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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…………………….………………………………………………………. Patient’s Data…………………………………………………………………………. Genogram…………………………………………………………………………….. Family History……………………………………………………………………….. Developmental Data…………………………………………………………………... Physical Assessment……………………….………………………………………….. Complete Diagnosis…………………………………………………………………… Anatomy and Physiology……………………………………………………………… Etiology………………………………………………………………………………… Symptomatology…………………………………………………………….…………. Pathophysiology…………..……………………………………………………….…… Doctor’s Order……………………………………………………………………..…… Diagnostic Examiation.…………………………………………………………………. Drug Study……………………………………………………………………………… Procedural Report………………………………………………………………………. Nursing Theories………………………………………………………………………… Nursing Care Plans………………………………………………………………………. Discharge Planning………………………………………………………………………. Prognosis………………………………………………………………………………….. Conclusion………………………………………………………………………………… Recommendation…………………………………………………………………………. Bibliography……………………………………………………………………………….
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 husband’s 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 Ma’am 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
He is their ultimate strength and hope. May they find the right path towards God. but as well as better individuals.holistic teachings that encouraged them not only to be better nurses. 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. they are very thankful to the Almighty Father for gracing them with His wonderful blessings. They pray for His loving guidance as they continue their journey in their nursing careers. for the financial and moral support and for understanding. . 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. as he wishes them to. And above all. Thank you for the love.
Pima Indians. the gallbladder is an organ that people can live without.INTRODUCTION The gallbladder is a small pear-shaped organ which aids in the digestive process. People who have a history of gallstones are at increased risk for cholecystitis.a digestive liquid continually secreted by the liver. The gallbladder tends to be taken for granted – ignored of the proper care and conditioning.000 have undergone cholecystectomies. many people are unaware of their gallbladder. an extrapolated . race and age are just some factors that leave a room for gallbladder complications to occur.000 in the same year and over 500. Despite its importance in the digestion of fat. The bile becomes concentrated in the gallbladder. The bile in turn emulsifies fats and neutralizes acids in partly digested food.077 deaths in 2002. It affected 20. This study is about cholecystitis. Cholecystitis affects women more often than men and is more likely to occur after age 40. Its function is to store and concentrate bile . Lifestyle together with heredity. and Hispanic populations. In the Philippines alone.5 million people (1988-1994) with a mortality record of 1. Fortunately enough. cholecystitis has an increased prevalence among people of Scandinavian descent. This later causes irritation and is probably the leading cause of inflammation. whereas cholelithiasis is less common among individuals from sub-Saharan Africa and Asia. The most common cause of cholecystitis is gallstones (90% of the cases). this fact contributes to the laxity of the majority. In the international level. Perhaps. sex. Hospitalizations total up to 636.
they too are predisposed to lifestyle modification – especially diet and food preferences which can contribute to the disease. As teen-agers living in a fast-phased world and governed by schedules. Furthermore.nih. this case is quite interesting since it does not always affect only females and elderly. As nursing students and future nurses. Moreover. Through this. All in all. they are hoping that they will be able to find the right plan of care and sound interventions.073. Much often this small organ is not given importance. It can affect everyone. these will help them to become efficient nurses and better persons later on. they would want to understand and appreciate more on what is happening to a patient with cholecystitis.prevalence of 5. Consequently. they would like to give credit and to know more of the nature and function of the gallbladder.niddk. Thus they are in a pursuit for knowledge to be able to impart it to others. the student nurses hope to apply their learning in taking care not only of their patients but also of themselves. despite the cholecystitis’ low incidence. they are interested on what will be the necessary management that will be given.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. not forgetting the patient’s rights as a person.040 people are affected by the disease last 2007. (http://digestive. With this study. It can be alarming since many people are confused and unaware of the symptoms presented. .
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. • Research on the anatomy and physiology of the clients affected system.Objectives After 5 days of data gathering. Police and to those directly and indirectly involve with the completion of this case. Determine and interpret the medical management employed including laboratory and diagnostic procedures. research and analysis. • • Research and understand the disease process of the patient’s illness. . laboratory exams and etc. to have complete information about the patient’s current condition. 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. the student nurses will be able to: • Gather significant data from the patient’s chart which includes the doctor’s order. • Research on the possible causes and also the symptoms the patient experienced that may suggest the current condition of the patient. Specific Objectives under Cognitive aspect Within the 5 days span of duty.
.• Identify and study the drugs prescribed to the patient which affects the patient’s current situation.
.T. • Formulate nursing care plans and apply them to satisfy the patient’s needs and give appropriate nursing interventions. Affective With the knowledge gained and through the application of this knowledge.Psychomotor In this aspect.E. Police’s need for the improvement of his general welfare. 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.D and validate the patient’s prognosis according to categories. • Make a discharge plan for the patient using M. Specific Objectives under Psychomotor aspect Within the 5 days span of duty. the student nurse’s 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.O. 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.H.
and for the betterment of nursing care. 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 patient’s chart and to his family and etc. ..Specific Objectives under Affective aspect Within the 5 days span of duty. • Assume the role of being the patient’s advocate.
1962 General Santos City Married Cabantian. Country Homes. Joseph (3C) 325-5 Dr. Wolter right upper quadrant pain Cholecystitis T/C Cholelithiasis .PATIENT’S 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. 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. Batucan. 2009 at 10:40 am 01-36-90 St.
Mr.5˚C Sources of info: R – 28 cpm P – 109 bpm Temp Chart. and his wife . Police himself.BP –120/90 mmHg – 36.
GENOGRAM Lolo A± Lola Lolo B †ħ Lola Dad A B 1 ħ Mo 3 4 5 6 A Mr. Police Sis Stepbrod Ø Step- BB 1 Legend: BB 2 ħ: Hypertensive ±: Unknown cause of death Ø: Suicide Δ: Died of childhood illness †: Deceased .
Step-sis has her own family at Leyte. Step-brod and Step-sis. He had suicide because of altered mental status due to shabu use. He grew up at General Santos City where the relatives of his mother live. Family Background Mr. “ingon sa doctor naa man gud . his parents got separated because of third party. With his mother’s second family. Step-brod died at the age of 18 because of suicide. he had another two siblings. Today. he does not know any significant disease they have or had. Currently. The couple had difficulty conceiving a child because Anna has an obstetrical problem.HEALTH HISTORY A. Police is the eldest among Mr. Police has been married to Anna for 15 years. Mom‘s two children. Dad‘s and Mrs. He doesn’t also know the causes of deaths of his grandmother and grandfather on the paternal side. he could not recall. Because Mr. Police had been assigned at work before. When Mr. what he only knows is that the eldest sister of her mother has hypertension. Mr. and that his grandfather on the maternal side died of hypertension. Mom’s live-in partner at Davao City. They met at Mandug. Police was a first year high school. He lived with his mother and Mrs. On the other hand. Davao City. while his father returned to Leyte where his other relatives live. where Mr. Police had been away from the relatives of his father. But his younger sister died of a childhood illness at the age of three years old. She verbalized.
aged six years old. He has a set of close friends who are also policemen like him. he goes back to General Santos City. He is a Roman Catholic. nine years after their marriage. Police graduated at MATS with a 4-year degree of BS-MT. His wife said he smokes three boxes of cigarettes everyday. B. Niño fiesta. He has also been an alcoholic drinker since he was 13 years old. who does not always goes to Church every Sundays but is a Sto. He is a “barkadista” as his wife. He is not as close as the children are to Anna. On his rest day. Police has been a smoker since he was 20 years old. to attend certain activities in celebrating Sto. He enjoys watching TV. Mr. and sometimes does the cooking as he likes to. they were blessed with BB 1 who is now a kindergarten student. he had been assigned to San Pedro Police Station for a year already. But he enjoys playing with them sometimes and taking them out on weekends. then have a two-day rest. goes with his friends and has a drinking session. He drinks three glasses of . BB 2 followed. Personal Background Mr. But because he couldn’t find a job with the course he had. he stays in their house and on the evening. he had sixmonth training to become a policeman. He works 24 hours straight. Currently. describes him. Every January. Two years after.daw gas-gas akoang matres. Niño devotee. Anna.” Fortunately.
He stopped because his friends also decided to stop. which only lasted for six months (September 2008.” as Anna verbalized. as an exercise.alcoholic drink everyday. and other pica-pica. . Moreover. But he enjoyed boxing with his friends. Moreover.February 2009). he eats meat. chicaron. he is a “meat-addict. Furthermore. he has no known drug and food allergy. Everyday. he doesn’t have a regular exercise. he does not eat vegetables but eats all kinds of fruits. and could not sleep without eating such. With regards to his diet. He also eats lots of pulutan during their drinking sessions such as laman-loob.
Moreover. Police experienced common illness such as colds. D. and fever during his childhood. he would realize that he should have a healthy control over his health.C. Moreover. History of Past Illness Mr. Five years prior to admission (2004). But she is hoping that because of this hospitalization. . He was then advised to control his diet and have a regular exercise but he was not given any maintenance drug. he was not compliant with the doctor’s advice. he had to undergo an operation which means he had to have a sick leave from his work. Anna is also expecting that her husband would regain his strength back soon. Effects/ Expectations of Illness to Self/ Family Because of his condition. Anna also has to watch over him and she has to leave the children under the care of her elder sister for a while. However. He also had chicken pox during his childhood. They were having an annual check up when he discovered that he has elevated blood sugar. that he would cease drinking and smoking. Furthermore. Anna is worried of the effect of the operation to the health of her husband. he was diagnosed with diabetes with an FBS result of 7. Moreover.8 mmol/dL. cough. he could not recall at what age he got the disease and as well as the management of his chicken pox.
Two years ago (2007). He was then given Lopicard 5mg tab OD. which was said to be intolerable. pain is elicited. He said he also had an increased level of pain tolerance so he also didn’t mind to take any pain relievers. but only for two months. History of Present Illness A month prior to admission. E. He had elevated blood pressure of 180/100 as he could remember during the VS taking at the emergency room. The doctor advised him to cease smoking and drinking alcohol. The pain was tolerable so he did not seek medical attention yet. Police experienced right upper quadrant pain associated with a sense of bloatedness. He had also lost his appetite because of the pain. without nausea and vomiting. when pressure is applied on the RUQ of the abdomen. and pain on the suboccipital area (nape) associated with headache. His scleras were also slightly icteric during admission and he was positive with Murphy’s sign. Until three days prior to admission. he was experiencing palpitations. patient had severe right upper quadrant pain. and as well as to avoid over fatigue.Emergency Room at Davao Medical School . So he sought consultation at OutPatient Department. Moreover. He stopped smoking. as a maintenance anti-hypertensive medication. he was admitted to Davao Medical Center due to loss of consciousness. Prior to that. He was admitted for one day and was diagnosed with hypertension. Mr.
. Ultrasound revealed cholecystitis. so patient was advised admission and operation.Foundation Hospital.
The erectionrelated problem of Mr. impotence. These impulses are usually displaced. Police’s diabetes. energy is directed towards his work . Police does not damage the couple’s relationship. Police and Anna have a Freud’s Psychosexual Theory good sexual relationship. Police has an erection-related problem. Mr. though they sometimes do not achieve sexual satisfaction. Furthermore. Stages Justification Mr. This stage involves a reactivation of the pregenital impulses. such as frigidity. the couple are able to maintain a healthy sexual relation with each other. It even made the couple more mature and understanding of each other’s sexual needs. even in public. Moreover. Though Mr. Anna said that she understands that this might be due to Mr. Police compensates by wooing his wife through romantic dinners and being sweet with her. An inability to resolve conflicts can result in sexual problems. and the individual passes to the genital stage of maturity.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. and the inability to have a satisfactory sexual relationship.
as a policeman. Police’s energy towards his social relationships to other people. . being committed to his work and as well as to his colleagues. who are also the recipient of Mr.
. as he works as a policeman. and community. If this task is not met. Simply having or wanting children does not in and of itself achieve generativity. Moreover. He doesn’t allow his wife to work to make sure that the children receive a direct parental guidance in their growing years.Stage 7: Generativity Erikson’s Psychosocial Theory Stage 7: Generativity vs. Police is able to send his child to a private school. he is satisfied with his service to the public through their protection and crime control activities. Stagnation The middle adult years are a time of concern for the next generation as well as involvement with family.) A C H I E V E D vs. Moreover. to ensure a high standard of his educational needs. stagnation results. he works alone to provide the family’s financial needs. Mr. friends. Sociallyvalued work and disciplines are expressions of generativity. There is a desire to make a contribution to the world. He yearns for the community’s peace and order and is achieved through his public service as a policeman. and the person becomes selfabsorbed and obsessed with his or her own needs or regresses to an earlier level of coping. Stagnation (Middle Adulthood 40-65 yrs.
He even said that wants them to live their remaining life happy and satisfied with it. for them to become like him. he teaches them values such as honour. as he stayed on his job for already more than 20 years already. Moreover. Though his children are still four and six years old. Mr. and honesty. Police said that he is blessed with their relationship because Anna is not just a wife to her. . he said that he visits them at least once or twice a year. but also a friend.Mr. he is able to obtain a satisfactory occupational performance. a responsible citizen of our country. As his parents are also getting old. In addition. Police said that it is Middle Adulthood Havighurst’s 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 one’s spouse as a person Adjusting to aging parents Achieving adult social and civic responsibility normal that in his age. whom he could confide his problems. people get disease because they are aging. respect.
.Moreover. he has achieved social and civic responsibility through his public service as a policeman.
Papules on the face observed. he weighs 85 kg and stands 5’5” and has a body mass index of 31. was lying in bed. VITAL SIGNS BP= 120/180 mm Hg T= 36 °C SKIN Skin was warm to touch. with epidural catheter. and with good skin turgot. Patient is responsive and coherent when awaken. with an IVF # 3 D5NSS 1L at the level of 80 cc. Aside from that. Patient was on NPO. with Jackson Pratt drain. Police. asleep.PHYSICAL ASSESSMENT GENERAL SURVEY At 4 pm on April 30. Neither jaundice nor cyanosis observed. regulated at 120 cc/hr. No bruises or discolorations observed. a 46 year old Filipino male. Patient was in good grooming. Respiratory distress was not noted. intact dressing at right upper quadrant of the abdomen. status post open cholecystectomy. PR= 85 bpm RR= 15 cpm . Patient was not cyanotic. with nevi noted on the right side of the nose. He appeared endomorphic. Mr. slightly dry. infusing well at right metacarpal vein. physical assessment was done. with complain of pain at the incision site. wearing clean patients gown.18 which denotes that he belong to the obese type I which ranges from 30 – 34. with slightly soaked. with a pain scale of 6 out of 10. 2009. rough.9. No edema noted.
tenderness. Hair was black in color with fair amount of white and gray strands. lacerations. Skull and face were symmetrical with an equal distribution of hair. masses and depressions noted. short. dry. No lesions. . There was no dandruff or infestation present. and fine.HEAD Skull size was normocephalic.
lacrimal duct openings were evident at the nasal side of the upper and lower lids. Lid margins were clear. EARS Ears were symmetrical with same size bilaterally and color consistent with face. masses. swelling. Police did not use any corrective aids such as glasses or contact lenses. Eyebrows were evenly distributed and symmetrically aligned with no of flakes. with no discharges and no discolorations observed. Face portrayed emotions with symmetrical movements. Pinnas were free from lesions. discolorations present. The face was round. No edema or tenderness over lacrimal gland observed. Eyelashes were evenly distributed and slightly curled outward. Blinking reflex was present. Small anterior polar opacification was observed on both eyes. No edema seen in the periorbital region. Skin around the eyes was intact with equal movement. EYES Mr. and discharges and were in line with the eyes. Nystagmus. Eyelids close symmetrically. with no edema. strabismus and lid lag were not evident. scars and lesions noted. redness. No masses or involuntary movement. lesions. External . His pupils were equal within 1-2 mm diameter in size and both have a brisk reaction to light and uniform reaction to accommodation. Eye color was dark brown. tenderness.FACE The forehead was furrowed with wrinkles. Shiny smooth and pink palpebral conjunctiva noted.
flexion. Tonsils were not inflamed. No jugular vein distention was noted. discharges and foreign bodies noted. NECK Neck was symmetrical with no masses or swelling noted. masses. sores or lesions. Range of motion was normal and moves easily without discomfort upon rotation. Right upper first premolar tooth was absent. No inflammation. Tongue was in central position and moves freely with no swelling or ulcerations observed. masses present. Teeth were yellowish in color with some dental caries noted. No pain on the mastoid process was reported upon palpation. Nasal septum is intact and in midline. and irregularities upon palpation. . extension and hyperextension. No nasal flaring was observed. No tenderness in his sinuses upon palpation. NOSE The nose was symmetrical with no deformities. Gag reflex was present as evidenced by patient swallowing. Thyroid was not enlarged has no nodules. MOUTH Mouth was proportional and symmetrical. Halitosis was also noted. No discharges were present. Lips were rust colored and were dry with no presence of ulcerations.canals were clear with no cerumen seen. masses. Trachea is symmetrical and in midline without deviation. Gross hearing acuity was good. skin lesions.
No adventitious breath sounds heard upon auscultation. Chest wall was intact. intact dressing on the right upper quadrant with Jackson Pratt drain. inverted and in the midline. Breasts were symmetrical with no edema noted. Pulsations were not visible.BREAST Nipples were dark brown in color. ABDOMEN Abdomen was slighty enlarged and globular when patient was in supine position. hiccups noted. thrills or murmurs present upon auscultation. HEART Apical heart beat was present upon auscultation with a point of maximal impulse at the 5th intercostal space left midclavicular line. with slightly soaked. CHEST and LUNGS No thorax deformity observed. Lymph nodes were not palpable. Uniform temperature also noted. No crusting and masses noted. No abnormal beats. and infections. No dyspnea. Both axilla were free of lesions rashes. The . Symmetrical chest expansion was observed during respiration. with cardiac rate of 85 beats per minute with a regular rhythm. No cough present. Respiratory rate was 15 cycles per minute with regular breathing pattern. no tenderness and masses noted. palpitations. hemoptysis. No use of accessory muscles during breathing observed.
Patient had not yet voided since he had arrived from the OR. deformities and atrophy. Hip joint and thighs were symmetrical with no deformities present. Neither pallor nor bone enlargements were noted upon inspection of the upper extremities. No inflammation noted in the lower extremities. Range of motion was active and not limited. Upper extremities were not edematous. BACK & EXTREMITIES Symmetrical shoulder movement observed during respiration. elbows and forearms were free from nodules. arms. A permanent tattoo was present on his right deltoid area. patient verbalized that he had not noted any discharges from his genitalia nor presence of papules or ulcerations. Range of motion was not limited. . However. anchordesigned.abdomen had hypoactive bowel sounds of two bowel sounds per minute. Spine was located at the midline with no discrepancies noted. GENITO –URINARY Unable to perform inspection in the genitourinary region. Radial and brachial pulses were present. No edema noted at both legs. Shoulders. Tenderness noted on the right upper quadrant near the incision site.
Pathophysiology for the Health Professions. Pathophysiology. Source: Carol Mattson Porth. Brunner & suddarth’s Textbook of Mecial-Surgical Nursing !0th Edition. Source: Barbara Gould.C. Bare. B.. S. S. Cholecystitis refers to inflammation of the gallbladder and cystic duct. Saunders Elsivier Cholecystitis refers to inflammation of the gallbladder.DEFINITION OF COMPLETE DIAGNOSIS CHOLECYSTITIS Cholecystitis is the inflammation of the galbladder Source: Smeltzer. Brunner & suddarth’s Textbook of Mecial-Surgical Nursing 11th Edition.C. Concepts of Altered Health Sciences CHOLELITHIASIS The presence of calculi in the gallbladder Source: Smeltzer.. which are masses of solid material or calculi that forms in the bile. Third Edition. Bare.G.G. Cholelithiasis refers to formation of gallstones. B. .
mainly cholesterol and bilirubin. Pathophysiology. Third Edition. Saunders Elsivier Cholelithiasis. or gallstones. is caused by precipitation of substances contained in bile. Pathophysiology for the Health Professions.Source: Barbara Gould. Source: Carol Mattson Porth. Concepts of Altered Health Sciences .
Left lobe. lies under the diaphragm. Location and size of the liver. weighs approximately 1. caudate lobe.ANATOMY AND PHYSIOLOGY HEPATOBILLARY TREE LIVER A. Bile ducts .forms about one sixth of the liver 2. Liver lobes and lobules. Right lobe. occupies most of the right hypochondrium and part of the epigastrium. divides into right lobe proper.anatomical units of the liver.largest gland in the body.two lobes separated by the falciform ligament 1. and quadrate lobe 3.forms about five sixths of the liver. Hepatic lobules. small branch of hepatic vein extends through the center of each lobule C.5 kg. B.
Liver converts ammonia to urea 3. Glycogen is converted back to glucose (glycogenolysis) and release as needed into the blood stream to maintain normal level of the blood glucose. Small bile ducts form right and left hepatic ducts 2. Right and left hepatic ducts immediately join to form one hepatic duct 3. -glucose can be synthesized by the liver through the process gluconeogenesis 2. Glucose Metabolism -after a meal. Protein Metabolism -Liver synthesizes almost all of the plasma protein including albumin. alpha and beta globulins. which opens into the duodenum D. blood clotting factors plasma lipoproteins . Ammonia Conversion -use of amino acids from protein for gluconeogenesis result in the formation of ammonia as a by product. Functions of the liver 1. stored the hepatocytes.1. glucose is taken up from the portal venous blood by the liver which and is converted in into glycogen (glycogenesis). Hepatic duct merges with cystic duct to form the common bile duct.
electrolytes such as sodium. products of detoxification. bicarbonate. Fat Metabolism -Fatty acid can be broken down for the production of energy and production of ketone bodies 5.4. bile salts -collected and stored in the gallbladder and emptied in the intestine when needed for digestion a. Bile Formation -bile is formed by the hepatocytes -composed of water. lecithin. and bile pigments (e. Vitamin and Iron Storage -stores vitamin A.g. bilirubin) are wastes products excreted by the liver and eventually eliminated in the feces GALLBLADDER . Drug Metabolism 7. E. K 6. fatty acids. Sodium bicarbonate increases pH for optimum enzyme function c. D. chloride. potassium. calcium. cholesterol. Lecithin and bile salts emulsify fats by encasing them in shells to form tiny spheres called micelles b. Cholesterol.
• There is essentially no submucosa separating the connective tissue from serosa and adventitia. . • Under the epithelium there is a layer of connective tissue (lamina propria). a peptide hormone secreted by the duodenum. It is at the same level as the transpyloric plane. • The common bile romero duct then joins the pancreatic duct.The gallbladder (or cholecyst. • Beneath the connective tissue is a wall of smooth muscle (muscularis externa) that contracts in response to cholecystokinin. Anatomy • The cystic duct connects the gall bladder to the common hepatic duct to form the common bile duct. sometimes gall bladder) is a small organ whose function in the body is to harbor bile and aid in the digestive process. • The fundus of the gallbladder is the part farthest from the duct. located by the lower border of the liver. which are pouches inside the lining. Microscopic anatomy The different layers of the gallbladder are as follows: • The gallbladder has a simple columnar epithelial lining characterized by recesses called Aschoff's recesses. and enters through the hepatopancreatic ampulla at the major duodenal papilla.
It consists of a fundus. ejecting the concentrated bile into the duodenum. the gallbladder contracts.Size and Location of the Gallbladder The gallbladder is a hollow. It can hold 30 to 50 ml of bile. body and neck. pear-shaped sac from 7 to 10 cm (3-4 inches) long and 3 cm broad at its widest point. It lies on the undersurface of the liver’s right lobe and is attached there by areolar connective tissue. Instead. Then later. Structure of the Gallbladder Serous. it is absorbed into the blood. Jaundice a yellow discoloration of the skin and mucosa. and mucous layers compose the wall of the gallbladder.7 US fluid ounces / 1. when digestion occurs in the stomach and intestines. results when obstruction of bile flow into the duodenum occurs. muscular. 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. which is released when food containing . The gallbladder stores about 50 mL (1. similar in structure to those of the stomach. Bile is thereby denied its normal exit from the body in the feces.8 Imperial fluid ounces) of bile. The mucosal lining is arranged in folds called rugae. and an excess of bile pigments with a yellow hue enters the blood and is deposited in the tissues.
. increasing its potency and intensifying its effect on fats. stimulating the secretion of cholecystokinin (CCK). Most digestion occurs in the duodenum. After being stored in the gallbladder the bile becomes more concentrated than when it left the liver. produced in the liver. The bile. emulsifies fats and neutralizes acids in partly digested food.fat enters the digestive tract.
2 mg/dL. which is not soluble in plasma. the normal level of total serum bilirubin is 0. It is formed from senescent red blood cells. which is rapidly converted to free bilirubin thru biliverdin reductase. this bilirubin is still called free bilirubin. Conjugated bilirubin is secreted as a constituents of bile. In the intestine. approximately 5% is absorbed into the general circulation and then excreted by the kidneys. is transported in the blood attached to plasma albumin. making it soluble to bile. Even when it is bound to albumin. approximately one half of the bilirubin is converted into a higly soluble substance called urobilinogen by the intestinal flora. Free bilirubin. the hemoglobin from the red blood cell is broken down from biliverdin. Urobilinogen is either absorbed into the portal circulation or excreted in the feces. free bilirubin is converted to conjugated bilrubin thru glucoronyl transferase.1 to 1.BILIRUBIN PRODUCTION AND ELIMINATION Bilirubin is the substance that gives bile its color. it passes through the bile ducts into the small intestine. As it passes through the liver. Inside the hepatocytes. Laboratory measurements of bilirubin usually measure the free and the . In the process of degradation. free bilirubin is released from its albumin carrier molecule and moved into the hepatocytes. and in this form. A small amount of urobilinogen. Usually. only a small amount of bilirubin is found in the blood. Most of the urobilinogen that is absorbed is returned to the liver to be re-excreted into the bile.
These are reported as the direct (conjugated) bilirubin and the indirect (unconjugated or free) bilirubin. .conjugated bilirubin as well as the total bilirubin.
refined carbohydrate. high sodium) Present Present Rationale Increased intake of calories. SOURCE: Harrison’s Principle of Medications and Oral Contraceptives Absent Internal Medicine. simvastatin. Patients with cholesterol gallstones secrete a greater fraction of dietary cholesterol into bile than do normal subjects. Oral contraceptive steroids increase biliary cholesterol secretion and . Competitive inhibitors of 3-hydroxy-3methylglutaryl coenzyme A (HMGCoA) reductase (lovastatin.ETIOLOGY AND SYMPTOMATOLOGY Precipitating Factors: Factors Diet (high cholesterol. pravastatin) decrease biliary cholesterol saturation. and saturated fats has all been postulated to cause cholesterol gallstones. gemfibrozil) that lower serum cholesterol by increasing biliary cholesterol secretion increase the risk of cholesterol gallstones by twofold to threefold. cholesterol. 16th Edition Hypolipidemic agents (clofibrate. Estrogen therapy is associated with an increased risk of developing cholesterol gallstones. high calorie.
resulting in increased fasting and residual volumes. which is 20 times normal. Third Edition. Gallstones from during TPN because of decreased gallbladder motility from lack of mealstimulated cholesystokinin (CKK) release.saturation but do not affect gallbladder motility. Stone analysis has not . SOURCE: Harrison’s Principle of Spinal Cord Injury Absent Internal Medicine. SOURCE: Harrison’s Principle of Primary Biliary Cirrhosis Absent Internal Medicine. is believed to be secondary to abnormal gallbladder motility and probably biliary hypersecretion of cholesterol from the progressive reduction in body mass. 16th Edition Patients with primary biliary cirrhosis have an increased prevalence of gallstones. Pathophysiology for the Health Professions. 16th Edition Patients with spinal cord injury have 10% incidence of forming gallstones within the first year after injury. This high risk. Source: Barbara Gould. Saunders Total Parenteral Nutrition Absent Elsivier TPN is a powerful risk factor for gallstone formation.
been performed. and malaria dramatically increase the risk of pigment stone formation because of increased biliary secretion of total bilirubin conjugates. the predominant conjugate in healthy individuals. 16th Edition Inherited hemolytic anemia. SOURCE: Harrison’s Principle of Diabetes Mellitus Present Internal Medicine. thalassemia. diabetes mellitus itself does not appear to be an independent risk factor for cholesterol gallstone disease. sickle cell disease. SOURCE: Harrison’s Principle of . 16th Edition Despite obesity and increased total body cholesterol synthesis and decreased gallbladder motility seen in patients with diabetes. SOURCE: Harrison’s Principle of Hemolytic Syndromes Absent Internal Medicine. chronic hemolysis associated with artificial heart vavles. but the elevated cholesterol saturation of bile in these patients suggest that they form cholesterol stones. sphericytosis. at the expense of the bilirubin diglucuronide. especially bilirubin monoglucoronide.
or parasitic infestation (Ascaris lumbricoides. the risk correlates positively with the extent and duration of ileal dysfunction. 16th Edition Brown pigment stones are frequently found in the intrahepatic bile ducts and are always associated with infection by colonic organisms usually E. careful studies now show that most patients with ilieal dysfuncyion form black pigment. not cholesterol stones. and Bypass Absent Patients with ileal dysfunction have a strikingly increased risk for developing gallstones. 16th Edition Ileal Disease. Resection. or other helminthes). Intraductal stones developing after cholecystectomy are invariable associated with bile stasis. and/or retained suture material.Internal Medicine. SOURCE: Harrison’s Principle of Internal Medicine. Although ilieal disease or resection leads to cholesterol supersaturation and cholesterol stone formation in some patients . biliary tree infection. Gallstones develop in 3050% of patients with ileal Chron’s disease. SOURCE: Harrison’s Principle of Biliary Infection Absent Internal Medicine.coli. 16th Edition .
have a 25-40% chance of developing gallstones within 4 months. During rapid weight loss. and secrete more of it into the bile. Saunders Elsivier Obese patients undergoing rapid weight loss (1-2% of body weight or approximately 1-2 kg/week). Pathophysiology for the Health Professions. biliary cholesterol saturation increases acutely as cholesterol is mobilized from adipose tissue and skin and secreted into bile. leading to bile that is often greatly supersaturated with cholesterol. 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. 16th Edition Rapid Weight Loss/ Fasting diets Absent . either by very low caloric dieting or gastric stapling. Third Edition. Source: Barbara Gould.Obesity Present Obesity is strongly associated with increased gallstone prevalence. SOURCE: Harrison’s Principle of Internal Medicine.
Saunders Advancing Age Present Elsivier The incidence increases with age. Less than 5-6% of the population under age 40 have stones. Concepts of Altered Race Absent Health Sciences Prevalence highest in North American Indians. 16th Edition . and beyond menopause the increased risk disappears. Source: Carol Mattson Porth. Source: Barbara Gould. Before puberty this risk is negligible. hereditary aspects SOURCE: Harrison’s Principle of Internal Medicine. Third Edition. and Chilean Hispanics. greater in Northern Europe and North America than in Asia. Pathophysiology for the Health Professions. lowest in Japan. Chilean Indians. familial disposition. Pathophysiology.Predisposing Factors: Factors Gender Present Absent Rationale Women have twice the risk as men of developing cholesterol gallstones because estrogen increases biliary cholesterol secretion. in contrast to 25-30% of those over 80.
Heredity Absent Family history alone imparts increased risk. elevated estrogen and progesterone levels increase biliary cholesterol secretion. such as defects in lipoprotein receptors (hyperlipidemia syndromes). SOURCE: Harrison’s Principle of Parity/ Pregnancy Absent Internal Medicine. 40% of women develop biliary sludge in their gallbladder and 12% of women form their first stones during pregnancy. Elevated progesterone also inhibits gallbladder contractility. SOURCE: Harrison’s Principle of Internal Medicine. especially with more than two children. 16th Edition Pregnancy is an independent risk factor for cholesterol gallstones. which engender marked increases in cholesterol biosynthesis. 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. During pregnancy. The risk increases with increasing parity. 16th Edition .
Pathophysiology. whereas pain in acute cholecystitis is caused by inflammation of the gallbladder wall. 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. which: develops quickly. The pain often begins suddenly following a meal. Concepts of Tenderness Present .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. is severe. Source: Carol Mattson Porth. Pathophysiology. The pain of biliary colic is caused by the functional spasm of the cystic duct when obstructed by stones. called biliary colic. lasts about one to three hours before fading gradually. right scapula or shoulder. Source: Carol Mattson Porth. The pain may radiate to the back. isn't helped by over-the-counter and isn't helped by passing wind.
Fever occurs in about one third of people with acute cholecystitis. 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. which is inspiratory arrest during deep palpation in the right upper quadrant. Pathophysiology for the Health Professions. Source: Barbara Gould.4° F (38° C) and may be accompanied by chills Fever and chills Absent . Pain is usually accompanied by nausea and vomiting. 16th Edition These signs and symptoms may accompany a gallbladder attack.Murphy’s Sign Present Altered Health Sciences The patient with acute inflammation of the gallbladder might have a positive Murphy’s sign. The fever tends to rise gradually to above 100. Third Edition. SOURCE: Harrison’s Principle of Nausea and Vomiting Absent Internal Medicine.
People tend not to eat.SOURCE: Harrison’s Principle of fLoss of appetite and Anorexia Present Internal Medicine. SOURCE: Harrison’s Principle of Internal Medicine. 16th Edition . especially fatty or oily foods. As a result. 16th Edition The pain often begins suddenly following a large or rich meal. in order not to experience that pain. Fat absorption is also impaired for the lack of bile salts. rapid loss of weight and anorexia can occur.
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 .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.
The cholesterol carrying capacity of the micelles and residual vesicles is exceeded A 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 .
ecteric sclera.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. dark urine Irritation of the gallbladder wall . gray stools Fibrosis Liver Cirrhosis S/S jaundice. pruritus. Vit ADEK deficiency.
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, Murphy’s sign, nausea and vomiting, fever, elevated wbc, anorexia
Release of prostaglandins within the gallbladder wall
IF TREATED: Open Cholecystectomy Laparoscopic Cholecystectomy Litotripsy Ursodeoxycholicacid
IF NOT TREATED
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
Ulcerations of the mucosa
Adhesion to an adjacent hollow viscus (duodenum)
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
tachycardia Septic Shock DEATH . chills.Dehydration Necrosis Hypovolemia Perforation in the intestinal wall Hypovolemic shock Generalized Peritonitis Sepsis S/S fever.
Z 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 spleen’s ability to function properly or loss of function Rupture Hypovolemia Invasion of bacteria from the blood. diarrhea. and margination of chromatin Death HEPATIC ENCEPHALOPATHY S/S Anorexia. a prominent nucleolus. anemia. Liver tenderness. Nausea. or lymph or through the bowel wall Increases in blood waste product since spleen is not able to properly destroy RBC’s Hypovolemic shock Spontaneous Bacterial Peritonitis Death S/S Fever. abdominal pain Sepsis Astrocytes become swollen Death S/S Thrombocytop enia. Jaundice . leukopenia Septic Shock Development of a large pale nucleus.
Cerebral edema Increased intracranial pressure Brain Hernation Hepatic Coma DEATH .
M 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 K .
admit under 10:40am Walter G. Batucan who is an expert on General Surgery. Billiary and Pancreatic Surgery.28 other blood Platelet – 222 components that will X10^9/L help determine the underlying diagnosis. and the Segmentersproportion of various 0.2 X hemoglobin. Liver. Remarks Done Low fat diet Done Labs: CompleteBloodCount.DOCTOR’S ORDER Date & Order Time 04-27-09 Pls.46 of each blood cell in a X10^12/L given specimen of Hematocrit – blood. Gallbladder. Batucan Rationale Dr. PlateletCount Blood Typing Complete blood count Done is the determination of Hemoglobin – the quantity of each 172g/dL quantity of each type RBC – 5. often including 0. cholesterol becomes insoluble and crystallizes. 10^9/L hematocrit. For proper evaluation and management and care under Dr. Bile contains large amount of cholesterol that usually remains dissolved in the bile but when there is oversaturation with cholesterol.53 the amount of WBC – 15.72 white cells. Low fat diet serves as a prevention and treatment for gallstone formation. Patient is to undergo Done an invasive surgery Blood type – which could lead to O+ . LymphocytePlatelet count and 0.
the adjacent spaces. Prior to surgery. Done Normal Sinus Rhythm . cloudy Rxn:6 Spec. including the ribs. An indicator of health and disease.030 Glucose (-) Albumin (+++) Pus cells 24/hpf RBC 1-2/hpf Mucus threads (+) Done > Suggestive of an inflammatory lung disease compatible with bibasal pneumonia. Ordered so as to check patient’s cadiopulmonary condition before undergoing an invasive surgery. Please correlate clinically. the heart must first be checked to determine whether or Done Yellow. ECG is a recording of the electrical impulses of the heart. 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. Such test is an important indicator of how well the heart is functioning. it is helpful in the detection of renal or metabolic disorders.Urinalysis Chest X-ray ECG blood loss therefore blood typing is done before blood can be transfused on him to replace the loss blood. Chest X-ray provide a good outline of the heart nad major blood vessels and ussualy can reveal a serious disease in the lungs. gravity1. and the chest wall.
7umol/L Done 228U/L .3umol/L Done 7.497mmol/L Done 33. Direct and Indirect bilirubin are differentiation on why there is an increased bilirubin.84mmol/L DONE 148umol/L Done 0. Measuring serum creatinine is used to indicate renal function.Fasting Blood Sugar Creatinine Uric Acid Total Bilirubin Direct Bilirubin Indirect Bilirubin Alkaline Phosphatase not it can handle the surgery. Evaluates impairment of the liver or hemolytic anemia. Direct bilirubin is associated with liver dysfunction or blockage while Indirect bilirubin is related to destruction of red blood cells. and is usually produced at a fairly constant rate by the body. Prior to surgery. It is mainly filtered by the kidney. gout and leukemia. Creatinine is a breakdown product of creatine phosphate in muscle. This enzyme test is used chiefly as an index of liver and bone Done 6. though a small amount is actively secreted. 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.6umol/L Done 25. Measurement of uric acid is most commonly in evaluation of renal failure.
Albumin Attach result disease when correlated with other clinical findings. Pls. Torno Prior to surgery Cadiofor Cardio-Pulmonary Pulmonary system clearance – co must first be diagnosed management whether or not the patient’s circulatory and respiratory system can handle the surgery. or if not enough protein is being absorbed by the body. schedule for lap Surgical removal of the cholecystectomy gallbladder using a Done Done Done . Dr. Done 55. c/o patient’s stock and was ordered to continue his maintenance medication. Torno is an Intenist whose specialty is cardio and pulmo. Please refer to Dr. The test helps in determining if a patient has liver disease or kidney disease. Cannot entirely rule out calculus in the cystic duct Done 04-28-09 7am Meds: Lopicard 5mg tab OD – Patient is hypertensive. Done Cholecystitis with bile sludge formation and suggestive hydrophoric change.4 Refer accordingly 11:20am Call doctor’s attention immediately once any unusuality occurs. attaching the result in the chart allows better diagnosis and analysis for the rest of the medical team involved in his upcoming surgery. ultrasound Prior to admission patient had undergone UTZ.
Dr. It is the permission obtained from the patient that he is to undergo a surgical procedure. It is also used for hydration and electrolyte replacement.Secure consent Anesthesiologist: Eugene Barinaga Dr. thus a follow up must be made in order for the doctors to correlate the findings. Batucan. chart review done laparascope is indicated for acute cholecystitis. Lab results are not yet available. Start vitamin K 10g IV OD Follow up all lab results and attach to chart 10am Start PLR iL @ KVO rate 04-28-09 12:20pm Anesthesiologist: Pre-op Evaluation Thanks for this referral Patient seen and evaluated. Anesthesiologist made rounds to the patient so as to establish a therapeutic Done Done Done Done Done . K IVTT that was ordered beforehand and for future medications. Securing consent ensures the safety of both the medical team and the patient. The referral was made so as to ensure a safe and successful surgical procedure. Pre-operative standard operating procedure so as to prevent excessive bleeding during the actual surgical procedure. Barinaga may be the partner anesthesiologist of Dr. PLR an isotonic solution that resembles blood serum used as passage for the Vit.
Barinaga Done Done Done Done . 7am was ordered for it was the most convenient time for patient. 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. Reschedule OR tomorrow OR schedule was not at 7am indicated on prior orders. Inform OR. 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 he’ll undergo. Done Accepted by patient Done 04 -28-09 3pm Pre-meds: Midiazolan 15mg 1tab ½ An anti-anxiety drug.Anesthesia plans explained consequences and benefits explained Nothing per orem temporary at 5am after breakfast 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. his medical team and the OR staffs. tab @ 12nn tomorrow given so as to relieve with 30cc of water. Barinaga Informing Dr. patient’s anxiety regarding his upcoming surgery. Dr.
Schedule at 7am After rescheduling the day. Continue Lopicard Patient may continue with his maintenance medication. Pls. Barinaga due to the rescheduling of the surgery. OR finally gave the time for the patient’s surgery. Anesthesiologist aware The new anesthesiologist was made aware of the upcoming surgery for Done Done Done 04-28-09 5pm 10pm Done Done . HPN due to history of hypertension and T/C due to high serum glucose as shown in his FBS.regarding the scheduled surgery allows him time to prepare and ready himself for the upcoming surgical procedure. Patient was diagnosed with CAP low risk due to the findings above. his surgeon then rescheduled the operation maybe due to patient having pneumonia. reschedule surgery After being seen by his on Thursday internist. Start Sulperazone 1. 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 Patient showed signs and symptoms of pneumonia. Anesthesiologist: Dr Change of Tozon anesthesiologist instead of Dr.5g Given to treat IV q8 respiratory infection and also serves as preoperative prophylaxis.
For open Patient has gangrenous cholecystectomy instead gallbladder and open of lap chole cholecystectomy is indicated for such. Plan carry out above For abrupt orders implementation. Metoclopramide 1amp Promotes gastric IVTT at 6am emptying prior to surgery. IntraOp NPO now Patient was put on NPO for he is to undergo surgery the following day. Ranitidine 1amp IVTT at Patient was on NPO so 6am ranitidine. an H2 antagonist. Although Sulperazone Batucan – Sulperazone and Cefoxitin can serve will serve as pre-op as pre-operative antibiotic management prophyaxis. prior to OR Kindly inform Dr. For Surgery tomorrow at The scheduled 7am once cleared procedure will be carried out once the Internist cleared the patient for surgery. Batucan Sulperazone over Cefoxitin maybe because the former is more potent than the latter but still it’s the attending physician’s decision on what drug to give. No absolute Surgery can now be contraindication to done after CP planned surgery CP ok clearance was done. the discontinue Cefoxitin if internist chose ok with Dr.04-29-09 10:40am 04-29-09 1:40pm 5pm 04-30-09 12mn him to be prepared. was ordered because it inhibits the action of histamine at the H2 Done Done Done Done Done Done Done . Cefoxitin (Monowell) Serves as pre1amp IVTT ANST now operative prophylaxis.
3. nutrients and electrolytes.redness. 04-30-09 To PACU PostOp For intensive monitoring after the surgery and for recovery. 2. IVF D5NSS iL at 120cc/hr To replenish fluids. Ranitidine 50mg q8 Ranitidine serves as IVTT post surgery antacid and to prevent ulcer of which is ketorolac’s adverse effect. VS q15 until stable. Done Done Done Done Done Done Done . NPO Nothing per orem until patient passes out flatus for he still has no peristalsis and so as to avoid aspiration. fever. serves also as a post operative analgesia. Tramadol 50mg q6 Relief of moderate to IVTT moderately severe pain. Meds: 1. then Monitoring the vital q1° X 4hrs then q4° signs determines patient’s body’s reaction after he had undergone the surgery and so as for prompt intervention for any deviations in vital signs.receptors of the parietal cells inhibiting gastric acid secretion. and pain. swelling. Ketorolac 30mg q8 Short-term IVTT management (up to 5 days) of moderately severe acute pain and reduces signs and symptoms of inflammation .
Ordered because morphine increases biliary spasm. Postoperative patients are at risk of these.25 MSO4 OD c/o Dr. convulsion and to lower the blood pressure. Tozon Morphine precaution I & O q shift Refer accordingly 04-30-09 5pm IVFTF: D5NSS 120cc/hr iL Post operative prophylaxis Bupivacaine serves as analgesia for surgery added with magnesium sulfate so as to prevent seizue. Accurate measurement of a patient's fluid intake and output will identify those patients at risk of becoming dehydrated or overhydrated. Done Done Done Done Done Done . Anesthetics and surgery affect the hormones regulating fluid and electrolyte balance (Aldosterone and ADH). Sulperazone 1.4.25% 10cc + 0.5g q8 IVTT Epidural anesthesia: Bupivacaine 0. placing the client at risk for decreased urine output and fluid and electrolyte imbalances. Monitoring I & O help assess fluid balance. Call doctor’s attention immediately once any unusuality occur at To continue IVTT medication administration and to replenish electrolyte and fluid loss due to the surgical procedure.
DIAGNOSTIC EXAMINATIONS Exam Result Reference Clinical Indication Interpretatio n Nursing Responsibility Range Hematology (April 27. 2009) .
The hemoglobin determination test is used to screen for diseases associated with anemia and in determining acid-base balance.0-6.Hemoglobi n 172 M: 140170 F: 120 – 150 g/dL Hemoglobin is an important component of red blood cells that carries oxygen and carbon dioxide to and from tissues. Erythrocyt e 5.46 4. This test is used to evaluate any type of Above normal range. The oxygen carrying capacity of the blood is also determined by the Hemoglobin concentration. .0 X10^9/L Within normal range.
Blood Typing O+ This blood test is performed to match donor blood with recipient who requires blood transfusion. but produce antibodies against both types of antigens. B. Because of this arrangement. . Inform the patient the result of the test. 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. Type O people have red blood cells with neither antigen. Blood typing identifies the inherited antigens that compromise one of four possible blood types: A. Hence. type O can be safely given to any person with any ABO blood type. O. Follow up results in the laboratory. AB.
e Range Urinalysis (April 27. 2009) Exam Result Referenc Clinical Indication Interpretatio n Nsg Responsibility .
urates and uric acid in the urine composition. RBC. pus. This helps to indicate presence of WBC. phosphates. Specific gravity is above 1. The color of urine changes in many disease states due to the presence of abnormal pigment. . Alkaline urine may appear Prepare client: -Explain that this test is to Appearance Cloudy Clear Urine specimen may appear clear to cloudy. bacteria. Amber colored urine is normal but it indicates high specific gravity and a small amount of urine. excretion of cloudy urine may not be abnormal since the change on urine pH may cause precipitation within the bladder of normal urinary constituents.Physical Exam Color Amber Yellow Urine specimens may vary in color from pale yellow to dark amber.020 and output less than 1L per day However.
diagnosis and evaluation of change in his respiratory system.X-ray Report (April 27. Please correlate clinically. Nursing Responsibilities: Explain to the patient that the chest x-ray will be used for screening. patient also has pneumonia which then needs an Internist to determine whether he can proceed with the scheduled surgery. Rest of the lung fields is clear. Interpretation: Chest X-ray was ordered so as to assess the patient’s cadio and pulmonary system prior to surgery and it was found out that aside from having cholecystitis. This test also gives valuable information on the condition of the heart. 2009) Chest PA Clinical Indication: Chest X-ray is done to diagnose pulmonary disease and diseases of the mediastinum and bony thorax. There are infiltrates on both lung bases. lungs. . Impression: Suggestive of an inflammatory lung disease compatible with bibasal pneumonia. Findings: Heart is within normal limit in size. 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. gastrointestinal tract and thyroid gland. Lateral CP sinuses are sharp.
.- 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. Place the electrodes accurately. Place patient in a supine position in the bed or table. Nursing Responsibilities: Inform patient on why and how the test is done. painless and a safe test. Tell him that this is not an invasive procedure. 2009) Rate: 25 min PR interval: 0.10second Rhythm: Sinus QRS: 0. Inform the patient regarding the result.08second Axis: +15° QTc: 0. Prepare the skin (shave if there is excess hair) by applying contact paste or prejelled discs. .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.
Range Blood Chemistry (April 27, 2009) FBS 6.84 4.20 – 6.40 mmol/L
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.
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
Explain the purpose and the procedure of the test. may indicate obstructive jaundice of which is a result of obstruction of the common bile duct or hepatic ducts due to stones or neoplasm.4 umol/L 2. and hemolytic anemia. A NORMAL level of total bilirubin reules out any significant impairment in the excretory function of the liver or excessive hemolysis of red blood cells.0 – 21. may indicate hemolytic anemia. Above normal range. Tell patient that 10ml venous blood is to be collected before he eats his breakfast. .0 – 3. Differentiation of bilirubin is done to determine which of the problems above is the cause of the elevation of total bilirubin. Inform patient regarding the test result.0 umol/L 0.7 2.6 25. An in crease in Above normal range.Total Bilirubin Direct Bilirubin Indirect Bilirubin 33. may indicate choledocholithi asis.0 – 17 umol/L The measurement of bilirubin is important in evaluating liver function.3 7. Above normal range.
497 0. Inform the patient regarding the result.4 umol/L 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. Explain the purpose and the procedure of the test. Inform the patient regarding the result. Explain the purpose and the procedure of the test. could be associated with nitrogen retention and with increase in urea. gout and leukemia. In liver disease.Uric Acid 0. the blood level Within normal range . Above normal range.2 – 0. Monitor patient’s intake and output so as to determine if he has a decreased renal function. creatinine and other nonprotein nitrogenous substances in the blood. 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. May indicate a decreased renal function.
may indicate renal disease. Explain the purpose and the procedure of the test. .rises when excretion of this enzyme is impaired as a result of obstruction in the biliary Albumin 55. Above normal range. This test can help determine if a patient has liver disease or kidney disease. Inform the patient regarding the result. or if the body is not absorbing enough protein.4 38 – 51 g/L tract.
Quetionable echoes are seen in the partly obscured cystic duct. . The width AP diameter of the common bile duct is 0. The intrahepatic ducts are not dilated.6cm to 4. no focal lesions noted intraluminally. 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).) The liver is normal in size and tissue attenuation with smooth external outline.1cm low level echoes are seen in the dependent portion of the gallbladder.4cm.Ultrasound Report (04/27/09) Ultrasound Report (This report is based on sonographic findings and must be correlated clinically. No cystic or solid parenchymal lesions demonstrated here. Impression: > Cholecystitis with bile sludge formation and suggestive hydrophoric change. The pancreas is obscured by overlying bowel gas preluding adequate assessment. The gallbladder is significantly distended to 11.1cm (length X AP dm) with diffusely thickened walls that measures up to 1. he then needs to undergo open cholecystectomy instead of lap cholecystectomy.
Reducing heart burden lessens the heart muscle's demand for oxygen. blocking calcium transport relaxes artery muscles and dilates coronary arteries and other arteries of the body. Inform him that water is permitted. Antihypertensive Mode of Action: Blocks the transport of calcium into the smooth muscle cells lining the coronary arteries and other arteries of the body. amlodipine is useful in preventing chest pain (angina) resulting from coronary artery spasm. Inform patient regarding the result. Instruct him not to eat solid food for the 12 hours prior to exam to allow greatest dilation of the gallbladder. Dosage: Lopicard 5mg tab OD . DRUG STUDY Generic Name: Amlodipine besylate Brand Name: Lopicard Classification: Calcium channel blocker. Since calcium is important in muscle contraction. and further helps to prevent angina in patients with coronary artery disease. By relaxing coronary arteries. Inform patient that ultrasound is a noninvasive procedure. Antianginal. 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.Nursing Responsibilities: Explain the purpose and the procedure of the test.
fatigue. drowsiness. 5. Increased antihypertensive effects with other antihypertensives. muscle cramps. headache. 6. 3. Nursing Responsibilities: 1. light-headedness. 2. Assess patient for contraindication. lactation Side Effects: dizziness.Drug Interaction: Risk of congestive heart failure with betaadrenergic blockers. 4. Instruct him to take drug exactly as prescribed by his physician. . Monitor patient’s vital signs carefully while adjusting drug to therapeutic dose. difficulty breathing Drug . chest pain. sick sinus syndrome. palpitations. edema of the lower extremities. heart block (second or third degree). vomiting. Assess for baseline data. nausea. impaired hepatic or renal function. arrhythmias. Administer drug without regard to meals. flushing. abdominal discomforts Adverse Effects: asthenia. stomach pain. Possible increased serum levels and toxicity of cyclosporine if taken concurrently. Instruct patient to take drug with meals if stomach upset occurs. yellowing of the eyes or skin.Indication: Hypertension Contraindication: Hypersensitivity to amlodipine.
Oral care if patient vomits. 11. noise and temperature if he experiences headache and report if it is intolerable so that medication may be given. . Instruct him to report intolerable side effects so management can be done.Instruct him to report any adverse effects that he may experience.7.Instruct him to adjust lighting. Instruct him to eat frequent small meals if vomiting occurs. 9. 12. Tell patient that he may experience some side effects brought upon by the drug. 10. 8.
mineral oil: may inhibit Gi absorption of vitamin K Oral anticoagulants: decreased anticoagulant effect . demonstrated by ecchymoses. and X. diaphoresis. GI bleeding. hypoprothrombinemia CONTRAINDICATION: Hypersensitivity. Vitamin K deficiency causes an increase in bleeding tendency. usually after rapid IV administration DRUG INTERACTION: Cholestyramine. severe hepatic disease. last few wk of pregnancy SIDE EFFECTS: Dizziness.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. all of which are essential for blood clotting. flushing. hematuria. erythema. epistaxis. pain swelling and hematoma at injection site ADVERSE REACTION: Anaphylaxis or anaphylactoid reactions. Vitamin K malabsoption. DOSAGE: Vitamin K 10g IV OD INDICATION: Prevention of bleeding. transient hypotension after IV administration. rapid and weak pulse. IX. VII.
Assess for baseline data. Antibiotics: may inhibit vitamin K production leading to bleeding NURSING RESPONSIBILITIES : 1. . hematuria. 3. monitor for bleeding. 8. Monitor protime during treatment. Tell patient that he may experience side effects brought about by the drug and to report intolerable ones so as prompt interventions be done. 4. to take this medication as directed. Assess for contraindication. 7. Teach patient not to take other supplements. 5. unless directed by prescriber. 2. 6. Instruct patient to report symptoms of bleeding: bruising. nosebleeds. Instruct patient to report adverse effect that he may experience. Stress the need for periodic lab tests to monitor coagulation level. bleack tarry stools. pulse and BP.
Dosage: Midazolam 15mg 1tab ½tab at 12nn with 30cc of water Indication: Sedation. acute alcoholic marrow-angle shock. an inhibitory neurotransmitter. anxiolysis. salivation. dysarthria. headache. intoxication. diarrhea. pregnancy (cleft lip or palate. rigidity. disorientation. potentiates the effects of gamma amino butyric acid (GABA). inguinal hernia. tremor. dry mouth. anxiolytic and amnesia effects occur at doses below those needed to cause sedation. vomiting. incontinence.Generic Name: Midazolam HCl Brand Name: Dormicum Classification: Benzodiazepine (short-acting). diaphoresis. apathy. dystonia. light-headedness Adverse Effects: Lethargy. CNS depressant. dreams. neonatal withdrawal syndrome reported in infants). constipation. neonates Side Effects: Drowsiness. GI upset. stupor.Anxiolytic. ataxia. and amnesia prior to surgery Contraindication: acute Hypersensitivity glaucoma. cardiac defects. to benzodiazepines. has little effect on cortical function. microencephaly. fatigue. nausea. delirium. Anticonvulsant Mode of Action: Acts mainly at the limbic system and reticular formation. dizziness.psychoses. euphoria. vivid dreams. crying. difficulty concentrating. vertigo. nervousness. hiccups. pyloric stenosis have been reported when used in the first trimester. . coma.
paresthesias. respiratory depression. laryngospam. gastric disorder. nystagmus. extrapyramidal symptoms. tachycardia. jaundice. respiratory arrest . bradycardia.psychomotor retardartion. drug dependence. hepatic dysfunction. bronchospam. gynecomastia. urticaria.
Instruct him to take the drug exactly as prescribed. and the drug is a potent amnesiac and he will not remember what has happened on him. 4. or OTC drugs before receiving the drug. Assess for baseline data. Nursing Responsibilities: 1. Instruct him to avoid alcohol. 7. Carefully monitor VS during administration. Keep patient on bed for 3hours. 8. rifampicin. carbamazepine. Assess patient for contraindication. 6. ketoconazole and itraconazole. 2. .Drug – Drug Interaction: Increased CNS depression with alcohol. during and for at least 2 – 6hours after administration. other benzodiazepines. Halothane. clarithromycin. Monitor level of consciousness before. thiopental requirements may be reduced during concurrent use. verapamil. 9. barbiturates. erythromycin. Teach him that the drug helps him to relax and will make him sleep. Increased respiratory depression with opiates. antiretroviral agents. phenobarbital. opioids. or sleep – inducing. other sedatives and anaesthetics. Plasma concentrations increased by CYP3A4 inhibitors such as cimetidine. diltiazem. 5. phenobarbital. Midazolam concentration decreased by phenytoin. not to permit ambulation upon administration. 3. quinupristin with dalfopristin. Tell patient that he may experience side effects brought upon by the drug.
.Instruct patient to report adverse effects that he may experience.10.
headache. S.Generic Name: Cefoperazone Na 1 g. H. hematuria. parainfluenzae. coli. seizure. E. shock Drug – Drug Interaction: Increased nephrotoxicity with aminoglycosides Increased bleeding effects with anticoagulant . Sulbactam Na 0. or renal failure Side Effects: diarrhea. nausea. leukopenia. pyrogenes. Klebsiella. anaphylaxis.5g q8 IVTT Indication: Treatment of respiratory infection caused by S. H. inflammation at IV site. dizziness. hypotension. Post operative prophylaxis Contraindication: Hypersensitivity to cephalosporin or penicillin. S. aureus. liver toxicity. pain at injectionsite. nephrotoxicity. Perioperative prophylaxis. antibiotic Mode of Action: Inhibits bacterial cell wall synthesis causing cellular death Dosage: Sulperazone 1. influenzae. vasculitis. rash Adverse Effects: paresthesia. abdominal pain. vomiting. pneumoniae.5 g Brand Name: Sulperazone® [vial] Classification: Cephalosporin. bone marrow depression.
Disulfiram-like reaction may occur if alcohol is taken 72hrs after drug administration .
6. 5.Instruct patient to avoid alcohol because severe reactions could occur. 7. Have vitamin K injection readily available in case of hypoprothrombinemia. 10. Inject slowly over 3-5 minutes. Instruct him to report intolerable side effects so management can be done. Oral care if patient vomits. Assess for contraindication. Minimize stimuli (adjust temperature. 11. 2. 9. 3. Instruct him to eat frequent small meals if vomiting occurs. Tell patient that he may experience side effects that are brought about by the drug. 8. . 4. lighting and avoid noise) if headache occurs and if intolerable pain medication may be given as ordered. Assess for baseline data.Nursing Responsibilities: 1.Tell patient to report any adverse effects that he may experience.
decreased hematocrit. headache. flatulence. superinfection. Disulfiram-like reaction may occur if alcohol is taken within 72hours after drug administration. liver toxicity. Renal excretion inhibited by probenecid. stomach upset Adverse Effects: Lethargy. convulsion. leukopenia. Cephalosporin (second generation) Mode of Action: Bactericidal: inhibits synthesis of bacterial cell wall. anaphylaxis. decreased platelet. causing cell death. diarrhea. rash. Side Effects: Nausea. anorexia. nephrotoxicity. Drug –Drug Interaction: Enhanced nephrotoxicity with aminoglycosides and loop diuretics e. . dizziness. pseudomembranous colitis. vomiting.Generic Name: Cefoxitin Sodium Brand Name: Monowell Classification: Antibiotic. phlebitis. fever. Increase bleeding with oral anticoagulants. Dosage: Cefoxitin 1 amp IVTT ANST now prior to OR Indication: Surgical prophylaxis Contraindication: Hypersensitivity to cephalosporins or penicillins.g. furosemide. paresthesias. pain on injection site.
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.
urticaria. constipation. tricyclic antidepressants . rash. somnolence. local burning or itching at IV site Adverse Effects: malaise. cholinergic agonist. leukopenia. nausea. dizziness. Side Effects: headache. Dosage: Ranitidine 50mg q8 IVTT Indication: Post surgery antacid to prevent ulcer formation Contraindication: Hypersensitivity to ranitidine. vertigo. thrombocytopenia.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. histamine. insomnia. vomiting. pancytopenia. inhibiting basal gastric acid secretion and gastric acid secretion that is stimulated by food. lactation. insulin. abdominal discomforts. diarrhea. gastrin. tachycardia. and pentagastrin. bradycardia. impotence. hepatitis Drug – Drug Interaction: Increased effects of warfarin. gynecomastia.
Assess for baseline data. Instruct patient to take his meal if nausea or vomiting occurs. 4. 2. 3. Instruct him to report intolerable side effects so as prompt intervention could be done. Oral care if vomiting occurs. .Nursing Responsibilities: 1. Tell patient that he may experience side effects brought about by the drug. 6. 7. 5. Assess patient for contraindication. 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. Instruct him to report adverse effects that he may experience. 8.
rash. dizziness. pallor. centrally acting Mode of Action: Binds to mu-opioid receptors and inhibits the reuptake of norepinephrine and serotonin. somnolence. anaphylactoid reactions Drug – Drug Interaction: Carbamazepine reduces the effect of tramadol by increasing its inactivation in the body. causes many effects similar to opioids – dizziness. . post surgery analgesia Contraindication: Hypersensitivity to tramadol or opioids or acute intoxication with alcohol. anxiety. tachycardia. constipation. vertigo Adverse Effects: Confusion. constipation – but does not have the respiratory effects. headache. dry mouth. nausea. headache. visual disturbances. diarrhea. somnolence. vomiting. sedation. or psychoactive drugs Side Effects: Nausea. sweating.Generic Name: Tramadol HCl Brand Name: Ultram Classification: Analgesic. opioids. seizure. Dosage: Tramadol 50mg q 6° IVTT Indication: Relief of moderate to moderately severe pain. drowsiness. bradycardia.
for example. 6. Control environment (temperature. . narcotics. Oral care for dry mouth and vomiting. Nursing Responsibilities: 1. thereby increasing the concentration of tramadol by 50%-60%. 3. Parnate) or selective serotonin inhibitors [(SSRIs. Tramadol may increase central nervous system and respiratory depression when combined with alcohol. anesthetics. 4. Tell patient that he may experience side effects brought upon by the drug. Quinidex) reduces the inactivation of tramadol. 8. Assess for baseline data. Quinidine (Quinaglute. 7. 9. Combining tramadol with monoamine oxidase inhibitors (for example. lighting) if sweating or CNS effects occur. 2. 5. Encouraged small frequent meals if vomiting occurs. Encourage him to increase oral fluid intake. Instruct patient to report adverse effects that he may experience. fluoxetine (Prozac)] may result in severe side effects such as seizures or a condition called serotonin syndrome. tranquilizers or sedative hypnotics. Assess for contraindications. Instruct him to report side effects that are intolerable.
Generic Name: Ketorolac tromethamine Brand Name: Toradol Classification: NSAID. diarrhea. It blocks the enzymes that cells use to make prostaglandins (cyclooxygenase 1 and 2). bleeding. GI pain Adverse Effects: gastric or duodenal ulcer. peripheral edema.redness. headaches. and pain . bone marrow depression . insomnia. dyspepsia. nausea. membrane. swelling. Dosage: Ketorolac 30mg q8 IVTT Indication: For short-term management (up to 5 days) of moderately severe acute pain that otherwise would require narcotics. Contraindication: Hypersensitivity to ketorolac. somnolence. As a result. aspirin allergy Side fluid Effects: rash. abdominal pain. pain as well as inflammation and its signs and symptoms . fever. fever. liver failure. and pain of inflammation and that also are believed to be important in the production of non-inflammatory pain. renal Impariment. pancytopenia. neutropenia. platelet inhibition. mucous drowsiness. dry dizziness. It most often is used after surgery. leukopenia. heartburn.are reduced. sweating. ringing in the ears. constipation. retention. dysuria. chemicals that cells of the immune system make that cause the redness. Nonopioid analgesic Mode of Action: Reduces the production of prostaglandins. thrombocytopenia. renal impairment.
. 5. Increase risk of lithium toxicity with lithium (Eskalith) Reduced kidney function with concominatnt use with angiotensin converting enzyme (ACE) inhibitors. 10. Instruct to report signs of bleeding such as black tarry stool. Assess patient for contraindication. Increase risk of bleeding with anticoagulants (warfarin). 4. 6. Tell patient that he may experience side effects brought upon by the drug. Encouraged oral fluid intake to avoid dry mucous membrane. Infuse slowly as a bolus over no less than 15 seconds. 3. aspirin Increased risk of nephrotoxicity with other nephrotoxins (aminoglycosides.Drug – Drug Interaction: Increased levels of ketorolac in the body and increased side effects with Probenecid (Benemid). 7. 2. Instruct to report intolerable side effects for prompt intervention. Administer with ranitidine to avoid ulceration. weakness and dizziness upon standing. Assess for baseline data. Provide comfort measures if headache occurs. 8. cyclosporine) Nursing Responsibilities: 1.Instruct to report if he experiences adverse effects. 9.
lightheadedness Adverse Effect: convulsion. tingling around the mouth. nausea. subtype EP1 (PGE2EP1). cardiac arrest. dizziness. hypotensive shock. unconsciousness. 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. numbness of tongue. ringing of the ears. by slowing the propagation of the nerve impulse. tinnitus. inflammation.g. and hyperalgesia Dosage: Bupivacaine 0. Side Effects: nervousness. lignocaine. blurred vision. analgesia for surgery Contraindication: Hypersensitivity to bupivacaine or other local anesthesia e. tremor. drowsiness.25MSO4 OD Indication: Local or regional anesthesia. tachycardia. bradycardia. feeling of disorientation. blood clotting disorder. myocardial depression. which inhibits the production of prostaglandins. respiratory arrest. seizures. low blood pressure. vomiting. thereby reducing fever.Generic Name: Bupivacaine Brand Name: Bupican Classification: Anesthesia Mode of Action: Block the generation and the conduction of nerve impulses.25% 10cc + 0. arrhythmias. . presumably by increasing the threshold for electrical excitation in the nerve.
Drug – Drug Interaction: Additive effects when used with antiarrhythmic drugs .
. 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. report to the anesthesiologist any signs and symptoms of adverse effects. 8. 2. 6. Assess for baseline data. Continue to monitor patient following discontinuation of anesthesia. Assess for contraindication. 4. 7.Nursing Responsibilities: 1. Monitor for side effects. Oral care if vomiting occurs. 3. Monitor for occurrence of adverse effects. Monitor vital signs carefully. drug depresses the pulmonary and cardiac system. 5.
tetany . collapse. acts peripherally to produce vasodilation. headache.25% 10cc + 0. excessive bowel movement. appendicitis. hypothermia. sweating.Generic Name: Magnesium Sulfate Brand Name: Classification: Electrolyte. hypocalcemia. dizziness. flushing. flaccid. myocardial damage. magnesium paralysis. vomiting. palpitations Adverse Effects: fainting.25MSO4 OD Indication: Parenteral anticonvulsant for the prevention and control of seizures. nausea. hepatitis. hypotension. lowers BP while in surgery Contraindication: Hypersensitivity to magnesium sulfate. Dosage: Bupivacaine 0. 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. heart block. abdominal pain. Antiepilecptic. intestinal and biliary tract obstruction Side Effects: weakness. intoxication. cardiac and CNS depression. attracts and retains water in the intestinal lumen and distends the bowel to promote mass movement and relieve constipation. Antihypertensive. larger doses cause lowering of blood pressure. fecal impactation. circulatory depressed reflexes.
If it is suppressed. Reduces antibiotic activity of streptomycin. Assess for baseline data. Administer with caution if flushing and sweating occurs. 10. Volume for volume replacement when excessive bowel movement and vomiting occurs to replace the loss fluid. 3. pancuronium. Discard unused portion. Assess for contraindication. vecuronium) CNS depression and peripheral transmission defects produced by magnesium is antagonized by calcium. Monitor knee-jer reflex before repeated parenteral administration. Oral care when vomiting occurs. do not administer the drug for it may cause respiratory center failure. Have calcium gluconate readily available if signs and symptoms of hypermagnesemia occur. 5. 8. Nursing Responsibilities: 1. . atracurium.Instruct patient to report adverse effects immediately. 4. 9. 6. tetracycline and tobramycin when given together. 2. 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. Do not administer unless solution is clear and container is undamaged. 7.Drug – Drug Interaction: Potentiation of neurotransmuscular neuromuscular blockade relaxants produced by nondepolarizing (tubocurarine.
Batucan. Wolter Operation: Open Cholecystectomy Anesthesiologists: Dr.Procedural Report on Open Cholecystectomy Surgeon: Dr. Togon Date of Surgery: 04/30/09 at 7:00 am Definition .
If unexpected pathology is encountered. A . as requested. Discussion Cholecystectomy may be performed to treat chronic or acute cholecystitis. there are excessive adhesions. Note: Cholecystectomy. Pad all bony prominences and areas vulnerable to skin and neurovascular pressure of trauma. is the preferred treatment for symptomatic gallstones unless the patient is extremely obese. with or without cholelithiasis. or if there is excessive bleeding or surgical injury. The patient is supine. both arms may be extended on padded armboards. or to resect a malignancy. A pillow may be placed under the sacrum and/ or under the knees to avoid straining back muscles.Cholecystectomy is the excision (removal) of the gallbladder. if acute inflammation distorts normal tissue planes. performed laparoscopically. or ductal or vascular anomalies exist. 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.
The surgeon must be aware of anomalies of these structures. The wound is closed in layers. A foley catheter is not routinely placed. A drain (e. Hemoclips). right paramedian.g. Machines and Supplies Draping . Skin Preparation Begin at the intended site of incision. An electrosurgical dispersive pad is applied. cystic artery. Jackson-Pratt ™) may be employed exiting a stab wound and secured to the skin with a stitch. either right subcostal (most frequently used). The cystic duct. The skin is closed with interrupted stitches.. Instruments. and common bile duct are exposed. or skin staples. The cystic artery is clamped (using two right-angle clamps) and ligated with a suture passed on a long instrument or by clips (e. The gallbladder is grasped (generally with a Pean clamp).g. tapes. or medline. or midline. Procedure The incision is right subcostal. The underlying liver bed may be reperitonealized. The gallbladder is mobilized by incising the overlying peritoneum and after local dissection is removed.nasogastric tube may be inserted by the anesthesia provider.. right paramedian. The abdominal cavity is entered in the usual manner. extending from the axilla to the pubic symphysis and down to the table on the sides. as is the cystic duct.
if requested Laser (e. or (1) #11 Suction tubing Hemoclips or similar ligating clips . if unavailable.• 4 folded towels and a laparotomy sheet Equipment • • Folded blanket or pad (for positioning) Sequential compression device with disposable leg wraps.g.. (2) #10. if ordered • • • Suction Ultrasound generator. a uteroscope or small cystoscope may be substituted Supplies • • • • • Antiembolitic hose Basin set Blades. (1) #15. 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.
condition of skin preoperatively) must be documented in the operative record for continuity of care and for medicolegal reasons.g. available Nursing Responsibilities Preoperative • All care that is given and observations made regarding the patient (e. optional • Mushroom-tipped (retention) catheters.g. available • • Culture tubes. Pezzer or Malecot. peanut or Kittner sponges) Drains.g. Thrombostat™..g. Avitene™.• • • • Electrosurgical pencil and cord with holder and scrape pad Needle magnet or counter Dissectors (e. e.. Jackson-Pratt or Hemovac™). Surgicel™.. e.g. .g. Penrose 1” or suction drain (e. • The nurse conveys to the patient that he will act as the patient’s advocate by speaking for him while the patient is in surgery. Helistat™.. one aerobic and one anaerobic Hemostatic agent e..
list of meds & allergies) Check the chart for patient’s sensitivities and allergies e. 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. • Instruct what to leave at home such as jewelry. watch. previous medication use. immune function. Explain nursing . allergy to iodine.g. • Inform the patient of the scheduled date and time of the surgery and where to report • • Instruct what to bring (insurance card.• Assess health factors that affects the patient preoperatively: nutritional status. cardiovascular status. he ascertains that the patient has no history of allergy to radiopaque dye. drug or alcohol use. psychosocial factors. • When the circulator reviews patient allergies with the patient. as well as the spiritual and cultural beliefs. medications and contact lenses • Instruct what to wear ( loose fitting. endocrine function. hepatic and renal function. Document allergies noted preprocedure and document alternative used.
• Respect cultural. • All medications. • Assess and document patient’s anxiety level and level of knowledge regarding the intended procedure. • • • Decrease fear Teach deep-breathing.. Scrub person should use a marking pen on labels to identify all . on the opening field must be labeled. 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. dyes. Clarify misconceptions by answering the patient’s questions in a knowledgeable manner and refer questions to the surgeon as necessary. etc. 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.procedures before performing them and the sequence of perioperative events. • A protective facial shield is suggested for those scrubbed to avoid inadvertent splashing of contaminated fluids onto mucous membranes and eyes.
• Keep the patient adequately covered to maintain patient’s privacy.g.. 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. • • • 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 .solutions. • Take appropriate measures to maintain patient’s body temperature e. expose only the immediate area involved for the procedure. offer warm blanket or raise room temperature as necessary.
The incision is extended with Pott’s scissors.• • Be careful in handling of sharp instruments at all times The scrub person sets up the instruments on the back table for the surgeon. • • Have T-tubes available following common duct exploration One syringe is filled with saline. Postoperative • The circulator accompanies the anesthesia provider and the patient to the PACU. 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. • Usually a stab wound is made in the cystic duct using a #11 blade. • Scrub person needs to have a right angle clamp (Mixter) available throughout the dissection of the biliary tree. he/she gives the PACU perioperative .
Philadelphia . verify & identify operative status & surgeon performed. Report for abnormalities especially for signs and symptoms of shock • Perform safety checks – good body alignment. assess neurological status (LOC) • PACU nurse observes the patient’s breathing. side rails and maintain patent airway and cardiovascular stability • Relieve pain and anxiety Reference pp.. Pocket Guide to the Operating Room.A. Davis Company. • • PACU nurse assumes the role as the patient’s advocate. 148-153. 3rd edition F. • Assess the patient: appraise air exchanges status & note skin color.practioner a detailed intraoperative patient report regarding the course of events as they apply to the individual. monitors blood pressure and vital signs. Goldman 2008. and documents all pertinent information. Maxine A.
Every activity must respect the structural wholeness of the individual because well-being depends on it. Every activity is a product of the dynamic social systems to which the individual belongs. about which she states: The conservation principles address the integrity of the individual… from birth to death. The patient last April 30. vital signs was monitored. The relationship between effective wound management and positive patient outcomes draws on Levine’s four conservation principles. and desires of the “self”’ who makes the choices. To regain structure and function. Patient was encouraged to take a rest. Incision was made. Every activity requires an energy supply because nothing works without it. Every activity is chosen out of the abilities. To have an effective wound healing and prevent complications. and spirit. body. In addition.Nursing Theories Ma. Cholecystectomy was done to remove the gallbladder. 2009 was on status post cholecystectomy. to promote healing. She states that conventional medicine has become increasingly technological. typically centering on treatment to cure disease with medications and surgery. spiritual beliefs. Estine Levine’s Conservation Model Levine’s 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. Dr Watson relates that caring is intrinsic to the therapeutic interpersonal relationship between the nurse and patient. In contrast. antibiotics was also given. nurses traditionally incorporate humanistic. Jean Watson Dr Watson believes that a new paradigm is emerging in health care. To meet the psychological or spiritual needs of patients. or suggestions or through a trusting therapeutic nurse-patient relationship. Aseptic technique in wound dressing was applied to prevent possibility of infection. life experience. the body needs to restore structural integrity through repair and healing. the caring approach of nursing focuses on conscious compassionate skills that help patients achieve a healthy state of mind. altruistic values by using the power of prayer. Ten primary carative factors form the structure of Dr Watson's caring theory Psychological caring-healing therapies strive to instill hope or faith. its quantity and characteristic. The nurse's relationship and . It is very important to take note of the discharges.
initiating self-understanding. cope with their health needs. nursing is based on an art and science that mould the attitudes. in the physiologic needs. and provide opportunities for personal growth. and providing silence was practiced to relieve patient’s anxiety. Patient was on NPO. sick or well. To view Abdellah’s 21 nursing problems according to Maslow’s hierarchy of needs. good hygiene and physical comfort. Faye Abdellah According to her.interpersonal teaching enables the patient to provide self-care. determine personal needs. cough and deep breathing exercises to prevent post operative complications. Patient’s needs was attended such as proper positioning. fluid and electrolyte balance. rest and sleep and to facilitate the maintenance of regulatory mechanisms and functions. elimination. . listening to his concerns. Being available to the patient. promote optimal activity: exercise . Therapeutic communication is implemented through nonverbal behavior and listening. facilitating nonpossessive warmth. and technical skills of the individual nurse into the desire and ability to help people . and communicating with personalized responses to develop a helping. intellectual competencies. the nurse must facilitate the maintenance of a supply of oxygen to all body cells. trusting relationship After developing a therapeutic trusting relationship. maintain good body mechanics and prevent and correct deformities. It is very important to take into consideration the diet after NPO because the body is on the process of repairing. 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. nutrition of all body cells. Medications were also given such as anxiolytic medicines to decrease anxiety. the nurse can help the patient relax before surgery with the caring-healing therapies of holistic nursing.
Observe and document care. Evaluation Goal met. the gallbladder becomes distended.Nursing Care Plan Date/ Time April 27. 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. mind from ®Relieves ductal spasm. development of 2.” The patient had identified relaxing techniques such as deep breathing 3. worry which is helpful in 4. severity and will be able to: character of pain. 2009 311pm Cues S: “ Sakit jud akoa tiyan karun (pointing at the right upper quadrant of the abdomen). Report pain cause of pain and provides is controlled if information about disease not relieved.”. Administer minimizing Chenodeoxycholic acid. and diversional activities as 2. the patient verbalized. medyo sakit pero dili na pareha ganina. Administer smooth exercises and muscle relaxants. ® Chenodeoxycholic acid is . progression/ resolution. 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. inflamed and eventually infected. mura man ug gimakumot na dili nako masabtan. situation ® Anticholinergics relieves reflex spasm or smooth muscle contraction and assist in pain management. The patient may have biliary colic with excruciating upper right abdominal pain Objectives of Nursing Interventions Care Within my 8 hr 1. pain. freeing the nitroglycerin as ordered. Administer indicated for anticholinergics as individual indicated. Demonstrate complications and the use of effectiveness of relaxation skills interventions. as verbalized by the patient. ® Assists in differentiating 1. the client location. Inflammation and swelling depresses the free nerve endings and cause the pain. “ Na ok ok raman ko karun.
Promote bedrest.shallow breathing R N that radiates to the back or right shoulder. ® Severe pain not relieved by routine measures may indicate developing complications/ need for further intervention 8. Source: Porth CM. patient will naturally assume least . Philippines: Lippincott Williams & Wilkins. infectious reducing 6. ® Bedrest in Fowler’s position reduces intraabdominal pressures. ® Reduces itching or pruritus from bile salts in skin 7. (2002). Pathophysiolog y: Concepts of Altered Health States. Note response to medication and report if pain is not being relieved. however. Hyperlipidemic agents. 5. a natural bile acid that decreases cholesterol synthesis reducing size of gallstones. allowing patient to assume position of comfort. Antibiotics ® To treat process inflammation.
Provide diversional activities such as watching television. redirects attention. Encourage use of relaxation techniques such as deep breathing exercises. 10. 9. calamine lotion. maintain a cool room temperature. Use soft. cotton lines. Control environmental temperature. cool or moist compress as indicated. Make time to listen to complaints and maintain frequent contact with the patient. ®Promotes rest. may enhance coping.painful position. 12. ®Helpful in alleviating . ®Cool surroundings aid in minimizing dermal discomfort. ® Reduces irritation/ dryness of skin and itching sensation. 11.
which can relieve pain.anxiety and refocusing attention. .
“ Kung sige ko ug istorya sa ako ginabati ug sa ako kaguol kay mabwasan ang ako kaguol. the remaining feelings relate to anxiety. ®Helps patient to accept what is happening and reduce level of anxiety. Encourage patient to acknowledge reality of stress without denial or reassurance that everything will be alright.Date/ Time April 28. Nursing Diagnosis Application to Clinical Practice. Report anxiety is reduced to a 2. personal threats are also involved. Provide information about measures being taken to correct or alleviate condition. These threats can produce vague feelings ranging from mild uneasiness to panic. Be available for listening and talking as needed. 3.” 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. Lippincott Williams and Wilkins. Be available to the patient. Nursing Interventions 1. although some uneasiness may be attributed to fear.” 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. Helpful in discussing sensitive subjects.Verbalize awareness of feelings of anxiety and health ways to deal with them. mura ko ug nahadlok karun sa ako operasyon ug unsa ang mahitabo sa akua panhuman ato. 11th Ed. Information can provide . 2009 311pm Cues S: “Wala ko kasabot sa ako gibati. promotes expression of feelings. the client will be able to: 1. Demonstrates concern and willingness to help. Identifying a threat as merely surgery is too simplistic. Magwapo ako ginhawa kung muhinga ko ug lalom. Identify patient’s manageable perception of the threat level. Patient was able to identify ways reducing anxiety such as use of deep breathing exercises. 2005 Objectives of Care Within my 4 hour care. Moreover. because neither nurse nor patient knows the final outcome. ® Establishes rapport. ®Helps recognition of extent of anxiety and identification of measures that may be helpful for the individual. Source: CarpenitoMoyet. False reassurance is not helpful. and anxiety was reduced to a manageable level. Maintain frequent contacts with the patient/SO. Evaluation Goal met. represented by the situation.
4. Change position frequently when on bedrest. Patient refused to perform range of motion exercises for a fear of experiencing pain after the activity. support affected body parts or joints with pillows. 2. Maintains maintains muscle strength/ optimal position joint mobility.Date/ Time April 28. Evaluation Goal partially met. Provide skin massage. Elsevier Health Sciences. Keep linens dry and wrinkle-free.Verbalize willingness to and demonstrate participation in activities Nursing Interventions 1. ®Decreases discomfort. Source: Monks. ® Pain impairs mobility and activity. 2002 Objectives of Care Within my 8 hour care. enhances of function as circulation and prevents evidenced by skin breakdown. ®Stimulates circulation and prevents skin irritation. the absence of contractures 3. well. Home health nursing: assessment and care planning. the client will be able to: 1. ®Mobilizes secretions. Full function may be affected and be delayed. ®To permit maximal effort or involvement in activity. Encourage deep breathing and coughing.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. . Administer medication prior to activity as needed for pain relief. and decubitus Keep skin clean and dry ulcers. there were no contractures and complications observed after an 8 hour care with the client. 2. On the other hand. Elevate head of bed Turn side to side.
7. ®Maintains joint flexibility.improves lung expansion and reduces risk of respiratory complications. 5. ®Early ambulation prevents postop complications. Assist with active and passive range of motion exercises. prevents contractures and aids in reducing muscle tension. 6. Encourage early ambulation. 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. Support abdomen when ambulating. Splinting provides incisional support/ decreases muscle tension to promote cooperation .
®To prevent fatigue.with therapeutic regimen. Provide adequate rest periods in between activities. . Provide diversion such as talking with the patient or watch television. ®Decreases boredom. promotes relaxation. 8.
The surgeon then removes your gallbladder by reaching in through the incision and gently lifting it out. 4. Within the span of care. Be free of complications such as heavy bleeding at the incision site. of dressing and change of 3. semi-fowler’s position. Check the incisional drain. the client will be able to: 1.Date/ Time April 30. Evaluation Goal met. ®Facilitates drainage of bile. Place patient in low or positions.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. may contain breakdown blood and blood-stained through fluid. zinc oxide or karaya powder around the incision. hemorrhage was not observed and patient was able to demonstrate 2. Observe color and behaviors to character of the drainage. Use sterile Vaseline gauze. 2. intact dressing at right upper quadrant of the abdomen. Clean the skin with soap and water. Demonstrate behaviors to prevent skin breakdown Nursing Interventions 1. 2009 Cues S/O: Incision at right upper quadrant with Jackson Pratt drain with slightly soaked. normally changing to participation greenish brown (bile color) in the change after the first several hours. . 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. prevent skin ®Initially. ® Incision site drains are used to remove any accumulated fluid and bile. make sure that they are free flowing. Change dressings as often as necessary. Correct positioning prevents back up of the bile in the operative area.
. 6. Source: http://www. ®Necessary for treatment or prohylaxis for abscess or infection. nih. ®Developing jaundice may indicate obstruction of the bile flow. 5. development of fever. urine for change in color.gov/medline plus/ency/articl e/002930. Investigate increased or consistent RUQ pain. ®Signs of suggestive of abscess or fistula formation requiring medical intervention. 7. Then your gallbladder will be removed.belly. 8. tachycardia. just below your ribs. Administer antibiotics. Observe skin. leakage of bile drainage from wound. The surgeon will cut the bile duct and blood vessels that lead to the gallbladder. sclerae. ®Clay colored stools result when bile is not present in the intestines. Note color and consistency of stools.nlm.htm ®Keeps the skin around the incision clean and provides a barrier to protect skin from excoriation.
.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.
Strenuous exercise and lifting should be avoided. Normal activities. including returning to work. Once home. Police should comply with the medications he has been prescribed with in order to aid in the recovery state after surgery. so it is important to take it easy. But compared to open cholecystectomy. he must know and understand the general knowledge of the drugs. Light exercise such as walking is recommended. he needs to refer to his physician immediately. If he experiences any adverse effects. A major advantage of the procedure is that it patients can return to work in 1 to 2 weeks. their side effects and their adverse effects. it is advised to have 4 to 6 weeks duration time for recovery.Discharge Planning Medicines: • • • • Tramadol Ketorolac Ranitidine Sulperazone Mr. it is possible to tire more easily than usual to begin with. Laparoscopic cholecystectomy usually requires only one night in the hospital. With regards to his medications. Exercise: Cholecystectomy actually requires time to recover. Patient must follow his surgeon's advice about . can usually be resumed after about a week.
Some people will have dissolvable stitches. the nurse must advise about caring for the stitches. Health Teachings: • Explain to patient what to expect afterwards. so it's important to discuss any pain with the doctors or nurses. Now that the patient had his gallbladder removed. He shouldn't drive until he is confident that he could perform an emergency stop without discomfort. . hygiene and bathing. Consequently. to prevent other complications. It is important to rest and let the body recover after surgery.driving. The anaesthetist will prescribe painkillers. there is likely to be some pain. Suffering from pain can slow down recovery. • On discharge. the rest is up to him. and will arrange an outpatient appointment for the stitches to be removed. he must have his lifestyle and diet modified. As the anaesthetic wears off. Treatment: Gallbladder disease usually is treated by removing the gallbladder. if necessary. which do not need to be removed.
Out-patient Care: Remind patients that regular check-ups are important to ensure that the patient condition is constantly monitored by the doctor. Remind him to complete the full course of the antibiotic treatment. • Explain to patient to refer for unusualities immediately. inflamed or swollen the abdomen swells . he should contact his doctor:any of the wounds start to bleed • • • any of the wounds become more painful.• Instruct patient to comply with the home medications that would be given by his physician. If any of the following symptoms are noted. red. • Encourage him to comply with the dietary modifications. • Encourage patient to do the recommended light exercises such as walking. limit the intake of saturated fat and avoid the consumption of alcoholic beverages to prevent the occurrence of serious post-cholecystectomy side-effects. Avoid doing strenuous activities which could slow down his recovery.
diabetes and disorders of the nervous system. PROGNOSIS Category Poor Fair Good Rationale . operated patients need to make drastic lifestyle and dietary changes. operated patients also need to take vitamin and mineral supplements and bile salts to aid the process of digestion. Also. they should eat smaller amounts of food during a single meal. patients who have suffered cholecystectomy are exposed to a high risk of developing heart disease. In order to prevent the occurrence of serious post-cholecystectomy side-effects. vitamins and minerals.• • pain is not relieved by the prescribed painkillers a fever develops. Considering the fact that the organism is unable to completely absorb important nutrients without the help of the gall bladder. This is due to inappropriate synthesis and assimilation of vital nutrients. They should limit the intake of saturated fat and avoid the consumption of alcoholic beverages. These could be signs of an infection that may need to be treated with antibiotics Diet: In time. 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.
the obstruction brought about by the Duration of illness / . The pain was tolerable so he did not seek medical attention yet. So he sought consultation at Out-Patient Department. patient had severe right upper quadrant pain. Police experienced right upper quadrant pain associated with a sense of bloatedness. without nausea and vomiting. He had also lost his appetite because of the pain. Mr. Ultrasound revealed cholecystitis. Moreover. pain is elicited. He waited for the pain to become intolerable before seeking medical advice.Onset of illness / A month prior to admission. Mr. He said he also had an increased level of pain tolerance so he also didn’t mind to take any pain relievers. His scleras were also slightly icteric during admission and he was positive with Murphy’s sign.Emergency Room at Davao Medical School Foundation Hospital. Police did not immediately seek medical attention as he had persistent RUQ pain a month ago. when pressure is applied on the RUQ of the abdomen. Until three days prior to admission. Though no complications aroused yet. which was said to be intolerable. so patient was advised admission and operation. Moreover.
DMSFH is a hospital environment. the institution very with an for the conducive healing. most of our organs are already used and abused. Police during his admission. The wear and tear theory states that as one grows older. The client is almost 50 years old. and high sodium). high calorie. diabetes Attitude and willingness to medication and treatment Environment / / mellitus and obesity.cholecystitis caused his icteric sclera. As one ages. Moreover. one also becomes more susceptible to infections and organ Family support / failure. Moreover. Police . which could have been absent if he Precipitating factors / sought medical attention earlier. Only three out of eleven known precipitating factors are present with Mr. he let himself be admitted to the hospital and to undergo surgery as he is determined to get well as soon as possible. Police said he would undergo any treatment regimen he has to as long as his condition would get better. Anna is always watching over Mr. the personnel in which includes medical team are very responsive to Age / the needs of the patients. Police’s case which is the following: diet (high cholesterol. Mr. She said she will always be with Mr.
of categories rated GOOD (3) divided by TOTAL NO.4-3.3 2. of categories rated POOR (1) + No. as he vowed him during their wedding day.57 Scoring for General Prognosis: 1-1.through his ups and downs. Police.7-2. Police. Total 0/7 3/7 4/7 Computation: No. Moreover. of categories rated FAIR (2) + No. OF CATEGORIES= SCORE FOR GENERAL PROGNOSIS.0 =FAIR =GOOD General Prognosis: The general prognosis of the client is good.6 =POOR 1. This means that the client has a good chance of recovering from his illness. =0(1) + 3(2) + 4(3) = 6 + 12 =18/7 =2. and together with them are the encouragement and support they give Mr. relatives come to Davao to visit Mr. .
cholecystitis is the most common problem resulting from gallbladder stones. It reminded them again that nursing profession entails a deep sense of responsibility and challenging tasks. the student nurse’s one week exposure and duty at the Davao Medical School Foundation Hospital has been a memorable experience to them. Predisposing factors can include heredity. The only one who can help yourself is you alone. age. which carries bile from the gallbladder. clinical manifestations. Joseph (3C) ward. one has to take action towards preventing the disease to happen. 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 challenged and motivated them to work hard to provide the appropriate and effective nursing intervention and care. It occurs when a stone blocks the cystic duct. medical. They underwent extensive research in order to comprehensively understand his condition. the student nurses has identified and understood the causative factors of cholecystitis. After five days of exposure at St. With the proper knowledge about the nature of the disease as well as its preventive measures along with .Conclusion Generally. its signs and symptoms. Upon learning his case. Moreover. With the presented factors that cannot already be modified. pharmacological and nursing interventions through obtaining cues and health history in conjunction to the disease process. sex and race. diagnostic studies.
Furthermore complicated cholecystitis has 25% mortality (eg. not just for the sake of other people that depend on him. but most especially for himself ~ a primary obligation that he must fulfil. one can surely direct himself away from the complications.responsibility and sense of will. empyema of gallbladder). it is a duty of every human person to take care of his own body.” . “No matter how the disease has already reached an alarming incidence rate or not. gangrene. Our gallbladder is not to be taken for granted. There have been reports that mortality can be as high as 15% for immunocompromised patients.
he must carry out his responsibilities in fighting his own condition. Police’s case. 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. the patient’s 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 than anything else. With this. the group has come up with the following recommendations: To the client: Recovering after open cholecystectomy surgery doesn’t depend solely on the healthcare team. 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. After thoroughly studying Mr. there must be willingness to recover on the part of the patient. He is encouraged to verbalize his thoughts and feelings to his medical attendants. Moreover.Recommendation Every exposure is a learning experience filled with lessons. because it would be better for him to express whatever is causing stress on his part thus. To the patient’s family Undeniably. such as his nurses.
In addition. To the fellow student nurses It is not through a single effort that you learn the entirety of a certain illness. Be sensitive and respond to the needs of other group members. Rather. To the group Maintain practicing teamwork and unity within the group so that better output will be formulated. they are encouraged to be oriented and educated with the basic facts about the patient’s condition so that they will understand his condition better. they should always asked the student nurses for assistance.more effort in the recovery process. they should give their emotional support to boost the patient’s morale. If one is done with the task. Through this. advices. they would be able to know how to manage and meet his needs when he is discharged from the institution where he is admitted. Be open-minded to suggestions and prevent intensive discussions so that healthy relationship within the group will be maintained. Fix the problems in a peaceful manner. More than that. Being calm is always a good move. They should not only be physically present. try to help the others and contribute something that would make the work better. Not only that. or clarifications because they are always ready to lend a helping hand. 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. You should realize that your patients are also humans. The scar alone after surgery is one of the major disadvantages. quality-level lectures and affiliations with various medical institutions for the students’ exposures and duties. It is through this that you can provide the quality and holistic nursing care that patients need. Nursing students of AdDU should be committed to the goal of being men and women for others. To the Ateneo de Davao University. 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. 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. though suffering from a chronic illness. To the Professional Medical World Open cholecystectomy undeniably has its own disadvantages. You should always be humane in treating and approaching them so that you can be of help in the best way you can. They should not only appreciate the concepts during lecture session but should also positively digest the experiences they get from their duties and exposures. Minilaparotomy cholecystectomy presents exposition difficulties. As student nurses. and . forums or trainings.College of Nursing The AdDU. Furthermore.College of Nursing has been exerting much effort in providing the best exposures to its nursing students.
They are to look forward to further studies and improvement. it is also less aesthetic. The group would like to comment on the success of the emergence of new studies and invention. Such new technique presented for minilaparotomy cholecystectomy is transcylindrical. less invasive and more aesthetic procedure is preferred.laparoscopy requires expensive equipment and additional training. Laparotomy is more painful. the people’s trend as well as preference also changes. Researches and studies have been conducted to discover a new technique of minimal invasive cholecystectomy. and requires a longer convalescence. causes trauma to the abdominal wall. As much as possible. As the medical field advances. . a cheaper.
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