A. INTRODUCTION Cholecystitis is an inflammation of the gallbladder wall and nearby abdominal lining.

Cholecystitis is usually caused by a gallstone in the cystic duct, the duct that connects the gallbladder to the hepatic duct. The presence of gallstones in the gallbladder is called cholelithiasis. Cholelithiasis is the pathologic state of stones or calculi within the gallbladder lumen. Calculouscholecystitis is the cause of more than 90% of cases of acute cholecystitis (Feldman, Friedman and Brandt,2006). Gallstones are crystalline structures formed by hardening or adherence of particles of normal or abnormal bile constituents. According to various theories, there are four possible explanations for stone formation. First, bile may undergo a change in composition. Second, gallbladder4 stasis may lead to bile stasis. Third, infection may predispose a person to stone formation. Fourth, genetics and demography can affect stone formation. Sometimes, persons with gallbladder disease have few or no symptoms. Others, however, will eventually develop one or more of the ff. symptoms; (1.) Frequent bouts of indigestion, especially after eating fatty or greasy foods, or certain vegetables such as cabbage, radishes, or pickles, (2.)Nausea and bloating (3.) attacks of sharp pains in the upper right part of the abdomen.This pain occurs when a gallstone causes a blockage that prevents the gallbladder from emptying (usually by obstructing the cystic duct). (4) Jaundice may occur if a gallstone becomes stuck in the common bile duct, which leads into the intestine blocking the flow of bile from both the gallbladder and the liver. This is a serious complication and usually requires immediate treatment.
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The only treatment that cues gallbladder disease is surgical removal of the gallbladder, called cholecystectomy. Generally, when stones are present and causing symptoms, or when the gallbladder is infected and inflamed, removal of the organ is usually necessary. When the gallbladder is removed, the surgeon may examine the bile ducts, sometimes with x-rays, and remove any stones that may be lodged there. The ducts are not removed so that the liver can continue to secrete bile into the intestine. Most patients experience no further symptoms after cholecystectomy. However, mild residual symptoms can occur, which can usually be controlled with a special diet and medication.

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I. DEMOGRAPHIC DATA A. Initials of Clients Name: E.Q. B. Address: Blk 2 Lot 3 Section 35 Bellview Meadows Subd. Brgy.BagtasTanza Cavite C. Age: 61 years old D. Birth date: August 24, 1951 E. Birthplace: Albay, Bicol F. Gender: Female G. Civil status: Widowed H. Religion: Roman Catholic I. Educational attainment: 2nd Year High School J. Usual Source of Medical Care: San Lazaro Hospital, UST and KP K. Date of Admission: December 5, 2012 L. Time of Admission: 11:50 am M. Hospital: Korea-Philippines Friendship Hospital N. Date of Interview: December 7, 2012 O. Primary Informant: Patient (E.Q.) P. Secondary Informant: None Q. Other Data Source: Patients chart and health care provider Occupation: Vegetable Stand Vendor Monthly Income: 3,000 Php
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II. REASON FOR SEEKING HEALTH CARE Prior to admission, client had fever for 1 day and experienced abdominal pain for 3 days with a pain scale of 10 out 10 on Right Upper Quadrant radiating from front to back upon admission which cause the patient to seek for medical assistance.

III. HISTORY OF PRESENT ILLNESS According to the patient she experienced the pain since 2003( month and date not stated) and she had an check-up on the same year at University of Sto. Tomas Medical Center with Dr. Alvin Quino as her physician. She had a request for ultrasound and given a medication of Buscopan for 3 days. The client also mentioned that she uses boiled guava leaves and she drinks it. She even calls for midwife for massage regarding her pain. At first clients perception about her disease is ang alam ko kasi lamig lang siya eh as verbalized by the patient. At present upon occurring of pain she was on their house lying on bed when it triggers again and tend the patient to have consultation at Korea-Philippines Friendship Hospital under Dr.Calma as her attending physician last November 27, 2012. She have undergone for ultrasound at Divine Grace last Dec. 4 2012. And after the result has being read, she was diagnosed to have Cholecystolithiasis or presence of stone on the gall bladder. Her physician decided her to be admitted at KP on Dec. 5, 2012 and was scheduled for Cholecystectomy on Dec. 7, 2012.

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IV. PAST MEDICAL HISTORY According to the patient, she was diagnosed to have a mass on her xyphoidprocesswhen she was 15 years old at San Lazaro Hospital Manila. She doesnt remember the name of the doctor who prescribed her to take Kremil-S and Tetralac during that time. After that, the patient didnt hesitate to return to any health institution for further check-ups or assessments. She used herbal medicines ofFeligayonProducts since year 2000 up to now as her pain reliever. Moreover, the patient said that she doesnt experience any incidence of injury and accidents. She was never been hospitalized. In regards on her immunization, patient stated that she was fully immunized before she reached one year old. According to her, she has the possibility to be allergic to contraceptive pills because according to her observation, her baby got rashes when she breastfeeds her which she thought to be due to her intake of pills. The patient also stated that she had a history of taking multivitamins (Revicon) regularly when she was 30 years old up to when she turned 40. The patient also stated that she takes B6B12 for her joints twice a day irregularly. The patient had her last check-up this November 27 at KPFH with Dr.Calma.

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V.OBSTETRIC GYNECOLOGICAL HISTORY The patent stated that she had her menarche when she was 15 years old.She have a regular cycle of 28 days with a usual amount of 3 pads/ day for 5 days she sometimes experienced dysmenorrhea client usually take Midol and herbal medicine for menstruation. But when patient is at age of 45 years old her menstruation stops for 9 months which is not normal but after 9 months she experience menorrhagia. The client experiences her menopause when she was 55 years old.

G5 P5 T5 P0 L5 M0

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VI. HEREDO-FAMILIAL HISTORY

MATERNAL SIDE

BA 83 y/0 HPN DA 83 y/o MA HPN

DA HPN

PA 83 yrs old

46 yrs old HPN

EQ 61 yrs old

INTERPRETATION As seen above the genogram, patient has history of hypertension on both sides. Other than that, patient has no known diseases that can contribute to her present condition.

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VII. SOCIO-ECONOMIC The type of family structure is extended client lives with her grand children and in laws. Since client EQs husband died the breadwinner of the family is her eldest son who is working in Makati. Upon the interview, the patient stated that their average monthly income is Php 6,000 and they usually spends Php100 per day for their food, 2000 for electricity, and health maintenance varies depending upon the condition but is not consistent. They owned the house in which they were residing. They were also affiliated to Phil Health in order to suffice the patients hospitalization. Below is the estimated breakdown of their expenditures as of the month of November. Expenses: Food: 100 php Electricity: 2000 php Food: 100 Php/ day x 30 days 3000 Php

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VIII. DEVELOPMENTAL HISTORY

Erik Ericksons Psychosocial Development Erik Erikson's theory of psychosocial development is one of the best-known theories of personality in psychology. Erikson believed that personality develops in a series of stages it describes the impact of social experience across the whole lifespan. Elements of Eriksons psychosocial stage theory are the development of ego identity. Ego identity is the conscious sense of self that we develop through social interaction. According to Erikson, our ego identity is constantly changing due to new experiences and information we acquire in our daily interactions with others. In addition to ego identity, Erikson also believed that a sense of competence motivates behaviors and actions. Each stage in Erikson's theory is concerned with becoming competent in an area of life. If the stage is handled well, the person will feel a sense of mastery, which is sometimes referred to as ego strength or ego quality. If the stage is managed poorly, the person will emerge with a sense of inadequacy. In each stage, Erikson believed people experience conflict that serves as a turning point in development. In Erikson's view, these conflicts are centered on either developing a psychological quality or failing to develop that quality. During these times, the potential for personal growth is high, but so is the potential for failure.

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Stage 1: Trust vs. Mistrust: Infancy (Birth to 18 Months) The patient grows up living with her Grandmother. According to her she was very close to her Lola. Upon questioning the client reminisces about her childhood days, she stated that, Sabi saakin ng Lola ko dati, hindi daw ako lumalapit sa ibang tao sa mama ko at sakanya lang kasi pag iba na humahawak sakin iyak na daw ako ng iyak . She was a breastfed baby during her birth until she got 1year old. The patient verbalized that, Isang beses daw wala yung Lola ko tapos ang kasama lang ni mama ay yung kaibigan nya, tapos tinakot takot daw ako nun kaya lalo daw akong di sumama at di nasanay sa ibang tao. In her case, the patient developed mistrust with other people because of what she experienced when she was child. if we Failing to build trust because our needs are not met, we may end up with a subconscious feeling of unimportance and a mistrust of other people around us.

Stage 2: Autonomy vs. Shame: Early Childhood (18 Months to 3 Years) During this stage the patient learn to master some skills for her. She learned to walk, talk and feed herself through the help of her mother and her sisters. She was learning finer motor development as well as the much appreciated toilet training. The patient recalls that when she was 3 years old, she knew how to say NO if she did not want to do certain activities and normally her Lola is the one whos choosing what clothes she will wear even if she doesnt like it. Her parents allowed her to do as she pleased. Though if she did something wrong they would commend her in her actions.
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It concludes that, the patient is in the process having disgrace of doing things or in learning other important skills; she may feel great shame and hesitation of her capabilities and experience low confidence as a result.

Stage 3: Initiative vs. Guilt: Play Age (3 to 5 Years) During this period, the patient experiences a desire to copy the adults around us and take initiative in creating play situations. In this stage a child will begun to explore the world by using a wonderful word "WHY?. As she verbalized, sabi saakin nung

Lola ko, dati daw pag may ginagawa sya ginagaya ko daw madalas pag nagwawalis sya o nagliligpit, yung Lola ko naman hinahayaan lang ako para daw paglaki ko masipag ako. She also verbalized that after school she and her playmates used to play bahay-bahayan or playing there dolls. The patient also begun to use that wonderful word for exploring the world She commonly asked her Grandmother Lola bakit pobinigay ako nila mama sayo? or Mahal po ba ako nila? . The client is in the process of asking many questions to know the truth and to adopt on the reality. Her Grandmother answers her questions honestly and it came up to positive outcome. If a childs questions treat as insignificant, it will result to embarrassing or may develop negative behaviour then the child may have feelings of guilt for being an irritant. Too much guilt can make the child slow to interact with others and may inhibit their creativity, it can also effect the child to exercise self control or have a conscience. A healthy balance between initiative and guilt is important. Success in this stage will lead to the virtue of purpose.

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Stage 4: Industry (competence) vs. Inferiority (6 - 12 years) The patient at this stage learned to read and write, to do sums, to make things on their own. The patient verbalized that, Naaalala ko pa nun yung guro naming magaling sya pero minsan may pag ka sadista, uso naman yun dati pag mali ginawa o ginagawa mo pinapalo ka pero ok lang naman yun mas natuto ako na magsipag sa pag-aaral para di mapalo. She also stated that, her Grandmother is always there for her to encourage, to educate and also to give advices in a nice way every time she was having trouble in her studies. If children are encouraged and reinforced for their initiative, they begin to feel industrious and feel confident in their ability to achieve goals. If this initiative is not encouraged, if it is restricted by parents or teacher, then the child begins to feel inferior, doubting his own abilities and therefore may not reach his potential. Stage 5: Identity vs. Confusion: Adolescents (13 19 years) In this stage, adolescence, children explore their independence and develop sense of self. Those who receive proper encouragement and reinforcement through personal exploration will emerge from this stage with a strong sense of self and a feeling of independence and control. Those who remain unsure of their beliefs and desires will feel insecure and confused about themselves and the future. According to the client she was aware in her appearance as a female, she knew where group of friends she belongs. Her Grandmother is strict when it comes to handling herself, on how to act as a female and sometimes discouraging her to make friends with boys. The patient didnt have any confusion about her identity.

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Stage 6: Intimacy vs. Isolation: Young Adult (20 24 years)

This stage covers the period of early adulthood when people are exploring personal relationships. Erikson believed it was vital that people develop close, committed relationships with other people. Those who are successful at this step will form relationships that are committed and secure. Remember that each step builds on skills learned in previous steps. Erikson believed that a strong sense of personal identity was important for developing intimate relationships. Studies have demonstrated that those with a poor sense of self tend to have less committed relationships and are more likely to suffer emotional isolation, loneliness, and depression. The patient in this stage feels loved and beloved. This is the time that she really made a decision in her life to have a serious relationship with her first husband. She decided to have a commitment that will last forever. So what she did she come to her true friends to ask some advices. This is also a stage that the patient seeks stable job for her family. Love and affiliation was shown by the patient.

Stage 7: Generativity vs.Stagnation: Mid-adult (25-64 years) During this period, patient is already having her own family. Her love with her husband resulted to ___ childrens. As the mother of the family, she gets the obligations and responsibilities that she was able to show. However, she sometimes feels unproductive due to her long stay at the hospital. With that, she does not have any
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source of income thus making it hard for her to withstand the responsibility in the family that made her feel dissatisfaction.

The patient had developed sense of generativity or the sense of being productivity and accomplishment during this stage. At this stage of middle adulthood one is preoccupied with establishing and guiding the new generation. Constructing a life, a career, to have founded a family and to contribute to society are the most important elements of this stage. Someone who lacks those attributes might feel at the margin of the world, passive and with a lack of purpose and productivity. Generativity is the concern of establishing and guiding the next generation. Socially-valued work and disciplines are expressions of generativity. During Middle Ages the primary developmental task is one of contributing to society and helping to guide future generations. When a person makes a contribution during this period, perhaps by raising a family or working toward the betterment of society, a sense of generativity a sence of productivity and accomplishment results. In contrast, a person who is self-centered and unable or unwilling to help society move forward develops a feeling of stagnation dissatifiscation with the relative lack of productivity. ( Pilliteri, 5th edition) In regards with this stage, during adulthood, we continue to build our lives, focusing on our career and family. Those who are successful during this phase will feel that they are contributing to the world by being active in their home and community. Those who fail to attain this skill will feel unproductive and uninvolved in the world.

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IX. GORDONS FUNCTIONAL ASSESSMENT

A. HEALTH PERCEPTION HEALTH MANAGEMENT T he patient verbalized that the most important factors for a healthy life is just eating nutritious foods, having a balance diet and having enough hours of sleep. She does not smoke nor drinks alcohol. She doesnt believe in faith healer but believes in herbal medicines. Prior to hospitalization, E.Q stated that she thought that she was alright. She also stated that she seldom get sick and have coughs and colds. She did not consult any medical help until she could no longer tolerate her symptoms. She only took herbal medicines like Feligayon Products as pain reliever. She was a fully immunized child. The patient has been in the hospital since December 5, 2012 and had undergone an operation on December 7, 2012. Prior to operation, she stated, Mahina po ako ngayon. Sana pagkatapos ng operasyon magaling na ako. After the operation, she verbalized wellness even though there is pain in the incision site.

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B. NUTRITIONAL METABOLIC MEALS December 5, 2012 BREAKFAST 2 pcs of Bread 1 cup of coffee LUNCH cup of Lugaw 1 glass of water (120 ml) 1 cup of rice 1 pc. Ginataang Tilapia 1 glass of water NPO 2 pcs of Bread 1 cup of coffee December 6, 2012 December 7, 2012 cup of Lugaw 1 glass of water (120 ml)

DINNER

cup of cup of Lugaw Lugaw 1 glass of 1 glass of water water (120 (120 ml) ml) NPO

TOTAL FLUID 300 ml INTAKE 300 ml 120 ml

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The patient had her diet as tolerated but is ordered in nothing perm orem diet prior to operation. According to the patient, her meal before hospitalization usually includes vegetables, fish and rice. She stated that she likes to eat gata. She only weighs 52 kgs and verified no weight loss or weight gain. There are no changes in appetite or eating discomfort. According to her when he has wound it heals well. He doesnt have any dentures. The patient daily meal doesnt meet the nutritional guides for adult. An adult should have at least 5 cup of rice and alternative daily (Nutritional Guidelines for Filipino, 2000 ed. P.13 FNRI-DOST). She may have imbalanced nutrition less than body requirements since she use to eat lugaw in her hospitalization.

C. ELIMINATION
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The patient usually urinates 7 times a day (840mL): 5 times on day and 2 times on night. Her urine color is orange. Catheter was inserted before the operation and passes out orange color. She defecates once a day regularly without any difficulties or using of laxatives. The color of her stool is golden brown. She doesnt exhibit excessive perspiration.

D. ACTIVITY-EXERCISE The patient stated that her usual activities during her stay at the hospital are just lying in bed and having conversations with her son. She seldom does anything because she experiences body weakness. She just stay on her bed, sleeping. Her only exercise would be her walk to the bathroom if needed. According to her, her usual activities before her illness were taking care of her grandchildren.

E. SLEEP REST E.Q stated that she usually sleep at night at around 8 pm and wakes up at around 2:00 to 3:00 am. She stated that even though she sleeps early or late at night she stills wakes up early in the morning. However, she feels quite rested upon waking up and ready for the day. But during hospitalization, the patient sleeps for about 4 to 5 hours at night. Her sleep is disrupted due to pain felt on her incision site.

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CONSTRUCTS HOURS OF SLEEP SLEEPING TIME WAKING TIME BEDTIME RITUALS FEELING UPON WAKING UP PROBLEMS ENCOUNTERED

MON 7hours 8pm 3am pray Feels rested NONE

TUES 7hours 8pm 3am pray Feels rested NONE

WED 7hour s 8pm 3am pray Feels rested NONE

THURS 7hours 8pm 3am pray Feels rested NONE

FRI 7hour s 8pm 3am pray Feels rested NONE

SAT 7hours 8pm 3am pray Feels rested NONE

SUN 7hours 8pm 3am pray Feels rested NONE

F. COGNITIVE PERCEPTUAL Upon the interview, the patient was able to answer all the questions coherently and appropriately. She stated that she had blurred vision but stopped wearing reading glass nor hearing aids though she experienced slight difficulty in hearing. As observed, the patient is able to read the sample reading materials with little difficulty. As Tic Tac Test was performed, the patient heard the ticking of the watch after 5 seconds. She doesnt complain any changes in taste. Other than that, there are no significant changes in patients perception. She shows good memory and was able to remember recent and past events. She easily learned something by responding and asking follow-up questions. She had no difficulty in making decisions because according to her, her children were the one who is responsible in decision making. She stopped her studies when she was 2nd year high school due to her own reasons. After that, she started selling vegetables in Bicol.
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G. SELF PERCEPTUAL SELF PATTERN Upon assessment, the patient appeared calm. When asked how she would describe herself, she stated that she was approachable person and can easily deal with others. She experienced lesser problems because all her children were in stable life and all of them support her in financial especially during hospitalization.. The patient sees herself as a friendly person. When we asked her what she feels about being hospitalized she told us that she feels fine and she added that he wants to go home already. When asked about her illness, she verbalizes, at first it was alright for her because she doesnt know that it was serious. But after explaining it to her, she accepted her condition and wanted to cure and get well soon.

H. ROLE RELATIONSHIP The patient was widowed since her husband died due to hypertension on 1992. As of now, she lives with her eldest and youngest son together with their own family. They usually spend time watching television and eating meals together. She enjoys taking care of her grandchildren. She stated that she and some of her siblings werent able to see each other again, only her mom and eldest son are there when she is visiting their hometown in Bicol. She misses them a lot.

I. SEXUALITY REPRODUCTIVE
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She stated that she had her menarche when she was 15 years old. She have a regular cycle of 28 days with a usual amount of 3 pads/ day for 5 days she sometimes experienced dysmenorrheal client usually take Midol and herbal medicine for menstruation. But when patient reached the of 45 years old her menstruation stops for 9 months which is not normal but after 9 months she experience menorrhagia. She had given birth to five live children. The patient verbalizes that since her husband died; she never had another sexual partner. J. COPING STRESS E.Q experienced lesser problems because all her children were in stable life and all of them support her in financial. But whenever there are problems, she just talks to her children to take things over.The big change in her life is when he found out that she has gallstones. When he has problem he usually share it with her friends and family and according to him it is effective

K. VALUE BELIEF PATTERN Patient E.Q grew in a Roman Catholic faith. She always attends mass every Sunday together with her family. She believes in God as her saviour and puts everything in Him. She prays at night before sleeping to ask God for good health.
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According to her, her family is the most important thing in her life. She verbalized, Sila ang nagsisilbing buhay ko at nagbibigay ng lakas ng loob sa araw-araw.

X. COMPREHENSIVE PHYSICAL EXAMINATION A. Vital Signs

T= 36.1 C PR= 84 bpm

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RR= 19 cpm BP= 120/80 mmHg

B. Anthropometric Data

Weight = 52 kg Height = 53

C. General Appearance

Upon assessment the patient was observed that her body build is proportionate to her weight and height. Due to major surgical procedure done, the patient still at bed rest. When moving or sitting she needs support from her relative however, the patient is relaxed. In regards to her over all hygiene and grooming the patient was observed neat and clean. There is a quite breath odor but there is no body odor noted. The patient does not shown any signs of distress but slightly looks weak in appearance. Mentally, the patient is conscious and coherent. Upon interview the patient is very cooperative in answering all the questions that is being asked to her. Her responses are appropriate to the questions and logical in sequence. The speech that is being delivered was audible and easy to understand and moderate in pace. All her statements are correlated to the previous information that she said.
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D. Physical Assessment

Body Part Examined Integument SKIN

Review of System Nangangati ang skin kosa parte ngtiyan as verbalized by the patient.

Actual Finding I: Even and uniform slight brown complexion -longitudinal incision site in the RUQ of abdomen. P: normal skin turgor

Normal Finding Varies from light to deep brown; from ruddy pink to light pink, generally uniform, no edema, no abrasions or other lesions

Clinical Significance -Incision site is due to the surgical operation done to the patient called Cholecystectom y. It is the removal of gallbladder as a management of Cholecystitis. (Brunner &Suddarths MedicalSurgical Nursing; 10th ed. Vol.1, page 1177) -Can cause infection if wound dressing was not taken care properly.

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Hair

Walanaman akongkuto as verbalized by the patient

I: short, straight, thick -evenly distributed -patches of white hair near the scalp. -without infestation

Evenly distributed. Thick, silky and resilient hair. No infection or infestation.

Presence of white hair is related to old age. (Fundamentals of Nursing 5thEdition, Kozier and Erbs, page 478)

Nail

Nag gugupitnama nakongkuko lingo-linggo as verbalized by the patient.

I: Convex curvature; 160 Smooth texture -pinkish nail bed -surrounding tissues still intact. P - color comes back 4 seconds when pinched(blanch test)

Convex curvature; angle of nail plate about 160 Smooth texture Nail bed pinkish in light-skinned clients; darkskinned clients may have brown or black pigmentation Intact epidermis Prompt return of pink or usual color (generally less than 4 seconds) Rounded and smooth skull contour Uniform consistency; absence of

NORMAL

Head

Di namannasak itanguloko as verbalized by the patient.

I: symmetrically round P:smooth skull contour -no nodules or masses

NORMAL

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nodules or Eyes and Vision Malabo naangmatak o, di naakomasya dongmakapa gbasapagwal angsalamin as verbalized by the patient. I: Eyebrows symmetrically aligned; equal movement Eyelashes equally distributed; curled slightly outward -corneas are clear, transparent and sensitive. -Pupils are equally round, reactive to light and accommodation. -sclera appears yellowish P: No edema or tearing Blinks when the cornea is touched. Visual Acuity: wearing eyeglasses with grade of R eye- 200-250 Ears and Hearing Medyomahi nana din angpandinig ko as verbalized by the patient. L eye- 300 -Symmetrically aligned auricles, firm and not tender; pinna recoils after it is folded Watch Tick Test: able to hear ticking in both ears after 5 secs. Have no tenderness.
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masses. Hair evenly distributed; skin intact Equally distributed, curled slightly outward. PERRLA.

Elderly patients usually occur visual changes due to loss of elasticity and transparency of the lens. (Fundamentals of Nursing 5th Edition, Kozier and Erbs, page 490)

Color is same as the facial feature, aligned with the outer cantus of the eye, elastic and can be folded.

Elderly patients can occur mild sensorineural hearing loss. (Fundamentals of Nursing 5th Edition, Kozier and Erbs, page

494)

Nose and Sinuses

Ayosnaman ang pangamoyko as verbalized by the patient.

I: Uniform in color, symmetrical and no discharge Pink nasal mucosa P: Sinuses not tender I: Lips slightly dry, symmetrical Buccal mucosa, oropharynx and uvula are pinkish. Teeth: 3 missing teeth on upper (molar) and 5 on lower teeth (molar) Pinkish gums Tongue is in central position, can move freely No discharges

Symmetric and straight, no discharge, tenderness or lesions Uniform in color, elastic and symmetric in contour. Should be 32 teeth for adult, shiny tooth enamel, pink gums, and without lesions. Central position of the tongue, pink in color, smooth and no lesions.

NORMAL

Mouth and Oropharynx

Di pa koakonakaka pagtooth brush, dalawangara wna as verbalized by the patient.

Tooth loss can occur as a result of gum disease but is preventable if a good dental hygiene is being maintained. (Fundamentals of Nursing 5th Edition, Kozier and Erbs, page 503)

NECK Neck Muscles

Wala naming nasakitsalee gko as verbalized by the patient.

Neck muscles equal in size, no swelling Coordinated movements No palpable lymph nodes Placed in the midline of neck Ascends during

Muscles are equal in size, coordinated, smooth in movement with no discomfort. Central placement in midline of the neck, not visible

NORMAL

Lymph Nodes

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Trachea Thyroid Gland

swallowing

on inspection, lobes may not be palpated

THORAX and LUNGS Posterior Thorax

Hindi namanakona hihirapanghu minga as verbalized by the patient.

Chest symmetric, skin intact; uniform temperature Chest wall intact; no tenderness; no masses; Symmetric chest expansion and vocal fremitus Absence of adventitious sounds. Effortless respiration Full symmetric excursion

Structure is symmetric, no tenderness.

NORMAL

Anterior Thorax Breast and Axillae Walanaman gmasakitsap artengyan as verbalized by the patient.

Same as posterior vocal fremitus Rounded in shape; generally symmetric, uniform in color -minimal striae present Everted nipple, dark brown in color No tenderness, masses and nipple Rounded shape; skin uniform in color Nipple is round; everted and equal in size, similar in color No masses, nodules, NORMAL

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discharge.

tenderness, or nipple discharge.

ABDOMEN

Hindi nakatuladdat iyungsakit, ngayonnasa kitnalangdahi lsatahi as verbalized by the patient.

Minimal striae visible Flat, rounded and no evidence of enlargement Longitudinal incision site at RUQ about 3 inches long normoactive bowel sounds P- no tenderness or rebound tenderness noted

Uniform color, flat rounded; no evidence of enlargement of liver or spleen; Symmetric contour; audible bowel sounds; No tenderness

-Incision site is due to the surgical operation done to the patient called Cholecystectom y. It is the removal of gallbladder as a management of Cholecystitis. (Brunner &Suddarths MedicalSurgical Nursing; 10th ed. Vol.1, page 1177) -Can cause infection if wound dressing was not taken care properly.

GENITALS

Hair distributed in the shape of an inverse triangle some part of white hair

Pubic hair distributed in the shape of an inverse triangle,

NORMAL

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Skin of vulva slightly darker than the rest of the body No inflammation, RECTUM AND ANUS swelling, or discharge Intact perineal skin, anal sphincter has good tone.

hair growth should not extend over the abdomen

Intact perineal skin; usually slightly more pigmented than the skin of the buttocks Anal sphincter has good tone.

NORMAL

XI. ANATOMY AND PHYSIOLOGY ANATOMY AND PHYSIOLOGY

Gastrointestinal Tract The gastrointestinal tract (GIT) consists of a hollow muscular tube starting from the oral cavity, where food entersthe mouth, continuing through the pharynx, esophagus, stomach and intestines to the rectum and anus, where food isexpelled. There are various accessory organs that assist the tract by secreting enzymes to help break down food into itscomponent nutrients. Thus the salivary glands, liver, pancreas and gall bladder have important functions in the digestivesystem. Food is propelled along the length of the GIT by peristaltic movements of the muscular walls. The primarypurpose of the gastrointestinal tract is to break down food into nutrients, which can be absorbed into the body to provideenergy.
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Function of Liver The liver has many functions. Some of the functions are: to produce substances that break down fats, convert glucose to glycogen, produce urea (the main substance of urine), make certain amino acids (the building blocks of proteins), and filter harmful substances from the blood (such as alcohol), storage of vitamins and minerals (vitamins A, D, K and B12) and maintain a proper level or glucose in the blood. The liver is also responsible for producing cholesterol. It produces about 80% of the cholesterol in your body. Function of duodenum The duodenum is largely responsible for the breakdown of food in the small intestine. Brunners glands, which secrete mucus, are found in the duodenum. The duodenum is composed of a very thin layer of cells that form the muscularis mucosae. The duodenum is almost entirely retroperitoneal. The pH in the duodenum is approximately six. It also regulates the rate of emptying of the stomach via hormonal pathways. Function of Pancreas The pancreas is a small organ located near the lower part of the stomach and the beginning of the small intestine. This organ has two main functions. It functions as an exocrine organ by producing digestive enzymes, and as endocrine organ by producing hormones, with insulin being the most important hormone produced by the pancreas.
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The pancreas secretes its digestive enzymes, through a system of ducts into the digestive tract, while it secretes its variety of hormones directly into the bloodstream. Abnormal pancreatic function can lead to pancreatitis or diabetes mellitus. Function of cystic duct Bile can flow in both directions between the gallbladder and the common hepatic duct and the (common) bile duct. In this way, bile is stored in the gallbladder in between meal times and released after a fatty meal. Function of traverse colon The large intestine comes after the small intestine in the digestive tract and measures approximately 1.5 meters in length. Although there are differences in the large intestine between different organisms, the large intestine is mainly responsible for storing waste, reclaiming water, maintaining the water balance, and absorbing some vitamins, such as vitamin K. Function of gall bladder The gallbladder (or cholecyst) is a small organwhose function in the body is to harbor bileand aid in the digestive process. The function of the gallbladder is to store bile and concentrate. Bile is a digestive liquid continually secreted by the liver. The bile emulsifies fats and neutralizes acids in partly digested food. A muscular valve in the common bile opens, and the bile flows from the gallbladder into the cystic duct, along the common bile duct, and into the duodenum (part of the small intestine).

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The different layers of the gallbladder are as follows:

The gallbladder has a simple columnar epithelial lining characterized by Recessescalled Aschoff's recesses, which are pouches inside the lining. Under the epithelium there is a layer of connective tissue (lamina propria). Beneath the connective tissue is a wall of smooth muscle(muscularisexterna) that contracts in response tocholecystokinin, a peptide hormonesecreted by theduodenum. There is essentially nosubmucosaseparating the connective tissue fromserosaandadventitia.

Size and Location of the Gallbladder The gallbladder is a hollow, pear-shaped sac from 7 to 10 cm (3-4 inches) long and 3 cm broad at its widest point. It consists of a fundus, body and neck. It can hold 30 to 50 ml of bile. It lies on the undersurface of the livers right lobe and is attached there by areolar connective tissue.

Structure of the Gallbladder Serous, muscular, and mucous layers compose the wall of the gallbladder. The mucosal lining is arranged in folds called rugae, similar in structure to those of the stomach. Causes of Cholelithiasis Cholelithiasis is the presence of stones in the gallbladder. From the Greek roots chole means bile and lithos means stone. Different kinds of stones have different causes and different risk factors. Cholesterol stones are believed to be more common among Fat and FertileFemales of Forty years and above.

Obesity is a major risk factor. Obese people produce and secrete higher amounts of cholesterol. This increases the risk for development of cholesterol stones. Women who have experienced multiple pregnancies are more prone to gallstones because of the high levels of the hormone progesterone during pregnancy. This hormone reduces the contractility of the gallbladder and leads to retention of bile. Prolonged retention can lead to cholesterol stones.

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Birth control pills and hormone replacement therapy: The hormonal changes with these drugs mimic pregnancy and therefore increase the risk of gallstones. Females, especially in the reproductive age, are more likely to develop cholesterol stones than males. The female-to-male ratio is 4:1 this is due to the female hormone estrogen that increases cholesterol secretion. However, with age this difference between the two sexs decreases. Gallstones continue to form throughout life and the prevalence is greatest in the elderly age group. Predisposition to cholesterol stones is hereditary in 25% of cases. There are many different genes that contribute to this risk. Diet rich in refined carbohydrates and saturated fats is associated with a higher risk for gallstones.

Black pigment gallstones are seen more often in individuals whose hemoglobin breaks down rapidly leading to increased production of the bile pigment bilirubin. This includes those with following:

Bleeding disorders such as sickle cell anemia, hereditary spherocytosis and beta thalassemia. Liver cirrhosis

Brown pigment stones are formed when cholesterol stones are colonized with bacteria. Enzymes from these bacteria react with bilirubin conjugates and fatty acids. Over time, calcium salts may accumulate on these cholesterol stones to produce mixed stones. Both men and women are equally at risk of developing pigment stones. Complications of Cholelithiasis Inflammation of the gallbladder. A gallstone that becomes lodged in the neck of the gallbladder can cause inflammation of the gallbladder (cholecystitis). Cholecystitis can cause severe pain and fever. Blockage of the common bile duct. Gallstones can block the tubes (ducts) through which bile flows from your gallbladder or liver to your small intestine. Jaundice and bile duct infection can result. Blockage of the pancreatic duct. The pancreatic duct is a tube that runs from the pancreas to the common bile duct. Pancreatic juices, which aid in digestion, flow through the pancreatic duct. A gallstone can cause a blockage in the pancreatic duct,

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which can lead to inflammation of the pancreas (pancreatitis). Pancreatitis causes intense, constant abdominal pain and usually requires hospitalization. Gallbladder cancer. People with a history of gallstones have an increased risk of gallbladder cancer. But gallbladder cancer is very rare, so even though the risk of cancer is elevated, the likelihood of gallbladder cancer is still very small.

XII.PATHOPHYSIOLOGY PATHO-PHYSIOLOGY OF CHOLECYSTOLITHIASIS

Modifiable Factors Age (61 y/o) Food rich in CHO and Fat (habit of eating gata viands) Multiple pregnancies (5 children) Non-modifiable factors Hormonal Factors Estrogen Female Production

Decreased Contractility Delayed Emptying Bile Stasis Viscosity of the bile

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Bile acid synthesis

cholesterol synthesis on the liver

Supersaturated bile Precipitation of bile Releasing of protein which lately crystalize Stone formation
Prevention of Bile from entering SI

Pus Accumulation Pressure on liver cells

Bile salts and Pigments enter blood stream Duct Fever 37.7C

Acute abdominal Obstruction on Common Hepatic Bile N&V, Duct chills pain, related to fever, / Cystic Duct jaundice, low grade fever Blocks Digestive enzymes
Inflammation / spasm of Biliary

Circulation of Bile pigment

Pressure on Auto digestion organ

Circulation of bile through blood Jaundice (yellow schlera) and Pruritus (itching of skin on RUQ)

Pancreatitis / Cholecystitis Abdominal pain (RUQ)

XIII. MEDICAL MANAGEMENT

A. Laboratory Test

Name: E.Q. Age/sex: 61/F Birthdate: 24-Aug-51

Hospital no.: 333231 Date of test: Dec. 5, 2012 Physician: CALMA

HEMATOLOGY

Lab Test

Indications

Normal Findings

Actual Finding s

Clinical Significance

Nursing Responsibilities

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ERYTHROCYTES HEMOGLOBIN HEMATOCRIT LEUKOCYTE NEUTROPHILS EOSINOPHILS (P) BASOPHILS (P) LYMPHOCYTES(P) MCH MCV MCHC RDW MPV Platelets

This test is used to evaluate anemia, leukemia, reaction to inflammation and infections, peripheral blood cellular characters, State of hydration and dehydration, Polycythemia, Hemolytic disease of the newborn, to manage chemotherapy decisions.

M: 4.6 6.2 F: 4.2 - 5.4 M: 140 180 F: 120 140 M: 42.0 52.0 F: 37.0 47.0 50.0 70.0 1.0 4.0 0.0 1.0 25.0 40.0 27.0 31.0 M: 80 94; F: 81 99 33.0 37.0 11.5 14.5 7.2 11.1 150 - 450

4. 82 144.0 42.9

The result of the test shows that the client has low eosinophils (eosinopenia), high neutrophils (neutrophilia) and

Pretest: -Check for doctors order. -Identify the patient using at least two unique identifiers before providing care, treatment, or services. -Inform the patient this test can assist in evaluating the amount of hemoglobin in the blood to assist in diagnosis and monitor therapy. Intratest: - Instruct the patient to
cooperate fully and to follow directions. Direct the patient to breathe normally and to avoid unnecessary movement. -Remove the needle and

74.2 0.1 0.1 15.0 31.5 87.7 35.9 12.8 10.2 177 %

high MCH or Mean corpuscular hemoglobin. Neutrophils increased with acute infections, trauma or surgery, leukemia, malignant disease, necrosis.

apply direct pressure with dry gauze to stop bleeding. -Observe/assess venipuncture site for bleeding or hematoma formation and secure gauze with adhesive bandage. -Promptly transport the specimen to the laboratory for processing and analysis. PostTest: -A report of the results will be sent to the requesting physician, who will discuss the results with the patient. -Depending on the results of this procedure, additional testing may be performed to evaluate or monitor progression of the disease process and determine the need for a change in therapy. Evaluate test results in relation to the patient's symptoms and other tests performed.

Eosinophils decreased with stress, use of some medications.

Increased in macrolytic anemias, decreased in microcytic anemia.

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Name: E.Q. Age/sex: 61/F Birthdate: 24-Aug-51

Hospital no.: 333231 Date of test: Nov. 30, 2012 Physician: CALMA

ULTRASOUND
Findings: Liver is not enlarged with increased parenchymal echogenicity Intrahepatic ducts are not dilated No focal masses or calcifications seen Gallbladder is normal in size with at least two reflective echoes measuring about seventeen and fourteen mm Gallbladder wall is thin Common bile duct is not dilated Pancreas and spleen are homogeneous and not enlargedthere are no focal masses seen Both kidneys are normal in size with homogenous echo pattern Right kidney measures 99 x 42 mm while the left kidney measures 111 x 49 mm Central echo complexes of both kidneys are intact No renal stones or masses seen corticom edullary borders are distinct the urinary bladder is moderately distended with no intra luminal echoes seen the bladder wall is smooth the abdominal aorta measures 40 mm in its widest diameter with no abnormal dilatation 100% - there are no enlarged para-aortic nodes seen there are no masses or free fluid

IMPRESSION:

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UNREMARKABLE ULTRASOUND OF THE PANCREAS, SPLEEN, KIDNEYS, URINARY BLADDER AND ABDOMINAL AORTA CHOLELITHIASIS, AS DESCRIBED CONSIDER FATTY INFILTRATION OF THE LIVER

Name: E.Q. Age/sex: 61/F Birthdate: 24-Aug-51 CLINICAL CHEMISTRY

Hospital no.: 333231 Date of test: Dec. 7, 2012 Physician: CALMA

TEST Glucose (random) Creatinine

RESULT 3.75 53.8

REFERENCE RANGE 2.75 4.13 mmol/L M: 62-106 mmol/L F: 44-90 mmol/L

CLINICAL SIGNIFICANCE Normal Normal

SGOT (AST)

36.1

M: up to 40 u/L F: up to 39 u/L

Normal

SGPT (ALT)

44.7

M: 0.17-0.68 mckat/L F: 7-35 U/L or 0.120.60 mckat/L

High levels of ALT may be caused by: Liver damage from conditions such as hepatitis or cirrhosis. Lead poisoning.

Exposure to carbon tetrachloride. Decay of a large tumor (necrosis).

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 Many medicines, such as statins, antibiotics, chemotherapy, aspirin, narcotics, and barbiturates.
Mononucleosis.

Growth spurts, especially in young children. Rapid growth can cause mildly elevated levels of ALT. Sodium Potassium 136.2 3.21 75 -200 mmol/L 3.6-5.5 mmol/L Normal Diarrhea, Adrenocortical insufficiency

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B. DRUG STUDIES

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Name of drug Generic: kalium durule Brand name: Potassium Chloride Form: tablet Route: oral Dose: 4doses up to AM Frequency: TID Classification :
Electrolyte

Indications Prevention and correction of potassium deficiency; when associated with alkalosis, use potassium chloride; when associated with acidosis, use potassium acetate, bicarbonate , citrate, or gluconate

Action Principal intracellular cation of most body tissues, participates in a number of physiologic processes maintaining intracellular tonicity, transmission of nerve impulses, contraction of cardiac, skeletal, and smooth muscle, maintenance of normal renal function; also plays a role in carbohydrate metabolism and various enzymatic reactions.

Contraindicati on Contraindicated with allergy to tartrazine, aspirin (tartrazine is found in some preparations marketed as Kaon-Cl, KlorCon); severe renal impairment with oliguria, anuria, azotemia; untreated Addisons disease; hyperkalemia; adynamia episodica hereditaria; acute dehydration; heat cramps; GI disorders that delay passage in the GI tract. Use cautiously with cardiac disorders, especially if treated with digitalis

Side effects Arrythmias -heart block hypotension -cardiac arrest - respiratory paralysis, -nausea and vomiting -abdominal pain

Adverse effects -Rash -GI obstruction -GI bleeding -GI ulceration or perforation Hyperkalemia -ECG changes (peaking of T waves, loss of P waves, depression of ST segment, prolongation of QTc interval) -Tissue sloughing -local necrosis -local phlebitis -venospasm with injection

Nursing Management PRE: Verify doctors order Watch out for levels of potassium electrolyte level to prevent hyperkalemia. Observe 10 rights of giving medication. Watch out for possible adverse reaction of the patient INTRA: Arrange for serial serum potassium levels before and during therapy. Administer oral drug after meals or with food and a full glass of water to decrease GI upset. Dissolve effervescent tablets completely in 38 oz of cold water, juice, or other suitable beverage, and have patient drink it slowly. Caution patient not to chew or crush tablets; have patient swallow tablet whole. POST: Teach patient that they may find wax matrix capsules in the stool. The wax matrix is not absorbed in the GI tract.

Have periodic blood tests and medical evaluation. Watch out for these side effects: Nausea, vomiting, diarrhea (taking the drugs with meals, diluting them further may help).

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Name of drug Generic: Metoclopramide Brand name: reglan Form: liquid Route: IV Dose: 10mg Frequency: single dose PTOR Classification:GI
stimulant, Antiemetic, Dopaminergic blocker

Indications Prophylaxis of postoperati ve nausea and vomiting when nasogastric suction is undesirable

Action Stimulates motility of upper GI tract with out stimulating gastric, biliary, or pancreat ic secretions ;

Contraindica tion Contraindicate d with allergy to metoclopramide GI hemorrhage Mechanical obstruction or perforation Epilepsy

Side effects restlessness -drowsiness fatigue -insomnia -dizziness -anxiety -transient hypertension -nausea and diarrhea

Adverse effects

Nursing Management

-extra pyramidal PRE: reactions Check the doctor's order -Neuroleptic Check the expiration date of malignant the drug syndrome Assess the client's -anxiety understanding about the -depression drug -irritability Observe 10 rights in drug -tardive administration. dyskinesia. Assess for allergy to -arrhythmias metoclopramide. (supraventricular Assess for other tachycardia, brad contraindications. ycardia) Keep diphenhydramine -hypertension injection readily available in -hypotension case extra pyramidal -constipation reactions occur (50 mg IM). -dry mouth, Have phentolamine readily - gynecomastia. available in case of methemoglo hypertensive crisis. binemia INTRA: -neutropenia Monitor BP carefully during -leucopenia IV administration. -agranulocytosis Monitor for extra pyramidal reactions, and consult physician if they occur. Give direct IV doses slowly over 1-2minutes. For IV infusion, give over at least 15minutes. POST: Dispose of used materials properly. Educate patient about side effects. Instruct to report involuntary movement of the face, eyes, or limbs, severe depression, and severe diarrhea.

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Name of drug Generic: omeprazole Brand name: Form: tablet Route: oral Dose: 10mg Frequency: OD

Indications treatment of active duodenal ulcer, gastroesop hageal reflux disease (GERD), including erosive esophagitis and symptomati c GERD

Action Hough to be a gastric pump inhibitor and that it blocks the final step of acid production . By inhibiting the Hydrogen/ Potassium ATP-ase system at the secretory surface of the gastric parietal cell..

Contraindi cation Contraindicate d with hypersensitivit y to omeprazole or its components

Side effects Depres sion -agitation -aggres sion hallucina tions -confu sion

Adverse effects

Nursing Management

-headache PRE: - dizziness Check the doctor's order - asthenia Check the expiration date of the -vertigo drug - insomnia Assess the client's understanding -apathy about the drug -anxiety -paresthesias, INTRA: -dream The capsule should be taken 30 abnormalities minutes before eating and is to be rash, swallowed whole. inflammation, Antacid can be administered with urticaria, pruritu Omeprazole. s,alopecia, Monitor vital signs dryskin diarrhea, POST: abdominal pain, Monitor for adverse effect. nausea, vomiting, Report to the physician if chest constipation, pain, abdominal pain and fecal dry mouth discoloration occurred ,tongue atrophy Report severe headache, ,URI symptoms, worsening of symptoms, fever, cough, epistaxis chills.

Name of drug Generic: metronidazole

Indications

Action Disrupts DNA and protein synthesis in suscepti ble organisms

Contraindicat ion Contraindicated in patients hyper sensitive to drug or other nitroimidazole derivatives -Use cautiously

Side effects -stomach -pain -diarrhea -dizziness -loss of balance -vaginal itching or

Adverse effects -Seizures -dizziness -headache -Tearing (topicalonly) -abdominal pain, -anorexia,

Nursing Management PRE: Check the doctor's order Check the expiration date of the drug assess patients and familys knowledge of drug therapy assess patient infection watch carefully for edema because

Acute infection with Brand name: susceptible flagyl 46 | P a g e anaerobic bacteria Form: liquid

Name of drug

Indications Treatment and prevention of heartburn, acid indigestion, and sour stomach.

Action Inhibits the action of histamine at the H2 receptor site located primarily in gastric parietal cells, resulting in inhibition of gastric acid secretion. In addition, ranitidine bismuth citrate has some antibacterial action against H. pylori.

Contraindica tion Contraindicat ed in patient hypersensitivi ty, Crosssensitivity may occur; some oral liquids contain alcohol and should be avoided in patients with known intolerance. Use Cautiously in patient with Renal impairment, geriatric patients

Side effects
-headache consti pation -diarrhea -upset stomach -dizziness -difficulty -sleeping -blurred vision

Adverse effects -Confusion -dizziness -drowsiness -hallucination s -headache -Arrhythmias -Altered taste -black tongue -constipation -dark stools -diarrhea -drug-induced hepatitis -nausea -Decreased sperm count impotence -Gyneco mastia -Agranulo cytosis -Aplastic Anemia -neutropenia -thrombo cytopenia

Nursing Management PRE: Check the doctor's order Check the expiration date of the drug Assess the client's understanding about the drug Assess patient for epigastric or abdominal pain and frank or occult blood in the stool, emesis, or gastric aspirate. INTRA: Administer drug through IV
Inform patient that it may cause

Generic: Ranitidine Brand name: Zantac Form: liquid Route: Intravenous Dose: 50mg Frequency: q8
CLASSIFICATION

drowsiness or dizziness.
Inform patient that increased

Therapeutic: Anti-ulcer agents Pharmacologic: Histamine H2 antagonists

fluid and fiber intake may minimize constipation.

Inform patient that medication may temporarily cause stools and tongue to appear gray black. POST black, tarry stools; fever, sore throat; diarrhea; dizziness; rash; confusion; or

Advise patient to report onset of

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hallucinations to health care professional promptly.

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Name of drug

Indications Short term manageme nt of pain in the surgical site (up to 5days)

Action

Contraindic ation

Side effects

Adverse effects

Nursing Management PRE: Check the doctor's order Check the expiration date of the drug Assess the client's understanding about the drug Assess pain (note type, location, and intensity) prior to and1-2 hr following administration Check sensitivity,ANST(-) INTRA: Administer drug through IV route. Monitor vital signs Caution patient to avoid concurrent use of alcohol, aspirin, NSAIDs, acetaminophen, or other OTC medications without consulting health care professional. Watch out for bleeding POST: Advise patient to report if rash, itching, visual disturbances, tinnitus, weight gain, edema, black stools, persistent headache, orinfluenza-like syndromes (chills,fever, muscles aches and pain) occur

Generic: ketorolac Brand name: Toradol Form: liquid Route: Intravenous Dose: 30mg Frequency: q8
CLASSIFICATION

-Headache AntiContraindica -dizziness inflammatory ted with -somnolenc and analgesic significant -insomnia activity; renal inhibits prosta impairment, , -fatigue -tinnitus glandins and aspirin -ophthal leukotriene allergy, synthesis recent mologic GI bleed effects or perforatio -constipa n.Use tioh cautiously with impaired -heartburn hearing; allergies; hepatic conditions

Analgesic, antipyretic, antiinflammatory

-drowsiness -abnormal thinking -euphoria -asthma -dyspnea -edema -pallor -vasodilation -GI Bleeding -abnormal taste -diarrhea -dry mouth -dyspepsia -GI pain -nausea - oliguria -renal toxicity -pruritis -purpura -sweating -urticaria -prolonged bleeding time -injection site paresthesia allergic reaction, anaphylaxis

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Name of drug Generic: cefuroxime Brand name: Yurocef Form: powder. Route: Intravenous Dose: 750 mg Frequency: q8 Classification: anti-infective

Indications Used in the treatment of susceptible surgical infections, and urinary tract infections.

Action - antiinfectivea 2nd generation cephalospo rin that inhibits cell-wall synthesis, promoting osmotic instability; usually bactericidal .

Contraindicati on contraindicated in patients with renal impairment, , elderly and in rare cases it causes hypersensitive ty.

Side effects -nausea -vomiting -diarrhea -stomach pain -headache -dizziness -fussiness

Adverse effects

Nursing Ma

-Diarrhea PRE: -Decreased Check -Hgb/Hct Check -Eosinophilia of the Nausea/vomiting Asses Vaginitis under -Transient rise in drug hepatic Asses transaminases Thrombophlebitis INTRA: -Transient Inspe neutropenia & injecti leucopenia for sig -Increase in BUN Monit & creatinine manif -Rash hyper Recon with 8 Slowl over 3

POST: Evalu adver Repo persis signs Anem C. MEDICAL MANAGEMENT

Procedures Oxygen via Nasal Cannula regulated @ 2-3 L/min

Indication Oxygen therapy is the administration of oxygen at a concentration greater than that found in the environmental atmosphere. The goal of this is to provide adequate transport of oxygen in the blood while decreasing the work breathing

Nursing Responsibilities Pre: Determine the need for oxygen therapy by verifying the doctors order. Ensure precautions ad safety measures to be used when

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and reducing stress on the myocardium. Uses to relief hypoxemia and prevention of damage to the tissue cells as a result of oxygen lack.

oxygen is in use. Intra: Monitor and maintain the prescribed flow rate. Post: Assess the patients tolerance to breath effectively without support or oxygen.

Jackson Pratt

a medical device that is commonly used as a postoperative drain for collecting bodily fluids from surgical sites. The device consists of an internal drain connected to a grenade-shaped bulb via plastic tubing. The flexible bulb has a plug that can be opened to pour off collected fluid. Each time fluid is removed, the patient, caregiver or healthcare provider squeezes the air out of the bulb and replaces the plug. The resulting vacuum creates suction in the drainage tubing, which draws fluid from the surgical site.

Pre: The drainage tube must be connected immediate to a drainage receptacle. Intra: Measure how much fluid you collected. Write the amount of drainage, and the date and time you collected it, Watch the skin around the drain for these signs of infection: increased redness increased pain increased swelling Other signs of infection: fe ver greater than 101 F cl oudy yellow, tan, or foulsmelling drainage Post Check for incision site. Observe for signs of bleeding and infection. Keep incision dry and intact.

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 Practice proper wound dressing to prevent cross contamination.

D. SURGICAL MANAGEMENT

Procedures Cholecystectomy

Indication For acute and chronic cholecystitis. It is a common treatment of symptomatic gallstones and other gallbladder conditions. Performed when patients condition precludes more

Nursing Responsibilities Pre: Monitor vital signs. Reviews previous obtained laboratory result to obtain information about the patients nutritional status. Intra:

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extensive surgery or when an acute inflammatory reaction is severe.

Check for vital signs and assess skin for paleness. Post: Monitor vital signs and inspect the surgical incision site and any drains for bleeding. Instruct patient and family to report any change in the color of the stools, because this may indicate complications.

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XIV. NURSING MANAGEMENT

a. Problem List

Actual Nursing Problems

1. Deficient Knowledge 2. Fear 3. Acute Pain 4. Impaired Tissue Integrity 5. Impaired Physical Mobility 6. Activity Intolerance

Potential Nursing Problems

1. Risk For Aspiration 2. Risk For Aspiratio

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b. Nursing Care plan Table 1: Deficient Knowledge

Assessment Subjective: Paano ba ang gagawin sa akin sa operating room? Diagnosis Deficient knowledge related to unfamiliarity with information resources as manifested by verbalization of request for information Background Knowledge Cholecystecto my is the surgical removal of the gallbladder, which is located in the abdomen. Gallbladder problems are usually the result of gallstones that can block the gallbladder causing the organ to swell Planning Goal: After the shift, the client will be knowledgeable about the upcoming procedure Implementatio n Assess clients level of knowledge Provide information relevant only to the situation Provide positive reinforcement Use short, simple sentences and concepts. Repeat and summarized as needed. Discuss one topic at a time; avoid giving too much information Rationale To determine factors pertinent to the learning process To prevent overload Can encourage continuation of efforts To facilitate learning Evaluation After nursing intervention, the goal was met as evidenced by understanding of the patient about her condition and upcoming operation

Objective: Anxiety noted Restless ness observed

Planning: After nursing intervention the client will be able to:

Participate in learning process Exhibit

Can arouse interest or limit

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increased interest and assume responsibility for own learning by beginning to look for information and asks questions Verbalized understanding of condition, disease process and treatment

Begin with information the client already knows and move to what the client does not know, progressing from simple to complex Deal with the clients anxiety or other strong emotions Provide for feedback or positive reinforcement and evaluation of learning and acquisition

sense of being overwhelmed

It may interfere with the clients ability to learn

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Table 2: Fear
Assessment Subjective: Hindi ba delikado ang gagawin sa aking operasyon?, as verbalized by the patient Diagnosis Fear related to surgical procedure as manifested by non verbal evidenced of fear such as worry and tense Background knowledge Undergoing cholecystect omy, patient may perceive threat like the outcome of the surgery that is consciously recognized by the patient as danger Planning After 8 hours of nursing intervention, the client will be able to: Implementation Monitor vital signs Ascertain clients perception of what is occurring and how this affects life Discuss clients perceptions and fearful feelings Rationale This can be altered when fear is present Fear is a defensive mechanism in protecting oneself but, if left unchecked, can become disabling to the clients life Promotes atmosphere of caring and permits explanation or correction of misperceptions Facilitates understanding of the situation Enhances sense of trust To prevent confusion of Evaluation After nursing intervention, the goal was met as evidenced by patients fear was lessened and more relaxed behavior

Objective: Apprehens ion Tense observed Increase tension Worry restlessne ss

1) Acknowle dge and discuss fears, recognizing healthy versus unhealthy fears 2) Demonstr ate through use of effective coping behaviors 3) Lessened fear

Provide appropriate information about the procedure Provide opportunity to questions and answer honestly Explain

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procedure within level of clients ability of understanding

information overload To promote relaxation

Instruct deep breathing exercises

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Table 3: Acute Pain

Assessment Subjective: Masakit ang inoperahan sa akin, as verbalized by the patient Diagnosis Acute pain related to post surgical incision as manifested by verbalization of feelings and observed evidence of pain Background knowledge In performing cholecystecto my, surgical incision is done. By which, the incision causes direct irritation to the nerve endings by chemical mediators released at the site such as bradykinin. The irritation will send signal to the cortex and thalamus of the brain, thus producing pain perception Planning After nursing 8 hours of nursing intervention, the client will be able to: Implementatio n Assess clients assessment of pain Use pain rating scale Observe non verbal cues of pain Rationale To have baseline data To measure the quantity of pain Observations may not be congruent with verbal reports o may be only indicator present when client is unable to verbalize To promote non pharmacological pain management To distract attention and reduce tension Evaluation After nursing intervention, the goal was met as evidenced by

Objective: 9 out of 10 level of pain Facial grimace noted Guardi ng behavior observed With protective gestures

1) Report pain is relieved or controlled 2) Verbalized non pharmacological methods that provide relief 3) Demonstra te use of relaxation skills and diversional activities, as indicated, for individual situation

1) Pain scale of 7 from 9 2) Verbalizatio n of nonpharmacologic al methods 3) Demostratio n of relaxation techniques such as chatting to others

Provide comfort measures and calm activities Instruct in and encourage relaxation

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techniques, such as watching TV or listening to music Identify ways of avoiding or minimizing pain such as splinting incision Encourage adequate rest periods Identify specific signs/symptoms and changes in pain characteristic requiring immediate attention

To prevent fatigue

Table 4: Impaired Tissue Integrity

Assessment Diagnosis Backgroun d Knowledg Planning Implementatio n Rationale Evaluation

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e Objective: Incision at right upper quadrant of the abdomen With Jackson Pratt Impaired tissue integrity related to incision secondary to surgical procedure Cholecyste ctomy is the surgical removal of the gallbladder, which is located in the abdomen. Gallbladder problems are usually the result of gallstones that can block the gallbladder causing the organ to swell After the shift, the client will be: Assess clients condition Note poor hygiene or health practices Determine nutritional status Change dressing as often as needed Check the incision daily to inspect for signs of infection, complications and healing Instruct the patient to practice aseptic technique, for cleansing, dressing, or medicating lesions. Promote early mobility Monitor laboratory studies Emphasize for need of 62 | P a g e To have baseline data It may interfere with the healing After all the nursing intervention, the goal was met as evidenced by the following: Understanding about her conditions Knowledgeable on ways to promote healing And prevent complications

Verbalize understanding of condition and causative factors Demonst rate behaviors and lifestyle changes to promote healing and prevent complications or recurrence

To avoid crosscontamination Promotes timely intervention and revision of plan care

Reduce risk for crosscontamination

To promote circulation

adequate nutrition and fluid intake

Detection for presence of infection and contamination To optimized tissue healing

Table 5: Impaired Physical Mobility

Assessment Subjective: Hindi pa ako masyadong nagkikilos, kasi sumasakit ang sugat ko. At baka bumuka pag pinuwersa ko ang sarili ko, as verbalized by the patient Diagnosis Impaired physical mobility related to pain as manifested by pain verbalizatio n and weakness Background knowledge Presence of surgical incision procedures the patient to be reluctant in doing movements such as ROM, because they may induce pain sensation Planning After 3 hours of nursing intervention, the client will be able to: Verbalize understanding of situation and individual treatment regimen and safety measures Participat e in ADLs and desired Implementatio n Assess patients over all condition Determine situations that contributes immobility Assess degree of pain Assess nutritional status Instruct in use of side rails and other safety aids Assist wit treatment of Rationale To have baseline data Evaluation After nursing intervention, the goal was met as evidenced by the verbalization of understanding of safety measures and participation in ADLs with evidenced of well being.

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 Pain upon assessment Weakness observed Pallor noted Slowed movement Postural instability Uncoordinat ed movements

activities

underlying condition causing pain Instruct to have adequate rest periods Encourage participation in self care, diversional Encourage adequate intake of fluids and nutritious foods

To ensure safety

To reduce fatigue Enhances self concept and sense of independence Promotes well being and maximizes energy production

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Table 6: Activity Intolerance

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Assessment Subjective: Nanghihina pa din ako at hindi pa ako masyadong nagalaw kasi masakit pa din ang sugat ko, as verbalized by the patient

Diagnosis Activity intolerance related to pain as manifested by the patients verbalization of weakness and pain

Background knowledge Post-operative patient usually is under bed rest for few days that may hinder them to their usual activity. Presence of surgical incision procedures causes the patient to be reluctant in doing personal activities, because this may result in the stimulation of nerve endings, thus, increase pain reception

Planning After 8 hours of nursing intervention, the client will be able to:

Implementatio n Assess patients condition Note presence of factors contributing activity intolerance Note treatmentrelated factors, such as side effects and interactions of medications Increase activity gradually Assist client with activities

Rationale To have baseline data

Evaluation After nursing intervention, the goal was met as evidenced by ttentive participation of the patient of planned activities

Objective: Pallor noted Pain upon assessment(fa cial grimace, guarding behavior) Weaknes s observed Fatigue noted

1) Use identified technique to enhance activity tolerance 2) Participa te willingly in necessary/desi red activities 3) Report measurable increase in activity

To conserve energy To protect client from energy

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Promote comfort measures and provide for relief of pain Encourage client to maintain positive attitude Encourage to eat nutritious foods

To enhance ability to participate in activities

Table 7: Risk for Aspiration

Assessment Objective: Reduced level of consciousness Impaired swallowing Evidence d of excess secretions on the mouth while in sedation Loud snoring(noisy respiration) Diagnosis Risk for aspiration related to induction of general anesthesia as manifested by reduced level of consciousness and presence of secretions Background knowledge Prior to any surgical procedure, general anesthesia is induced. It relaxes the muscles of the body and depresses the sensation of pain, thus the gag and swallowing reflexes is temporarily suppressed and may lead to aspiration Planning After 4 hours of nursing intervention, the client will be able to: The patient will be maintained in safe and homeostasis condition Implementati on Assess patients condition Monitor vital signs Note patients level of consciousness and awareness of surrounding Rationale For baseline data As impairment in these areas increase patients risk for aspiration To mobilized thickened secretions that may interfere with swallowing To clear secretions in the airway Evaluation After 4 hours of nursing intervention, the goal was met as the patient was maintained in safe and homeostasis condition as evidenced by: Noiseless respiration Decrease secretions on airways

Assist with postural drainage Assist with assistive breathing

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devices (oxygen cannula) Instruct the patient to cough Watch out for increase secretions and difficulty of breathing

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Table 8: Risk for Infection

Assessment Objective: Inadequat e secondary defenses Post surgical incision Diagnosis Risk for infection related to inadequate secondary defenses as manifested by surgical incision Background Knowledge The patient is at risk of acquiring infection due to the break in the continuity of the first line defense which is the skin. The patient shall have undergone cholecystect omy, thus there is an incision and suture made in the Planning Short term goal: Implementati on Assess clients condition Stress proper hand hygiene Change surgical or other wound dressings, as indicated, using proper technique for changing/dispo sing of contaminated materials Keep side rails up Assist in ADLs Emphasiz e for proper Rationale To have baseline data A first-line defense against health-care associated infections To limit crosscontamination Evaluation After nursing intervention the goal was met as evidenced by the patient knowledgeable about preventing the spread of infection

After nursing intervention, the client will be knowledgeabl e in reducing or preventing infection

To avoid injury

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abdomen. If there is a breakage in the skin, the pathogens will easily invade the bodys immune system, thus increasing risk for infection.

hygiene of the wound

To prevent spread of infection

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C. Ongoing Appraisal

PROGRESS NOTES December 7, 2012 2:00 pm to 10:00 pm Received patient lying on bed, conscious and cooperative. Initial vital signs are as follows: T:___C, PR:___ bpm, RR: ___ cpm and BP:___ mmHg with IV fluid on metacarpal vein D5LR 1L x 8 hrs in 30-31 gtts/min. The client was on DAT (diet as tolerated). On the first contact with the patient, we established rapport to promote trust and good communication with the patient. The patient was cooperative during the assessment. We easily gathered information concerning to her condition. Nursing interventions were rendered such as monitoring vital signs positioning and health teachings. Patient shows willingness to learn by asking questions regarding the operation performed and her condition. December 8, 2012 10 2:00 pm to 10:00 pm On our second interaction, good nurse patient relationship was rendered within the ward. We had follow-up interview to the patient regarding the post-op and other information related to the patient. The patient was more vocal and shares her experiences after the surgery. We observed that during the interview, the patient shows positive outlook after the surgery. She was able to answer the questions. Our last day of meeting with the patient. We visited the patient for evaluations. The patient was still in recovery. We ask some questions and she was able to answer those. Patient showed positive behaviour and cooperation for the improvement of her condition.

DECEMBER 10, 2012

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Summary of Client health status as Last Day of Contact

On our last day of meeting, the patient was conscious and well cooperative. We visited the patient for evaluations. The patient was still in recovery. We ask some questions and she was able to answer those. We had also added health teachings to improve her status. Patient showed positive behavior and cooperation for the

improvement of her condition.

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XV. BIBLIOGRAPHY

2002, Kozier, Erbs, Blais and Wilkinson; Fundamentals of Nursing ; 5 th Edition, pp. 478, 490, 494, 503, Brunner &Suddarths Medical- Surgical Nursing; 10 th Edition, Vol.1, page 1177)

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