin, antibiotic Mode of Action: Inhibits bacterial cell wall synthesis causing cellular death Dosage: Sulperazone 1.5g q8 IVTT Indication: Treatment of respiratory infection caused by S. pneumoniae, H. parainfluenzae, S. aureus, E. coli, Klebsiella, H. influenzae, S. pyrogenes; Perioperative prophylaxis; Post operative prophylaxis Contraindication: Hypersensitivity to cephalosporin or penicillin, or renal failure Side Effects: diarrhea, nausea, vomiting, headache, dizziness, hypotension, abdominal pain, pain at injectionsite, inflammation at IV site, rash Adverse Effects: paresthesia, seizure, liver toxicity, nephrotoxicity, bone marrow depression, leukopenia, anaphylaxis, hematuria, vasculitis, shock Drug Drug Interaction: Increased nephrotoxicity with aminoglycosides Increased bleeding effects with anticoagulant

 Disulfiram-like reaction may occur if alcohol is taken 72hrs after drug administration

Nursing Responsibilities: 1. Assess for contraindication. 2. Assess for baseline data. 3. Inject slowly over 3-5 minutes. 4. Have vitamin K injection readily available in case of hypoprothrombinemia. 5. Tell patient that he may experience side effects that are brought about by the drug. 6. Instruct him to report intolerable side effects so management can be done. 7. Instruct him to eat frequent small meals if vomiting occurs. 8. Oral care if patient vomits. 9. Minimize stimuli (adjust temperature, lighting and avoid noise) if headache occurs and if intolerable pain medication may be given as ordered. 10. 11. Instruct patient to avoid alcohol because severe reactions Tell patient to report any adverse effects that he may could occur. experience.

Generic Name: Cefoxitin Sodium Brand Name: Monowell Classification: Antibiotic; Cephalosporin (second generation) Mode of Action: Bactericidal: inhibits synthesis of bacterial cell wall, causing cell death. Dosage: Cefoxitin 1 amp IVTT ANST now prior to OR Indication: Surgical prophylaxis Contraindication: Hypersensitivity to cephalosporins or penicillins. Side Effects: Nausea, vomiting, diarrhea, flatulence, anorexia, headache, phlebitis, rash, fever, pain on injection site, dizziness, stomach upset Adverse Effects: Lethargy, pseudomembranous colitis, paresthesias, liver toxicity, nephrotoxicity, convulsion, leukopenia, decreased hematocrit, decreased platelet, anaphylaxis, superinfection, Drug Drug Interaction: Enhanced nephrotoxicity with aminoglycosides and loop diuretics e.g. furosemide. Renal excretion inhibited by probenecid. Increase bleeding with oral anticoagulants. Disulfiram-like reaction may occur if alcohol is taken within 72hours after drug administration.

Nursing Responsibilities: 1. Assess patient for contraindication. 2. Assess for baseline data. 3. Have vitamin K readily available in case of hypoprothrombinemia occurs. 4. Instruct patient to avoid alcohol for 3days after drug administration because serious reactions often occur. 5. Tell patient that he may experience some side effects brought upon by the drug. 6. Instruct him to report intolerable side effects so management can be done. 7. Instruct him to eat frequent small meals if vomiting occurs. 8. Oral care if patient vomits. 9. Instruct him to report any adverse effects that he may experience.

Generic Name: Metoclopramide Brand Name: Octamide PFS, Reglan Classification: GI stimulant, antiemetic, dopaminergic blocker Mode of Action: Stimulates the muscles of the gastrointestinal tract including the muscles of the lower esophageal sphincter, stomach, and small intestine by interacting with receptors for acetylcholine and dopamine on gastrointestinal muscles and nerves; decreases the reflux of stomach acid by strengthening the muscle of the lower esophageal sphincter; stimulates the muscles of the stomach and thereby hastens emptying of solid and liquid meals from the stomach and into the intestines; interacts with the dopamine receptors in the brain and can be effective in treating nausea. Dosage: Metoclopramide 1amp IVTT @ 6am Indication: Stimulation of gastric emptying prior to surgery Contraindication: Hypersensitivity to metoclopramide, GI hemorrhage, mechanical obstruction or perforation; pheochromocytoma (may cause hypertensive crisis); epilepsy Side Effects: drowsiness, restlessness, fatigue, anxiety, insomnia, depression, sedation, nausea, diarrhea, urinary frequency Adverse Effects: parkinsonm-like reactions, involuntary muscle

movements, facial grimacing, dystonic reactions resembling tetanus, transient hypertension, tardive dyskinesia, myoclonus

Drug Drug Interaction Decreased absorption of Cefprozil, cimetidine, digoxin from the stomach Increased oral bioavailability or absorption of acetaminophen, cyclosporine, ethanol, levodopa, tetracycline Decreased effect on gastric emptying with anticholinergic, opioid analgesics, levodopa Increased risk of serious adverse effects due to excess release of neurotransmitters (Marplan), with MAOIs (Nardil), for example, isocarboxazid (Parnate), phenelzine tranylcypromine

selegiline (Eldepryl), and procarbazine (Matulane) Nursing Responsibilities: 1. Assess patient for contraindication. 2. Assess for baseline data. 3. Give direct IV dose slowly (over 1 to 2 minutes). 4. Monitor BP carefully during IV administration. 5. Monitor for extrapyramidal reactions, and consult physician if they occur. 6. Keep diphenhydramine injection readily available incase of extrapyramidal reactions. 7. Have phentolamine readily available in case of hypertensive crisis (most likely to occur with undiagnosed pheochromocytoma). 8. Tell patient that he may experience side effects brought upon by the drug. 9. Instruct patient to report involuntary movement of the face, eyes or limbs, severe depression, severe diarrhea. 10. Provide a safe environment if restlessness, involuntary muscle movement occur.

Generic Name: Ranitidine Brand Name: Zantac Classification: Histamine 2 antagonist Mode of Action: Competitively inhibits the action of histamine at the H2 receptors of the parietal cells f the stomach, inhibiting basal gastric acid secretion and gastric acid secretion that is stimulated by food, insulin, histamine, cholinergic agonist, gastrin, and pentagastrin. Dosage: Ranitidine 50mg q8 IVTT Indication: Post surgery antacid to prevent ulcer formation Contraindication: Hypersensitivity to ranitidine, lactation. Side Effects: headache, rash, dizziness, vertigo, constipation, diarrhea, nausea, vomiting, abdominal discomforts, local burning or itching at IV site Adverse Effects: malaise, insomnia, somnolence, urticaria, tachycardia, bradycardia, leukopenia, pancytopenia, thrombocytopenia, gynecomastia, impotence, hepatitis Drug Drug Interaction: Increased effects of warfarin, tricyclic antidepressants

Nursing Responsibilities: 1. Assess patient for contraindication. 2. Assess for baseline data. 3. Tell patient that he may experience side effects brought about by the drug. 4. Instruct patient to take his meal if nausea or vomiting occurs. 5. Oral care if vomiting occurs. 6. Adjust lighting and temperature and avoid noise if he experiences headache and instruct him to report if it is intolerable so that medication may be given. 7. Instruct him to report intolerable side effects so as prompt intervention could be done. 8. Instruct him to report adverse effects that he may experience.

Generic Name: Tramadol HCl Brand Name: Ultram Classification: Analgesic, centrally acting Mode of Action: Binds to mu-opioid receptors and inhibits the reuptake of norepinephrine and serotonin; causes many effects similar to opioids dizziness, somnolence, nausea, constipation but does not have the respiratory effects. Dosage: Tramadol 50mg q 6 IVTT Indication: Relief of moderate to moderately severe pain; post surgery analgesia Contraindication: Hypersensitivity to tramadol or opioids or acute intoxication with alcohol, opioids, or psychoactive drugs Side Effects: Nausea, constipation, dizziness, headache, drowsiness, vomiting, somnolence, sedation, headache, dry mouth, sweating, diarrhea, rash, visual disturbances, vertigo Adverse Effects: Confusion, anxiety, seizure, tachycardia, bradycardia, pallor, anaphylactoid reactions Drug Drug Interaction: Carbamazepine reduces the effect of tramadol by increasing its inactivation in the body.

 Quinidine (Quinaglute, Quinidex) reduces the inactivation of tramadol, thereby increasing the concentration of tramadol by 50%-60%. Combining tramadol with monoamine oxidase inhibitors (for example, Parnate) or selective serotonin inhibitors [(SSRIs, for example, fluoxetine (Prozac)] may result in severe side effects such as seizures or a condition called serotonin syndrome. Tramadol may increase central nervous system and respiratory depression when combined with alcohol, anesthetics, narcotics, tranquilizers or sedative hypnotics. Nursing Responsibilities: 1. Assess for contraindications. 2. Assess for baseline data. 3. Tell patient that he may experience side effects brought upon by the drug. 4. Instruct him to report side effects that are intolerable. 5. Control environment (temperature, lighting) if sweating or CNS effects occur. 6. Encouraged small frequent meals if vomiting occurs. 7. Oral care for dry mouth and vomiting. 8. Encourage him to increase oral fluid intake. 9. Instruct patient to report adverse effects that he may experience.

Generic Name: Ketorolac tromethamine Brand Name: Toradol Classification: NSAID, Nonopioid analgesic Mode of Action: Reduces the production of prostaglandins, chemicals that cells of the immune system make that cause the redness, fever, and pain of inflammation and that also are believed to be important in the production of non-inflammatory pain. It blocks the enzymes that cells use to make prostaglandins (cyclooxygenase 1 and 2). As a result, pain as well as inflammation and its signs and symptoms - redness, swelling, fever, and pain - are reduced. Dosage: Ketorolac 30mg q8 IVTT Indication: For short-term management (up to 5 days) of moderately severe acute pain that otherwise would require narcotics. It most often is used after surgery. Contraindication: Hypersensitivity to ketorolac, renal Impariment, aspirin allergy Side fluid Effects: rash, ringing in the ears, headaches, dry dizziness, mucous

drowsiness, abdominal pain, nausea, diarrhea, constipation, heartburn, retention, somnolence, insomnia, dyspepsia, membrane, sweating, peripheral edema, GI pain Adverse Effects: gastric or duodenal ulcer, renal impairment, liver failure, dysuria, bleeding, platelet inhibition, neutropenia, leukopenia, pancytopenia, thrombocytopenia, bone marrow depression

Drug Drug Interaction: Increased levels of ketorolac in the body and increased side effects with Probenecid (Benemid). Increase risk of lithium toxicity with lithium (Eskalith) Reduced kidney function with concominatnt use with angiotensin converting enzyme (ACE) inhibitors. Increase risk of bleeding with anticoagulants (warfarin), aspirin Increased risk of nephrotoxicity with other nephrotoxins (aminoglycosides, cyclosporine) Nursing Responsibilities: 1. Assess patient for contraindication. 2. Assess for baseline data. 3. Infuse slowly as a bolus over no less than 15 seconds. 4. Administer with ranitidine to avoid ulceration. 5. Tell patient that he may experience side effects brought upon by the drug. 6. Encouraged oral fluid intake to avoid dry mucous membrane. 7. Provide comfort measures if headache occurs. 8. Instruct to report intolerable side effects for prompt intervention. 9. Instruct to report signs of bleeding such as black tarry stool, weakness and dizziness upon standing. 10. Instruct to report if he experiences adverse effects.

Generic Name: Bupivacaine Brand Name: Bupican Classification: Anesthesia Mode of Action: Block the generation and the conduction of nerve impulses, presumably by increasing the threshold for electrical excitation in the nerve, by slowing the propagation of the nerve impulse, and by reducing the rate of rise of the action potential. The analgesic effects of Bupivacaine are thought to be due to its binding to the prostaglandin E2 receptors, subtype EP1 (PGE2EP1), which inhibits the production of prostaglandins, thereby reducing fever, inflammation, and hyperalgesia Dosage: Bupivacaine 0.25% 10cc + 0.25MSO4 OD Indication: Local or regional anesthesia; analgesia for surgery Contraindication: Hypersensitivity to bupivacaine or other local anesthesia e.g. lignocaine, blood clotting disorder, low blood pressure, Side Effects: nervousness, tingling around the mouth, tinnitus, tremor, dizziness, blurred vision, ringing of the ears, feeling of disorientation, nausea, vomiting, drowsiness, numbness of tongue, lightheadedness Adverse Effect: convulsion, seizures, unconsciousness, arrhythmias, tachycardia, bradycardia, cardiac arrest, hypotensive shock, respiratory arrest, myocardial depression,

Drug

Drug

Interaction:

Additive

effects

when

used

with

antiarrhythmic drugs

Nursing Responsibilities: 1. Assess for contraindication. 2. Assess for baseline data. 3. Monitor vital signs carefully, drug depresses the pulmonary and cardiac system. 4. Monitor for side effects. 5. Tell patient that he may experience side effects brought about by the drug and if such is/are intolerable he must report them so as prompt interventions be done. 6. Oral care if vomiting occurs. 7. Monitor for occurrence of adverse effects, report to the anesthesiologist any signs and symptoms of adverse effects. 8. Continue to monitor patient following discontinuation of anesthesia.

Generic Name: Magnesium Sulfate Brand Name: Classification: Electrolyte, Antiepilecptic, Antihypertensive, Laxative Mode of Action: An important cofactor for enzymatic reactions and plays an important role in neurochemical transmission and muscular excitability; prevents or controls and convulsions the by blocking of neuromuscular transmission decreasing amount

acetylcholine liberated at the end plate by the motor nerve impulse; attracts and retains water in the intestinal lumen and distends the bowel to promote mass movement and relieve constipation; acts peripherally to produce vasodilation; larger doses cause lowering of blood pressure. Dosage: Bupivacaine 0.25% 10cc + 0.25MSO4 OD Indication: Parenteral anticonvulsant for the prevention and control of seizures, lowers BP while in surgery Contraindication: Hypersensitivity to magnesium sulfate, heart block, myocardial damage; abdominal pain, appendicitis, fecal impactation, hepatitis, intestinal and biliary tract obstruction Side Effects: weakness, dizziness, excessive bowel movement,

sweating, flushing, headache, nausea, vomiting, palpitations Adverse Effects: fainting, magnesium paralysis, intoxication, hypothermia, hypotension, circulatory

depressed

reflexes,

flaccid,

collapse, cardiac and CNS depression, hypocalcemia, tetany

Drug Drug Interaction: Potentiation of neurotransmuscular neuromuscular blockade relaxants produced by nondepolarizing (tubocurarine,

atracurium, pancuronium, vecuronium) CNS depression and peripheral transmission defects produced by magnesium is antagonized by calcium. Reduces antibiotic activity of streptomycin, tetracycline and tobramycin when given together. Nursing Responsibilities: 1. Assess for contraindication. 2. Assess for baseline data. 3. Do not administer unless solution is clear and container is undamaged. Discard unused portion. 4. Monitor knee-jer reflex before repeated parenteral administration. If it is suppressed, do not administer the drug for it may cause respiratory center failure. 5. Administer with caution if flushing and sweating occurs. 6. Have calcium gluconate readily available if signs and symptoms of hypermagnesemia occur. 7. Tell patient that he may experience some side effects brought about by the drug and instruct him to report intolerable side effects so as prompt intervention be done. 8. Oral care when vomiting occurs. 9. Volume for volume replacement when excessive bowel movement and vomiting occurs to replace the loss fluid. 10. Instruct patient to report adverse effects immediately.

Procedural Report
on Open Cholecystectomy

Surgeon: Dr. Batucan, Wolter Operation: Open Cholecystectomy Anesthesiologists: Dr. Togon

Date of Surgery: 04/30/09 at 7:00 am Definition Cholecystectomy is the excision (removal) of the gallbladder. Discussion Cholecystectomy may be performed to treat chronic or acute cholecystitis, with or without cholelithiasis, or to resect a malignancy. Note: Cholecystectomy, performed laparoscopically, is the preferred treatment for symptomatic gallstones unless the patient is extremely obese, there are excessive adhesions, or ductal or vascular anomalies exist. If unexpected pathology is encountered, if acute inflammation distorts normal tissue planes, or if there is excessive bleeding or surgical injury, the laparoscopic procedure is promptly converted to open cholecystectomy. Type of Anesthesia General anesthesia Thoracic epidural anesthesia (as an alternative)

Preparation of the Patient Antiembolitic hose may be put on the legs, as requested. The patient is supine; both arms may be extended on padded armboards. A pillow may be placed under the sacrum and/ or under the

knees to avoid straining back muscles. Pad all bony prominences and areas vulnerable to skin and neurovascular pressure of trauma. A nasogastric tube may be inserted by the anesthesia provider. A foley catheter is not routinely placed. An electrosurgical dispersive pad is applied. Skin Preparation Begin at the intended site of incision, either right subcostal (most frequently used), right paramedian, or medline, extending from the axilla to the pubic symphysis and down to the table on the sides. Procedure The incision is right subcostal, right paramedian, or midline. The abdominal cavity is entered in the usual manner. The gallbladder is grasped (generally with a Pean clamp). The cystic duct, cystic artery, and common bile duct are exposed. The surgeon must be aware of anomalies of these structures. The cystic artery is clamped (using two right-angle clamps) and ligated with a suture passed on a long instrument or by clips (e.g., Hemoclips), as is the cystic duct. The gallbladder is mobilized by incising the overlying peritoneum and after local dissection is removed. The underlying liver bed may be reperitonealized. A drain (e.g., Jackson-Pratt ) may be employed exiting a stab wound and secured to the skin with a stitch. The wound is closed in layers. The skin is closed with interrupted stitches, tapes, or skin staples.

Instruments, Machines and Supplies Draping 4 folded towels and a laparotomy sheet

Equipment Folded blanket or pad (for positioning) Sequential compression device with disposable leg wraps, if ordered Suction Ultrasound generator, if requested Laser (e.g., Nd: YAG laser fiber or pulsed dye) when requested

Instrumentation Major procedures tray Long Metzenbaum scissors Hemoclip or other ligating clip appliers Biliary tract tray (for common duct exploration) Choledochoscope when requested; if unavailable, a uteroscope or small cystoscope may be substituted Supplies Antiembolitic hose Basin set Blades, (2) #10, (1) #15, or (1) #11 Suction tubing

Hemoclips or similar ligating clips Electrosurgical pencil and cord with holder and scrape pad Needle magnet or counter Dissectors (e.g, peanut or Kittner sponges) Drains, e.g., Penrose 1 or suction drain (e.g., Jackson-Pratt or Hemovac), optional

Mushroom-tipped (retention) catheters, e.g., Pezzer or Malecot, available

Culture tubes, one aerobic and one anaerobic Hemostatic agent e.g., Surgicel, Helistat, Thrombostat, Avitene, available

Nursing Responsibilities Preoperative All care that is given and observations made regarding the patient (e.g., condition of skin preoperatively) must be

documented in the operative record for continuity of care and for medicolegal reasons. The nurse conveys to the patient that he will act as the patients advocate by speaking for him while the patient is in surgery.

Assess health factors that affects the patient preoperatively: nutritional status, drug or alcohol use, cardiovascular status, hepatic and renal function, endocrine function, immune function, previous medication use, psychosocial factors, as well as the spiritual and cultural beliefs.

When the circulator reviews patient allergies with the patient, he ascertains that the patient has no history of allergy to radiopaque dye.

Inform the patient of the scheduled date and time of the surgery and where to report

Instruct what to bring (insurance card, list of meds & allergies) Check the chart for patients sensitivities and allergies e.g. allergy to iodine. Document allergies noted preprocedure and document alternative used.

Instruct what to leave at home such as jewelry, watch, medications and contact lenses

Instruct what to wear ( loose fitting, comfortable clothes and flat shoes)

Remind the patient not to eat or drink if directed The patient may have fear and anxiety regarding the surgical procedure and the unfamiliar environment. Explain nursing procedures before performing them and the sequence of perioperative events.

Assess and document patients anxiety level and level of knowledge regarding the intended procedure. Clarify

misconceptions by answering the patients questions in a knowledgeable manner and refer questions to the surgeon as necessary. Decrease fear Teach deep-breathing, coughing or incentive spirometer Provide emotional support to the patient regarding feelings of altered body image by providing the patient an opportunity to express her feelings. Respect cultural, spiritual and religious beliefs

Intraoperative It is imperative that the patient be positioned over the correct area on the table to ensure accurate visualization of the biliary tract. A protective facial shield is suggested for those scrubbed to avoid inadvertent splashing of contaminated fluids onto mucous membranes and eyes. All medications, dyes, etc., on the opening field must be labeled. Scrub person should use a marking pen on labels to identify all solutions. All medication containers should be kept in the room until the completion of the procedure.

Instruments used on the gallbladder are isolated in a basin (considered contaminated)

Prevent musculoskeletal injuries to team members by employing ergodynamic measures when positioning the patient.

Take

appropriate

measures

to

maintain

patients

body

temperature e.g., offer warm blanket or raise room temperature as necessary. Keep the patient adequately covered to maintain patients privacy, expose only the immediate area involved for the procedure. Strictly follow the principles of surgical asepsis Keep surgical conscience Count all instruments and sharps with circulating nurse before and after the procedure Know the name and use of the instrument Never pile the instruments on top of each other Know the name and use of the instrument and handle the instrument individually Hand the surgeon the correct instrument Pass the instrument firmly and decisively Be careful in handling of sharp instruments at all times

The scrub person sets up the instruments on the back table for the surgeon.

Scrub person needs to have a right angle clamp (Mixter) available throughout the dissection of the biliary tree.

Usually a stab wound is made in the cystic duct using a #11 blade. The incision is extended with Potts scissors.

Have T-tubes available following common duct exploration One syringe is filled with saline, and a second syringe is filled with radiopaque dye diluted to half strength (labeled

accordingly) Scrub person takes care to make certain that the saline or dye catheters are devoid of air bubbles (which can be confused for calculi) Use a small basin to accept the specimen Aerobic and anaerobic cultures may be taken of the bile or gallbladder bed.

Postoperative The circulator accompanies the anesthesia provider and the patient to the PACU; he/she gives the PACU perioperative practioner a detailed intraoperative patient report regarding the course of events as they apply to the individual.

Assess the patient: appraise air exchanges status & note skin color; verify & identify operative status & surgeon performed; assess neurological status (LOC)

PACU nurse observes the patients breathing, monitors blood pressure and vital signs, and documents all pertinent

information. PACU nurse assumes the role as the patients advocate.. Report for abnormalities especially for signs and symptoms of shock Perform safety checks good body alignment, side rails and maintain patent airway and cardiovascular stability Relieve pain and anxiety

Reference pp. 148-153, Maxine A. Goldman 2008, Pocket Guide to the Operating Room. 3rd edition F.A. Davis Company.Philadelphia

Nursing Theories Ma. Estine Levines Conservation Model Levines conservation model provides a thoughtful basis for making effective wound management choices in order to improve wound healing and consequently ameliorate individual well being and quality of life. The relationship between effective wound management and positive patient outcomes draws on Levines four conservation principles, about which she states: The conservation principles address the integrity of the individual from birth to death. Every activity requires an energy supply because nothing works without it. Every activity must respect the structural wholeness of the individual because well-being depends on it. Every activity is chosen out of the abilities, life experience, and desires of the self who makes the choices. Every activity is a product of the dynamic social systems to which the individual belongs. The patient last April 30, 2009 was on status post cholecystectomy. Cholecystectomy was done to remove the gallbladder. Incision was made. To have an effective wound healing and prevent complications, vital signs was monitored. Patient was encouraged to take a rest. To regain structure and function, the body needs to restore structural integrity through repair and healing. It is very important to take note of the discharges, its quantity and characteristic. Aseptic technique in wound dressing was applied to prevent possibility of infection. In addition, to promote healing, antibiotics was also given. Jean Watson Dr Watson believes that a new paradigm is emerging in health care. She states that conventional medicine has become increasingly technological, typically centering on treatment to cure disease with medications and surgery. In contrast, the caring approach of nursing focuses on conscious compassionate skills that help patients achieve a healthy state of mind, body, and spirit. Dr Watson relates that caring is intrinsic to the therapeutic interpersonal relationship between the nurse and patient. Ten primary carative factors form the structure of Dr Watson's caring theory Psychological caring-healing therapies strive to instill hope or faith. To meet the psychological or spiritual needs of patients, nurses traditionally incorporate humanistic, altruistic values by using the power of prayer, spiritual beliefs, or suggestions or through a trusting therapeutic nurse-patient relationship. The nurse's relationship and

interpersonal teaching enables the patient to provide self-care, determine personal needs, and provide opportunities for personal growth. Therapeutic communication is implemented through nonverbal behavior and listening, facilitating nonpossessive warmth, initiating self-understanding, and communicating with personalized responses to develop a helping, trusting relationship After developing a therapeutic trusting relationship, the nurse can help the patient relax before surgery with the caring-healing therapies of holistic nursing. Being available to the patient, listening to his concerns, and providing silence was practiced to relieve patients anxiety. Medications were also given such as anxiolytic medicines to decrease anxiety.

Faye Abdellah

According to her, nursing is based on an art and science that mould the attitudes, intellectual competencies, and technical skills of the individual nurse into the desire and ability to help people , sick or well, cope with their health needs.

To view Abdellahs 21 nursing problems according to Maslows hierarchy of needs, in the physiologic needs, the nurse must facilitate the maintenance of a supply of oxygen to all body cells, nutrition of all body cells, fluid and electrolyte balance, elimination, maintain good body mechanics and prevent and correct deformities, good hygiene and physical comfort, promote optimal activity: exercise , rest and sleep and to facilitate the maintenance of regulatory mechanisms and functions. Patients needs was attended such as proper positioning, cough and deep breathing exercises to prevent post operative complications. Patient was on NPO, but it is very important to increase fluid intake and eat high caloric foods to prevent dehydration and weakness due to increased metabolic demands of the body. It is very important to take into consideration the diet after NPO because the body is on the process of repairing.

Nursing Care Plan Date/ Time April 27, 2009 311pm Cues S: Sakit jud akoa tiyan karun (pointing at the right upper quadrant of the abdomen), mura man ug gimakumot na dili nako masabtan., as verbalized by the patient. Need C O G N I T I V E Nursing Diagnosis Acute Pain related to inflammation and distortion of tissues If gallstone obstruct the cystic duct, the gallbladder becomes distended, inflamed and eventually infected. Inflammation and swelling depresses the free nerve endings and cause the pain. The patient may have biliary colic with excruciating upper right abdominal pain Objectives of Nursing Interventions Care Within my 8 hr 1. Observe and document care, the client location, severity and will be able to: character of pain. Assists in differentiating 1. Report pain cause of pain and provides is controlled if information about disease not relieved. progression/ resolution, development of 2. Demonstrate complications and the use of effectiveness of relaxation skills interventions. and diversional activities as 2. Administer indicated for anticholinergics as individual indicated. situation Anticholinergics relieves reflex spasm or smooth muscle contraction and assist in pain management. Evaluation Goal met.

P E R C E O: Grimaced P face T With guarding U behavior A Restlessness L Rigidity of the abdomen P RR= 32cpm A Splinted T respiration T with short and E

Although pain was not totally relieved, the patient verbalized, Na ok ok raman ko karun, medyo sakit pero dili na pareha ganina. The patient had identified relaxing techniques such as deep breathing 3. Administer smooth exercises and muscle relaxants, freeing the nitroglycerin as ordered. mind from Relieves ductal spasm. worry which is helpful in 4. Administer minimizing Chenodeoxycholic acid. pain. Chenodeoxycholic acid is

shallow breathing

R N

that radiates to the back or right shoulder. Source: Porth CM. (2002). Pathophysiolog y: Concepts of Altered Health States. Philippines: Lippincott Williams & Wilkins.

a natural bile acid that decreases cholesterol synthesis reducing size of gallstones. 5. Antibiotics To treat process inflammation. infectious reducing

6. Hyperlipidemic agents. Reduces itching or pruritus from bile salts in skin 7. Note response to medication and report if pain is not being relieved. Severe pain not relieved by routine measures may indicate developing complications/ need for further intervention 8. Promote bedrest, allowing patient to assume position of comfort. Bedrest in Fowlers position reduces intraabdominal pressures; however, patient will naturally assume least

painful position. 9. Use soft, cotton lines, calamine lotion, cool or moist compress as indicated, Reduces irritation/ dryness of skin and itching sensation. 10. Control environmental temperature, maintain a cool room temperature. Cool surroundings aid in minimizing dermal discomfort. 11. Encourage use of relaxation techniques such as deep breathing exercises. Provide diversional activities such as watching television. Promotes rest, redirects attention, may enhance coping. 12. Make time to listen to complaints and maintain frequent contact with the patient. Helpful in alleviating

anxiety and refocusing attention, which can relieve pain.

Date/ Time April 28, 2009 311pm

Cues S: Wala ko kasabot sa ako gibati, mura ko ug nahadlok karun sa ako operasyon ug unsa ang mahitabo sa akua panhuman ato.

Need S E L F P E R C E P T I O N

Nursing Diagnosis Anxiety related to gallbladder removal surgery Anticipated surgery can be a source of many threats. These threats can produce vague feelings ranging from mild uneasiness to panic. Identifying a threat as merely surgery is too simplistic, personal threats are also involved. Moreover, although some uneasiness may be attributed to fear, the remaining feelings relate to anxiety. Source: CarpenitoMoyet. Nursing Diagnosis Application to Clinical Practice, 11th Ed. Lippincott Williams and Wilkins, 2005

Objectives of Care Within my 4 hour care, the client will be able to: 1.Verbalize awareness of feelings of anxiety and health ways to deal with them.

Nursing Interventions 1. Be available to the patient. Maintain frequent contacts with the patient/SO. Be available for listening and talking as needed. Establishes rapport, promotes expression of feelings. Demonstrates concern and willingness to help. Helpful in discussing sensitive subjects.

Evaluation Goal met. Patient was able to identify ways reducing anxiety such as use of deep breathing exercises, and anxiety was reduced to a manageable level, Kung sige ko ug istorya sa ako ginabati ug sa ako kaguol kay mabwasan ang ako kaguol. Magwapo ako ginhawa kung muhinga ko ug lalom.

O: Restlessness Reports of uncertainty S and being E scared L F C O N C E P T P A T T E R N

2. Report anxiety is reduced to a 2. Identify patients manageable perception of the threat level. represented by the situation. Helps recognition of extent of anxiety and identification of measures that may be helpful for the individual. 3. Encourage patient to acknowledge reality of stress without denial or reassurance that everything will be alright. Provide information about measures being taken to correct or alleviate condition. Helps patient to accept what is happening and reduce level of anxiety. False reassurance is not helpful, because neither nurse nor patient knows the final outcome. Information can provide

Date/ Time April 28,20 09 311pm

Cues S: Report of pain O: Limited range of motion Slowed movement Decreased posturing change speed

Need A C T I V I T Y E X E R C I S E P A T T E R N

Nursing Diagnosis Impaired physical mobility related to pain at incision site. Pain impairs mobility and activity. Full function may be affected and be delayed. Source: Monks. Home health nursing: assessment and care planning. Elsevier Health Sciences, 2002

Objectives of Care Within my 8 hour care, the client will be able to: 1.Verbalize willingness to and demonstrate participation in activities

Nursing Interventions 1. Administer medication prior to activity as needed for pain relief. To permit maximal effort or involvement in activity.

Evaluation Goal partially met. Patient refused to perform range of motion exercises for a fear of experiencing pain after the activity. On the other hand, there were no contractures and complications observed after an 8 hour care with the client.

2. Change position frequently when on bedrest; support affected body parts or joints with pillows. Decreases discomfort, 2. Maintains maintains muscle strength/ optimal position joint mobility, enhances of function as circulation and prevents evidenced by skin breakdown. the absence of contractures 3. Provide skin massage. and decubitus Keep skin clean and dry ulcers. well. Keep linens dry and wrinkle-free. Stimulates circulation and prevents skin irritation. 4. Encourage deep breathing and coughing. Elevate head of bed Turn side to side. Mobilizes secretions,

improves lung expansion and reduces risk of respiratory complications. 5. Assist with active and passive range of motion exercises. Maintains joint flexibility, prevents contractures and aids in reducing muscle tension. 6. Provide safe environment such as giving assistance in sitting and transferring from bed to chair or chair to bed and use of wheelchair if possible. Avoids accidental injuries and falls. 7. Encourage early ambulation. Support abdomen when ambulating. Early ambulation prevents postop complications. Splinting provides incisional support/ decreases muscle tension to promote cooperation

with therapeutic regimen. Provide adequate rest periods in between activities. To prevent fatigue. 8. Provide diversion such as talking with the patient or watch television. Decreases boredom, promotes relaxation.

Date/ Time April 30, 2009

Cues S/O: Incision at right upper quadrant with Jackson Pratt drain with slightly soaked, intact dressing at right upper quadrant of the abdomen, status post open cholecystecto my

Need N U T R I T I O N A L M E T A B O L I C P A T T E R N

Nursing Diagnosis Impaired tissue integrity related to surgical incision In gallbladder removal surgery, a surgeon makes a large incision (cut) in your belly to open it up and see the area. The surgeon then removes your gallbladder by reaching in through the incision and gently lifting it out.The surgeon will make a 5 to 7 inch incision in the upper right part of your

Objectives of Care Within an 8 hour care, the client will be able to: 1. Be free of complications such as heavy bleeding at the incision site. 2. Demonstrate behaviors to prevent skin breakdown

Nursing Interventions 1. Check the incisional drain, make sure that they are free flowing. Incision site drains are used to remove any accumulated fluid and bile. Correct positioning prevents back up of the bile in the operative area. 2. Observe color and character of the drainage. Initially, may contain blood and blood-stained fluid, normally changing to greenish brown (bile color) after the first several hours. 3. Place patient in low or semi-fowlers position. Facilitates drainage of bile. 4. Change dressings as often as necessary. Clean the skin with soap and water. Use sterile Vaseline gauze, zinc oxide or karaya

Evaluation Goal met. Within the span of care, hemorrhage was not observed and patient was able to demonstrate behaviors to prevent skin breakdown through participation in the change of dressing and change of positions.

belly, just below your ribs. The surgeon will cut the bile duct and blood vessels that lead to the gallbladder. Then your gallbladder will be removed. Source: http://www.nlm. nih.gov/medline plus/ency/articl e/002930.htm

powder around the incision. Keeps the skin around the incision clean and provides a barrier to protect skin from excoriation. 5. Observe skin, sclerae, urine for change in color. Developing jaundice may indicate obstruction of the bile flow. 6. Note color and consistency of stools. Clay colored stools result when bile is not present in the intestines. 7. Investigate increased or consistent RUQ pain; development of fever, tachycardia; leakage of bile drainage from wound. Signs of suggestive of abscess or fistula formation requiring medical intervention. 8. Administer antibiotics. Necessary for treatment or prohylaxis for abscess or

infection. 9. Monitor laboratory studies such as WBC Leukocytosis reflects inflammatory process such as abscess formation or development or peritonitis or pancreatitis.

Date/ Time April 30, 2009 311pm

Cues S/O: Surgical incision at right upper quadrant

Need H E A L T H P E R C E P T I O N H E A L T H M A N A

Nursing Diagnosis Risk for infection related to presence of surgical incision The skin is the first line of defense against infection. Any break in its continuity may allow microorganisms to enter the body which in turn can cause the infection, and since the patient had undergone cholecystectom y, there is a break of continuity of the skin, which may contribute to the development of

Objectives of Care Within an 8 hr care, the client will be able to: 1. Be free of purulent drainage or erythema; be afebrile

Nursing Interventions 1. Monitor vital signs. Note onset of fever, chills, diaphoresis, changes in mentation, and complaints of increasing abdominal pain. Suggestive of presence of infection/ developing sepsis, abscess or peritonitis. 2. Practice good hand washing and aseptic wound care. Reduce risk of spread of bacteria. 3. Inspect incision and dressings. Note characteristics of drainage from wound. Provides early detection of developing infectious process and monitor resolution of pre-existing peritonitis. 4.Administer antibiotics May be given

Evaluation Goal met. Within the span of care, temperature remained normal, patient was not afebrile. No purulent drainage noted.

G E M E N T P A T T E R N

future infections. Source: Mattson Porth, Essentials of Pathophysiolog y Concepts of Altered Health Status, Lippincott Williams and Wilkins, 2007

prophylactically or to reduce number of multiplying microorganisms in the presence of infection to decrease spread and seeding of the abdominal cavity. 5. Use sterile gloves for wound care. Practice aseptic technique. Prevents invasion of bacteria or microorganisms at site and eventually prevents possible infection. 6. Instructed to maintain clean dry clothes preferably cotton fabric Skin friction caused by stiff or rough clothes leads to irritation of fragile skin and increases risk for infection. 7. Cleanse incision site with povidone iodine. Disinfects site and prevents multiplication of microorganisms which may cause infection.

8. Instruct client not to wet incision site. Microorganisms thrive at damp areas and makes it conducive for replication. 9. Provide a cool environment. Adjust air conditioner as preferred by the client. Hot room temperature induces sweating which may inhibit the healing of wound and eventually cause moisture at the area delaying the healing process.

Discharge Planning Medicines: Tramadol Ketorolac Ranitidine Sulperazone Mr. Police should comply with the medications he has been prescribed with in order to aid in the recovery state after surgery. With regards to his medications, he must know and understand the general knowledge of the drugs, their side effects and their adverse effects. If he experiences any adverse effects, he needs to refer to his physician immediately. Exercise: Cholecystectomy actually requires time to recover. Laparoscopic cholecystectomy usually requires only one night in the hospital. A major advantage of the procedure is that it patients can return to work in 1 to 2 weeks. But compared to open cholecystectomy, it is advised to have 4 to 6 weeks duration time for recovery. Once home, it is possible to tire more easily than usual to begin with, so it is important to take it easy. Strenuous exercise and lifting should be avoided. Light exercise such as walking is recommended. Normal activities, including returning to work, can usually be resumed after about a week. Patient must follow his surgeon's advice about

driving. He shouldn't drive until he is confident that he could perform an emergency stop without discomfort.

Treatment: Gallbladder disease usually is treated by removing the gallbladder. Now that the patient had his gallbladder removed, the rest is up to him. It is important to rest and let the body recover after surgery. Consequently, to prevent other complications, he must have his lifestyle and diet modified. Health Teachings: Explain to patient what to expect afterwards. As the anaesthetic wears off, there is likely to be some pain. The anaesthetist will prescribe painkillers. Suffering from pain can slow down recovery, so it's important to discuss any pain with the doctors or nurses. On discharge, the nurse must advise about caring for the stitches, hygiene and bathing, and will arrange an outpatient appointment for the stitches to be removed, if necessary. Some people will have dissolvable stitches, which do not need to be removed.

Instruct patient to comply with the home medications that would be given by his physician. Remind him to complete the full course of the antibiotic treatment.

Encourage patient to do the recommended light exercises such as walking. Avoid doing strenuous activities which could slow down his recovery.

Encourage him to comply with the dietary modifications; limit the intake of saturated fat and avoid the consumption of alcoholic beverages to prevent the occurrence of serious post-cholecystectomy side-effects.

Explain to patient to refer for unusualities immediately.

Out-patient Care: Remind patients that regular check-ups are important to ensure that the patient condition is constantly monitored by the doctor. If any of the following symptoms are noted, he should contact his doctor:any of the wounds start to bleed any of the wounds become more painful, red, inflamed or swollen the abdomen swells pain is not relieved by the prescribed painkillers

a fever develops.

These could be signs of an infection that may need to be treated with antibiotics Diet: In time, patients who have suffered cholecystectomy are exposed to a high risk of developing heart disease, diabetes and disorders of the nervous system. This is due to inappropriate synthesis and assimilation of vital nutrients, vitamins and minerals. In order to prevent the occurrence of serious post-cholecystectomy side-effects, operated patients need to make drastic lifestyle and dietary changes. They should limit the intake of saturated fat and avoid the consumption of alcoholic beverages. Also, they should eat smaller amounts of food during a single meal. People who have had gall bladder removal surgery are advised to eat around 5 or 6 smaller meals a day instead of 2 or 3 usual meals. Considering the fact that the organism is unable to completely absorb important nutrients without the help of the gall bladder, operated patients also need to take vitamin and mineral supplements and bile salts to aid the process of digestion. PROGNOSIS Category Onset of illness Poor Fair / Good Rationale A month prior to admission, Mr. Police experienced right upper quadrant pain associated with a sense of

bloatedness, without nausea and vomiting. The pain was tolerable so he did not seek medical attention yet. He said he also had an increased level of pain tolerance so he also didnt mind to take any pain relievers. Until three days prior to admission, patient had severe right upper quadrant pain, which was said to be intolerable. Moreover, when pressure is applied on the RUQ of the abdomen, pain is elicited. He had also lost his appetite because of the pain. His scleras were also slightly icteric during admission and he was positive with Murphys sign. So he sought consultation at Out-Patient Department- Emergency Room at Davao Medical School Foundation Hospital. Ultrasound revealed cholecystitis, so patient was Duration of illness / advised admission and operation. Though no complications aroused yet, Mr. Police did not immediately seek medical attention as he had persistent RUQ pain a month ago. He waited for the pain to become intolerable before seeking medical advice. Moreover, the obstruction brought about by the cholecystitis caused his icteric sclera, which could have been absent if he sought medical attention earlier.

Precipitating factors

Only Mr.

three Polices

out

of

eleven which

known is the

precipitating factors are present with case following: diet (high cholesterol, high calorie, and high sodium), diabetes mellitus and obesity. Mr. Police said he would undergo any treatment regimen he has to as long as his condition would get better. Moreover, he let himself be admitted to the hospital and to undergo surgery as he is determined to get / well as soon as possible. DMSFH is a hospital environment, the institution very with an for the

Attitude and willingness to medication and treatment Environment

conducive

healing. Moreover, the personnel in which includes medical team are very responsive to Age / the needs of the patients. The client is almost 50 years old. The wear and tear theory states that as one grows older, most of our organs are already used and abused. As one ages, one also becomes more susceptible to infections and organ Family support / failure. Anna is always watching over Mr. Police during his admission. She said she will always be with Mr. Police through his ups and downs, as he vowed him during their wedding day. Moreover, relatives come to Davao to

visit Mr. Police, and together with them are the encouragement and support they give Mr. Police. Total 0/7 3/7 4/7

Computation:

No. of categories rated POOR (1) + No. of categories rated FAIR (2) + No. of categories rated GOOD (3) divided by TOTAL NO. OF CATEGORIES= SCORE FOR GENERAL PROGNOSIS. =0(1) + 3(2) + 4(3) = 6 + 12 =18/7 =2.57 Scoring for General Prognosis: 1-1.6 1.7-2.3 2.4-3.0 =POOR =FAIR =GOOD

General Prognosis: The general prognosis of the client is good. This means that the client has a good chance of recovering from his illness.

Conclusion Generally, the student nurses one week exposure and duty at the Davao Medical School Foundation Hospital has been a memorable

experience to them. The exposure had been an avenue for further development and enhancement of their skills and capabilities in rendering care and promoting holistic wellness to their clients. It reminded them again that nursing profession entails a deep sense of responsibility and challenging tasks. After five days of exposure at St. Joseph (3C) ward, the student nurses has identified and understood the causative factors of cholecystitis, its signs and symptoms, clinical manifestations, diagnostic studies, medical,

pharmacological and nursing interventions through obtaining cues and health history in conjunction to the disease process. They underwent extensive research in order to comprehensively understand his condition. Upon learning his case, it challenged and motivated them to work hard to provide the appropriate and effective nursing intervention and care. Moreover, cholecystitis is the most common problem resulting from gallbladder stones. It occurs when a stone blocks the cystic duct, which carries bile from the gallbladder. Predisposing factors can include heredity, age, sex and race. With the presented factors that cannot already be modified, one has to take action towards preventing the disease to happen. The only one who can help yourself is you alone. With the proper knowledge about the nature of the disease as well as its preventive measures along with

responsibility and sense of will, one can surely direct himself away from the complications. Our gallbladder is not to be taken for granted. There have been reports that mortality can be as high as 15% for immunocompromised patients. Furthermore complicated cholecystitis has 25% mortality (eg, gangrene, empyema of gallbladder). No matter how the disease has already reached an alarming incidence rate or not, it is a duty of every human person to take care of his own body, not just for the sake of other people that depend on him, but most especially for himself ~ a primary obligation that he must fulfil.

Recommendation Every exposure is a learning experience filled with lessons. After thoroughly studying Mr. Polices case, the group has come up with the following recommendations: To the client: Recovering after open cholecystectomy surgery doesnt depend solely on the healthcare team. More than anything else, there must be willingness to recover on the part of the patient. With this, he must carry out his responsibilities in fighting his own condition. He is encouraged to verbalize his thoughts and feelings to his medical attendants, such as his nurses, because it would be better for him to express whatever is causing stress on his part thus, hindering his recovery or yet understand that the things that his nurses is doing for him is for his own good and betterment in life. He is encouraged to willingly and actively participate in therapeutic activities that will render improvement of his condition. Moreover, he should fight his as much as he can through complying with the treatment being given to him and through continuing his rehabilitation process so that the chances of his recovery will be greater.

To the patients family Undeniably, the patients family plays a significant part in his battle against the disease. The family members should be involved with his treatment as much as possible since their support motivates him to exert

more effort in the recovery process. They should not only be physically present. More than that, they should give their emotional support to boost the patients morale. In addition, they are encouraged to be oriented and educated with the basic facts about the patients condition so that they will understand his condition better. Not only that, they should always asked the student nurses for assistance, advices, or clarifications because they are always ready to lend a helping hand. Through this, they would be able to know how to manage and meet his needs when he is discharged from the institution where he is admitted.

To the group Maintain practicing teamwork and unity within the group so that better output will be formulated. Be sensitive and respond to the needs of other group members. If one is done with the task, try to help the others and contribute something that would make the work better. Being calm is always a good move. Fix the problems in a peaceful manner. Be open-minded to suggestions and prevent intensive discussions so that healthy relationship within the group will be maintained.

To the fellow student nurses It is not through a single effort that you learn the entirety of a certain illness. Rather, it takes continued research and study in order to be more updated with information that will render an insightful understanding of what

it is all about. As student nurses, you should do your best to be equipped with the necessary knowledge that will help you in your endeavors especially when you go on duty in units where intensive care is needed. It is through this that you can provide the quality and holistic nursing care that patients need. You should realize that your patients are also humans, though suffering from a chronic illness. You should always be humane in treating and approaching them so that you can be of help in the best way you can. Nursing students of AdDU should be committed to the goal of being men and women for others. They should not only appreciate the concepts during lecture session but should also positively digest the experiences they get from their duties and exposures. To the Ateneo de Davao University- College of Nursing The AdDU- College of Nursing has been exerting much effort in providing the best exposures to its nursing students. The faculty and staff are encouraged to continue elevating the standard of the Ateneo Nursing Curriculum through quality training of Clinical Instructors in the advent of seminar, forums or trainings, quality-level lectures and affiliations with various medical institutions for the students exposures and duties.

To the Professional Medical World Open cholecystectomy undeniably has its own disadvantages. The scar alone after surgery is one of the major disadvantages. Furthermore, Minilaparotomy cholecystectomy presents exposition difficulties, and

laparoscopy

requires

expensive

equipment

and

additional

training.

Laparotomy is more painful, causes trauma to the abdominal wall, and requires a longer convalescence; it is also less aesthetic. Researches and studies have been conducted to discover a new technique of minimal invasive cholecystectomy. Such new technique presented for minilaparotomy cholecystectomy is transcylindrical. As the medical field advances, the peoples trend as well as preference also changes. As much as possible, a cheaper, less invasive and more aesthetic procedure is preferred. The group would like to comment on the success of the emergence of new studies and invention. They are to look forward to further studies and improvement.

BIBLIOGRAPHY

http://www.nottingham.ac.uk/nursing/sonet/rlos/bioproc/resources.html http://www.le.ac.uk/pa/teach/va/anatomy/case2/frmst2.html http://www.le.ac.uk/pa/teach/va/anatomy/case5/frmst5.html http://digestive.niddk.nih.gov/statistics Barbara Howard, Clinical and Pathologic Microbiology, 2nd Edition Carol Porth, Pahtophysiology Concepts of Altered Health Sciences, 7th Edition

Pathology 3rd Edition by Stanley L. Robbins, M.D. Tortora et. Al., Microbiology An Introduction, 8th Edition Kasper et. Al., Harrisons Principle of Internal Medicine, 16th Edition Deglin, Judith H., Vallerand, April H. Daviss Drug Guide for Nurses, 10th ed. F.A. Davis Company, Philadelphia, Pennsylvania,2007.

Damjanov, I., Linder, J. Andersons Pathology. 10th edition USA: MosbyYearbook 1996. Fauci A. et al. Harrisons Principles of Internal Medicine. 16th edition. USA: The o McGraw-Hill Companies 2005.

Bullock, B. Henze, R. Focus on Pathophysiology. Philadelphia, USA:Lippincott, o Williams and Wilkins 2006.

Clinical Applications of Nursing Diagnoses. F.A. Davis Company, Philadelphia. o 4th edition.

Nutritional Therapy and Pathophysiology. Nelms, Sucher, Long. 2007. Thomson o Brooks/Cole, The Thomson Corporation. 10 Davis Drive Belmont, CA, USA.

Bare, Brenda G., Cheever, Kerry H., Hinkle, Janice L., Smeltzer, Suzanne C. o Brunner & Suddarths Textbook of Medical- Surgical Nursing, 11th ed. Vol.1. o Lippincott Williams & Wilkins, 2008.

Doenges, Marilynn E., Moorhouse, Mary Frances, Murr, Alice C. Nursing Care o Plans 7th ed. F.A. Davis Company, Philadelphia,

Pennsylvania,2006. Karch, Amy M. 2007 Lippincotts Nursing Drug Guide. Lippincott Williams & o Wilkins, 2007. MIMS, 108th ed. CMPMedica Asia Pte Ltd, Singapore, 2004.

Porth, Carol M. Essentials of Pathophysiology: Concepts of Altered Health States. o 2nd ed. Lippincott Williams & Wilkins, 2007.

pp. 148-153, Maxine A. Goldman 2008, Pocket Guide to the Operating Room. 3rd edition o F.A. Davis Company.Philadelphia