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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. And above all. Thank you for the love. they are very thankful to the Almighty Father for gracing them with His wonderful blessings. May they find the right path towards God. as he wishes them to.holistic teachings that encouraged them not only to be better nurses. . but as well as better individuals. 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. 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 pray for His loving guidance as they continue their journey in their nursing careers.
this fact contributes to the laxity of the majority. cholecystitis has an increased prevalence among people of Scandinavian descent. Perhaps. In the international level. The bile becomes concentrated in the gallbladder. This study is about cholecystitis. Hospitalizations total up to 636. The most common cause of cholecystitis is gallstones (90% of the cases). Its function is to store and concentrate bile . It affected 20. Lifestyle together with heredity. and Hispanic populations. Pima Indians. the gallbladder is an organ that people can live without. an extrapolated .a digestive liquid continually secreted by the liver. race and age are just some factors that leave a room for gallbladder complications to occur. sex. Cholecystitis affects women more often than men and is more likely to occur after age 40. many people are unaware of their gallbladder.000 have undergone cholecystectomies. In the Philippines alone. The bile in turn emulsifies fats and neutralizes acids in partly digested food.5 million people (1988-1994) with a mortality record of 1. People who have a history of gallstones are at increased risk for cholecystitis. whereas cholelithiasis is less common among individuals from sub-Saharan Africa and Asia.INTRODUCTION The gallbladder is a small pear-shaped organ which aids in the digestive process. The gallbladder tends to be taken for granted – ignored of the proper care and conditioning. This later causes irritation and is probably the leading cause of inflammation.000 in the same year and over 500. Despite its importance in the digestion of fat. Fortunately enough.077 deaths in 2002.
Through this. these will help them to become efficient nurses and better persons later on.073.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. It can be alarming since many people are confused and unaware of the symptoms presented. they too are predisposed to lifestyle modification – especially diet and food preferences which can contribute to the disease. the student nurses hope to apply their learning in taking care not only of their patients but also of themselves. they would like to give credit and to know more of the nature and function of the gallbladder. Consequently. they would want to understand and appreciate more on what is happening to a patient with cholecystitis. they are hoping that they will be able to find the right plan of care and sound interventions. not forgetting the patient’s rights as a person.040 people are affected by the disease last 2007. they are interested on what will be the necessary management that will be given. (http://digestive. Moreover. despite the cholecystitis’ low incidence. Furthermore. . this case is quite interesting since it does not always affect only females and elderly. All in all. Much often this small organ is not given importance.prevalence of 5.nih. As teen-agers living in a fast-phased world and governed by schedules.niddk. Thus they are in a pursuit for knowledge to be able to impart it to others. It can affect everyone. As nursing students and future nurses. With this study.
to have complete information about the patient’s current condition. • Research on the anatomy and physiology of the clients affected system. laboratory exams and etc. • • Research and understand the disease process of the patient’s illness. research and analysis. 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. . GENERAL OBJECTIVES Cognitive The student nurses’ first main goal is to gain knowledge through the completion of the case study and to impart this learning to Mr. Police and to those directly and indirectly involve with the completion of this case. Specific Objectives under Cognitive aspect Within the 5 days span of duty. the student nurses shall have devised objectives that will guide them for the proper understanding and fair interpretation of the case of their chosen patient.Objectives After 5 days of data gathering. Determine and interpret the medical management employed including laboratory and diagnostic procedures.
.• Identify and study the drugs prescribed to the patient which affects the patient’s current situation.
Affective With the knowledge gained and through the application of this knowledge. . • Make a discharge plan for the patient using M.H.O.E. 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.D and validate the patient’s prognosis according to categories.T. Police’s need for the improvement of his general welfare.Psychomotor In this aspect. 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. Specific Objectives under Psychomotor aspect Within the 5 days span of duty. • Formulate nursing care plans and apply them to satisfy the patient’s needs and give appropriate nursing interventions. 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.
expectations of his condition to him gather significant data from the patient’s chart and to his family and etc. . • Assume the role of being the patient’s advocate. 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. and for the betterment of nursing care.Specific Objectives under Affective aspect Within the 5 days span of duty..
Joseph (3C) 325-5 Dr.PATIENT’S DATA Personal Data Name: Age: Sex: Nationality: Date of Birth: Place of Birth: Civil Status: Address: Religion: Mr. Batucan. Country Homes. Davao City Christianity (Roman Catholic) College Graduate PNP Educational attainment: Occupation: Clinical Data Admitting Date and Time: Case Number: Ward: Room/ Bed: Attending Physician: Chief Complaint: Diagnosis: VS upon admission: April 27. Police 46 years old Male Filipino August 28. 1962 General Santos City Married Cabantian. 2009 at 10:40 am 01-36-90 St. Wolter right upper quadrant pain Cholecystitis T/C Cholelithiasis .
Mr.5˚C Sources of info: R – 28 cpm P – 109 bpm Temp Chart.BP –120/90 mmHg – 36. Police himself. and his wife .
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 .
HEALTH HISTORY A. Because Mr. he does not know any significant disease they have or had. He grew up at General Santos City where the relatives of his mother live. Police was a first year high school. what he only knows is that the eldest sister of her mother has hypertension. while his father returned to Leyte where his other relatives live. “ingon sa doctor naa man gud . Step-brod and Step-sis. Mom‘s two children. She verbalized. Currently. On the other hand. Today. Police had been away from the relatives of his father. and that his grandfather on the maternal side died of hypertension. The couple had difficulty conceiving a child because Anna has an obstetrical problem. he had another two siblings. Step-brod died at the age of 18 because of suicide. Dad‘s and Mrs. Police has been married to Anna for 15 years. Mr. where Mr. They met at Mandug. he could not recall. Mom’s live-in partner at Davao City. With his mother’s second family. When Mr. Police is the eldest among Mr. Family Background Mr. Step-sis has her own family at Leyte. his parents got separated because of third party. Davao City. But his younger sister died of a childhood illness at the age of three years old. He had suicide because of altered mental status due to shabu use. He doesn’t also know the causes of deaths of his grandmother and grandfather on the paternal side. He lived with his mother and Mrs. Police had been assigned at work before.
describes him. He enjoys watching TV. he had sixmonth training to become a policeman. Niño fiesta. He has also been an alcoholic drinker since he was 13 years old. He is a Roman Catholic. He is not as close as the children are to Anna. Police has been a smoker since he was 20 years old. But he enjoys playing with them sometimes and taking them out on weekends. He is a “barkadista” as his wife. goes with his friends and has a drinking session. Currently. nine years after their marriage. B. and sometimes does the cooking as he likes to. BB 2 followed.” Fortunately. who does not always goes to Church every Sundays but is a Sto. then have a two-day rest. to attend certain activities in celebrating Sto. Anna. Two years after. He works 24 hours straight. Mr. His wife said he smokes three boxes of cigarettes everyday.daw gas-gas akoang matres. he had been assigned to San Pedro Police Station for a year already. aged six years old. they were blessed with BB 1 who is now a kindergarten student. Police graduated at MATS with a 4-year degree of BS-MT. On his rest day. Every January. But because he couldn’t find a job with the course he had. He has a set of close friends who are also policemen like him. Personal Background Mr. he stays in their house and on the evening. he goes back to General Santos City. Niño devotee. He drinks three glasses of .
Moreover. .” as Anna verbalized. Moreover. He stopped because his friends also decided to stop. he has no known drug and food allergy. as an exercise. With regards to his diet. and could not sleep without eating such. which only lasted for six months (September 2008.alcoholic drink everyday. But he enjoyed boxing with his friends. Furthermore. He also eats lots of pulutan during their drinking sessions such as laman-loob. he does not eat vegetables but eats all kinds of fruits. Everyday. he is a “meat-addict.February 2009). he eats meat. chicaron. and other pica-pica. he doesn’t have a regular exercise.
Effects/ Expectations of Illness to Self/ Family Because of his condition. and fever during his childhood.C. Police experienced common illness such as colds. Moreover. Anna is worried of the effect of the operation to the health of her husband. he was not compliant with the doctor’s advice. He also had chicken pox during his childhood. Moreover.8 mmol/dL. . They were having an annual check up when he discovered that he has elevated blood sugar. However. he would realize that he should have a healthy control over his health. Anna also has to watch over him and she has to leave the children under the care of her elder sister for a while. he could not recall at what age he got the disease and as well as the management of his chicken pox. History of Past Illness Mr. He was then advised to control his diet and have a regular exercise but he was not given any maintenance drug. D. that he would cease drinking and smoking. he was diagnosed with diabetes with an FBS result of 7. Moreover. cough. Furthermore. Five years prior to admission (2004). Anna is also expecting that her husband would regain his strength back soon. he had to undergo an operation which means he had to have a sick leave from his work. But she is hoping that because of this hospitalization.
He had also lost his appetite because of the pain. as a maintenance anti-hypertensive medication. pain is elicited. History of Present Illness A month prior to admission. The pain was tolerable so he did not seek medical attention yet. So he sought consultation at OutPatient Department. The doctor advised him to cease smoking and drinking alcohol. His scleras were also slightly icteric during admission and he was positive with Murphy’s sign. Police experienced right upper quadrant pain associated with a sense of bloatedness. patient had severe right upper quadrant pain. 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. he was admitted to Davao Medical Center due to loss of consciousness. Moreover. Prior to that. He was admitted for one day and was diagnosed with hypertension. Until three days prior to admission. and pain on the suboccipital area (nape) associated with headache. without nausea and vomiting. E. He had elevated blood pressure of 180/100 as he could remember during the VS taking at the emergency room. he was experiencing palpitations. Mr. and as well as to avoid over fatigue. when pressure is applied on the RUQ of the abdomen.Emergency Room at Davao Medical School . which was said to be intolerable.Two years ago (2007). He stopped smoking. He was then given Lopicard 5mg tab OD.
Foundation Hospital. . Ultrasound revealed cholecystitis. so patient was advised admission and operation.
Police does not damage the couple’s relationship. Furthermore.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. such as frigidity. impotence. Police’s diabetes. the couple are able to maintain a healthy sexual relation with each other. Mr. though they sometimes do not achieve sexual satisfaction. It even made the couple more mature and understanding of each other’s sexual needs. The erectionrelated problem of Mr. This stage involves a reactivation of the pregenital impulses. Anna said that she understands that this might be due to Mr. energy is directed towards his work . Police has an erection-related problem. An inability to resolve conflicts can result in sexual problems. and the inability to have a satisfactory sexual relationship. even in public. Police compensates by wooing his wife through romantic dinners and being sweet with her. Though Mr. Stages Justification Mr. and the individual passes to the genital stage of maturity. Moreover. Police and Anna have a Freud’s Psychosexual Theory good sexual relationship. These impulses are usually displaced.
Police’s energy towards his social relationships to other people. being committed to his work and as well as to his colleagues. .as a policeman. who are also the recipient of Mr.
Simply having or wanting children does not in and of itself achieve generativity. he is satisfied with his service to the public through their protection and crime control activities. He doesn’t allow his wife to work to make sure that the children receive a direct parental guidance in their growing years. friends. and the person becomes selfabsorbed and obsessed with his or her own needs or regresses to an earlier level of coping. as he works as a policeman. If this task is not met. stagnation results.Stage 7: Generativity Erikson’s Psychosocial Theory Stage 7: Generativity vs. Mr.) A C H I E V E D vs. . to ensure a high standard of his educational needs. There is a desire to make a contribution to the world. Moreover. he works alone to provide the family’s financial needs. Stagnation The middle adult years are a time of concern for the next generation as well as involvement with family. Police is able to send his child to a private school. Moreover. and community. Stagnation (Middle Adulthood 40-65 yrs. He yearns for the community’s peace and order and is achieved through his public service as a policeman. Sociallyvalued work and disciplines are expressions of generativity.
Mr. he teaches them values such as honour. he said that he visits them at least once or twice a year. people get disease because they are aging. Police said that it is Middle Adulthood Havighurst’s Development al Theory Middle Adulthood (40-65 yrs. he is able to obtain a satisfactory occupational performance. 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. as he stayed on his job for already more than 20 years already. and honesty. Police said that he is blessed with their relationship because Anna is not just a wife to her. . Moreover. As his parents are also getting old. He even said that wants them to live their remaining life happy and satisfied with it. but also a friend. a responsible citizen of our country. Though his children are still four and six years old. respect. for them to become like him. In addition. whom he could confide his problems. Mr.
he has achieved social and civic responsibility through his public service as a policeman.Moreover. .
Patient was not cyanotic. VITAL SIGNS BP= 120/180 mm Hg T= 36 °C SKIN Skin was warm to touch. and with good skin turgot. a 46 year old Filipino male. was lying in bed. status post open cholecystectomy. 2009. PR= 85 bpm RR= 15 cpm . Police. with Jackson Pratt drain. Respiratory distress was not noted. slightly dry. with an IVF # 3 D5NSS 1L at the level of 80 cc.PHYSICAL ASSESSMENT GENERAL SURVEY At 4 pm on April 30. Aside from that. asleep. Mr.9. rough. with a pain scale of 6 out of 10. No bruises or discolorations observed. intact dressing at right upper quadrant of the abdomen. with slightly soaked. Patient is responsive and coherent when awaken. wearing clean patients gown. with epidural catheter. he weighs 85 kg and stands 5’5” and has a body mass index of 31. with nevi noted on the right side of the nose. infusing well at right metacarpal vein. regulated at 120 cc/hr. He appeared endomorphic. Patient was in good grooming. with complain of pain at the incision site.18 which denotes that he belong to the obese type I which ranges from 30 – 34. No edema noted. Papules on the face observed. Neither jaundice nor cyanosis observed. physical assessment was done. Patient was on NPO.
short. Hair was black in color with fair amount of white and gray strands. masses and depressions noted. No lesions. lacerations. and fine. tenderness. Skull and face were symmetrical with an equal distribution of hair. There was no dandruff or infestation present. dry. .HEAD Skull size was normocephalic.
His pupils were equal within 1-2 mm diameter in size and both have a brisk reaction to light and uniform reaction to accommodation.FACE The forehead was furrowed with wrinkles. Face portrayed emotions with symmetrical movements. lacrimal duct openings were evident at the nasal side of the upper and lower lids. No edema or tenderness over lacrimal gland observed. Eyebrows were evenly distributed and symmetrically aligned with no of flakes. External . Blinking reflex was present. Small anterior polar opacification was observed on both eyes. discolorations present. lesions. Eyelashes were evenly distributed and slightly curled outward. with no discharges and no discolorations observed. The face was round. tenderness. Lid margins were clear. with no edema. Shiny smooth and pink palpebral conjunctiva noted. No masses or involuntary movement. Eyelids close symmetrically. Police did not use any corrective aids such as glasses or contact lenses. No edema seen in the periorbital region. swelling. strabismus and lid lag were not evident. Skin around the eyes was intact with equal movement. and discharges and were in line with the eyes. redness. masses. scars and lesions noted. EYES Mr. Eye color was dark brown. Pinnas were free from lesions. EARS Ears were symmetrical with same size bilaterally and color consistent with face. Nystagmus.
No inflammation. . Halitosis was also noted. Right upper first premolar tooth was absent. flexion. Tonsils were not inflamed. Thyroid was not enlarged has no nodules. Teeth were yellowish in color with some dental caries noted. skin lesions. NOSE The nose was symmetrical with no deformities. No tenderness in his sinuses upon palpation. No nasal flaring was observed. masses. Nasal septum is intact and in midline. masses. sores or lesions. Gag reflex was present as evidenced by patient swallowing. No jugular vein distention was noted. MOUTH Mouth was proportional and symmetrical. discharges and foreign bodies noted. extension and hyperextension. No discharges were present.canals were clear with no cerumen seen. and irregularities upon palpation. Lips were rust colored and were dry with no presence of ulcerations. No pain on the mastoid process was reported upon palpation. Gross hearing acuity was good. Range of motion was normal and moves easily without discomfort upon rotation. masses present. Tongue was in central position and moves freely with no swelling or ulcerations observed. NECK Neck was symmetrical with no masses or swelling noted. Trachea is symmetrical and in midline without deviation.
ABDOMEN Abdomen was slighty enlarged and globular when patient was in supine position. no tenderness and masses noted. with cardiac rate of 85 beats per minute with a regular rhythm. Lymph nodes were not palpable. Pulsations were not visible. Respiratory rate was 15 cycles per minute with regular breathing pattern. No crusting and masses noted. Both axilla were free of lesions rashes. Chest wall was intact. Uniform temperature also noted. No cough present. Breasts were symmetrical with no edema noted. hiccups noted. and infections. with slightly soaked. Symmetrical chest expansion was observed during respiration. The . CHEST and LUNGS No thorax deformity observed. intact dressing on the right upper quadrant with Jackson Pratt drain. No abnormal beats. HEART Apical heart beat was present upon auscultation with a point of maximal impulse at the 5th intercostal space left midclavicular line. inverted and in the midline. No dyspnea. hemoptysis. No use of accessory muscles during breathing observed. No adventitious breath sounds heard upon auscultation.BREAST Nipples were dark brown in color. thrills or murmurs present upon auscultation. palpitations.
No inflammation noted in the lower extremities. A permanent tattoo was present on his right deltoid area. deformities and atrophy. patient verbalized that he had not noted any discharges from his genitalia nor presence of papules or ulcerations. No edema noted at both legs. anchordesigned. arms. Patient had not yet voided since he had arrived from the OR. Neither pallor nor bone enlargements were noted upon inspection of the upper extremities. However. Radial and brachial pulses were present. Tenderness noted on the right upper quadrant near the incision site. GENITO –URINARY Unable to perform inspection in the genitourinary region. Shoulders. BACK & EXTREMITIES Symmetrical shoulder movement observed during respiration. Spine was located at the midline with no discrepancies noted. Hip joint and thighs were symmetrical with no deformities present. . Upper extremities were not edematous. Range of motion was not limited.abdomen had hypoactive bowel sounds of two bowel sounds per minute. Range of motion was active and not limited. elbows and forearms were free from nodules.
Brunner & suddarth’s Textbook of Mecial-Surgical Nursing 11th Edition.C. Third Edition. Saunders Elsivier Cholecystitis refers to inflammation of the gallbladder.. S. S. Cholecystitis refers to inflammation of the gallbladder and cystic duct. Bare..G. Brunner & suddarth’s Textbook of Mecial-Surgical Nursing !0th Edition.C. Concepts of Altered Health Sciences CHOLELITHIASIS The presence of calculi in the gallbladder Source: Smeltzer. B. which are masses of solid material or calculi that forms in the bile. Source: Barbara Gould. Pathophysiology. Cholelithiasis refers to formation of gallstones.DEFINITION OF COMPLETE DIAGNOSIS CHOLECYSTITIS Cholecystitis is the inflammation of the galbladder Source: Smeltzer. Source: Carol Mattson Porth.G. B. Pathophysiology for the Health Professions. . Bare.
Pathophysiology. is caused by precipitation of substances contained in bile. or gallstones. Saunders Elsivier Cholelithiasis. Third Edition.Source: Barbara Gould. mainly cholesterol and bilirubin. Source: Carol Mattson Porth. Concepts of Altered Health Sciences . Pathophysiology for the Health Professions.
and quadrate lobe 3. Hepatic lobules. Location and size of the liver.5 kg.forms about five sixths of the liver. lies under the diaphragm.forms about one sixth of the liver 2.ANATOMY AND PHYSIOLOGY HEPATOBILLARY TREE LIVER A. weighs approximately 1.two lobes separated by the falciform ligament 1. B.anatomical units of the liver. Right lobe. Liver lobes and lobules.largest gland in the body. small branch of hepatic vein extends through the center of each lobule C. Bile ducts . Left lobe. divides into right lobe proper. caudate lobe. occupies most of the right hypochondrium and part of the epigastrium.
Ammonia Conversion -use of amino acids from protein for gluconeogenesis result in the formation of ammonia as a by product.1. alpha and beta globulins. Liver converts ammonia to urea 3. Glucose Metabolism -after a meal. Small bile ducts form right and left hepatic ducts 2. Hepatic duct merges with cystic duct to form the common bile duct. glucose is taken up from the portal venous blood by the liver which and is converted in into glycogen (glycogenesis). Right and left hepatic ducts immediately join to form one hepatic duct 3. Protein Metabolism -Liver synthesizes almost all of the plasma protein including albumin. which opens into the duodenum D. stored the hepatocytes. Functions of the liver 1. blood clotting factors plasma lipoproteins . Glycogen is converted back to glucose (glycogenolysis) and release as needed into the blood stream to maintain normal level of the blood glucose. -glucose can be synthesized by the liver through the process gluconeogenesis 2.
bilirubin) are wastes products excreted by the liver and eventually eliminated in the feces GALLBLADDER . bile salts -collected and stored in the gallbladder and emptied in the intestine when needed for digestion a. electrolytes such as sodium. Fat Metabolism -Fatty acid can be broken down for the production of energy and production of ketone bodies 5. Vitamin and Iron Storage -stores vitamin A. cholesterol. Bile Formation -bile is formed by the hepatocytes -composed of water.4.g. calcium. D. chloride. Sodium bicarbonate increases pH for optimum enzyme function c. products of detoxification. potassium. and bile pigments (e. bicarbonate. Cholesterol. K 6. E. Lecithin and bile salts emulsify fats by encasing them in shells to form tiny spheres called micelles b. Drug Metabolism 7. lecithin. fatty acids.
located by the lower border of the liver. • Beneath the connective tissue is a wall of smooth muscle (muscularis externa) that contracts in response to cholecystokinin. 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. • The fundus of the gallbladder is the part farthest from the duct. sometimes gall bladder) is a small organ whose function in the body is to harbor bile and aid in the digestive process. • There is essentially no submucosa separating the connective tissue from serosa and adventitia. It is at the same level as the transpyloric plane. Anatomy • The cystic duct connects the gall bladder to the common hepatic duct to form the common bile duct. • Under the epithelium there is a layer of connective tissue (lamina propria). a peptide hormone secreted by the duodenum.The gallbladder (or cholecyst. . • The common bile romero duct then joins the pancreatic duct. and enters through the hepatopancreatic ampulla at the major duodenal papilla.
The gallbladder stores about 50 mL (1. During this time the gallbladder concentrates bile fivefold to tenfold. It consists of a fundus. It lies on the undersurface of the liver’s right lobe and is attached there by areolar connective tissue. Bile is thereby denied its normal exit from the body in the feces. similar in structure to those of the stomach. and mucous layers compose the wall of the gallbladder. pear-shaped sac from 7 to 10 cm (3-4 inches) long and 3 cm broad at its widest point. Instead. body and neck. Then later. It can hold 30 to 50 ml of bile. it is absorbed into the blood. The mucosal lining is arranged in folds called rugae.7 US fluid ounces / 1. Structure of the Gallbladder Serous. Jaundice a yellow discoloration of the skin and mucosa. when digestion occurs in the stomach and intestines.8 Imperial fluid ounces) of bile. and an excess of bile pigments with a yellow hue enters the blood and is deposited in the tissues. ejecting the concentrated bile into the duodenum. 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. the gallbladder contracts.Size and Location of the Gallbladder The gallbladder is a hollow. which is released when food containing .
The bile.fat enters the digestive tract. emulsifies fats and neutralizes acids in partly digested food. After being stored in the gallbladder the bile becomes more concentrated than when it left the liver. stimulating the secretion of cholecystokinin (CCK). Most digestion occurs in the duodenum. increasing its potency and intensifying its effect on fats. produced in the liver. .
BILIRUBIN PRODUCTION AND ELIMINATION Bilirubin is the substance that gives bile its color.1 to 1. As it passes through the liver. the normal level of total serum bilirubin is 0. only a small amount of bilirubin is found in the blood. the hemoglobin from the red blood cell is broken down from biliverdin. Conjugated bilirubin is secreted as a constituents of bile. It is formed from senescent red blood cells. Urobilinogen is either absorbed into the portal circulation or excreted in the feces. A small amount of urobilinogen. Most of the urobilinogen that is absorbed is returned to the liver to be re-excreted into the bile. free bilirubin is converted to conjugated bilrubin thru glucoronyl transferase. and in this form. it passes through the bile ducts into the small intestine. approximately one half of the bilirubin is converted into a higly soluble substance called urobilinogen by the intestinal flora. which is not soluble in plasma. is transported in the blood attached to plasma albumin. Usually. approximately 5% is absorbed into the general circulation and then excreted by the kidneys. Inside the hepatocytes.2 mg/dL. In the intestine. free bilirubin is released from its albumin carrier molecule and moved into the hepatocytes. Laboratory measurements of bilirubin usually measure the free and the . Free bilirubin. which is rapidly converted to free bilirubin thru biliverdin reductase. In the process of degradation. making it soluble to bile. this bilirubin is still called free bilirubin. Even when it is bound to albumin.
conjugated bilirubin as well as the total bilirubin. . These are reported as the direct (conjugated) bilirubin and the indirect (unconjugated or free) bilirubin.
SOURCE: Harrison’s Principle of Medications and Oral Contraceptives Absent Internal Medicine. high sodium) Present Present Rationale Increased intake of calories.ETIOLOGY AND SYMPTOMATOLOGY Precipitating Factors: Factors Diet (high cholesterol. Patients with cholesterol gallstones secrete a greater fraction of dietary cholesterol into bile than do normal subjects. high calorie. gemfibrozil) that lower serum cholesterol by increasing biliary cholesterol secretion increase the risk of cholesterol gallstones by twofold to threefold. 16th Edition Hypolipidemic agents (clofibrate. Competitive inhibitors of 3-hydroxy-3methylglutaryl coenzyme A (HMGCoA) reductase (lovastatin. refined carbohydrate. pravastatin) decrease biliary cholesterol saturation. Oral contraceptive steroids increase biliary cholesterol secretion and . Estrogen therapy is associated with an increased risk of developing cholesterol gallstones. cholesterol. and saturated fats has all been postulated to cause cholesterol gallstones. simvastatin.
Stone analysis has not . Pathophysiology for the Health Professions. 16th Edition Patients with primary biliary cirrhosis have an increased prevalence of gallstones. is believed to be secondary to abnormal gallbladder motility and probably biliary hypersecretion of cholesterol from the progressive reduction in body mass. SOURCE: Harrison’s Principle of Primary Biliary Cirrhosis Absent Internal Medicine. This high risk. which is 20 times normal. Saunders Total Parenteral Nutrition Absent Elsivier TPN is a powerful risk factor for gallstone formation.saturation but do not affect gallbladder motility. Source: Barbara Gould. Gallstones from during TPN because of decreased gallbladder motility from lack of mealstimulated cholesystokinin (CKK) release. SOURCE: Harrison’s Principle of Spinal Cord Injury Absent Internal Medicine. 16th Edition Patients with spinal cord injury have 10% incidence of forming gallstones within the first year after injury. Third Edition. resulting in increased fasting and residual volumes.
sphericytosis. and malaria dramatically increase the risk of pigment stone formation because of increased biliary secretion of total bilirubin conjugates. chronic hemolysis associated with artificial heart vavles. diabetes mellitus itself does not appear to be an independent risk factor for cholesterol gallstone disease. 16th Edition Inherited hemolytic anemia.been performed. SOURCE: Harrison’s Principle of Diabetes Mellitus Present Internal Medicine. thalassemia. but the elevated cholesterol saturation of bile in these patients suggest that they form cholesterol stones. SOURCE: Harrison’s Principle of . at the expense of the bilirubin diglucuronide. sickle cell disease. especially bilirubin monoglucoronide. SOURCE: Harrison’s Principle of Hemolytic Syndromes Absent Internal Medicine. the predominant conjugate in healthy individuals. 16th Edition Despite obesity and increased total body cholesterol synthesis and decreased gallbladder motility seen in patients with diabetes.
Although ilieal disease or resection leads to cholesterol supersaturation and cholesterol stone formation in some patients . the risk correlates positively with the extent and duration of ileal dysfunction. Intraductal stones developing after cholecystectomy are invariable associated with bile stasis. biliary tree infection. careful studies now show that most patients with ilieal dysfuncyion form black pigment. or other helminthes). 16th Edition Brown pigment stones are frequently found in the intrahepatic bile ducts and are always associated with infection by colonic organisms usually E.coli.Internal Medicine. SOURCE: Harrison’s Principle of Internal Medicine. Gallstones develop in 3050% of patients with ileal Chron’s disease. 16th Edition Ileal Disease. and/or retained suture material. SOURCE: Harrison’s Principle of Biliary Infection Absent Internal Medicine. and Bypass Absent Patients with ileal dysfunction have a strikingly increased risk for developing gallstones. not cholesterol stones. or parasitic infestation (Ascaris lumbricoides. 16th Edition . Resection.
leading to bile that is often greatly supersaturated with cholesterol. Pathophysiology for the Health Professions. Source: Barbara Gould. SOURCE: Harrison’s Principle of Internal Medicine. either by very low caloric dieting or gastric stapling. Saunders Elsivier Obese patients undergoing rapid weight loss (1-2% of body weight or approximately 1-2 kg/week).Obesity Present Obesity is strongly associated with increased gallstone prevalence. The risk is proportional to the increase in total body fat. Obese people synthesize more cholesterol in both hepatic and nonhepatic tissues. 16th Edition Rapid Weight Loss/ Fasting diets Absent . biliary cholesterol saturation increases acutely as cholesterol is mobilized from adipose tissue and skin and secreted into bile. Third Edition. have a 25-40% chance of developing gallstones within 4 months. and secrete more of it into the bile. During rapid weight loss. transport it to the liver.
Less than 5-6% of the population under age 40 have stones. Saunders Advancing Age Present Elsivier The incidence increases with age. Pathophysiology for the Health Professions.Predisposing Factors: Factors Gender Present Absent Rationale Women have twice the risk as men of developing cholesterol gallstones because estrogen increases biliary cholesterol secretion. and Chilean Hispanics. Before puberty this risk is negligible. Source: Barbara Gould. lowest in Japan. Chilean Indians. in contrast to 25-30% of those over 80. Concepts of Altered Race Absent Health Sciences Prevalence highest in North American Indians. familial disposition. hereditary aspects SOURCE: Harrison’s Principle of Internal Medicine. 16th Edition . greater in Northern Europe and North America than in Asia. Third Edition. Pathophysiology. and beyond menopause the increased risk disappears. Source: Carol Mattson Porth.
16th Edition . Elevated progesterone also inhibits gallbladder contractility. During pregnancy. which engender marked increases in cholesterol biosynthesis. SOURCE: Harrison’s Principle of Parity/ Pregnancy Absent Internal Medicine. SOURCE: Harrison’s Principle of Internal Medicine.Heredity Absent Family history alone imparts increased risk. such as defects in lipoprotein receptors (hyperlipidemia syndromes). 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. 40% of women develop biliary sludge in their gallbladder and 12% of women form their first stones during pregnancy. especially with more than two children. The risk increases with increasing parity. 16th Edition Pregnancy is an independent risk factor for cholesterol gallstones. elevated estrogen and progesterone levels increase biliary cholesterol secretion.
The pain may radiate to the back. Source: Carol Mattson Porth. right scapula or shoulder. Pathophysiology. The pain often begins suddenly following a meal.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. which: develops quickly. Concepts of Tenderness Present . The pain of biliary colic is caused by the functional spasm of the cystic duct when obstructed by stones. is severe. This can cause an attack of abdominal pain. Pathophysiology. Source: Carol Mattson Porth. whereas pain in acute cholecystitis is caused by inflammation of the gallbladder wall. isn't helped by over-the-counter and isn't helped by passing wind. called biliary colic. 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. lasts about one to three hours before fading gradually.
Pathophysiology for the Health Professions. Source: Barbara Gould. 16th Edition These signs and symptoms may accompany a gallbladder attack. SOURCE: Harrison’s Principle of Nausea and Vomiting Absent Internal Medicine. The fever tends to rise gradually to above 100.4° F (38° C) and may be accompanied by chills Fever and chills Absent . Fever occurs in about one third of people with acute cholecystitis. also due to the irritation and inflammation of the gallbladder wall. Pain is usually accompanied by nausea and vomiting. which is inspiratory arrest during deep palpation in the right upper quadrant.Murphy’s Sign Present Altered Health Sciences The patient with acute inflammation of the gallbladder might have a positive Murphy’s sign. Third Edition. Saunders Elsivier Gallstones sometimes get trapped in the neck of the gallbladder and can cause persistent pain that lasts more than several hours and is accompanied by fever.
rapid loss of weight and anorexia can occur. Fat absorption is also impaired for the lack of bile salts. especially fatty or oily foods. 16th Edition . 16th Edition The pain often begins suddenly following a large or rich meal. As a result. in order not to experience that pain. 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.
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 .
dark urine Irritation of the gallbladder wall . pruritus.CHOLELITHIASIS Gallstone tries to go out of the gallbladder Obstruction of the common bile duct by gallstones (Choledocholelithiasis) Obstruction of the cystic duct by gallstones Cholestasis Release of phospholipase from the epithelium of the gallbladder Absence of Bile in the duodenum ↑ levels of bilirubin/bile pigments in the circulation Disruption of mucous coat of the gallbladder epithelium Prolong Cholestasis Hydrolization of lecithin into lysolecithin Damages mucosal cells due to detergent action of bile salts Hepatomegaly S/S Indigestion. Vit ADEK deficiency. gray stools Fibrosis Liver Cirrhosis S/S jaundice. ecteric sclera.
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 .
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. anemia. abdominal pain Sepsis Astrocytes become swollen Death S/S Thrombocytop enia. leukopenia Septic Shock Development of a large pale nucleus. Liver tenderness.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. a prominent nucleolus. Nausea. Jaundice . and margination of chromatin Death HEPATIC ENCEPHALOPATHY S/S Anorexia.
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 .
Gallbladder. Batucan Rationale Dr.53 the amount of WBC – 15.28 other blood Platelet – 222 components that will X10^9/L help determine the underlying diagnosis. cholesterol becomes insoluble and crystallizes.46 of each blood cell in a X10^12/L given specimen of Hematocrit – blood. 10^9/L hematocrit.2 X hemoglobin. PlateletCount Blood Typing Complete blood count Done is the determination of Hemoglobin – the quantity of each 172g/dL quantity of each type RBC – 5. Billiary and Pancreatic Surgery. and the Segmentersproportion of various 0. Batucan who is an expert on General Surgery. admit under 10:40am Walter G.DOCTOR’S ORDER Date & Order Time 04-27-09 Pls. LymphocytePlatelet count and 0. Patient is to undergo Done an invasive surgery Blood type – which could lead to O+ . Liver. Remarks Done Low fat diet Done Labs: CompleteBloodCount. often including 0. Bile contains large amount of cholesterol that usually remains dissolved in the bile but when there is oversaturation with cholesterol. Low fat diet serves as a prevention and treatment for gallstone formation. For proper evaluation and management and care under Dr.72 white cells.
Done Normal Sinus Rhythm .030 Glucose (-) Albumin (+++) Pus cells 24/hpf RBC 1-2/hpf Mucus threads (+) Done > Suggestive of an inflammatory lung disease compatible with bibasal pneumonia. it is helpful in the detection of renal or metabolic disorders. including the ribs. Please correlate clinically. the adjacent spaces. Prior to surgery. Chest X-ray provide a good outline of the heart nad major blood vessels and ussualy can reveal a serious disease in the lungs. ECG is a recording of the electrical impulses of the heart. the heart must first be checked to determine whether or Done Yellow. cloudy Rxn:6 Spec.Urinalysis Chest X-ray ECG blood loss therefore blood typing is done before blood can be transfused on him to replace the loss blood. gravity1. Such test is an important indicator of how well the heart is functioning. Ordered so as to check patient’s cadiopulmonary condition before undergoing an invasive surgery. 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. and the chest wall. An indicator of health and disease.
This enzyme test is used chiefly as an index of liver and bone Done 6.7umol/L Done 228U/L . Measurement of uric acid is most commonly in evaluation of renal failure. Measuring serum creatinine is used to indicate renal function.497mmol/L Done 33. gout and leukemia.6umol/L Done 25. Evaluates impairment of the liver or hemolytic anemia. and is usually produced at a fairly constant rate by the body.3umol/L Done 7. Direct bilirubin is associated with liver dysfunction or blockage while Indirect bilirubin is related to destruction of red blood cells. 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.Fasting Blood Sugar Creatinine Uric Acid Total Bilirubin Direct Bilirubin Indirect Bilirubin Alkaline Phosphatase not it can handle the surgery. It is mainly filtered by the kidney. Prior to surgery. Direct and Indirect bilirubin are differentiation on why there is an increased bilirubin. Creatinine is a breakdown product of creatine phosphate in muscle. though a small amount is actively secreted.84mmol/L DONE 148umol/L Done 0.
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. c/o patient’s stock and was ordered to continue his maintenance medication. schedule for lap Surgical removal of the cholecystectomy gallbladder using a Done Done Done . attaching the result in the chart allows better diagnosis and analysis for the rest of the medical team involved in his upcoming surgery. Please refer to Dr. or if not enough protein is being absorbed by the body. Done 55. ultrasound Prior to admission patient had undergone UTZ.4 Refer accordingly 11:20am Call doctor’s attention immediately once any unusuality occurs. Done Cholecystitis with bile sludge formation and suggestive hydrophoric change. Torno is an Intenist whose specialty is cardio and pulmo. Dr. Pls.Albumin Attach result disease when correlated with other clinical findings. 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.
Dr. It is also used for hydration and electrolyte replacement. K IVTT that was ordered beforehand and for future medications. Barinaga may be the partner anesthesiologist of Dr.Secure consent Anesthesiologist: Eugene Barinaga Dr. Securing consent ensures the safety of both the medical team and the patient. Pre-operative standard operating procedure so as to prevent excessive bleeding during the actual surgical procedure. PLR an isotonic solution that resembles blood serum used as passage for the Vit. chart review done laparascope is indicated for acute cholecystitis. 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. thus a follow up must be made in order for the doctors to correlate the findings. Lab results are not yet available. Anesthesiologist made rounds to the patient so as to establish a therapeutic Done Done Done Done Done . It is the permission obtained from the patient that he is to undergo a surgical procedure. Batucan. The referral was made so as to ensure a safe and successful surgical procedure.
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. 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.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. patient’s anxiety regarding his upcoming surgery. Inform OR. Barinaga Done Done Done Done . tab @ 12nn tomorrow given so as to relieve with 30cc of water. Dr. his medical team and the OR staffs. Barinaga Informing Dr. 7am was ordered for it was the most convenient time for patient. Reschedule OR tomorrow OR schedule was not at 7am indicated on prior orders. 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.
Continue Lopicard Patient may continue with his maintenance medication. Barinaga due to the rescheduling of the surgery. 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 aware The new anesthesiologist was made aware of the upcoming surgery for Done Done Done 04-28-09 5pm 10pm Done Done . Anesthesiologist: Dr Change of Tozon anesthesiologist instead of Dr. Pls.5g Given to treat IV q8 respiratory infection and also serves as preoperative prophylaxis. Schedule at 7am After rescheduling the day. OR finally gave the time for the patient’s surgery. Patient was diagnosed with CAP low risk due to the findings above. Start Sulperazone 1. HPN due to history of hypertension and T/C due to high serum glucose as shown in his FBS. his surgeon then rescheduled the operation maybe due to patient having pneumonia. reschedule surgery After being seen by his on Thursday internist.regarding the scheduled surgery allows him time to prepare and ready himself for the upcoming surgical procedure.
Ranitidine 1amp IVTT at Patient was on NPO so 6am ranitidine. 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. Plan carry out above For abrupt orders implementation. Although Sulperazone Batucan – Sulperazone and Cefoxitin can serve will serve as pre-op as pre-operative antibiotic management prophyaxis.04-29-09 10:40am 04-29-09 1:40pm 5pm 04-30-09 12mn him to be prepared. an H2 antagonist. Metoclopramide 1amp Promotes gastric IVTT at 6am emptying prior to surgery. For open Patient has gangrenous cholecystectomy instead gallbladder and open of lap chole cholecystectomy is indicated for such. the discontinue Cefoxitin if internist chose ok with Dr. prior to OR Kindly inform Dr. Cefoxitin (Monowell) Serves as pre1amp IVTT ANST now operative prophylaxis. IntraOp NPO now Patient was put on NPO for he is to undergo surgery the following day. was ordered because it inhibits the action of histamine at the H2 Done Done Done Done Done Done Done . No absolute Surgery can now be contraindication to done after CP planned surgery CP ok clearance was done.
swelling.redness. serves also as a post operative analgesia.receptors of the parietal cells inhibiting gastric acid secretion. Meds: 1. NPO Nothing per orem until patient passes out flatus for he still has no peristalsis and so as to avoid aspiration. Ketorolac 30mg q8 Short-term IVTT management (up to 5 days) of moderately severe acute pain and reduces signs and symptoms of inflammation . 2. fever. and pain. 3. Done Done Done Done Done Done Done . 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. nutrients and electrolytes. IVF D5NSS iL at 120cc/hr To replenish fluids. Tramadol 50mg q6 Relief of moderate to IVTT moderately severe pain. VS q15 until stable. Ranitidine 50mg q8 Ranitidine serves as IVTT post surgery antacid and to prevent ulcer of which is ketorolac’s adverse effect. 04-30-09 To PACU PostOp For intensive monitoring after the surgery and for recovery.
Monitoring I & O help assess fluid balance. convulsion and to lower the blood pressure. Ordered because morphine increases biliary spasm. Anesthetics and surgery affect the hormones regulating fluid and electrolyte balance (Aldosterone and ADH). 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.4. placing the client at risk for decreased urine output and fluid and electrolyte imbalances. Postoperative patients are at risk of these. Done Done Done Done Done Done .5g q8 IVTT Epidural anesthesia: Bupivacaine 0. Sulperazone 1. Accurate measurement of a patient's fluid intake and output will identify those patients at risk of becoming dehydrated or overhydrated.25% 10cc + 0. 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.25 MSO4 OD c/o Dr.
DIAGNOSTIC EXAMINATIONS Exam Result Reference Clinical Indication Interpretatio n Nursing Responsibility Range Hematology (April 27. 2009) .
0-6. Erythrocyt e 5.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. The hemoglobin determination test is used to screen for diseases associated with anemia and in determining acid-base balance. .0 X10^9/L Within normal range. The oxygen carrying capacity of the blood is also determined by the Hemoglobin concentration.46 4. This test is used to evaluate any type of Above normal range.
Blood typing identifies the inherited antigens that compromise one of four possible blood types: A. but produce antibodies against both types of antigens.Blood Typing O+ This blood test is performed to match donor blood with recipient who requires blood transfusion. . B. Hence. Follow up results in the laboratory. AB. Because of this arrangement. type O can be safely given to any person with any ABO blood type. Type O people have red blood cells with neither antigen. Inform the patient the result of the test. O. 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.
2009) Exam Result Referenc Clinical Indication Interpretatio n Nsg Responsibility .e Range Urinalysis (April 27.
Amber colored urine is normal but it indicates high specific gravity and a small amount of urine. RBC. .020 and output less than 1L per day However.Physical Exam Color Amber Yellow Urine specimens may vary in color from pale yellow to dark amber. pus. 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. Specific gravity is above 1. urates and uric acid in the urine composition. This helps to indicate presence of WBC. phosphates. excretion of cloudy urine may not be abnormal since the change on urine pH may cause precipitation within the bladder of normal urinary constituents.
Lateral CP sinuses are sharp.X-ray Report (April 27. This test also gives valuable information on the condition of the heart. diagnosis and evaluation of change in his respiratory system. 2009) Chest PA Clinical Indication: Chest X-ray is done to diagnose pulmonary disease and diseases of the mediastinum and bony thorax. Rest of the lung fields is clear. Nursing Responsibilities: Explain to the patient that the chest x-ray will be used for screening. lungs. There are infiltrates on both lung bases. 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. gastrointestinal tract and thyroid gland. Findings: Heart is within normal limit in size. patient also has pneumonia which then needs an Internist to determine whether he can proceed with the scheduled surgery. . 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. Please correlate clinically. Impression: Suggestive of an inflammatory lung disease compatible with bibasal pneumonia.
Inform the patient regarding the result of the test.- Instruct the patient to take a deep breath and exhale. - Tell patient that the procedure takes only a few minutes. . then he is required to take another deep breath but hold it while the picture is taken.
.08second Axis: +15° QTc: 0.44seconds Position Intermediate Interpretation: Normal Sinus Rhythm >The electrical impulse is formed in the SA node and conducted normally. >This is the normal rhythm of the heart.ECG Result (April 27.10second Rhythm: Sinus QRS: 0. Inform the patient regarding the result. Nursing Responsibilities: Inform patient on why and how the test is done. Place patient in a supine position in the bed or table. Tell him that this is not an invasive procedure. 2009) Rate: 25 min PR interval: 0. painless and a safe test. Place the electrodes accurately. Prepare the skin (shave if there is excess hair) by applying contact paste or prejelled discs.
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
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. Tell patient that 10ml venous blood is to be collected before he eats his breakfast.0 umol/L 0. Explain the purpose and the procedure of the test.7 2. Above normal range. An in crease in Above normal range. Inform patient regarding the test result. and hemolytic anemia.0 – 3. may indicate hemolytic anemia.Total Bilirubin Direct Bilirubin Indirect Bilirubin 33.3 7. may indicate choledocholithi asis. Differentiation of bilirubin is done to determine which of the problems above is the cause of the elevation of total bilirubin. Above normal range.0 – 17 umol/L The measurement of bilirubin is important in evaluating liver function.6 25. .4 umol/L 2. 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 Uric acid is formed from the breakdown of nucleonic acids and is an end product of purine metabolism. Inform the patient regarding the result. May indicate a decreased renal function. Inform the patient regarding the result. Above normal range.497 0. Measurement of uric acid is most commonly in evaluation of renal failure. could be associated with nitrogen retention and with increase in urea. the blood level Within normal range . 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. gout and leukemia. In liver disease. Explain the purpose and the procedure of the test. Monitor patient’s intake and output so as to determine if he has a decreased renal function. Explain the purpose and the procedure of the test.Uric Acid 0. creatinine and other nonprotein nitrogenous substances in the blood.2 – 0.
Explain the purpose and the procedure of the test. may indicate renal disease. .rises when excretion of this enzyme is impaired as a result of obstruction in the biliary Albumin 55. or if the body is not absorbing enough protein.4 38 – 51 g/L tract. This test can help determine if a patient has liver disease or kidney disease. Above normal range. Inform the patient regarding the result.
The gallbladder is significantly distended to 11. No cystic or solid parenchymal lesions demonstrated here. 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.6cm to 4. Impression: > Cholecystitis with bile sludge formation and suggestive hydrophoric change. The intrahepatic ducts are not dilated. The width AP diameter of the common bile duct is 0.1cm (length X AP dm) with diffusely thickened walls that measures up to 1. no focal lesions noted intraluminally. he then needs to undergo open cholecystectomy instead of lap cholecystectomy.1cm low level echoes are seen in the dependent portion of the gallbladder.Ultrasound Report (04/27/09) Ultrasound Report (This report is based on sonographic findings and must be correlated clinically. Quetionable echoes are seen in the partly obscured cystic duct.4cm. The pancreas is obscured by overlying bowel gas preluding adequate assessment.
Antihypertensive Mode of Action: Blocks the transport of calcium into the smooth muscle cells lining the coronary arteries and other arteries of the body. Instruct him not to eat solid food for the 12 hours prior to exam to allow greatest dilation of the gallbladder. blocking calcium transport relaxes artery muscles and dilates coronary arteries and other arteries of the body. By relaxing coronary arteries. Reducing heart burden lessens the heart muscle's demand for oxygen. DRUG STUDY Generic Name: Amlodipine besylate Brand Name: Lopicard Classification: Calcium channel blocker.Nursing Responsibilities: Explain the purpose and the procedure of the test. and further helps to prevent angina in patients with coronary artery disease. Dosage: Lopicard 5mg tab OD . which reduces the burden on the heart as it pumps blood to the body. amlodipine is useful in preventing chest pain (angina) resulting from coronary artery spasm. Since calcium is important in muscle contraction. Inform patient regarding the result. Inform him that water is permitted. Antianginal. Inform patient that ultrasound is a noninvasive procedure. Relaxing the muscles lining the arteries of the rest of the body lowers the blood pressure.
Assess for baseline data. abdominal discomforts Adverse Effects: asthenia. Increased antihypertensive effects with other antihypertensives. Nursing Responsibilities: 1. flushing. fatigue. Instruct patient to take drug with meals if stomach upset occurs. difficulty breathing Drug .Drug Interaction: Risk of congestive heart failure with betaadrenergic blockers.Indication: Hypertension Contraindication: Hypersensitivity to amlodipine. palpitations. yellowing of the eyes or skin. Administer drug without regard to meals. heart block (second or third degree). 2. 4. Monitor patient’s vital signs carefully while adjusting drug to therapeutic dose. drowsiness. Possible increased serum levels and toxicity of cyclosporine if taken concurrently. Instruct him to take drug exactly as prescribed by his physician. 6. chest pain. sick sinus syndrome. edema of the lower extremities. stomach pain. Assess patient for contraindication. light-headedness. muscle cramps. arrhythmias. vomiting. 5. 3. headache. lactation Side Effects: dizziness. . impaired hepatic or renal function. nausea.
10. Tell patient that he may experience some side effects brought upon by the drug.Oral care if patient vomits. noise and temperature if he experiences headache and report if it is intolerable so that medication may be given. . 8. 11. Instruct him to eat frequent small meals if vomiting occurs. 9. Instruct him to report intolerable side effects so management can be done.Instruct him to adjust lighting.7. 12.Instruct him to report any adverse effects that he may experience.
hematuria. GI bleeding. all of which are essential for blood clotting.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. flushing. Vitamin K deficiency causes an increase in bleeding tendency. diaphoresis. DOSAGE: Vitamin K 10g IV OD INDICATION: Prevention of bleeding. severe hepatic disease. usually after rapid IV administration DRUG INTERACTION: Cholestyramine. hypoprothrombinemia CONTRAINDICATION: Hypersensitivity. and X. pain swelling and hematoma at injection site ADVERSE REACTION: Anaphylaxis or anaphylactoid reactions. transient hypotension after IV administration. epistaxis. last few wk of pregnancy SIDE EFFECTS: Dizziness. rapid and weak pulse. Vitamin K malabsoption. IX. VII. demonstrated by ecchymoses. mineral oil: may inhibit Gi absorption of vitamin K Oral anticoagulants: decreased anticoagulant effect . erythema.
6. Antibiotics: may inhibit vitamin K production leading to bleeding NURSING RESPONSIBILITIES : 1. Instruct patient to report symptoms of bleeding: bruising. Assess for contraindication. . unless directed by prescriber. pulse and BP. Assess for baseline data. 2. hematuria. Monitor protime during treatment. nosebleeds. Instruct patient to report adverse effect that he may experience. 8. 7. bleack tarry stools. monitor for bleeding. 3. Teach patient not to take other supplements. Stress the need for periodic lab tests to monitor coagulation level. 4. Tell patient that he may experience side effects brought about by the drug and to report intolerable ones so as prompt interventions be done. to take this medication as directed. 5.
constipation. crying. stupor. diarrhea. pregnancy (cleft lip or palate. dysarthria. . Anticonvulsant Mode of Action: Acts mainly at the limbic system and reticular formation. has little effect on cortical function. vertigo. GI upset. dry mouth. delirium. rigidity. to benzodiazepines. cardiac defects. disorientation. incontinence. coma. vomiting. CNS depressant. ataxia. vivid dreams. pyloric stenosis have been reported when used in the first trimester.psychoses. anxiolytic and amnesia effects occur at doses below those needed to cause sedation. salivation. intoxication. neonates Side Effects: Drowsiness. an inhibitory neurotransmitter. tremor. fatigue. diaphoresis. light-headedness Adverse Effects: Lethargy. dreams. inguinal hernia. headache. microencephaly. difficulty concentrating. and amnesia prior to surgery Contraindication: acute Hypersensitivity glaucoma. neonatal withdrawal syndrome reported in infants). nausea. anxiolysis. Dosage: Midazolam 15mg 1tab ½tab at 12nn with 30cc of water Indication: Sedation.Anxiolytic. euphoria. potentiates the effects of gamma amino butyric acid (GABA). acute alcoholic marrow-angle shock. dystonia. apathy.Generic Name: Midazolam HCl Brand Name: Dormicum Classification: Benzodiazepine (short-acting). hiccups. nervousness. dizziness.
paresthesias. drug dependence.psychomotor retardartion. bronchospam. respiratory arrest . laryngospam. respiratory depression. bradycardia. tachycardia. urticaria. extrapyramidal symptoms. jaundice. gastric disorder. gynecomastia. hepatic dysfunction. nystagmus.
Instruct him to avoid alcohol. antiretroviral agents. quinupristin with dalfopristin. verapamil. other sedatives and anaesthetics. or sleep – inducing. ketoconazole and itraconazole. Teach him that the drug helps him to relax and will make him sleep. Nursing Responsibilities: 1. 5. 2. barbiturates. rifampicin. phenobarbital. 6. Plasma concentrations increased by CYP3A4 inhibitors such as cimetidine. Carefully monitor VS during administration. 3. 8. Tell patient that he may experience side effects brought upon by the drug. or OTC drugs before receiving the drug. opioids. Increased respiratory depression with opiates. and the drug is a potent amnesiac and he will not remember what has happened on him. carbamazepine. Midazolam concentration decreased by phenytoin. erythromycin. 4. Assess for baseline data. . not to permit ambulation upon administration. phenobarbital. thiopental requirements may be reduced during concurrent use. Assess patient for contraindication. 7. diltiazem. Monitor level of consciousness before. Keep patient on bed for 3hours. 9. Halothane. during and for at least 2 – 6hours after administration. clarithromycin.Drug – Drug Interaction: Increased CNS depression with alcohol. Instruct him to take the drug exactly as prescribed. other benzodiazepines.
.10.Instruct patient to report adverse effects that he may experience.
nephrotoxicity. S. pain at injectionsite. inflammation at IV site. vomiting.5 g Brand Name: Sulperazone® [vial] Classification: Cephalosporin.5g q8 IVTT Indication: Treatment of respiratory infection caused by S. S. Perioperative prophylaxis. or renal failure Side Effects: diarrhea. hypotension.Generic Name: Cefoperazone Na 1 g. Post operative prophylaxis Contraindication: Hypersensitivity to cephalosporin or penicillin. shock Drug – Drug Interaction: Increased nephrotoxicity with aminoglycosides Increased bleeding effects with anticoagulant . H. aureus. pyrogenes. abdominal pain. influenzae. E. parainfluenzae. leukopenia. liver toxicity. seizure. headache. bone marrow depression. vasculitis. pneumoniae. dizziness. antibiotic Mode of Action: Inhibits bacterial cell wall synthesis causing cellular death Dosage: Sulperazone 1. H. nausea. coli. Sulbactam Na 0. anaphylaxis. hematuria. Klebsiella. rash Adverse Effects: paresthesia.
Disulfiram-like reaction may occur if alcohol is taken 72hrs after drug administration .
. lighting and avoid noise) if headache occurs and if intolerable pain medication may be given as ordered. 3. Oral care if patient vomits. Have vitamin K injection readily available in case of hypoprothrombinemia. Instruct him to report intolerable side effects so management can be done. 9. Assess for contraindication.Instruct patient to avoid alcohol because severe reactions could occur. Inject slowly over 3-5 minutes. 4. 11. Instruct him to eat frequent small meals if vomiting occurs. Assess for baseline data. 10.Tell patient to report any adverse effects that he may experience. 8.Nursing Responsibilities: 1. 6. 7. Minimize stimuli (adjust temperature. Tell patient that he may experience side effects that are brought about by the drug. 5. 2.
causing cell death. Dosage: Cefoxitin 1 amp IVTT ANST now prior to OR Indication: Surgical prophylaxis Contraindication: Hypersensitivity to cephalosporins or penicillins. Side Effects: Nausea. paresthesias.g. anaphylaxis. . superinfection. dizziness. flatulence. phlebitis. rash. Renal excretion inhibited by probenecid. diarrhea. headache.Generic Name: Cefoxitin Sodium Brand Name: Monowell Classification: Antibiotic. pain on injection site. anorexia. pseudomembranous colitis. convulsion. Drug –Drug Interaction: Enhanced nephrotoxicity with aminoglycosides and loop diuretics e. fever. decreased platelet. decreased hematocrit. Cephalosporin (second generation) Mode of Action: Bactericidal: inhibits synthesis of bacterial cell wall. Disulfiram-like reaction may occur if alcohol is taken within 72hours after drug administration. Increase bleeding with oral anticoagulants. stomach upset Adverse Effects: Lethargy. vomiting. leukopenia. liver toxicity. nephrotoxicity. furosemide.
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.
rash. thrombocytopenia. cholinergic agonist. tricyclic antidepressants . diarrhea. gastrin. Side Effects: headache. insulin. lactation. abdominal discomforts. vomiting. hepatitis Drug – Drug Interaction: Increased effects of warfarin. nausea. Dosage: Ranitidine 50mg q8 IVTT Indication: Post surgery antacid to prevent ulcer formation Contraindication: Hypersensitivity to ranitidine. somnolence. impotence. bradycardia. inhibiting basal gastric acid secretion and gastric acid secretion that is stimulated by food. histamine. gynecomastia. leukopenia. tachycardia.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. and pentagastrin. local burning or itching at IV site Adverse Effects: malaise. constipation. insomnia. dizziness. pancytopenia. urticaria. vertigo.
Nursing Responsibilities: 1. 8. Assess for baseline data. Instruct him to report intolerable side effects so as prompt intervention could be done. Instruct patient to take his meal if nausea or vomiting occurs. 6. 4. 2. 7. Oral care if vomiting occurs. 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. . Tell patient that he may experience side effects brought about by the drug. Assess patient for contraindication. Instruct him to report adverse effects that he may experience. 3. 5.
pallor. post surgery analgesia Contraindication: Hypersensitivity to tramadol or opioids or acute intoxication with alcohol. headache. or psychoactive drugs Side Effects: Nausea. causes many effects similar to opioids – dizziness. constipation. sweating. dry mouth. anaphylactoid reactions Drug – Drug Interaction: Carbamazepine reduces the effect of tramadol by increasing its inactivation in the body. rash. dizziness. constipation – but does not have the respiratory effects. centrally acting Mode of Action: Binds to mu-opioid receptors and inhibits the reuptake of norepinephrine and serotonin. seizure. tachycardia. nausea. drowsiness. somnolence. vomiting. anxiety. bradycardia. sedation. Dosage: Tramadol 50mg q 6° IVTT Indication: Relief of moderate to moderately severe pain. somnolence. opioids. visual disturbances.Generic Name: Tramadol HCl Brand Name: Ultram Classification: Analgesic. headache. . vertigo Adverse Effects: Confusion. diarrhea.
Oral care for dry mouth and vomiting. narcotics. tranquilizers or sedative hypnotics. Assess for contraindications. Encouraged small frequent meals if vomiting occurs. Quinidine (Quinaglute. Instruct him to report side effects that are intolerable. 7. anesthetics. 3. Tramadol may increase central nervous system and respiratory depression when combined with alcohol. thereby increasing the concentration of tramadol by 50%-60%. Tell patient that he may experience side effects brought upon by the drug. 2. 4. Instruct patient to report adverse effects that he may experience. 6. for example. Assess for baseline data. Parnate) or selective serotonin inhibitors [(SSRIs. Encourage him to increase oral fluid intake. Control environment (temperature. 5. 9. . 8. fluoxetine (Prozac)] may result in severe side effects such as seizures or a condition called serotonin syndrome. Combining tramadol with monoamine oxidase inhibitors (for example. lighting) if sweating or CNS effects occur. Quinidex) reduces the inactivation of tramadol. Nursing Responsibilities: 1.
nausea. Nonopioid analgesic Mode of Action: Reduces the production of prostaglandins. abdominal pain. liver failure. sweating. It blocks the enzymes that cells use to make prostaglandins (cyclooxygenase 1 and 2). It most often is used after surgery.redness.are reduced. pain as well as inflammation and its signs and symptoms . diarrhea. dysuria. membrane. and pain of inflammation and that also are believed to be important in the production of non-inflammatory pain. renal impairment. neutropenia. chemicals that cells of the immune system make that cause the redness. fever. renal Impariment. bone marrow depression . Contraindication: Hypersensitivity to ketorolac. Dosage: Ketorolac 30mg q8 IVTT Indication: For short-term management (up to 5 days) of moderately severe acute pain that otherwise would require narcotics. peripheral edema. heartburn. constipation. fever. GI pain Adverse Effects: gastric or duodenal ulcer. bleeding. swelling. somnolence. headaches.Generic Name: Ketorolac tromethamine Brand Name: Toradol Classification: NSAID. thrombocytopenia. As a result. and pain . ringing in the ears. aspirin allergy Side fluid Effects: rash. retention. insomnia. leukopenia. pancytopenia. mucous drowsiness. platelet inhibition. dry dizziness. dyspepsia.
. Instruct to report signs of bleeding such as black tarry stool. 9. Infuse slowly as a bolus over no less than 15 seconds. cyclosporine) Nursing Responsibilities: 1. 3. 5. Encouraged oral fluid intake to avoid dry mucous membrane. 7. Increase risk of bleeding with anticoagulants (warfarin). 2. 6.Drug – Drug Interaction: Increased levels of ketorolac in the body and increased side effects with Probenecid (Benemid). Instruct to report intolerable side effects for prompt intervention. weakness and dizziness upon standing. Assess for baseline data. 8.Instruct to report if he experiences adverse effects. Administer with ranitidine to avoid ulceration. Assess patient for contraindication. 10. Increase risk of lithium toxicity with lithium (Eskalith) Reduced kidney function with concominatnt use with angiotensin converting enzyme (ACE) inhibitors. 4. aspirin Increased risk of nephrotoxicity with other nephrotoxins (aminoglycosides. Tell patient that he may experience side effects brought upon by the drug. Provide comfort measures if headache occurs.
respiratory arrest. inflammation. Side Effects: nervousness. . bradycardia. low blood pressure.25MSO4 OD Indication: Local or regional anesthesia. myocardial depression. thereby reducing fever. presumably by increasing the threshold for electrical excitation in the nerve. tachycardia. lignocaine. vomiting. analgesia for surgery Contraindication: Hypersensitivity to bupivacaine or other local anesthesia e. unconsciousness. tingling around the mouth. tremor. lightheadedness Adverse Effect: convulsion.Generic Name: Bupivacaine Brand Name: Bupican Classification: Anesthesia Mode of Action: Block the generation and the conduction of nerve impulses. tinnitus. ringing of the ears. dizziness.g.25% 10cc + 0. and by reducing the rate of rise of the action potential. which inhibits the production of prostaglandins. numbness of tongue. blood clotting disorder. cardiac arrest. by slowing the propagation of the nerve impulse. feeling of disorientation. arrhythmias. nausea. hypotensive shock. and hyperalgesia Dosage: Bupivacaine 0. drowsiness. The analgesic effects of Bupivacaine are thought to be due to its binding to the prostaglandin E2 receptors. subtype EP1 (PGE2EP1). seizures. blurred vision.
Drug – Drug Interaction: Additive effects when used with antiarrhythmic drugs .
. Monitor for side effects. Assess for contraindication. Continue to monitor patient following discontinuation of anesthesia. 4. 6.Nursing Responsibilities: 1. Monitor for occurrence of adverse effects. drug depresses the pulmonary and cardiac system. 2. 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. Assess for baseline data. Monitor vital signs carefully. 8. report to the anesthesiologist any signs and symptoms of adverse effects. Oral care if vomiting occurs. 5. 7. 3.
heart block. circulatory depressed reflexes. nausea. lowers BP while in surgery Contraindication: Hypersensitivity to magnesium sulfate. hepatitis. hypothermia. fecal impactation. excessive bowel movement. Antiepilecptic. intoxication. cardiac and CNS depression. vomiting. sweating. prevents or controls and convulsions the by blocking of neuromuscular transmission decreasing amount acetylcholine liberated at the end plate by the motor nerve impulse. tetany . dizziness. Dosage: Bupivacaine 0. abdominal pain. Laxative Mode of Action: An important cofactor for enzymatic reactions and plays an important role in neurochemical transmission and muscular excitability. Antihypertensive. hypotension. hypocalcemia. collapse. acts peripherally to produce vasodilation. appendicitis. flaccid. palpitations Adverse Effects: fainting. larger doses cause lowering of blood pressure. myocardial damage.Generic Name: Magnesium Sulfate Brand Name: Classification: Electrolyte.25% 10cc + 0. magnesium paralysis.25MSO4 OD Indication: Parenteral anticonvulsant for the prevention and control of seizures. flushing. attracts and retains water in the intestinal lumen and distends the bowel to promote mass movement and relieve constipation. headache. intestinal and biliary tract obstruction Side Effects: weakness.
Have calcium gluconate readily available if signs and symptoms of hypermagnesemia occur. Assess for contraindication. Do not administer unless solution is clear and container is undamaged.Instruct patient to report adverse effects immediately. Assess for baseline data. 9. . 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. Discard unused portion. pancuronium. 5. Nursing Responsibilities: 1. 3. tetracycline and tobramycin when given together. If it is suppressed. 7. 8. Monitor knee-jer reflex before repeated parenteral administration. 10. 6. vecuronium) CNS depression and peripheral transmission defects produced by magnesium is antagonized by calcium. Administer with caution if flushing and sweating occurs. Oral care when vomiting occurs. Reduces antibiotic activity of streptomycin. do not administer the drug for it may cause respiratory center failure. atracurium. 4.Drug – Drug Interaction: Potentiation of neurotransmuscular neuromuscular blockade relaxants produced by nondepolarizing (tubocurarine. Volume for volume replacement when excessive bowel movement and vomiting occurs to replace the loss fluid.
Togon Date of Surgery: 04/30/09 at 7:00 am Definition .Procedural Report on Open Cholecystectomy Surgeon: Dr. Batucan. Wolter Operation: Open Cholecystectomy Anesthesiologists: Dr.
The patient is supine. there are excessive adhesions. performed laparoscopically. both arms may be extended on padded armboards. or ductal or vascular anomalies exist. Type of Anesthesia • • General anesthesia Thoracic epidural anesthesia (as an alternative) Preparation of the Patient Antiembolitic hose may be put on the legs. the laparoscopic procedure is promptly converted to “open” cholecystectomy. is the preferred treatment for symptomatic gallstones unless the patient is extremely obese. If unexpected pathology is encountered. or if there is excessive bleeding or surgical injury. with or without cholelithiasis. A pillow may be placed under the sacrum and/ or under the knees to avoid straining back muscles. Discussion Cholecystectomy may be performed to treat chronic or acute cholecystitis. Pad all bony prominences and areas vulnerable to skin and neurovascular pressure of trauma. Note: Cholecystectomy. A .Cholecystectomy is the excision (removal) of the gallbladder. or to resect a malignancy. if acute inflammation distorts normal tissue planes. as requested.
right paramedian. Machines and Supplies Draping . or skin staples.nasogastric tube may be inserted by the anesthesia provider. tapes. The wound is closed in layers. The gallbladder is grasped (generally with a Pean clamp). Skin Preparation Begin at the intended site of incision.g. The abdominal cavity is entered in the usual manner. The surgeon must be aware of anomalies of these structures. Procedure The incision is right subcostal. The underlying liver bed may be reperitonealized. A foley catheter is not routinely placed. The skin is closed with interrupted stitches. or midline. The cystic duct. either right subcostal (most frequently used). The cystic artery is clamped (using two right-angle clamps) and ligated with a suture passed on a long instrument or by clips (e. cystic artery. Instruments. An electrosurgical dispersive pad is applied. Hemoclips). or medline. Jackson-Pratt ™) may be employed exiting a stab wound and secured to the skin with a stitch. as is the cystic duct. A drain (e. extending from the axilla to the pubic symphysis and down to the table on the sides. The gallbladder is mobilized by incising the overlying peritoneum and after local dissection is removed. and common bile duct are exposed. right paramedian.g...
if unavailable. a uteroscope or small cystoscope may be substituted Supplies • • • • • Antiembolitic hose Basin set Blades.g. Nd: YAG laser fiber or pulsed dye) when requested Instrumentation • • • • • Major procedures tray Long Metzenbaum scissors Hemoclip or other ligating clip appliers Biliary tract tray (for common duct exploration) Choledochoscope when requested.• 4 folded towels and a laparotomy sheet Equipment • • Folded blanket or pad (for positioning) Sequential compression device with disposable leg wraps. (1) #15.. (2) #10. or (1) #11 Suction tubing Hemoclips or similar ligating clips . if requested Laser (e. if ordered • • • Suction Ultrasound generator.
• • • • Electrosurgical pencil and cord with holder and scrape pad Needle magnet or counter Dissectors (e.. available • • Culture tubes. one aerobic and one anaerobic Hemostatic agent e. e.g.g... • 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. Jackson-Pratt or Hemovac™).g. optional • Mushroom-tipped (retention) catheters. Thrombostat™. Helistat™. peanut or Kittner sponges) Drains.. condition of skin preoperatively) must be documented in the operative record for continuity of care and for medicolegal reasons. Avitene™. Surgicel™..g.g. e.g. Pezzer or Malecot. Penrose 1” or suction drain (e. . available Nursing Responsibilities Preoperative • All care that is given and observations made regarding the patient (e.
as well as the spiritual and cultural beliefs.g. psychosocial factors. allergy to iodine. 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. cardiovascular status.• Assess health factors that affects the patient preoperatively: nutritional status. list of meds & allergies) Check the chart for patient’s sensitivities and allergies e. watch. previous medication use. endocrine function. medications and contact lenses • Instruct what to wear ( loose fitting. drug or alcohol use. Document allergies noted preprocedure and document alternative used. hepatic and renal function. • Inform the patient of the scheduled date and time of the surgery and where to report • • Instruct what to bring (insurance card. • Instruct what to leave at home such as jewelry. immune function. Explain nursing . he ascertains that the patient has no history of allergy to radiopaque dye. • When the circulator reviews patient allergies with the patient.
• • • Decrease fear Teach deep-breathing. Clarify misconceptions by answering the patient’s questions in a knowledgeable manner and refer questions to the surgeon as necessary. dyes. spiritual and religious beliefs Intraoperative • It is imperative that the patient be positioned over the correct area on the table to ensure accurate visualization of the biliary tract. • A protective facial shield is suggested for those scrubbed to avoid inadvertent splashing of contaminated fluids onto mucous membranes and eyes.. • Respect cultural. etc.procedures before performing them and the sequence of perioperative events. • All medications. 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. • Assess and document patient’s anxiety level and level of knowledge regarding the intended procedure. Scrub person should use a marking pen on labels to identify all .
expose only the immediate area involved for the procedure. All medication containers should be kept in the room until the completion of the procedure.. offer warm blanket or raise room temperature as necessary. • • • 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.g. • Instruments used on the gallbladder are isolated in a basin (considered contaminated) • Prevent musculoskeletal injuries to team members by employing ergodynamic measures when positioning the patient. • Take appropriate measures to maintain patient’s body temperature e. • Keep the patient adequately covered to maintain patient’s privacy.
• • Have T-tubes available following common duct exploration One syringe is filled with saline.• • Be careful in handling of sharp instruments at all times The scrub person sets up the instruments on the back table for the surgeon. Postoperative • The circulator accompanies the anesthesia provider and the patient to the PACU. The incision is extended with Pott’s scissors. he/she gives the PACU perioperative . 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. • Scrub person needs to have a right angle clamp (Mixter) available throughout the dissection of the biliary tree. • Usually a stab wound is made in the cystic duct using a #11 blade.
Goldman 2008. Maxine A. Report for abnormalities especially for signs and symptoms of shock • Perform safety checks – good body alignment. side rails and maintain patent airway and cardiovascular stability • Relieve pain and anxiety Reference pp. and documents all pertinent information. verify & identify operative status & surgeon performed.Philadelphia . Davis Company. 3rd edition F. assess neurological status (LOC) • PACU nurse observes the patient’s breathing. • • PACU nurse assumes the role as the patient’s advocate.. monitors blood pressure and vital signs. 148-153.practioner a detailed intraoperative patient report regarding the course of events as they apply to the individual. • Assess the patient: appraise air exchanges status & note skin color. Pocket Guide to the Operating Room.A.
2009 was on status post cholecystectomy. Dr Watson relates that caring is intrinsic to the therapeutic interpersonal relationship between the nurse and patient. Jean Watson Dr Watson believes that a new paradigm is emerging in health care. To meet the psychological or spiritual needs of patients. Cholecystectomy was done to remove the gallbladder. Every activity must respect the structural wholeness of the individual because well-being depends on it. or suggestions or through a trusting therapeutic nurse-patient relationship. nurses traditionally incorporate humanistic. Every activity is a product of the dynamic social systems to which the individual belongs. The nurse's relationship and . vital signs was monitored. Incision was made. In contrast. antibiotics was also given. To regain structure and function. The relationship between effective wound management and positive patient outcomes draws on Levine’s four conservation principles. to promote healing. its quantity and characteristic. life experience. spiritual beliefs. altruistic values by using the power of prayer. the body needs to restore structural integrity through repair and healing. She states that conventional medicine has become increasingly technological. typically centering on treatment to cure disease with medications and surgery. Every activity requires an energy supply because nothing works without it. 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. The patient last April 30. Every activity is chosen out of the abilities. body.Nursing Theories Ma. Ten primary carative factors form the structure of Dr Watson's caring theory Psychological caring-healing therapies strive to instill hope or faith. In addition. To have an effective wound healing and prevent complications. It is very important to take note of the discharges. and spirit. Patient was encouraged to take a rest. Aseptic technique in wound dressing was applied to prevent possibility of infection. the caring approach of nursing focuses on conscious compassionate skills that help patients achieve a healthy state of mind. about which she states: The conservation principles address the integrity of the individual… from birth to death. and desires of the “self”’ who makes the choices.
. the nurse can help the patient relax before surgery with the caring-healing therapies of holistic nursing. Patient’s needs was attended such as proper positioning. cope with their health needs. and technical skills of the individual nurse into the desire and ability to help people . determine personal needs. nursing is based on an art and science that mould the attitudes. promote optimal activity: exercise . Being available to the patient. elimination. It is very important to take into consideration the diet after NPO because the body is on the process of repairing. and provide opportunities for personal growth. cough and deep breathing exercises to prevent post operative complications. intellectual competencies. in the physiologic needs. initiating self-understanding. Medications were also given such as anxiolytic medicines to decrease anxiety. maintain good body mechanics and prevent and correct deformities. trusting relationship After developing a therapeutic trusting relationship. Faye Abdellah According to her. and communicating with personalized responses to develop a helping. fluid and electrolyte balance.interpersonal teaching enables the patient to provide self-care. nutrition of all body cells. 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. facilitating nonpossessive warmth. and providing silence was practiced to relieve patient’s anxiety. sick or well. Patient was on NPO. rest and sleep and to facilitate the maintenance of regulatory mechanisms and functions. To view Abdellah’s 21 nursing problems according to Maslow’s hierarchy of needs. listening to his concerns. Therapeutic communication is implemented through nonverbal behavior and listening. good hygiene and physical comfort. the nurse must facilitate the maintenance of a supply of oxygen to all body cells.
“ Na ok ok raman ko karun. Report pain cause of pain and provides is controlled if information about disease not relieved. ® Assists in differentiating 1. Administer minimizing Chenodeoxycholic acid. 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. freeing the nitroglycerin as ordered. and diversional activities as 2. situation ® Anticholinergics relieves reflex spasm or smooth muscle contraction and assist in pain management. mura man ug gimakumot na dili nako masabtan. as verbalized by the patient. Inflammation and swelling depresses the free nerve endings and cause the pain. 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. mind from ®Relieves ductal spasm. Observe and document care. Demonstrate complications and the use of effectiveness of relaxation skills interventions. ® Chenodeoxycholic acid is . progression/ resolution. Administer indicated for anticholinergics as individual indicated. inflamed and eventually infected.Nursing Care Plan Date/ Time April 27. development of 2.” The patient had identified relaxing techniques such as deep breathing 3. The patient may have biliary colic with excruciating upper right abdominal pain Objectives of Nursing Interventions Care Within my 8 hr 1. the client location. pain. the patient verbalized. medyo sakit pero dili na pareha ganina. Evaluation Goal met. worry which is helpful in 4. the gallbladder becomes distended.”. 2009 311pm Cues S: “ Sakit jud akoa tiyan karun (pointing at the right upper quadrant of the abdomen). severity and will be able to: character of pain. Administer smooth exercises and muscle relaxants.
infectious reducing 6. a natural bile acid that decreases cholesterol synthesis reducing size of gallstones. ® Reduces itching or pruritus from bile salts in skin 7. Note response to medication and report if pain is not being relieved. Antibiotics ® To treat process inflammation. ® Bedrest in Fowler’s position reduces intraabdominal pressures.shallow breathing R N that radiates to the back or right shoulder. 5. (2002). Pathophysiolog y: Concepts of Altered Health States. allowing patient to assume position of comfort. Philippines: Lippincott Williams & Wilkins. ® Severe pain not relieved by routine measures may indicate developing complications/ need for further intervention 8. however. Promote bedrest. Hyperlipidemic agents. patient will naturally assume least . Source: Porth CM.
redirects attention. 12. Use soft. ® Reduces irritation/ dryness of skin and itching sensation. 9. cotton lines. Encourage use of relaxation techniques such as deep breathing exercises. maintain a cool room temperature.painful position. may enhance coping. 10. cool or moist compress as indicated. Provide diversional activities such as watching television. Make time to listen to complaints and maintain frequent contact with the patient. ®Helpful in alleviating . calamine lotion. 11. ®Promotes rest. ®Cool surroundings aid in minimizing dermal discomfort. Control environmental temperature.
which can relieve pain.anxiety and refocusing attention. .
Magwapo ako ginhawa kung muhinga ko ug lalom.Verbalize awareness of feelings of anxiety and health ways to deal with them. 3. Lippincott Williams and Wilkins. represented by the situation. the remaining feelings relate to anxiety. because neither nurse nor patient knows the final outcome. Demonstrates concern and willingness to help.Date/ Time April 28. mura ko ug nahadlok karun sa ako operasyon ug unsa ang mahitabo sa akua panhuman ato. Maintain frequent contacts with the patient/SO. Be available for listening and talking as needed. ® Establishes rapport. These threats can produce vague feelings ranging from mild uneasiness to panic. Report anxiety is reduced to a 2.” 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. Patient was able to identify ways reducing anxiety such as use of deep breathing exercises. ®Helps recognition of extent of anxiety and identification of measures that may be helpful for the individual. Provide information about measures being taken to correct or alleviate condition. Helpful in discussing sensitive subjects. personal threats are also involved. 11th Ed. and anxiety was reduced to a manageable level. although some uneasiness may be attributed to fear. Information can provide . Identifying a threat as merely surgery is too simplistic. Encourage patient to acknowledge reality of stress without denial or reassurance that everything will be alright.” 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. the client will be able to: 1. Nursing Interventions 1. 2009 311pm Cues S: “Wala ko kasabot sa ako gibati. Nursing Diagnosis Application to Clinical Practice. ®Helps patient to accept what is happening and reduce level of anxiety. 2005 Objectives of Care Within my 4 hour care. Moreover. promotes expression of feelings. Evaluation Goal met. False reassurance is not helpful. “ Kung sige ko ug istorya sa ako ginabati ug sa ako kaguol kay mabwasan ang ako kaguol. Identify patient’s manageable perception of the threat level. Source: CarpenitoMoyet. Be available to the patient.
Patient refused to perform range of motion exercises for a fear of experiencing pain after the activity. Administer medication prior to activity as needed for pain relief. Full function may be affected and be delayed. the absence of contractures 3. ®Stimulates circulation and prevents skin irritation. Keep linens dry and wrinkle-free. there were no contractures and complications observed after an 8 hour care with the client. Change position frequently when on bedrest. and decubitus Keep skin clean and dry ulcers.Date/ Time April 28. Source: Monks. support affected body parts or joints with pillows. 2002 Objectives of Care Within my 8 hour care. well. Elevate head of bed Turn side to side. 4. Encourage deep breathing and coughing. 2. ®Decreases discomfort. Provide skin massage. On the other hand. ®To permit maximal effort or involvement in activity. enhances of function as circulation and prevents evidenced by skin breakdown. Home health nursing: assessment and care planning. 2. ®Mobilizes secretions. . ® Pain impairs mobility and activity. Elsevier Health Sciences. Maintains maintains muscle strength/ optimal position joint mobility.Verbalize willingness to and demonstrate participation in activities Nursing Interventions 1.20 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. the client will be able to: 1. Evaluation Goal partially met.
6.improves lung expansion and reduces risk of respiratory complications. ®Early ambulation prevents postop complications. Encourage early ambulation. Support abdomen when ambulating. 5. 7. Assist with active and passive range of motion exercises. ®Maintains joint flexibility. prevents contractures and aids in reducing muscle tension. ®Avoids accidental injuries and falls. Splinting provides incisional support/ decreases muscle tension to promote cooperation . 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.
8. Provide diversion such as talking with the patient or watch television. promotes relaxation. Provide adequate rest periods in between activities. . ®Decreases boredom. ®To prevent fatigue.with therapeutic regimen.
2. Evaluation Goal met. intact dressing at right upper quadrant of the abdomen.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. Clean the skin with soap and water. Change dressings as often as necessary. the client will be able to: 1. ®Facilitates drainage of bile. Demonstrate behaviors to prevent skin breakdown Nursing Interventions 1. a surgeon makes a large incision (cut) in your belly to open it up and see the area. 4. normally changing to participation greenish brown (bile color) in the change after the first several hours. Observe color and behaviors to character of the drainage. of dressing and change of 3. prevent skin ®Initially. Correct positioning prevents back up of the bile in the operative area. . make sure that they are free flowing. 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. semi-fowler’s position. may contain breakdown blood and blood-stained through fluid. hemorrhage was not observed and patient was able to demonstrate 2. Check the incisional drain. Use sterile Vaseline gauze.Date/ Time April 30. 2009 Cues S/O: Incision at right upper quadrant with Jackson Pratt drain with slightly soaked. Be free of complications such as heavy bleeding at the incision site. Place patient in low or positions. The surgeon then removes your gallbladder by reaching in through the incision and gently lifting it out. zinc oxide or karaya powder around the incision. ® Incision site drains are used to remove any accumulated fluid and bile. Within the span of care.
belly. . Note color and consistency of stools. 6. ®Clay colored stools result when bile is not present in the intestines.nlm. 8. 7. nih. ®Signs of suggestive of abscess or fistula formation requiring medical intervention. 5. urine for change in color. just below your ribs.htm ®Keeps the skin around the incision clean and provides a barrier to protect skin from excoriation. tachycardia. Source: http://www. sclerae. development of fever. The surgeon will cut the bile duct and blood vessels that lead to the gallbladder.gov/medline plus/ency/articl e/002930. Observe skin. ®Necessary for treatment or prohylaxis for abscess or infection. leakage of bile drainage from wound. Then your gallbladder will be removed. Administer antibiotics. ®Developing jaundice may indicate obstruction of the bile flow. Investigate increased or consistent RUQ pain.
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.
Laparoscopic cholecystectomy usually requires only one night in the hospital. Normal activities. Once home. their side effects and their adverse effects. Police should comply with the medications he has been prescribed with in order to aid in the recovery state after surgery.Discharge Planning Medicines: • • • • Tramadol Ketorolac Ranitidine Sulperazone Mr. including returning to work. Exercise: Cholecystectomy actually requires time to recover. Patient must follow his surgeon's advice about . With regards to his medications. it is advised to have 4 to 6 weeks duration time for recovery. But compared to open cholecystectomy. A major advantage of the procedure is that it patients can return to work in 1 to 2 weeks. If he experiences any adverse effects. Light exercise such as walking is recommended. it is possible to tire more easily than usual to begin with. so it is important to take it easy. he must know and understand the general knowledge of the drugs. can usually be resumed after about a week. he needs to refer to his physician immediately. Strenuous exercise and lifting should be avoided.
so it's important to discuss any pain with the doctors or nurses. Suffering from pain can slow down recovery. He shouldn't drive until he is confident that he could perform an emergency stop without discomfort. It is important to rest and let the body recover after surgery. Consequently. hygiene and bathing. • On discharge. to prevent other complications. The anaesthetist will prescribe painkillers.driving. the nurse must advise about caring for the stitches. the rest is up to him. there is likely to be some pain. if necessary. Some people will have dissolvable stitches. he must have his lifestyle and diet modified. . Now that the patient had his gallbladder removed. and will arrange an outpatient appointment for the stitches to be removed. Treatment: Gallbladder disease usually is treated by removing the gallbladder. which do not need to be removed. As the anaesthetic wears off. Health Teachings: • Explain to patient what to expect afterwards.
Remind him to complete the full course of the antibiotic treatment. red. Out-patient Care: Remind patients that regular check-ups are important to ensure that the patient condition is constantly monitored by the doctor. • Explain to patient to refer for unusualities immediately. inflamed or swollen the abdomen swells .• Instruct patient to comply with the home medications that would be given by his physician. • Encourage patient to do the recommended light exercises such as walking. Avoid doing strenuous activities which could slow down his recovery. If any of the following symptoms are noted. • Encourage him to comply with the dietary modifications. limit the intake of saturated fat and avoid the consumption of alcoholic beverages to prevent the occurrence of serious post-cholecystectomy side-effects. he should contact his doctor:any of the wounds start to bleed • • • any of the wounds become more painful.
diabetes and disorders of the nervous system. In order to prevent the occurrence of serious post-cholecystectomy side-effects. they should eat smaller amounts of food during a single meal. Also. Considering the fact that the organism is unable to completely absorb important nutrients without the help of the gall bladder.• • pain is not relieved by the prescribed painkillers a fever develops. operated patients also need to take vitamin and mineral supplements and bile salts to aid the process of digestion. They should limit the intake of saturated fat and avoid the consumption of alcoholic beverages. patients who have suffered cholecystectomy are exposed to a high risk of developing heart disease. 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. These could be signs of an infection that may need to be treated with antibiotics Diet: In time. PROGNOSIS Category Poor Fair Good Rationale . vitamins and minerals. This is due to inappropriate synthesis and assimilation of vital nutrients. operated patients need to make drastic lifestyle and dietary changes.
Police experienced right upper quadrant pain associated with a sense of bloatedness. so patient was advised admission and operation. which was said to be intolerable. He had also lost his appetite because of the pain. So he sought consultation at Out-Patient Department. Moreover. Until three days prior to admission. patient had severe right upper quadrant pain. Police did not immediately seek medical attention as he had persistent RUQ pain a month ago. pain is elicited.Emergency Room at Davao Medical School Foundation Hospital. Moreover.Onset of illness / A month prior to admission. He waited for the pain to become intolerable before seeking medical advice. without nausea and vomiting. Ultrasound revealed cholecystitis. His scleras were also slightly icteric during admission and he was positive with Murphy’s sign. the obstruction brought about by the Duration of illness / . Mr. when pressure is applied on the RUQ of the abdomen. Mr. Though no complications aroused yet. He said he also had an increased level of pain tolerance so he also didn’t mind to take any pain relievers. The pain was tolerable so he did not seek medical attention yet.
Police said he would undergo any treatment regimen he has to as long as his condition would get better. Police’s case which is the following: diet (high cholesterol. the institution very with an for the conducive healing. Anna is always watching over Mr. one also becomes more susceptible to infections and organ Family support / failure. DMSFH is a hospital environment. As one ages. Mr. and high sodium). 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 during his admission. Moreover. the personnel in which includes medical team are very responsive to Age / the needs of the patients. Police .cholecystitis caused his icteric sclera. high calorie. which could have been absent if he Precipitating factors / sought medical attention earlier. She said she will always be with Mr. diabetes Attitude and willingness to medication and treatment Environment / / mellitus and obesity. Moreover. The client is almost 50 years old. most of our organs are already used and abused. The wear and tear theory states that as one grows older.
Police. of categories rated POOR (1) + No.0 =FAIR =GOOD General Prognosis: The general prognosis of the client is good.57 Scoring for General Prognosis: 1-1.6 =POOR 1.4-3.through his ups and downs. of categories rated FAIR (2) + No. Police. of categories rated GOOD (3) divided by TOTAL NO. Total 0/7 3/7 4/7 Computation: No. Moreover. .7-2. relatives come to Davao to visit Mr. =0(1) + 3(2) + 4(3) = 6 + 12 =18/7 =2.3 2. This means that the client has a good chance of recovering from his illness. and together with them are the encouragement and support they give Mr. OF CATEGORIES= SCORE FOR GENERAL PROGNOSIS. as he vowed him during their wedding day.
clinical manifestations. cholecystitis is the most common problem resulting from gallbladder stones. the student nurses has identified and understood the causative factors of cholecystitis. Upon learning his case. which carries bile from the gallbladder. It occurs when a stone blocks the cystic duct. one has to take action towards preventing the disease to happen. age. medical. sex and race. diagnostic studies. Predisposing factors can include heredity. it challenged and motivated them to work hard to provide the appropriate and effective nursing intervention and care.Conclusion Generally. Moreover. Joseph (3C) ward. With the proper knowledge about the nature of the disease as well as its preventive measures along with . The only one who can help yourself is you alone. With the presented factors that cannot already be modified. After five days of exposure at St. They underwent extensive research in order to comprehensively understand his condition. its signs and symptoms. the student nurse’s one week exposure and duty at the Davao Medical School Foundation Hospital has been a memorable experience to them. The exposure had been an avenue for further development and enhancement of their skills and capabilities in rendering care and promoting holistic wellness to their clients. pharmacological and nursing interventions through obtaining cues and health history in conjunction to the disease process. It reminded them again that nursing profession entails a deep sense of responsibility and challenging tasks.
responsibility and sense of will. There have been reports that mortality can be as high as 15% for immunocompromised patients. “No matter how the disease has already reached an alarming incidence rate or not. it is a duty of every human person to take care of his own body. not just for the sake of other people that depend on him.” . but most especially for himself ~ a primary obligation that he must fulfil. one can surely direct himself away from the complications. Furthermore complicated cholecystitis has 25% mortality (eg. Our gallbladder is not to be taken for granted. empyema of gallbladder). gangrene.
he must carry out his responsibilities in fighting his own condition. because it would be better for him to express whatever is causing stress on his part thus. He is encouraged to willingly and actively participate in therapeutic activities that will render improvement of his condition. More than anything else. He is encouraged to verbalize his thoughts and feelings to his medical attendants. Police’s case. After thoroughly studying Mr. there must be willingness to recover on the part of the patient. With this. To the patient’s family Undeniably. Moreover. such as his nurses.Recommendation Every exposure is a learning experience filled with lessons. 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. 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. The family members should be involved with his treatment as much as possible since their support motivates him to exert . 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. the patient’s family plays a significant part in his battle against the disease.
Rather. They should not only be physically present. Be sensitive and respond to the needs of other group members. Through this. try to help the others and contribute something that would make the work better. Being calm is always a good move. they should always asked the student nurses for assistance. they would be able to know how to manage and meet his needs when he is discharged from the institution where he is admitted. To the fellow student nurses It is not through a single effort that you learn the entirety of a certain illness. Fix the problems in a peaceful manner. Be open-minded to suggestions and prevent intensive discussions so that healthy relationship within the group will be maintained. or clarifications because they are always ready to lend a helping hand. More than that. they should give their emotional support to boost the patient’s morale.more effort in the recovery process. If one is done with the task. To the group Maintain practicing teamwork and unity within the group so that better output will be formulated. In addition. it takes continued research and study in order to be more updated with information that will render an insightful understanding of what . Not only that. advices. 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.
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. To the Ateneo de Davao University. forums or trainings.College of Nursing has been exerting much effort in providing the best exposures to its nursing students. You should realize that your patients are also humans. They should not only appreciate the concepts during lecture session but should also positively digest the experiences they get from their duties and exposures. and .it is all about.College of Nursing The AdDU. It is through this that you can provide the quality and holistic nursing care that patients need. though suffering from a chronic illness. To the Professional Medical World Open cholecystectomy undeniably has its own disadvantages. Furthermore. Nursing students of AdDU should be committed to the goal of being men and women for others. quality-level lectures and affiliations with various medical institutions for the students’ exposures and duties. 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. You should always be humane in treating and approaching them so that you can be of help in the best way you can. As student nurses. Minilaparotomy cholecystectomy presents exposition difficulties. The scar alone after surgery is one of the major disadvantages.
the people’s trend as well as preference also changes.laparoscopy requires expensive equipment and additional training. and requires a longer convalescence. less invasive and more aesthetic procedure is preferred. it is also less aesthetic. The group would like to comment on the success of the emergence of new studies and invention. Laparotomy is more painful. a cheaper. As the medical field advances. Such new technique presented for minilaparotomy cholecystectomy is transcylindrical. Researches and studies have been conducted to discover a new technique of minimal invasive cholecystectomy. As much as possible. They are to look forward to further studies and improvement. causes trauma to the abdominal wall. .
ac. • Bullock.. et al.uk/nursing/sonet/rlos/bioproc/resources.. 10th ed. 10th edition USA: MosbyYearbook 1996. • • • Damjanov. F. Anderson’s Pathology.nih. Harrison’s Principle of Internal Medicine. 2nd Edition Carol Porth. Al. I.nottingham. Judith H. 16th edition. 8th Edition Kasper et.le. Tortora et..A. Pahtophysiology Concepts of Altered Health Sciences.BIBLIOGRAPHY • • • • • • http://www. . Focus on Pathophysiology.html http://digestive.uk/pa/teach/va/anatomy/case2/frmst2. Davis’s Drug Guide for Nurses.gov/statistics Barbara Howard.2007. R. Philadelphia. USA: The o McGraw-Hill Companies 2005. B. April H. Al.. Clinical and Pathologic Microbiology.ac. USA:Lippincott. Pennsylvania. Vallerand. Davis Company. Microbiology An Introduction. Philadelphia. Henze.ac. Linder. J.html http://www. Fauci A.le.html http://www. Robbins.uk/pa/teach/va/anatomy/case5/frmst5. 7th Edition • • • • Pathology 3rd Edition by Stanley L.niddk. 16th Edition Deglin. Harrison’s Principles of Internal Medicine.D. M.
Alice C.1. 2008.2006.Surgical Nursing. Nelms. Kerry H. • Karch. 2007... Philadelphia. Mary Frances. The Thomson Corporation. Janice L. • Doenges. Nursing Care o Plans 7th ed. 10 Davis Drive Belmont.o Williams and Wilkins 2006. Sucher. 11th ed. Davis Company. Murr. .A. F. USA. Amy M. F. Marilynn E. Long. o 4th edition. CA. o Lippincott Williams & Wilkins. Thomson o Brooks/Cole. • Clinical Applications of Nursing Diagnoses.. o Brunner & Suddarth’s Textbook of Medical. Suzanne C. Philadelphia. Brenda G. Moorhouse. 2007. • Bare. Hinkle. 2007 Lippincott’s Nursing Drug Guide. Smeltzer. Cheever.A. Pennsylvania.. Lippincott Williams & o Wilkins. Vol. • Nutritional Therapy and Pathophysiology. Davis Company.
Maxine A. o 2nd ed. Singapore. CMPMedica Asia Pte Ltd. 3rd edition o F. Goldman 2008. Essentials of Pathophysiology: Concepts of Altered Health States. 108th ed. 148-153. Lippincott Williams & Wilkins. Davis Company.Philadelphia . Porth. 2004.A. Carol M.• • MIMS. 2007. • pp. Pocket Guide to the Operating Room.