Professional Documents
Culture Documents
College of Nursing
Bachelor of Science in Nursing
Submitted to:
Theresa Kintanar, R.N.
Ella Mae Navarro, R.N.
Clinical Instructors
Submitted by:
Lim, Stephanie Marie
Madrazo, Benedict Edmund
Mangitngit, Jeferson
Margaja, Dominique Dawn
Maulion, John Charls
Mendoza, Kathreen Glaiza
Nalzaro, Sheena Ann
Olalo, Angeli
Omandac, Alyssa
I. INTRODUCTION...............................................................................................
II. OBJECTIVES......................................................................................................
X. PATHOPHYSIOLOGY ......................................................................................
XVI. PROGNOSIS.......................................................................................................
more often in women than men. Gallstones are formed within the gallbladder and can
range in size from as small as a particle to golf-ball size, depending on how long they
is approximately $5 billion in the United States, where 75-80% of gallstones are of the
cholesterol type, and approximately 10-25% of gallstones are bilirubinate of either black
or brown pigment. In Asia, pigmented stones predominate, although recent studies have
Gallstones are rock-like accumulations of material that take shape inside the
gallbladder. There are different types of gallstones, but cholesterol stones are the most
common. The gallbladder stores bile in the liver. The bile is composed of bile salts, bile
Cholesterol stones can be green, white or yellow in color and are made primarily
of cholesterol while pigment stones are somewhat dark and made of bilirubin and
calcium salts in bile. Much has been learned about how gallstones are formed and experts
believe that gallstones may be caused by a number of factors such as inherited genetic
emptying the gallbladder enough may allow the bile to become compacted and form
stones. Increased levels of estrogen could raise cholesterol levels in bile, promoting the
formation of gallstones.
Persons with high cholesterol levels are more prone to develop Cholelithiasis.
Diets high in fats contribute to the formation of gall stones and over time the stones can
Our patient, given the code name: Mr. R, is a hardworking supervisor for a certain
mining industry. He was admitted in DMSFH to undergo a surgery that will remove his
able to choose Mr. R as our case, with the help of our clinical instructor. Mr. R’s disease
is in line with our concept which is Nephrology and he was able to give us his approval
Throughout this Case Presentation, numerous data about Mr. R’s disease will be
Many people have been kind and helpful to us in finishing this case study. We
First, we would like to thank the Almighty God for giving us guidance, strength
Second, we would like to thank each and everyone’s parents for their support
Third, we would like to thank our dearest clinical instructor, Ms. Theresa
Kintanar, for guiding us in choosing the appropriate family for our case study and for
Fourth, we would like to thank our group mates for their cooperation and
Fifth, we would like to thank all the personnel and staff members of St. Joseph
ward, Davao Medical School Foundation Hospital for their accommodation and
Lastly, we would like to extend our heartfelt gratitude to Mr. R. and his family for
To conduct a thorough and comprehensive study about Mr. R’s disease according
to the data that was gathered by conducting a series of interviews and extensive research.
Specific Objectives:
information
• To analyze the family health history as well as the history of past and present
illness for the knowledge of what could be the predisposing factors that might
theories
understanding
• To describe the current condition of our patient through the Physical assessment
• To explain the anatomy and physiology of different organs involved and affected
during cholelithiasis
• To list several factors, signs and symptoms of cholelithiasis that are present or
• To list the different orders of the physicians assigned to our patient together with
• To interpret the different results of our patient’s diagnostic exams together with
comparisons of normal values for the understanding of what changes during the
disease
• To classify the different drugs used by our patient so that we can identify its
• To analyze the different nursing theories that can be applied to our patient
• To gather all the references used upon making this case study
P ATIENT’S D ATA
Nationality: Filipino
Sex: Male
Time: 2:00 pm
H EALTH H ISTORY
residing at B-12 L12 P1 San Mateo Laverna Buhangin, Davao City. They are 7 in the
family including his parents. He is the third child among the five children. Our patient
Upon interview, Mr. R said that they had a family history of the same type of
disease, which is the Diabetes Mellitus. He mentioned that within the family, they had 2
cases from his mother’s side and on his father side of the family. His aunt from his
LIFESTYLE: ACTIVITIES
Mr. R described how his workplace is similar to his home in terms of stress. He
verbalized that there are times when he is stressed and there are others when he the
When asked about how he usually spends his days, Mr. R was able to formulate a
schedule that would describe his activities of daily living. He would wake up at 6:00am.
The first thing he would do is take a bath. Right after taking a bath, he takes his breakfast.
After brushing his teeth, he rides his transportation service to his office. By 8:00am, he
arrives in his office. Here, he usually does paper work, participates in interviews and
meetings, records data in his office computer and, on some occasions, perform field work
as a supervisor. After work, he has the option to either go home directly (7:00pm arrival)
or have a night out with his friends from work. There are times that he chooses to go out
and drink; the most would be two times in a week. For every time that he goes out to
drink, he would consume an average of 2 bottles. If he chooses to go out and spend the
night outside the house, he’d get home by around 12:00 midnight and onwards.
LIFESTYLE: DIET
Since his grade school years, Mr. R was fond of eating all kinds of “lechon.” He
occasionally. After he was diagnosed with Diabetes, he started eating less lechon and
more vegetables, whole grains and fish. During the interview, Mr. R was asked if he
knows any more changes in his diet. He only shrugged and said he was still unsure of
how his diet will change now that he is missing a gall bladder.
Mr. R was diagnosed of having Diabetes Mellitus type II last 1997. He was
advised by his doctor to be more particular on his diet (to eat more vegetables and fruits
and not to eat too much fatty foods) and do some exercise so that his diabetes will not get
He recalls being instructed to take buscopan and co-amoxiclav after being diagnosed.
Mr. R had also mentioned that he has a history of hypertension. This wasn’t
evident during the group’s assessment on Mr. R. However, Mr. R remembers that he had
gone to several hospitals and doesn’t remember where he was diagnosed with
hypertension. Mr. R does remember this happened in the year 1995. Since then, he had
Mr. R started experiencing a sharp RUQ pain in the year 1994. He suspected a
treatment for the pain, he frequently ate “lugaw” and he took a lot of rest. Eventually, the
pain went away but it came back three years later. In 1997, the year he was diagnosed
with Type 2 Diabetes Mellitus, he experienced the same sharp RUQ pain just like the one
in 1994. Knowing that his previous self-treatment was effective, he used it again, with an
additional advice from his doctor: drinking plenty of apple juice. Again, the pain went
away as expected. However, Mr. R did not know that his condition was actually getting
worse. Two years after the second incidence, the pain returned. Still not alarmed as he
was in the previous years, Mr. R still used his self-treatment for the pain in 1999. Mr. R
shared that after 1999, he experienced the pain every year already. He also shared that
By January 26, 2009, he experienced the worst pain of them all. He shared that his
self-treatment methods was able to ease the pain, but it surprisingly took longer than it
did before. By this time, he decided to have himself checked by a doctor. He was
Davao Medical School Foundation Hospital after being diagnosed with Calculous
Cholelithiasis.
GENOGRAM
D EVELOPMENTAL D ATA
DEVELOPMENTAL DATA
Psychosocial theorized that (45 years old and above) positively achieved
does not end with gladness, on hard times views his life as
healthier the they’ve led, will easily R did not have any
each stage enables That way, he can accept very supportive and
to have children
and family
support him no
He is also ready to
accept whatever
bring him.
Lawrence Lawrence Level III: He knows and
decision. His model the sole basis for makes sure that no
to separate, they
chose to follow
norms. Even
though it is against
society to separate,
they still
considered to
so would be the
right thing to do.
Robert Havighurst Middle Adulthood Mr. R is currently
(30-60 years)
Havighurst’s theorized that there working as a
This stage in a person’s
Developmental are six government
life is concerned with the
Milestones developmental employee. He
achievement of the
Theory stages of life, each works in DENR as
following tasks:
with essential tasks the chief mining
Fulfill civic and
Source: to be achieved. supervisor for
social
Fundamentals Mastery of a task in environmental and
of Nursing, responsibilities
3rd Edition one developmental safety division. He
By: Maintain an
Sue C. Delaune stage is essential for also votes, pays his
Patricia K. economic
Ladner mastery of tasks in taxes and abides
standard of
subsequent stages. the laws.
living
A successful
Assist
achievement of a Through his work
adolescent
task leads to as an Engineer, he
children to
happiness and to was able to earn
become
success with later enough money to
responsible,
tasks. However, send his children to
happy adults
failure leads to school. In addition,
X Relate to one’s
unhappiness in the his salary is also
partner
individual and enough to sustain
Adjust to
difficulty with later their daily needs.
physiological
tasks.
changes Mr. R is a hands on
children up to now.
According to him,
good people.
he is separated with
not communicate
anymore. However,
his children to
communicate with
their mother.
Our patient accepts
the changes
accompanied by
aging, especially
health. He accepts
his medications
religiously.
and is residing at
Bohol. According
to him, even
is in Bohol he still
continues to check
on his mother’s
condition.
Definition
and Suddarth's)
Calculous
- pertaining to calculus
(reference: Page 201, Mosby's Pocket Dictionary of Medicine, Nursing and Allied
Calculus
an abnormal stone formed in the body tissues by an accumulation of mineral salts.
(reference: Page 201, Mosby's Pocket Dictionary of Medicine, Nursing and Allied
Calculus
salts) that forms in an organ or duct of the body. Formation of calculi is known as
(reference: http://en.wikipedia.org/wiki/Calculus_(medicine)
Cholelithiasis
(reference: Page 256, Mosby's Pocket Dictionary of Medicine, Nursing and Allied
(http://wordnetweb.princeton.edu/perl/webwn?s=cholelithiasis)
P HYSICAL A SSESSMENT
Sex: Male
GENERAL SURVEY
Our patient, Mr. R was assessed on February 21, 2009 @ 6:00 am. He was
received lying on bed awake, conscious and coherent. He has an ongoing IVF of D5NSS
1 liter regulated at 140cc/° infusing well at R metacarpal vein at 300cc level. He weighs
his BMI reveals that he is overweight (25.62kg/m2) He was responsive and cooperative
VITAL SIGNS
6:00 am
BP – 120/80 mmHg
Temp. – 36.9°C
SKIN
Our patient has a tan complexion. He has a good skin turgor as skin goes back to
its previous state after being pinched and with a capillary refill of 2 seconds. He has dry
skin with a rough texture. Nails were properly trimmed and no traces of dirt were noted.
HEAD
Our patient’s head is normocephalic. Presence of hair was noted in the head and
in the upper and lower extremities. Lesions, bleeding and bruises were not seen upon
inspection. His hair is evenly distributed and majority of hair color is grey with several
strands of black and white hair. No signs of dandruff and lice noted.
EYES
Eyes are symmetrical with each other. The cornea is moist and white in color. The
iris appears to be black on both eyes. Pupils are equally round and reactive to light and
accommodation with a pupillary size of 2 mm. He needs reading glasses when reads
small texts. His eyebrows are thick and eyelashes are evenly distributed along the margin
of the eyelids; both eyes move in unison; no signs of scratches on both eyes and no
discharges noted.
EARS
The shape of the pinnaes is oval and with no discharges noted. Upper margin of
the pinnaes is in line with the outer canthus of the eyes. Ears are firm and non-tender.
Signs of lesions, lacerations, swelling and bruises were not seen upon inspection. He was
able to repeat a sentence when it was softly said behind his ears, which reveals that he
NOSE
External surface of the nose is smooth and oily. Nasolabial folds are symmetrical.
Nostrils are also symmetrical with no flaring and discharges noted. Nasal hairs are
present upon inspection. Nasal septum is not deviated. Both nostrils are patent. No signs
of tenderness were noted. Patient was able to distinguish the smell of rubbing alcohol
MOUTH
Lips are dry with minimal cracks. Teeth are not complete with dentures noted
upon inspection. A total of 3 cavities were also seen upon inspection of the teeth. Gums
and buccal mucosa are pinkish in color. Tongue is in the midline of the mouth. Tonsils
are not inflamed. No signs of inflammation and laceration on the uvula. Bleeding,
ulceration and swelling were not seen upon inspection. Patient was on soft diet and was
NECK
The neck of our patient can move easily without any difficulty, which includes
right and left lateral, right and left rotation, flexion and hyperextension. Neck can
properly support the head. No signs of enlargement and masses on the thyroid. Carotid
deformities noted.
Chest muscle expansion during inspiration and relaxation during expiration are
symmetrical and painless. There were no presence of scars and lesions. He was not in
respiratory distress. Respiratory rate is 18 cycles per minute and rhythm was regular.
Breath sounds were clear on both lungs indicating that he is free of cough or colds.
ABDOMEN
Patient’s abdomen is globular in shape, soft, and flabby. Bowel sounds are
hyperactive with 17 sounds counted within one full minute. Four intact and dry
commercially prepared dressings were seen upon inspection. One dressing was seen on
the umbilical area, another dressing was seen just below the xiphoid process, and two
other patches were seen in the upper and lower regions of the iliac. A dull pain was felt
GENITO-URINARY
pain or difficulty upon urination and defecation. Average urine output of patient was 31
UPPER EXTREMITIES
Patient’s upper limbs, shoulders and arms were symmetrical. No tenderness noted
on the bones of the wrist and fingers. No deformities and swelling noted. He could freely
LOWER EXTREMITIES
Both legs of the patient are symmetrical and can stretch, flex, rotate, extend and
bend without any difficulty. No signs of deformities, lesions, lacerations, bruises and
bleeding were seen upon inspection. Patient does not have any difficulty ambulating.
the liver. The liver is divided into a large right lobe and a smaller left
lobe. The falciform ligament divides the two lobes of the liver.
These hepatic lobules are the functioning units of the liver. Each
hepatic cells called hepatocytes. The hepatocytes secrete bile into the
Each sinusoid is lined with Kupffer cells, phagocytic cells that remove
amino acids, nutrients, sugar, old red blood cells, bacteria and debris
from the blood that flows through the sinusoids. The main functions of
the sinusoids are to destroy old or defective red blood cells, to remove
bacteria and foreign particles from the blood, and to detoxify toxins
the liver each minute, making it one of the most vascular organs in the
through the portal vein; the remaining 25% is oxygenated blood that is
Enzyme activation
Synthesis of plasma proteins, such as albumin and globulin, and clotting factors
membranous sac on the undersurface of the right lobe of the liver just
below the lower ribs. It is generally about 7.5 cm (about 3 in) long and
from 1 to 1.5 fluid ounces. The body (corpus) and neck (collum) of the
gallbladder extend backward, upward, and to the left. The wide end
bile produced in the liver. The cystic duct connects the gall bladder to
the common hepatic duct to form the common bile duct. This common
bile duct then joins the pancreatic duct, and enters through the
propria).
tissue from serosa and adventitia, but there is a thin lining of muscular
Function
The function of the gallbladder is to store bile, secreted by the
liver and transmitted from that organ via the cystic and hepatic ducts,
The purpose of bile is to; help the Lipases to Work, by emulsifying fat
into smaller droplets to increase access for the enzymes, Enable intake
concentrated than when it left the liver, increasing its potency and
Cholesterol Metabolism
coronary arteries.
E TIOLOGY AND S YMPTOMATOLOGY
PREDISPOSING
PRESENT ABSENT JUSTIFICATION
FACTORS
AGE / Mr. R is 53 years old; At his
age, the ability of his body to
heal itself is diminished,
making him more prone to
developing diseases like gall
stones.
GENDER / Although the disease is not
exclusive to one gender only,
statistics show that women
are more prone to develop gall
stones.
HEREDITY / Gallstones are very common
and thus suspected to be
hereditary. However, Mr. R’s
past illnesses (DM and
Hypertension) are found to
have hereditary causes. These
illnesses predispose him to
developing gall stones.
RACE / Statistics show that
Caucasians are more prone to
develop gallstones because
their race is exposed to
resources that provides a high
fat diet for them.
PRECIPITATING
PRESENT ABSENT JUSTIFICATION
FACTORS
Mr. R verbalized that since his
HIGH CHOLESTEROL
/ grade school years, he is fond
DIET
of eating all kinds of lechon.
OVERWEIGHT / Mr. R’s BMI was 25.62kg/m2.
HYPERTENSION / Mr. R was diagnosed with
Hypertension in 1995.
DIABETES MELLITUS II / Mr. R was diagnosed with type
2 DM in the year 1997.
NEGLIGENCE AND / Mr. R verbalized that he only
LACK OF KNOWLEDGE took Kremil-S and rest to treat
his sharp, intermittent RUQ
pain – a primary symptom of
cholelithiasis.
TREATMENT WITH / Mr. R never had the need of
ESTROGEN estrogen therapy.
ILEAL RESECTION OR / Mr. R’s ileus does not have a
ILEAL DISEASE disease had never been in
need of surgical manipulation.
SYMPTOMATOLOGY
DM II - ↓ glucose utilization
cell hunger
polyphagia
(with high cholesterol food preference)
DIAGNOSTIC PROCEDURE
interruption of bile flow
ultrasound of the hbt
Diagnosis:
CALCULOUS CHOLELITHIASIS
POOR PROGNOSIS
Feb. 18, Pls. admit under my service The patient is in need of DONE
2009 medical attention so he is
admitted in Davao Medical
School Foundation Hospital
Wt – 73 for preparations for the Pre-
kg operation.
Temp -
36˚C
BP-
120/80
RR-21
PR-26
HGT-120
TPRq4˚ Vital signs are recorded to DONE
obtain patients baseline data
and are useful for further
management. A temperature
higher than normal may
indicate the development of
infection. Pulse & respiration
is taken to watch out for
tachycardia - a sign of
hemorrhage & dehydration.
NPO post midnight The patient is maintained on DONE
NPO in order to prevent
aspiration from vomiting
which is one of the side
effects of anesthesia.
Labs:CBC, Blood typing, These entire lab tests are DONE
platelet count, Urinalysis, performed to screen for
Creatine,FBS,B1 B2, Alk alteration and to serve as a
phosphate, Protime, APTT, baseline data for future
Chest X-ray PA view. ECG comparison.
DONE
Please inform OR. To schedule the operation
and for the surgical team to
make their initial assessment
procedures on the patient
Refer Referral is done to correct
unusualities as soon as DONE
possible and to inform the
attending physician of the
patient's condition.
DONE
Informing the physicians of
Inform Dr. Laminose - aware the latest news about the
patient will mean better care
given to the patient.
May have low fat, diabetic diet To prevent the patient from DONE
eating foods that may
aggravate his illness which
may lead to complications
during the upcoming
operation
refer Referral is done to correct DONE
unusualities as soon as
possible and to inform the
attending physician of the
patient's condition.
To signal the cessation of the
@11pm D/C Hgt monitoring. monitoring of the patient’s DONE
blood glucose
Februar May go ahead of surgery if K+ Patients with low potassium
y.19,200 is > or = to 3.5 levels are prone to bradycardia DONE
9@ and will worsen when
6:30 am administered with anesthetics
during surgery. A normal level
of potassium is vital for
operations
DONE
@ 7am Please carry out IM Suggestions from internal
suggestions. medicine will help prepare the
patient for his upcoming
operation
@ 2am IVF TF: PNSS 1L and 60 Daily maintenance of body DONE
meqs Kcl @ 100 cc/hr. fluids when less Na+ and Cl-
are required.
Pre-op orders:
Februar To PACU; then to ward once For close monitoring of the DONE
y.20,200 stable patient. To watch out for any
9@ signs of unusualities.
9:35 am
VS q 15 mins. until stable; Vital signs is taken to provide DONE
then q hourly. baseline data and to watch for
any unusualities.
IVF rate; D5NSS to run in 160 To prevent hypoglycemia and DONE
cc/hr. dehydration.
IVF TF: D5NSS 1L @ 140 To follow-up IVF and maintain DONE
cc/hr. replacement of fluid and
electrolyte balance.
Meds: DONE
1. Ciprofloxacin 200g IVTT q Ciprofloxacin - to fight bacteria
8 x/ more doses then shift to in the body; to prevent or slow
ciprofloxacin 400g p.o. B.I.D. anthrax after exposure.
2. Ketorolac 30g IVTT q 8 Ketorolac - to reduce pain, fever
hours x 2 more doses. & inflammation.
3. Etoricoxib 120g p.o. B.I.D. Etoricoxib - to provide
to start at 6am tomorrow x 4 analgesic effect.
doses then decrease to OD Tramadol – to alleviate
thereafter. moderate to severe pain.
4. Tramadol retard 100 g to Ranitidine - promoting healing
start at 6pm tonight T.I.D. of stomach and duodenal ulcers,
5. Ranitidine 50g IVTT q 8 and in reducing ulcer pain.
hours x 3 doses.
O2 inhalation at 2 cpm Oxygen therapy is provided to DONE
prevent patient from hypoxia.
Keep patient warm and well Warmth makes the patient DONE
thermoregulated. comfortable and alleviate
anxiety that may be helpful for
his recovery.
Deep breathing exercise for 15 To expand the lung fully and DONE
minutes, 3x a day. prevent atelectasis.
Moderate high back rest. To promote breathing and chest DONE
expansion.
May turn to sides once able. To prevent pulmonary DONE
complications as well as other
complications.
Please do Hgt monitoring q 6 To monitor the blood sugar DONE
hours; may give 4 “u” HR SQ levels of the patient
for Hgt > 240.
Watch out for any To ensure that immediate DONE
unusualities; refer accordingly. nursing interventions can be
administered to avoid
complications; Referral is done
to correct unusualities as soon
as possible and to inform the
attending physician of the
patient's condition.
@ 11pm IVF TF: D5NSS 1L @ 140 For replacement of fluid DONE
cc/hr. electrolytes balance
maintenance.
D IAGNOSTIC E XAM
Urinalysis
PE CE
Rxn: 6.0
Microscopic Examination
Date: 2/18/09
X-Ray Report
Ultrasound Report
The liver is normal in size with mild diffuse increase in tissue attenuation. No
focal solid or cystic lesions demonstrated. The intra-hepatic ducts are not dilated. The
The gall bladder is adequately distended with slightly thickened walls measuring
Impression:
Calculous Cholecystitis
Hematology
F: 120 - 150
Erythrocytes 4.29 10^12/L 4.0 - 6.0
Leukocyte 6.9 10^9/L 5.0 - 10.0
Segmenters 0.53 % 0.45 - 0.65
Lymphocyte (P) 0.39 % 0.20 - 0.35
Monocyte (P) 0.06 % 0.02 - 0.06
Eosinophils 0.02 % 0.02 - 0.04
Hematocrit 0.41 -- F: 0.38 - 0.4
M: 0.40 - 0.60
thrombocyte 177 10^9/L 150.0 - 450.0
INCUBATION
Patient -- sec
Control -- sec
CORRECTED APTT
corrected
Date: 2/18/09
Blood Chemistry
Date: 2/19/09
Blood Chemistry
(-) BA
(-)FDA
Maintenance Meds:
1. Lipitor
2. Plitor
Present Illness:
18 years PTA, Patient noted abdominal pain located @ RUQ area. No consultation done.
6 years PTA, (+) recurrence of RUQ pain x 5 days UTZ done revealed gallstones. Took
Herbal meds. Patient did not consent for surgery. Patient tolerated the condition, until
Non Steroidal - 120 mg synthesis of - For the - Etoricoxib is Oral myalgia 1. Check renal
Anti- P.O. BID x prostanoid treatment of contraindicated to anticoagulants, and hepatic
weight changes,
inflammatory 4 doses mediators of rheumatoid patients with known diuretics and function
chest pain,
Drugs pain, arthritis, hypersensitivity to ACE inhibitors, periodically in
fatigue,
(NSAIDs) inflammation osteoarthritis Etoricoxib, Acetylsalicylic patients on long
paraesthesia,
and fever. , ankylosing acid, term therapy.
patients with active influenza-like
Selective spondylitis, Stop drug if
peptic ulceration or Cyclosporin and syndrome &
chronic low abnormalities
clinical dose gastro-intestinal (GI) Tacrolimus,
back pain, - Dry mouth, taste occur and notify
range. COX-2 bleeding, patients Lithium,
acute pain disturbance, prescriber.
has been Methotrexate,
and gout. who have developed mouth ulcers,
shown to be oral 2. because of
signs of asthma, flatulence,
primarily contraceptives, their antipyretic
acute rhinitis, nasal constipation,
responsible for and anti-
polyps, Prednisone/Pred appetite and
the inflammatory
angioneurotic nisolone,
actions, NSAIDs
active, highly Digoxin, drugs
oedema or urticaria may mask signs
selective metabolized by
following the and symptoms of
cyclooxygenas sulfotransferases
administration of infection
e-2 (COX-2)
acetylsalicylic acid (Ethinyl
inhibitor 3. Blurred or
or other Estradiol), drugs
within and diminished vision
metabolized by
above the and changes in
CYP
color vision may
- exhibits anti- isoenzymes,
occur
inflammatory, Ketoconazole,
analgesic and 4. serious G.I.
Rifampicin, and
antipyretic toxicity,
Antacids have
activities. It is including peptic
interaction with
a potent, orally ulcer and
Etoricoxib.
Generic Name: Ciprofloxacin
Brand Name: Ciloxan, Cipro, Cipro HC Otic, Cipro I.V., Cipro XR, Proquin XR
Classification Suggested Mode of Drug Side Effects/ Nursing
Indications Contraindications
s Dose Action Interactions Adverse Reactions Responsibilities
Fluroquinolone 400mg it's action complicated avoid taking GI – nausea CNS; seizures, • Arrange
P.O. depends intra- ciprofloxacin and confusion, depression, for culture and
Antibacterial
B.I.D. upon abdominal with antacids vomiting, dizziness, drowsiness, sensitivity tests
blocking infection which contain abdominal fatigue, hallucinations, before beginning
bacterial severe or aluminium, pain, headache, insomnia, therapy
DNA complicated magnesium or constipation light-headedness,
• continue
replication bone or joint calcium. paresthesia, restlessness,
CNS – therapy for 2
by binding infection, Sucralfate, tremor
headache, days after signs
itself to an which has a high
dizziness, CV; chest pain, and symptoms of
enzyme severe aluminium
fatigue,edema, thrombophlebitis infection are
called DNA respiratory content, also
lethargy gone
gyrase, tract infection, reduces the GI;
thereby bioavailability GU – renal pseudomembranous • be aware
inhibiting the severe skin of ciprofloxacin failure colitis, diarrhea, nausea, that Proquin XR
unwinding of structure to approximately abdominal pain or is not
Skin - rash
bacterial infection 4%. discomfort, constipation interchangeable
chromosomal severe or Ciprofloxacin and dyspepsia, with other forms
DNA during complicated should not be flatulence, oral
• ensure
and after the UTI, taken with dairy candidiasis, vomiting
that patients
replication. products or GU; crystalluria, swallow ER
infectious calcium-fortified interstitiial nephritis, tablets whole; do
diarrhea, juices alone, but not cut, crush, or
typhoid fever may be taken hematologic;
chew
pyelonephritis with a meal that leukopenia, neutropenia,
nosocomial contains these • ensure
pneumonia products. that patient is
musculoskeletal;
chronic well hydrated
Heavy exercise is aching, neck pain,
bacterial tendon rupture • give
discouraged, as
prostatitis antacids at least
achilles tendon Skin; rash,
acute 2 hrs after dosing
rupture has been pruritus
uncomplicated
reported in • monitor
cystitis
patients taking clinical response;
mild to ciprofloxacin. if no
moderate cute Achilles tendon improvement is
sinusitis rupture due to seen or a relapse
ciprofloxacin occurs, repeat
use is typically culture &
associated with sensitivity
renal failure.
•
encourage
patient to
complete full
course of therapy
Generic Name: Diazepam
Anxiolytics 10 mg PO OD A
benzodiaze
pine that preoperativ contraindicate Drug-drug CNS; Warn patient to avoid
probably e sedation d in patients drowsiness, activities that require
hypersensitive Cimetidine may slurred alertness and good
potentiates before to drug or soy decrease speech, coordination until
the effect endoscopic protein; in clearance of tremor, effects of drug are
of GABA, procedures patients diazepam and headache, unknown.
depresses
experiencing increase risk of fatigue
the CNS, muscle
shock, coma, adverse effects Warn patient not
and spasm
or acute CV; abruptly stop the drug
suppresses CNS
alcohol bradycardia, because withdrawal
the spread acute depressants may
intoxication hypotension symptoms may occur
of seizure alcohol increase CNS
activity. withdrawal depression EENT; tell patient to avoid
use cautiously
in patients diplopia, alcohol while taking the
Digoxin may blurred drug
with liver or increase risk of vision,
renal toxicity nystagmus notify patient that
impairment. smoking may decrease
Diltiazem may GI;nausea, drug's effectiveness
CNS depression constipation,
and prolong Take this medication
effects of diarrhea exactly as it was
diazepam prescribed for you. Do
GU; not take the medication
Drug-Herb incontinence in larger amounts, or
, urine take it for longer than
Kava may retention recommended by your
increase
doctor. Follow the
sedation Hepatic;
directions on your
jaundice
Drug-lifestyle prescription label.
Respiratory;
Alcohol use diazepam interacts with
apnea
may cause the plastic; therefore,
additive CNS Skin; rash introducing diazepam
effect into a container reduces
drug availability.
Smoking may
decrease
effectiveness of
drug
Generic Name: Potassium chloride
potassium salt 1 tab t.i.d. replaces indicated to contraindicated in Drug-drug; CNS; paresthesia of Teach patient signs and
potassium prevent patients with limbs, ;listlesness, symptoms of
ACE
and hypokalemia, severe renal confusion, hyperkalemia, and tell
inhibitors,
maintains impairment with weakness or patient to notify
digoxin,
potassium oliguria. heaviness of limbs, prescriber if they occur
potassium-
levels flaccids paralysis.
sparing Tell patient that drug is
diuretics may CV; postinfusion commonly used orally
cause phlebitis, with potassium-wasting
hyperkalemia. arrhytmias, heart diuretics to maintain
block, cardiac potassium levels.
arrest, hypotension,
Monitor ECG and
ECG changes
electrolytes levels
GI; nausea, during therapy
vomiting,
Swallow the tablets whole
abdominal pain,
with a full (8-ounce)
diarrhea.
glass of water. Do not
metabolic; chew or suck on the
hyperkalemia tablet.
Respiratory; Do not take more of it, do
respiratory paralysis not take it more often,
and do not take it for a
longer time than your
doctor ordered.
Generic Name: Nalbuphine
analgesics 5mg IVTT Unknown. adjunct to Drug-drug. CNS; Tell patient drug act as
contraindicate
Binds with balanced CNS dizziness, an antagonist and
d in patients
opiate depressants headache, may cause
anesthesi hypersensitive
receptors and sedatives sedation, withdrawal
a to drug
in the may cause vertigo, syndrome
moderate to
CNS, respiratory confusion, Advise the patient to
severe
altering depression, restlessnes avoid any activities
pain
perception hypertension, s. that requires
of and profound CV; alertness because this
emotinal sedation or bradycardi drug can cause
response coma. a, dizziness
to pain. Opoid hypotensio Explain to the patient
analgesics n, that the drug can
may decrease tachycardi cause constipation.
analgesic a, Tell the patient to
effect hypertensi report to the
Drug-lifestyle. on prescriber
Alcohol use EENT; immediately if there
may cause blurred is severe itcheness.
additive vision, dry
effects mouth
GI;
constipatio
n, nausea,
vomiting,
dyspepsia,
cramps
GU; urinary
urgency
Respiratory;
asthma
Skin;
burning,
clammines
s,
diaphoresi
s, pruritus
Generic Name: Tramadol
Betty Neuman’s systems model focuses on the wellness of the client system in
relation to the environmental stressors and reactions to stressors. These stressors include
intrapersonal (occur within person, e.g. emotions and feelings), interpersonal (occur
between individuals, e.g. role expectations), and extrapersonal stressors (occur outside
the individual, e.g. job or finance pressures). The nursing interventions involved in this
theory focuses on retaining or maintaining system stability on three preventive levels: [1]
the internal lines of resistance and/or removing the stressor.), and [3] Tertiary prevention
(offers support to the client and attempts to add energy to the system or reduce energy
Application to patient:
Last 2006, the patient was diagnosed of Cholelithiasis and was given medications
like pain reliever () and antibiotic (). The pain and discomfort were relieved because of
the medications given. After three years, he experienced recurrence of pain and
discomfort. This made him decide to consult his physician and agreed to the suggested
Our patient belongs to the tertiary prevention since he had already undergone
that would prevent him from developing the same condition. Additional information was
also given to the patient that would help hasten the healing process. Examples of health
teachings rendered to him are encouraging him to have a strict compliance of his
therapeutic regimen, to have a regular exercise and emphasizing the importance of
having a healthy and balance diet. Also, teach the patient and the family about the
Interpersonal, and Social. The major elements of the theory are seen in the interpersonal
systems in which two people, who are usually strangers, come together in a health care
organization to help and be helped to maintain a state of health that permits functioning
in roles. She states that client goals are met through the transaction between nurse and
client.
As health care providers, we need to learn how to interact and establish rapport
to our patients. We must encourage them to verbalize their concerns and feelings in
relationship with Mr. R. Because of this, we were able to obtain information regarding
his plans after his discharge. In line with this, involved Mr. R in creating a plan of care
and exploring means of achieving this upon his discharge. We must also give him enough
information especially on prevention of illnesses so that his role as an individual will not
be affected.
LYDIA HALL’S Care, Core, and Cure Model
Lydia Hall presented her theory of nursing visually by drawing three interlocking
circles, each circle presenting a particular aspect of nursing. The circle represents care,
core, and cure. The care circle represents the nurturing component of nursing and is
exclusive to nursing. The professional nurse provides bodily care for the patient and helps
the patient to complete such basic daily biological functions as eating, bathing,
elimination and dressing. When providing this care, the nurse’s goal is the comfort of the
patient. The core circle of patient care is based in the social sciences, involves the
therapeutic use of self, and is shared with other members of the health team. The
professional nurse, by use of the reflective technique helps the patient look at and explore
feelings regarding his or her current health status and related potential changes in
lifestyle. The cure circle of patient care is based in the pathological and therapeutic
sciences and is shared with other members of the health team. The professional nurse
helps the patient and family through the medical, surgical, and rehabilitative prescriptions
made by the physician. During this aspect of nursing care, the nurse is an active advocate
of the patient.
In the care circle, we were able to ensure client safety through raising side rails
of bed to prevent patient from falling, assisting patient whenever he ambulates, and
imparting health teachings that would help him to have a speedy recovery.
In the core circle, we were able to allow the patient to explore his feelings about
his condition through letting him express his concerns and worries regarding his
condition. Through this, the patient will be motivated to make appropriate decisions in
In the cure circle, we were able to perform a medical procedure that would help
the physician to determine the proper treatment that should carried-out to the patient.
N URSING C ARE P LANS
DATE/TIME CUES NEEDS NURSING OBJECTIVES NURSING INTERVENTIONS EVALUATION
DIAGNOSIS OF CARE
Feb. 21, S: C Acute pain r/t Within our 1.Observe and document location, severity (1- GOAL MET
2009 ‘’medyo O surgical tissue span of care, 10 pain scale), and character of pain(steady,
@ 5am sakit2x ang gi G trauma our patient will intermittent, colicky.) Patient was able
operahan diri N secondary to be able to: R: assists in differentiating cause of pain and to:
sa akong I laparoscopic provides information about disease
tiyan’’ as T cholelithiasis. - Follow progression/resolution, development of - minimize
verbalized by I interventio complications, and effectiveness of manipulation of
the patient. V R: Unpleasant ns to interventions. affected area and
O: E sensory and relieved 2.Promote bedrest , allowing patient to assume utilize relaxation
- Presence - emotional pain. position of comfort. techniques to
of P experience - Verbalized R: bedrest in low Fowler’s position reduces minimize pain.
patches E arising from minimal intraabdominal pressures; however, patient will -
on the R actual or pain. naturally assume least painful position. patient
operative C potential - - utilize 3.Encourage use of relaxation techniques, e.g., verbalized pain
sites. E tissue damage; comfort deep breathing exercises. scale of 3
- Grimaced P sudden or measures R: promotes rest, redirects attention, may
face T slow onset of and enhance coping.
when U any intensity techniques 4.Make time to listen to complaints and
patch on A from mild to effectively maintain frequent contact with the patient.
umbilicu L severe with an to reduce R: helpful in alleviating anxiety and refocusing
s was anticipated or or alleviate attention, which can relieve pain.
palpated P predictable pain. 5.Administer medications as indicated.
- Pain A end and R: to maintain ‘’acceptable’’ level of pain.
scale of T duration of Notify physician if regimen is inadequate to
5- T less than 6 meet pain control goal.
moderate E months. 6.Observe and document location, severity (1-
R 10 pain scale), and character of pain(steady,
N Source: intermittent, colicky.)
Nurse’s R: assists in differentiating cause of pain and
Pocket Guide, provides information about disease
Marilynn E. progression/resolution, development of
Doenges, complications, and effectiveness of
Mary Frances, interventions.
Moorhouse, 7.Promote bedrest , allowing patient to assume
Alice C. Murr position of comfort.
R: bedrest in low Fowler’s position reduces
intraabdominal pressures; however, patient will
naturally assume least painful position.
8.Encourage use of relaxation techniques, e.g.,
deep breathing exercises.
R: promotes rest, redirects attention, may
enhance coping.
9.Make time to listen to complaints and
maintain frequent contact with the patient.
R: helpful in alleviating anxiety and refocusing
attention, which can relieve pain.
10.Administer medications as indicated.
R: to maintain ‘’acceptable’’ level of pain.
Notify physician if regimen is inadequate to
meet pain control goal.
DATE/TIME CUES NEEDS NURSING OBJECTIVES NURSING INTERVENTIONS EVALUATION
DIAGNOSIS OF CARE
Feb. 21, S: C Knowledge Within our 1. Assess client's level of understanding. GOAL MET
2009 deficit span of care,
–“Dili ko O R: Facilitates planning of postoperative The patient was
@ 5am [Medications] r/t patient will be
sure kung teaching program, identifies content needs. able to:
unfamiliarity able to:
unsaon G with information - perform
nako ang resources. 2. Identify motivating factors for the necessary
akoang N individual.
diet karon –participate in interventions
I the learning R: Motivating factors will help in the correctly
na wala na
ko’y gall R: Absenc e or deficiency
process teaching process
T - verbalize
bladder.” of cognitive information understandi
3. provide information relevant to the
I situation.
O: related to specific ng of
V topic. –identify condition/disease
Patient is interferences to R: for the patient to be informed regarding
learning and her present condition. process and
S/P E
specific actions treatment.
laparoscop 4. Provide positive reinforcement.
ic - to deal with - Identify
cholecyste them R: to encourage continuation of efforts. medications
P
ctomy use to treat his
E 5. Identify information that needs to be
condition.
–exhibit increased remembered.
R
R: The client will know what specific
learning of medicines
C information will help out in remembering
taken. what is learned
E
6. Determine client's method of accessing
P information and include in teaching plans.
T R: to know teaching method to be used and to
help facilitate learning.
U
7 Provide written information and guidelines
A for client to refer to as necessary.
L R: Written information will be more reliable
for the client whenever information will be
P forgotten
A 8. Begin with information that client already
T knows and move to what the client does not
know.
T
R: This will ensure that the client will not
E have a hard time learning new things
Feb. 21, Objective: N Altered nutrition Within our 8 1.Monitor vital signs eb. 21, 2009 @
2009 less than body hours span of 6:00am
>loss of appetite U requirements related care, the ®serves as a baseline data
@ 5am as evidenced by to impaired fat patient will be
untouched meals T digestion due to able to 2.Monitor IVF
and as verbalized obstruction of bile achieve relief Goal met:
by the patient R ® To maintain the fluid and electrolytes
flow. of nausea and balance in the patient’s body
and his I vomiting.
significant 3. Monitor Intake and output. The patient was
others. T able to
®To determine any unusualties for demonstrate
>the patient has I immediate medical management.
undergone achievement in
laparascopic O relief of nausea
4. Assess for abdominal distention, and vomiting.
cholecystectomy. frequent belching, guarding, and
N reluctance to move.
A ®Nonverbal signs of discomfort
L associated with impaired digestion, gas
pain.
-
5. Consult with patient about
M likes/dislikes, foods that cause distress,
and preferred meal schedule.
E
®Involving patient in planning enables
T patient to have a sense of control and
encourages patient to eat.
A
B 6. Provide a pleasant atmosphere at
mealtime; remove noxious stimuli
T
P ROGNOSIS
Poor Fair Good
Category Justification
(1) (2) (3)
1. Duration It's been 14 years since the
of Illness first sign of pain
As soon as the pain got really
2. Onset of worse, he immediately sought
Illness medical treatment, but he
could have done this earlier
3. 2 out of 3 predisposing factors
Predisposin are present; his susceptibility
g Factors to the disease is unavoidable.
4.
His lifestyle could have been
Precipitatin
adjusted and hid disease could
g
have been avoided altogether
Factors
5.
Willingness
Patient verbalized that this
to take the
experience has taught him
medications
valuable lesson in keeping
or
healthy and preventing
compliance
illnesses by taking his
to
medication religiously
treatment
regimen
Patient verbalized that his
6.
home environment and work
environmen
place only give him
t
manageable stress.
During our interview Mr. R's
nephew was present; his son
7. family was also expected to visit in
support the morning; Mr. R was also
observed to answer two phone
calls from two of his siblings.
3 + 2 + 9 = 14
14/7 = 2
His disease could have been totally avoided just by a change in lifestyle and diet.
Mr. R could have paid attention to his weight gain and the rising issues about obesity and
what diseases it could bring about. And most of all, Mr. R should have had his RUQ pain
checked by a doctor early on. If the gall stones were still during its early stages, they
could have been removed by Mr. R taking medications and an invasive procedure could
have been avoided. However, the usual prognosis of post laparoscopic cholecystectomy
patients is usually very good. Having smaller incisions brings about lower risks for
infections. Early ambulation is readily done which then will bring about early recovery.
Mr. R has also been educated on the changes in his lifestyle that he could do in order for
him to have a good life ahead of him even if he doesn’t have a gall bladder anymore.
D ISCHARGE P LAN
MEDICATION
® Knowledge about what medications will make the client become aware of
what he is taking and for the family to participate more in the client’s treatment.
• Inculcate to the client to comply all the medications prescribed at the ordered
® Taking the drugs at the ordered dose, route and time limits the chance for
• Explain the side effects or adverse reactions of each medication. Instruct the client
and family to watch out for it and to report it immediately as soon as possible to
the physician.
® Explaining the side effects will let the client and family identify what harmful
effects to expect and for them to distinguish the adverse reaction to medication for
This can help the patient alleviate the problem and be able to experience the full
• Instruct client to avoid strenuous activities for at least a week or a month until
fully recovered.
Activities that require great muscle strength should be avoided to prevent injury
Walking is good exercise and could promote circulation, hence, proper healing.
To gain back the lost strength and be able to return to its normal state thus allow
This will help alleviate any pain or discomfort that patient will encounter
TREATMENT
• Explain the need of treatment after discharge and must take it seriously so as to
hospital but needs to be continued at home to make the client responsible towards
medication.
• Explain to the family the condition of the patient and give them factual
To have better understanding of the patient’s condition and to be able to know
what intervention they should give that could not alter the effect of the therapy.
HYGIENE
• Encourage having proper hygiene like taking a bath, meticulous hand washing,
Hygiene promotes comfort and cleanliness to the patient. It also increases the
keeping the nails neatly trimmed, maintaining own supplies/items for personal
necessities.
hygiene. Owning personal accessories for hygiene purposes keep client away
Calm, clean and non threatening environment may lessen the occurrence of
monitoring and care even after attainment of the course medical therapy.
Through constant visits as out patient, the physician would still monitor the
• Advice the client and the family to carry out follow-up diagnostic examinations
• Instruct the family to report any unusual signs and symptoms experienced by the
patient.
This will help detect early signs and symptoms of recurrence of the disease.
DIET
• Encourage client to eat a variety of nutritious foods like fruits and vegetables once
This hydrates the body for normal functioning and maintain acid-base balance.
• Advise client not to skip meals and have a regular eating pattern/schedule.