A Case Study on

Choledocholithiasis

Submitted by:
Jaelynn Faith Ombina
Angelika Isona
Warline R. Hyberts
Kenneth Pagasian
Christelle Cadiente

Table of Contents
Chapter I

Introduction

Chapter II

Objective

Chapter III

Patients Data

Chapter IV

Genogram

Chapter V

History of Illness

Chapter VI

Definition of Complete

Diagnosis
Chapter VII

Developmental Milestone

Chapter VIII

Physical Assessment

Chapter IX

Anatomy and Physiology

Chapter X

Etiology and Symptomatology

Chapter XI

Pathophysiology

Chapter XII

Doctors Order

Chapter XIII

Diagnostic and Laboratory Result

Chapter XIV

Drug Study

Chapter XV

Medical Surgical Management

Chapter XVI

Discharge Planning/ Health

Teaching
Chapter XVII

Nursing Care Plan

Chapter XVIII

Prognosis

Chapter XIX

References

Chapter XX

Acknowledgement

Introduction
Choledocholithiasis refers to the presence of gallstones
within the common bile duct. According to the National Health
and Nutrition Examination Survey (NHANES III), over 20 million
Americans are estimated to have gallbladder disease (defined as
the presence of gallstones on transabdominal ultrasound or a
history of cholecystectomy). Among those with gallbladder
disease, the exact incidence and prevalence of choledocholithiasis
are not known, but it has been estimated that 5 to 20 percent of
patients have choledocholithiasis at the time of cholecystectomy,
with the incidence increasing with age.

In Western countries, most cases of choledocholithiasis are

secondary to the passage of gallstones from the gallbladder into
the common bile duct. Primary choledocholithiasis (i.e., formation
of stones within the common bile duct) is less common. Primary
choledocholithiasis typically occurs in the setting of bile stasis
(e.g., patients with cystic fibrosis), resulting in a higher propensity
for intraductal stone formation. Older adults with large bile ducts
and periampullary diverticular are at elevated risk for the
formation of primary bile duct stones. Patients with recurrent or
persistent infection involving the biliary system are also at risk, a
phenomenon seen most commonly in populations from East Asia.

The causes of primary choledocholithiasis often affect the biliary

tract diffusely, so patients may have both extrahepatic and
intrahepatic biliary stones. Intrahepatic stones may be
complicated by recurrent pyogenic cholangitis.
Gallstones in Southeastern Asia (Extrapolated Statistics):
extrapolated prevalence is 5,073,040; Population Estimated Used
is 86,241,6972.

Objectives
This case study will help and serve us to enhance
o u r k n o w l e d g e t o u n d er s t a n d Choledocholithiasis by
assessing, analyzing and interpreting the collected data. This will
in turn give us a better idea of how we could give proper nursing
care making the right evaluation and right intervention to our
clients with this condition; And so that we may apply them on our
future exposures as students and eventually as nurses. We also
did this case study as part of our requirement in our clinical
exposure.

Defi ne Choledocholithiasis by identifying their signs and

symptoms, as well as its clinical manifestations.
Acquire baseline data.
Analyze the signs and symptoms and clinical manifestation
elicited by the patient and other problems that the pt. may
develop so that the student nurse may prioritize theses

problem to be able to render care in a systematic and logical

order.
Illustrate the pathophysiology of the pt. condition and
interrelate with it.
Apply appropriate nursing intervention and shallot aid the
student nurses produces competent and reliable plan of care
to help the patient health and medical understanding as
such conditions.
Develop specific nursing care plan, measure and attainable,
realistic and time bounded.
Recommend appropriate discharge planning the patients so
that the pt. will develop knowledge and understanding at
home for faster recovery.

Patients Data
PERSONAL DATA
Patients Name:

Mrs. Ling

Age:

39

Gender:

Female

Birth Date:

January 1, 1977

Civil Status:

Married

Occupation:

None

City Address:
Nationality:

Osmea, Compostella PRU-2

Filipino

Religion:

Roman Catholic

Educational Attainment: College Undergraduate

Source:

Patients Chart

CLINICAL/ADMITTING DATA
Date of admission:

4/18/2016

Time of admission:

1:20 PM

Hospital:

Davao Medical School Foundation

Ward:

Surgical

Room No:

324 - 4

Attending Physician:Dr. Velasco

Admitting Diagnosis:

Choledocholithiasis

VITAL SIGNS ON E.R. ADMISSION

Date of Admission:

April 18, 2016

Time:

1:20 PM

Temperature:

36.1 Degrees Celsius

Pulse Rate:

78 pm

Respiratory Rate:

20 cpm

Blood Pressure:

120/80 mm/Hg

Height:
Weight:

143 cm
67.5 kg

Genogram

History of Illness
After establishing rapport with the patient, I asked about her age
and what brought her to the hospital. The patient verbalized that
she is 39 years of age and began to experience pain roughly two
months prior admission but did not pay it any mind. On March 8,
2016, she experienced pain in the back so she went to the
hospital for another checkup. As the days went by, the pain
seemed to be getting worse, so on April 18, 2016 she decided to
go back to the hospital and was admitted.

When I asked about her lifestyle and her eating habits, the patient
verbalized that she used to eat fatty foods, especially in her
college days. When I asked her if she has any allergies to
medications and if she ever had any surgical procedure done
before, the patient stated No. The patient is happily married.
She has one son and owns a sari-sari store. The patient verbalized
she is very grateful to GOD that the surgery went well.

Social Health History

Patient does not consume alcoholic beverages. She stays home
majority of her time with family. Her family are very close and
spends time with each other on Sundays, while going to church.

Family History
The patients family does not exhibit any history of Hypertension,
Diabetes Mellitus, Asthma, Cancer, Angina, Abdominal Pain, Flank
Pain, Heat and Cold, Headache.

Definition of Complete
Diagnosis

1. Choledocholithiasis is the presence of at least one gallstone

in the common bile duct. The stone may be made up of bile
pigments or calcium and cholesterol salts.
Reference: https://www.nlm.nih.gov/medlineplus/ency/article/000274.htm

2. Choledocholithiasis denotes the presence of gallstone within

the bile ducts (common hepatic duct and/or common bile
duct).
Reference: http://radiopaedia.org/articles/choledocholithiasis

3. Choledocholithiasis is a disease of the common bile duct

which forms at the junction of the cystic duct from the
gallbladder and the common hepatic duct (from liver).
Reference: http://www.myvmc.com/diseases/common-bile-duct-stone-choledocholithiasischolangitis-obstructive-jaundice/

Nursing Theories
Environmental Theory

Florence Nightingale
Nursing is an act of utilizing the environment of the patient to assist him in
his recovery that involves the nurse`s initiative to configure environmental
settings appropriate for the gradual restoration of the patient`s health, and
that external factors associated with the patient`s surroundings affect life on
biologic and physiologic process and his development.

Rationale:
Us nurses need to give care and comfort to our patient because Florence
Nightingale believed that the environment has a big participation for faster
recovery of the patient. Similar to our patient, Ling, she surrounds herself in
a good environment so that she was able to achieve faster recovery not only
with the help of the health care team but as well as the environment.

Nursing Need theory

Virginia Henderson
The Nursing Need Theory was developed by Virginia A. Henderson. To define
the unique focus of the nursing practice, the theory focuses on the
importance of increasing the patients independence to hasten their
progression in the hospital.

Rationale:
As nurses, we not only provide care for our patients but encourage the
patients ability to care for himself. This can only be attained by promoting
the patients independence. This theory was applied with our patient, Ling,
who just came from having a major operation done, Cholecystectomy, and
was limited in movement due to pain from surgery, by assisting her in
transferring from bed to chair but allowing her to use her arms and legs as
well. In due time, she will gain back her strength and be able to do things on
her own again.

Care, Cure, Core Nursing Theory

Lydia Hall

Care, cure and core are the three Cs of Lydia Hall, where care is the sole
function of nurses. The Cure and Core are shared with other members of the
health care team.

Rationale:
Us nurses give therapeutic care and provide for teaching and learning
activities to our patient. We have a goal, an intervention and planning for the
patients care in order for him/her to get well. This includes giving medication
and other means of treatments. We provide therapeutic care by educating
our patient with their health, proper self-care and by diverting the patients
attention from their pain to recovery. One way we accomplish this is by
providing entertainment and well-meaning conversations.

Developmental
Milestone
Erikson`s Stage of Psychosocial Development
Eriksons (1959) theory of psychosocial development has eight distinct stages. Like
Freud, Erikson assumes that a crisis occurs at each stage of development. For Erikson
(1963), these crises are of a psychosocial nature because they involve psychological
needs of the individual (i.e. psycho) conflicting with the needs of society (i.e. social).
According to the theory, successful completion of each stage results in a healthy
personality and the acquisition of basic virtues. Basic virtues are characteristic
strengths which the ego can use to resolve subsequent crises.
Failure to successfully complete a stage can result in a reduced ability to complete
further stages and therefore a unhealthier personality and sense of self. These stages,
however, can be resolved successfully at a later time.

Stage

Description

Result

Justification

Intimacy vs.
Isolation
Young
Adulthood
(ages 18 to 40
yrs.)

Achieved
We begin to
share
ourselves more
intimately with
others. We
explore
relationships
leading toward
longer term
commitments
with someone
other than a
family
member.
Successful
completion of
this stage can
lead to
comfortable
relationships
and a sense of
commitment,
safety, and
care within a
relationship.
Avoiding
intimacy,
fearing
commitment
and
relationships

Patient Ling is
39 years old
and married.
She is very
much happy as
a mother of
only son. She
decided to own
and run a
small sari-sari
store, to be
able to care for
her son while
also earning an
income.

can lead to
isolation,
loneliness, and
sometimes
depression.
Success in this
stage will lead
to the virtue
of love.

Kohlberg`s Theory
The significance of this theory is focused on the moral
development of an individual. Moving from an orientation of
selfishness of the law and order stage, without passing through
the good boy/girl stage. This theory helps us understand that
morality starts from the early childhood years and can be affected
by several factors.

Stage

Description

Result

Justification

Conventional
Morality Law
and Order

The stage
Achieved
where most
adolescents
and adult
frame their
moral behavior
and
understand the
importance of
others and the
basic principles
of agency part
of the society
has
established
values that
should dictate
moral
behavior.

Patient is a
hands on
mother. She
chose to teach
her only son
good values
and good
moral which
can contribute
goodness in
the society.

Havighursts Developmental Task Theory

This theory suggests six stages of life: the infancy of early
childhood which lasts from infancy to early childhood. These are

babies who are just learning to walk and talk and figuring out the
world around them. Middle childhood, lasts from ages 6 to age 12.
During this time, children become more self-sufficient as they go
to school and make friends. Adolescence, which lasts from age 13
to age 18, comes with hormonal changes and learning about
having a life partner. Early adulthood, lasts from age 19 to age 30
which involves finding an occupation, as well as finding that life
partner. Middle age, lasts from age 30 to age 60. This is the time
when most people start a family and settle into their adults lives.
Later maturity lies around the age of 60. During this time people
adjust to life after work and begin to prepare themselves for
death.

Stage

Description
Maintaining
Middle Age
economic
(36-60 yrs. old) living and
performing
civic social
responsibility
Relating to
spouse as a
person and
adjusting to
physiological
changes

Result
Achieved

Justification
Mrs. Ling has a
happy family
and lives under
one roof with
her mother &
father. She is a
full time mom
and wife. She
also runs her
very own sarisari store.

Physical Assessment
General Survey:
Assessment was done in 1:40 PM of April 20, 2016 at DMSF
hospital recovery room
Vital Signs:
Patient is lying in a supine position and conscious, weak and
appears slightly chilling, fully covered with a blanket. With IVF
plain PNSS 1L to run at 100cc x2 cycle.
CEPHALOCAUDAL: From head to toe inspection, we observed
the patients willingness to cooperate during entire period of
assessment. She is able to stand but she cannot perform extra
activity.
SKIN: The clients skin is uniform in color, no scars noted
unblemished and no presence of any foul odor. He has a good skin
turgor and skins temperature is within normal limit
HAIR: The patients scalp is lighter than the color of his skin and has
no areas of tenderness. The hair is evenly distributed thick and it has
little white hair no presence of lice, no scars noted or papules.
MOUTH: The lips of the client are uniformly pink; moist,
symmetric and have a smooth texture. There is no discoloration of
the enamels, no retraction of gums, pinkish in color of gums. The
buccal mucosa of the client appeared as uniformly pink; moist,
soft, glistening and with elastic texture. The tongue of the client is
centrally positioned. It is pink in color, moist and slightly rough.
There is a presence of thin whitish coating. The smooth palates

are light pink and smooth while the hard palate has a more
irregular texture. The uvula of the client is positioned in the
midline of the soft palate.
NOSE: The patient nose color is same as face-symmetrical
appearance- the nose is at the center no redness in the nasal
mucosa no rashes noted no nodules upon palpation.
EYE: Hair is evenly distributed. The clients eyebrows are
symmetrically aligned and showed equal movement when asked
to raise and lower eyebrows. Eyelashes appeared to be equally
distributed and curled slightly outward. There was no presence of
discharges, no discoloration and lids close symmetrically with
involuntary blinks.
EAR: The Auricles are symmetrical and has the same color with
his facial skin. The auricles are aligned with the outer canthus of
eye. When palpating for the texture, the auricles are mobile, firm
and not tender. The pinna recoils when folded. During the
assessment of Watch tick test, the client was able to hear ticking
in both ears.
NECK: The neck is in the center same with facial skin no
deformities noted no nodules noted upon palpation
THORAX: There`s no sign of deformities no discoloration. The
chest wall is intact with no tenderness and masses. Theres a full
and symmetric expansion and the thumbs separate 2-3 cm during
deep inspiration when assessing for the respiratory excursion. The
client manifested quiet, rhythmic and effortless respirations. The
spine is vertically aligned. The right and left shoulders and hips
are of the same height.
HEART: There were no visible pulsations on the aortic and
pulmonic areas. There is no presence of heaves or lifts upon
auscultation
ABDOMEN: The abdomen of the client .is no discoloration The
abdomen has a symmetric contour. flat or rounded symmetrical

bilaterally because of the presence of incision and op site

dressing
UPPER EXTREMITIES: Able to perform full ROM not swelling or
inflammation noted no discoloration. Good skin turgor no nodules
noted no rashes noted; have same size and length coordinated
movement no present of tremor.
NAILS: no discoloration no deformities, nails are clean no scar
noted no nodules noted upon palpation.
INSPECTION AND PALPATION OF LOWER EXTRIMITIES: The
extremities are symmetrical in size and length. The muscles are
not palpable with the absence of tremors. They are normally firm
or showed smooth, coordinated movements. There was no
presence of bone deformities, tenderness and swelling. There was
no swelling, tenderness and joints move smoothly.
LEGS: Feet no discoloration, no deformities, no rashes noted, no
nodules upon palpation. normal deep tendon reflex upon
percussion normal.
GERITOURINARY: Patient verbalized she has normal hair
distribution and no presence of body lice in the genitalia. We
dont include the genitals part of our patient because we respect
the decision and maintain the privacy of the patient. The
menstruation of our patient is normal 3 - 4 days she`s stated. And
there`s no presence of burning sensation when she urinates.

Anatomy and
Physiology
Your digestive system is uniquely constructed to perform its
specialized function of turning food into the energy you need to
survive and packaging the residue for waste disposal. To help you
understand how the many parts of the digestive system work
together, here is an overview of the structure and function of this
complex system.

Mouth
The mouth is the beginning of the digestive tract; and, in fact,
digestion starts here when taking the first bite of food. Chewing
breaks the food into pieces that are more easily digested, while
saliva mixes with food to begin the process of breaking it down
into a form your body can absorb and use.
Esophagus
Located in your throat near your trachea (windpipe), the
esophagus receives food from your mouth when you swallow. By
means of a series of muscular contractions called peristalsis, the
esophagus delivers food to your stomach.
Stomach
The stomach is a hollow organ, or "container," that holds food
while it is being mixed with enzymes that continue the process of
breaking down food into a usable form. Cells in the lining of the
stomach secrete a strong acid and powerful enzyme that are
responsible for the breakdown process. When the contents of the
stomach are sufficiently processed, they are released into the
small intestine.

Small Intestine
Made up of three segments the duodenum, jejunum, and ileum
the small intestine is a 22-foot long muscular tube that breaks
down food using enzymes released by the pancreas and bile from
the liver. Peristalsis also is at work in this organ, moving food
through and mixing it with digestive secretions from the pancreas
and liver. The duodenum is largely responsible for the continuous
breaking-down process, with the jejunum and ileum mainly
responsible for absorption of nutrients into the bloodstream.
Contents of the small intestine start out semi-solid, and end in a
liquid form after passing through the organ. Water, bile, enzymes,
and mucous contribute to the change in consistency. Once the
nutrients have been absorbed and the leftover-food residue liquid
has passed through the small intestine, it then moves on to the
large intestine, or colon.
Pancreas
The pancreas secretes digestive enzymes into the duodenum, the
first segment of the small intestine. These enzymes break down
protein, fats, and carbohydrates. The pancreas also makes insulin,
secreting it directly into the bloodstream. Insulin is the chief
hormone for metabolizing sugar.
Liver
The liver has multiple functions, but its main function within the
digestive system is to process the nutrients absorbed from the
small intestine. Bile from the liver secreted into the small
intestine also plays an important role in digesting fat. In addition,
the liver is the bodys chemical "factory." It takes the raw
materials absorbed by the intestine and makes all the various
chemicals the body needs to function. The liver also detoxifies
potentially harmful chemicals. It breaks down and secretes many
drugs.
Gallbladder

The gallbladder stores and concentrates bile, and then releases it

into the duodenum to help absorb and digest fats.
Colon (large intestine)
The colon is a 6-foot long muscular tube that connects the small
intestine to the rectum. The large intestine is made up of the
cecum, the ascending (right) colon, the transverse (across) colon,
the descending (left) colon, and the sigmoid colon, which
connects to the rectum. The appendix is a small tube attached to
the cecum. The large intestine is a highly specialized organ that is
responsible for processing waste so that emptying the bowels is
easy and convenient.
Stool, or waste left over from the digestive process, is passed
through the colon by means of peristalsis, first in a liquid state
and ultimately in a solid form. As stool passes through the colon,
water is removed. Stool is stored in the sigmoid (S-shaped) colon
until a "mass movement" empties it into the rectum once or twice
a day. It normally takes about 36 hours for stool to get through
the colon. The stool itself is mostly food debris and bacteria.
These bacteria perform several useful functions, such as
synthesizing various vitamins, processing waste products and
food particles, and protecting against harmful bacteria. When the
descending colon becomes full of stool, or feces, it empties its
contents into the rectum to begin the process of elimination.
Rectum
The rectum (Latin for "straight") is an 8-inch chamber that
connects the colon to the anus. It is the rectum's job to receive
stool from the colon, to let the person know that there is stool to
be evacuated, and to hold the stool until evacuation happens.
When anything (gas or stool) comes into the rectum, sensors send
a message to the brain. The brain then decides if the rectal
contents can be released or not. If they can, the sphincters relax
and the rectum contracts, disposing its contents. If the contents
cannot be disposed, the sphincter contracts and the rectum
accommodates so that the sensation temporarily goes away.

Anus
The anus is the last part of the digestive tract. It is a 2-inch long
canal consisting of the pelvic floor muscles and the two anal
sphincters (internal and external). The lining of the upper anus is
specialized to detect rectal contents. It lets you know whether the
contents are liquid, gas, or solid. The anus is surrounded by
sphincter muscles that are important in allowing control of stool.
The pelvic floor muscle creates an angle between the rectum and
the anus that stops stool from coming out when it is not supposed
to. The internal sphincter is always tight, except when stool enters
the rectum. It keeps us continent when we are asleep or
otherwise unaware of the presence of stool. When we get an urge
to go to the bathroom, we rely on our external sphincter to hold
the stool until reaching a toilet, where it then relaxes to release
the contents.

The Gallbladder

The gallbladder is a pear-shaped, hollow structure located under

the liver and on the right side of the abdomen. Its primary
function is to store and concentrate bile, a yellow-brown digestive
enzyme produced by the liver. The gallbladder is part of the
biliary tract, which are the organs and ducts that create and
store bile and release it into the duodenum (the small intestine).
The gallbladder serves as a reservoir for bile while its not being
used for digestion. The gallbladder's absorbent lining
concentrates the stored bile. When food enters the small
intestine, a hormone called cholecystokinin is released, signaling
the gallbladder to contract and secrete bile into the small
intestine through the common bile duct.
The bile helps the digestive process by breaking up fats. It also
drains waste products from the liver into the duodenum, a part of
the small intestine.
An excess of cholesterol, bilirubin, or bile salts can cause
gallstones to form. Gallstones are generally small, hard deposits
inside the gallbladder that are formed when stored bile
crystallizes. A person with gallstones will rarely feel any
symptoms until the gallstones reach a certain size, or if the

gallstone obstructs the bile ducts. Surgical removal of the

gallbladder (cholecystectomy) is the most common way to treat
gallstones.

The cystic duct joins the gallbladder to the bile duct and is one of
the important structures needing proper identification and
division during a standard cholecystectomy. The cystic duct may
run a straight or a fairly convoluted course. Its length is variable
and usually ranges from 2 to 4 cm. Around 20% of cystic ducts
are less than 2 cm. Hence there may be very little space to put
clips or ligatures. True absence of the cystic duct is extremely rare
and if the duct is not seen is more likely to be hidden. The cystic
duct is usually 23 mm wide. It can dilate in the presence of
pathology (stones or passed stones). The normal bile duct is also
around 5 mm and hence can look like a mildly dilated cystic duct.

In general, a cystic duct larger than 5 mm (or the need to use a

very large clip to completely occlude the duct) should arouse a
suspicion of mistaken identity with the bile duct before it is
clipped or ligated.
The cystic duct joins the gallbladder at the neck and this angle
may be fairly acute. Also the mode of joining may be smooth
tapering or abrupt. On the bile duct side its mode of union shows
significant variations. Since such variations are not uncommon it
may not be safe to try and dissect the cystic duct to its junction
with the bile duct. It is important to remember that even in the
low insertion variety the cystic duct rarely goes behind duodenum
and therefore a ductal structure passing behind the duodenum is
more likely to be the bile duct itself. Double cystic ducts are
described but are exceedingly rare and therefore two ductal
structures entering the gallbladder should always be viewed with
suspicion. Also the cystic duct does not have vessels traveling on
its surface whereas the bile duct has such visible vessels.

C
holecystitis (ko-luh-sis-TIE-tis) is inflammation of the gallbladder.
Your gallbladder is a small, pear-shaped organ on the right side of

your abdomen, beneath your liver. The gallbladder holds digestive

fluid that's released into your small intestine (bile).
In most cases, gallstones blocking the tube leading out of your
gallbladder cause cholecystitis. This results in a bile buildup that
can cause inflammation. Other causes of cholecystitis include bile
duct problems and tumors. If left untreated, cholecystitis can lead
to serious, sometimes life-threatening complications, such as a
gallbladder rupture. Treatment for cholecystitis often involves
gallbladder removal

Etiology
PREDISPOSING
FACTOR

PRESENT/ABSEN
T

RATIONALE

JUSTIFCATION

Women
between 20 60 years of
age are twice
as likely to
develop
gallstone
than men.
Female
Estrogen
increases
cholesterol
levels in bile
and decrease
gallbladder
movement;
both of which
can lead to
gallstone

The patient is
female.

formation.

Age: 39 Years
Old

Race: Asian

Many of the
bodys
system and
protective
mechanism
become less
efficient with
age.
Body system
and
processes
become
sluggish.
Asians are
more
genetically
predisposed
to having
pigmented
stones
compared to
those living in
Western
Countries.
Patient with
diabetes
generally
have high

The patient is
39 years old.

Our patient is
Filipino.

Diabetes
Mellitus

PRECIPATATING
FACTOR

Pregnancy

X
PRESENT/ABSEN
T

Pills

Rapid
Weight
Loss

levels of fatty
acids called
Triglyceride.
These fatty
acids
increase the
risk for
gallstone
formation.
RATIONALE
Excess
estrogen from
pregnancy
increases risk
of gallstone
formation.
Birth control
pills appears
to increase
cholesterol
levels in bile,
resulting in
the decrease
of gallbladder
movement;
both of which
can lead to
gallstone
formation.
The body
metabolizes
fat during
weight loss,
which causes

The patient
has no
diabetes.

JUSTIFICATION

The patient is
not pregnant.

The patient is
using birth
control pills.

No rapid
weight loss
was noted by
the patient.

Pain

Pain

the liver to
secrete extra
cholesterol
into the bile,
contributing
to gallstone
formation.
Obesity most
likely tends to
reduce the
amount of
bile salt in
bile, resulting
in more
cholesterol
build up.
Obesity
decreases
gallbladder
emptying.
Pain that is
localized to
the
epigastrium
or RUQ,
sometimes
radiating to
the right
scapular tip
because of
forming of
stone in the
gallbladder.

The patient is
obese.

The patient
verbalized that
the pain is
present in the
RUQ of the
abdomen and
radiates to the
back of the
shoulder.

Chills

Nausea and
Vomiting

When the
common bile
duct becomes
Our patient
clogged by a
verbalized
gallstone,
that it is very
there is
cold.
blockage of
bile to the
common bile
duct.
Symptoms
and
The patient
complications always vomits
result from
effects
occurring
within the
gallbladder or
from stones
that escape
the
gallbladder to
lodge in the
CBD.

Symptomatology
SYMPTOMS

Pain in the
RUQ that
radiates to
the back of
the shoulder

PRESENT/ABSENT

RATIONALE

JUSTIFICATION

Pain that is
localized to
the
epigastrium
or right upper
quadrant,
sometimes
radiating to

The patient
verbalized that
the pain is
present in the
RUQ of the
abdomen and

the right
scapular tip
because of
forming of
stone in the
gall bladder
Symptoms
and
complications
result from
effects
occurring
within the
gallbladder or
from stones
that escape
the
gallbladder to
lodge in the
CBD.

Nausea &
Vomitting

Jaundice

Dark Urine

radiate to the
back of the
shoulder

The patient
always vomits

Not present
with our
patient

Not present
with our
patient

Fever

Chills

Not present
with our
patient

When the
common bile
duct clogged
by a gall stone
there was a
blockage of
bile in the
common bile
duct

Our patient
said
that its very
cold

Pathophysiology

Doctors Order
MEDICAL ORDER SHEET
Patient Name: Mrs. Ling
Age: 39 years old
Gender: Female
Admission Date: April 18, 2016

Date and Time

BP- 120/80 mmHg

Doctors Order
VSq4

PR- 78 bpm
RR- 20 cpm
T- 36.1*c
WT- 67.6 kg

IVF PNSS 1L @
100/hr.

Rationale
-To have a baseline
data.

Right arm.

-To replace fluid

balance patient is
NPO or cant drink
any fluid.

LSLF

-To reduce the

formation of the
stone.

HT- 143 cm

CBC

Tramadol

April 19, 2016

ERCP

IVF PNSS 1L @ 100

cc/hr

-Blood test used to

evaluate your
overall health and
detect a wide range
of disorder.
-Our patient is
experiencing pain,
Tramadol is an
analgesic which
relieves pain.
-Is the technique
that uses x-ray to
view patient Lings
bile and pancreatic
duct.

X-RAY for the lungs

-To replace fluid or

hydration for our
patient.

Anesthesia pre-op

-Is an imaging test

that uses radiation
to look at the lungs
of our patient.

Ampimax

-Is to provide
framework for
considering cardiac
risk of non-cardiac
surgery in a variety
of the patient and

operative.
NPO post- midnight
-Treatment for
following infection.
4/19/16

IVF- PNSS 1 L
@100cc/hr

ERCP today.

-To prevent nausea

and vomiting.

Tranexamic.
-Replacement of
fluid.

Omeprazole.
4/19/16
Metoclopramide.

-S/P ERCP.

-is the techniques

that uses X-ray to
view patient, and
bile pancreatic.
-Prevent excessive
nausea and
vomiting.

-back to the room.

6/20/16

NPO 4hrs.

-VSq30 once stable.

-To prevent
excessive bleeding.

-is used to treat

-Ampimax

-UDCA

-Omeprazole

-Tranexamic Acid

nausea and
vomiting.
-done ERCP.

-Prevent nausea and

vomiting after the
procedure.
-for monitoring.
-antibacterial.

-To help dissolve

stones from the
CBD.
-Prevent excessive
bleeding.

-to treat nausea and

vomiting.

Diagnostic and Lab

Results
Name: Mrs. Ling
Date: April 18, 2016

Physician: Dr. Velasco

Room: 324 4

CHEMICAL CHEMISTRY
Test Name

Result

Unit

SGPT/ALT

# 152

u/L

Range
Reference
0.00-3400

Rationale Justificati
on

Remarks: Sample run twice-control in range.

BLOOD CHEMISTRY
Test

Results

Unit

Sodium

135.6

mmol/L

Normal
Value
135-148

Potassium

3.57

mmol/L

3.5-5.3

Calcium

1.15

mmol/L

1.13-1.15

mmol/L

95-108

Chlorine

Rationale
Used to
detect
abnormal
concentrat
ion of the
urine.
This test
measures
the
amount of
potassium
in fluid
protein.
Is ordered
to screen
for
diagnose.
Is used to
detect
abnormal
concentrat
ion of

Magnesium

mmol/L

0.74-0.99

chloride.
Used to
measure
the level
of
magnesiu
m in the
blood.

HEMATOLOGY
Test

Result

Hemoglobin

121

Hematocrit

0.36

Norm
Clinical Indication
al
Values
120Measures the amount of
150
Hemoglobin in your blood
hemoglobin is a protein in
your red blood cells and
used to detect low
hemoglobin and describe as
being anemic, nutritional
iron polycythemia etc.
0.38- The ratio of the volume of
0.40
red blood cells to the total
volume of blood.
Decreased,
Bleeding, bone marrow
Nutritional problems.
When increase COPD
congenital heart disease or
severe dehydration.

Erythrocytes

4.20

4.06.0

Red blood cells (RBCs), also

called erythrocytes, are the
most common type of blood
cell and the vertebrae
organism's principal means
of delivering oxygen (O2) to
the bodys tissues.
Decrease chronic heart
failure sickle cell anemia.
Spherocytosis, High Fibrogen
Anemia.

Leukocytes

6.1

5.010.0

A colorless cell that

circulates in the blood and
body fluids and is involved in
counteracting foreign
substances and disease.
Decreased

Leukemia

Tuberculosis

Hyperplenism

MCV

85

80100

MCH

29

27-32

MCHC

34

32-36

Neutrophil

0.56

0.450.65

Neutrophil (also known

as neutrophils or
occasionally neutrocytes)
are the most abundant type
of granulocytes and the most
abundant (40% to 75%) type
of white blood cells in most
mammals. They form an
essential part of the innate
immune system.

Decrease:
Ulcers
Abscesses (collections
of pus)

Rashes

Wounds that take a

long time to heal.
Lymphocytes

0.35

0.200.35

A form of small leukocyte

(white blood cell) with a
single round nucleus,
occurring especially in the
lymphatic system.
Decrease
The number of lymphocytes
can temporarily decrease
during
Certain viral infections
(such as influenza and
hepatitis)
Fasting
Times of severe
physical stress
Use of corticosteroids
(such as prednisone)
Chemotherapy and/or

radiation therapy for

cancer
Monocyte

0.06

0.020.06

Monocytes are a type

of white blood cells,
or leukocyte. They are the
largest type of leukocyte,
and differentiates into: macr
ophages;
dendritic cells; and foam
cells. As a part of
the vertebrate innate
immune system monocytes
also influence the process
of adaptive immunity.

Decrease:
When monocytes decrease
infections include flu-like
symptoms,
coughing,
sore throat,
chills and fever,
frequent urination.
Eosinophil

0.03

0.020.4

Eosinophils are a type of

disease-fighting white blood
cell.
Decrease
Chronic myelogenous

leukemia, Churg-Strauss
syndrome, Crohn's disease,
Drug allergy, Eosinophilic
leukemia, Hay fever,
Hodgkin's lymphoma
(Hodgkin's disease)
Basophil

0.00

0.000.01

Basophil is a type of white

blood cell. They are the least
common of the granulocytes,
representing about 0.5 to 1%
of circulating white blood
cells. But they are the
largest granulocytes. They
are responsible for
inflammatory reactions
during immune response of
acute and chronic allergic
diseases.
Decreased
in anaphylaxis,
asthma,
atopic dermatitis
hay fever

Thrombocytes 235

150-450

Platelets, also
called thrombocytes
(thromb + cyte, "blood
clot cell"), are a
component of blood
whose function is to
stop bleeding by
clumping and clotting
blood vessel injuries.
Decreased
Bruising easily.
Tiny red spots, or
petechiae, under the
skin.
Unusual bleeding from
the gums or nose.
A lot of or long-lasting
bleeding from a small
cut or injection site.
Blood in the urine,
which may look pink,
red or brown
blood in the stool or
black-colored stool.
Vomiting blood or
something that looks
like coffee grounds.
Vaginal bleeding that
is different from and
lasts longer than the

normal menstrual
period.
Constant headache,
blurred vision or
change in level of
consciousness.

URINALYSIS
Parameters
Range Unit
Physical
Examination
Color

Result
Reference
Range
Light
Yellow

Clarity

Clear

Chemical
Analysis
pH

7.0

Results
Reference

Rationale

The color of
the urine is
helpful in
predicting the
concentration
of the
specimen.
Useful in
predicting the
presence of
the
contaminants
such as cells
or mucus.
Urine pH level
test is a test
that analyzes
the acidity or
alkalinity.

Specific Gravity

1.0%

Glucose

Negative

Protein

Negative

Urine
Flowcytometry
WBC

Is a measure
of the
concentration
of the solute in
the urine.
Test measures
the level of
glucose or
sugar in your
urine.
A protein urine
test measures
the amount of
the protein in
the urine.

3
017/uL

1
0-3

RBC

1
017/uL

0
0-3

Epith Cells

3
017/uL

1
0-3

Cast

Bacteria

0-

0-

1/uL

0
03

115 0278/uL

21
50

0-

Is help to
diagnose and
infection.
To check if
there was
bleeding.
Used in guided
tissue
regeneration.
Urinary casts
are tiny tube
shaped
particles that
can be found
when urine is
examined
under the
microscope.
To check what
specific

bacteria.
To identify if
there was a
serious
condition that
medical
needs.
Is the rationale
for urinary
alkalization in
patient.

Mucus Thread

Crystal

Drug Study
SULTAMICILLIN

Brand: Ampimax, Alfasid, Ampisid, Amplipen, Bactesul, Bactesyn,

Bitammon, Combicid, Devasid, Duobak, Duobaktam, Duocid,
Fipexiam, Nobecid, Picyn, Sulamp, Sulbamox IBL, Sulcid, Sultamat,
Sultamicilina, Sultasid, Sultibac, Unacid PD oral, Unasyna,
Viccillin-SX, Ampigen SB, Begalin, Bitammon, Sinif, Unacid PD
oral, Unasyn
Generic: Sultamicillin Tocilate
Classification: antibiotic
Dosage: Oral dosage
For treating Urinary Tract infections, respiratory tract infections
and Otitis media:
In case of adults: 375 to 750 mg to be used at regular intervals.
For children below 30 Kg: 25 to 50 mg per kilogram per day in 2
separated doses;

For children above 30 Kg: 375 to 750 mg to be used at regular

intervals.
Uncomplicated gonorrhea
Adult: 2.25 g of Sultamicillin along with probenecid 1 g.

Mode of Action: Chemical Effect: Inhibits beta lactamases in

penicillin-resistant microorganisms and it acts against sensitive
organisms during the stage of active multiplication by inhibiting
biosynthesis of cell wall mucopeptide Therapeutic Effect: Kills
susceptible bacteria Oral Onset: unknown Peak: 2 hr Duration: 6-8
hr
Indication: Uncomplicated gonorrhea, Otitis media, Respiratory
tract infection
Contraindication: hypersensitive to drug or any other penicillins,
use cautiously in patients with other drug allergies (especially to
cephalosporins) because of possible cross-sensitivity and in those
with mononucleosis because of high risk of maculopapular rash
Side Effects: CNS: thrombophlebitis, vein irritation GI: nausea,
vomiting, diarrhea glossitis, stomatitis, black hairy tongue,
enterocolitis Hematologic: anemia, thrombocytopenia, purpura,
eosinoophilia, leukopenia, agranulocytosis Skin: pain at injection
site Other: hypersensitivity reactions, anaphylaxis, overgrowth of
nonsusceptible organisms
Nursing Responsibilities:
1. Assess hypersensitivity to drug or other penicillins
2. Assess patients infection before starting therapy
3. Obtain specimen for culture and sensitivty
References/Source: Mosbys Nursing Drug Reference 2001

OMEPRAZOLE

Brand: Losec, Prilosec, Prilosec OTC, Zegerid

Generic: Omeprazole
Classification: substituted benzimidazole
Dosage: Adults with GERD who are unresponsive to H2-receptor
antagonist: 20 mg P.O. daily for 4 8 weeks. May increase dosage
to 40mg daily if needed and extend therapy up to 12 weeks.
Action: Chemical effect: Inhibits acid (proton) pump and
Children 2 to 16 years weighing less than 20 kg: 10 mg P.O daily
Children 2 to 16 years weighing 20 kg or more: 20 mg P.O daily
Indication: Erosive esophagitis; symptomatic, poorly responsive
gastroesophageal reflux disease (GERD); Pathologic

hypersecretory conditions (such as Zollinger-Ellison syndrome);

Duodenal ulcer; Gastric ulcer; Heartburn on 2 or more days per
week; Posterior laryngitis
Contraindications: Contraindicated in patients hypersensitive to
the drug or any of its components. In pregnant women, use
cautiously. In breast-feeding women, use cautiously; its unknown
if the drug appears I breast milk. In children ages 2 to 16 years,
drug may be used to treat GERD, erosive esophagitis, and for
maintenance of healing in erosive esophagitis (tablets and
capsules only).
Drug Interactions: Ampicillin esters, iron derivatives,
ketoconazole: May decrease absorption. Give separately.
Clarithromycin: May increase level of either drug. Monitor patient
for drug toxicity. Diazepam, phenytoin, warfarin: May decrease
hepatic clearance of these drugs, possibly leading to increased
levels. Monitor patient closely. Sucralfate: May delay absorption
and reduce omeprazole bioavailability. Separate administration
times by 30 minutes or more.
Adverse Effects: dizziness, headache, abdominal pain,
constipation, diarrhea, flatulence, nausea, vomiting, back pain,
cough, rash
Nursing Responsibilities:
1 Assess patients condition before starting therapy and
regularly thereafter to monitor drugs effectiveness.
2 Be alert for adverse reactions and drug interactions.
3 If adverse GI reaction occurs, monitor patients hydration.
4 Assess patients and familys knowledge of drug therapy
5 Give tablets or capsules 30 minutes before meals; powder
for oral suspension 1 hour before meals.
6 Use 2 tbs of water to mix 1 packet of powder for oral
suspension; dont use any other liquids or food
7 Lower doses arent needed for patients with renal or hepatic
impairment

8 Explain importance of taking drug exactly as prescribed.

9 Warn patient not to crush or chew tablets or capsules.
10Explain to patient how to reconstitute powder for oral
suspension: Empty packet contents into a small cup
containing 2 tbsp. of water; stir well and drink immediately.
Refill cup with water and drink.
References/Sources: Springhouse Nurses Drug Guide 2008
pg.921

TRAMADOL

Generic Name: Tramadol

Brand Name: Ultram, Ultram ER
Indications: Carbamazepine (Tegretol, Tegretol XR, Equetro
Carbatrol)reduces the effect of tramadol by increasing its
inactivation in the body. Quinidine (Quinaglute, Quinidex) reduces

the inactivation of tramadol, thereby increasing the concentration

of tramadol by50%-60%. Combining tramadol with
monoamineoxidase inhibitors (for example, Parnate) or selective
serotonin inhibitors (SSRIs, for example, fluoxetine Prozac]) may
result in severe side effects such as seizures or a condition called
serotonin syndrome.
Contraindications: Tramadol may increase central nervous system
and respiratory depression when combined with alcohol,
anesthetics, narcotics, tranquilizers or sedative hypnotics.
Actions: Tramadol is used in the management of mode rate to
mode rate severe pain. Extended release tablets are used
for moderate to moderately severe chronic pain in adults who
require continuous treatment for an extended period.
Side effects: Tramadol is generally well tolerated, and side effects
are usually transient. Commonly reported side effects include
nausea, constipation, dizziness, headache, drowsiness, and
vomiting. Less commonly reported side effects include itching,
sweating, dry mouth, diarrhea, rash, visual disturbances, and
vertigo. Some patients who received tramadol have reported
seizures. Abrupt withdrawal of tramadol may result in anxiety,
sweating, insomnia, rigors, pain, nausea, diarrhea, tremors, and
hallucinations.
Nursing Responsibilities:
1. Assess type, location, and
intensity of pain before and 2-3 hr (peak) after administration.
2. Assess BP & RR before and periodically during
administration. Respiratory depression has not occurred with
recommended doses.
3. Assess bowel function routinely. Prevention of constipation
should be instituted with increased intake of fluids and bulk
and with laxatives to minimize constipating effects.
4. Assess previous analgesic history. Tramadol is not
recommended for patients dependent on opioids or who
have previously received opioids for more than 1 wk; may
cause opioid withdrawal symptoms.

5. Prolonged use may lead to physical and psychological

dependence and tolerance, although these may be milder
than with opioids. This should not prevent patient from
receiving adequate analgesia. Most patients who receive
tramadol for pain d not develop psychological dependence. If
tolerance develops, changing to an agonist may be required
to relieve pain.
6. Tramadol is considered to provide more analgesia than
codeine 60 mg but less than combined
aspirin650mg/codeine 60 mg for acute postoperative pain.
7. Monitor patient for seizures.
8. May occur within recommended dose range. Risk increased
with higher doses and inpatients taking antidepressants
(SSRIs, tricyclics, or Mao inhibitors), opioid analgesics, or
other drugs that decrease the seizure threshold.
9. Overdose may cause respiratory depression and seizures.
Naloxone (Narcan)may reverse some, but not all, of the
symptoms of overdose. Treatment should be symptomatic
and supportive. Maintain adequate respiratory exchange.
10.
Encourage patient to cough and breathe deeply every 2
hr to prevent atelactasis and pneumonia.

METOCLOPRAMIDE

Brand Name: Plasil

Generic Name: Metoclopramide
Indication: prevention of chemotherapy-induced emesis,
treatment of postsurgical and diabetic gastric stasis, facilitation of
small bowel intubations in radiographic procedures, management
of esophageal reflux, treatment and prevention of postoperative
nausea and vomiting when nasogastric suctioning is undesirable
Drug Classification: Anti-emetics
Mechanism of Action: it blocks dopamine receptors and makes the
GI cells more sensitive to acetylcholine, leading to increased GI
activity and rapid movement of food through the upper GI tract.
Dosage: Tab Adult: 1tab tid, Syr Adult: 10 ml tid, children: 5-14 yr
2.5-5 mg tid, 3-5 yr 2mg bid
Special precaution: patients with history of depression, diabetic
patients, pregnancy and lactation children and geriatric patients
Pregnancy risk category: B
Adverse reaction: CNS: drowsiness, extrapyramidal reactions,
restlessness, anxiety, depression, irritability, tardive dyskinesia

CV: arrhythmias, hypertension, hypotension GI: constipations,

diarrhea, dry mouth, nausea Endo: gynecomastia
Contraindicated to: hypersensitivity, possible obstruction or
hemorrhage, history of seizure disorders, pheochromocytoma,
Parkinsons disease
Form: solution (oral concentrate), syrup (sugar free), tablet,
ampule
Nursing responsibilities:
1. Assess client for abdominal pain distention, bowel sound
2. Assess client for extrapyramidal reactions
3. Monitor for tardive dyskinesian
TRANEXAMIC ACID

Brand Name: Hemostan

Generic Name: Tranexamic Acid
Indications: antihemorrhagic and antifibrinolytic for effective
hemostasis in various surgical and clinical cases, in traumatic
injuries, post-tooth extraction and other dental procedures.

Drug Classification: Antihemophilic Agent

Mechanism of Action: Forms a reversible complex that displaces
plasminogen from fibrin resulting in inhibition of fibrinolysis, it
also inhibits the proteolytic activity of plasmin
Dosage: Capsule: 250 500 mg tid-qid. Injections: 250-500mg IM,
or by slow IV inj bid tid. During or after operation, 500-2500mg if
necessary by IV drip.
Special precaution: Not advisable to use for prolonged periods in
patients predisposed to thrombosis. Not recommended for
prophylaxis during pregnancy and before delivery. Opthalmic
exam before and during therapy required if patient is treated
beyond several days; caution in patients with cardiovascular,
renal, cerebrovascular disease.
Pregnancy risk category: B
Adverse reaction: GI disorders: nausea, vomiting. CNS: anorexia,
headache impaired renal insufficiency, hypotension when IV
injection is too rapid.
Contraindication: patients predisposed to thrombosis. Prophylaxis
during pregnancy and before delivery.
Form: 100mg/ml (10 mL) injection; 500mg tablet
Nursing Responsibility:
1. Dosage modification required in patients with renal
impairment
2. Watch out for any signs of bleeding
Reference/Sources:
https://www.scribd.com/doc/201340912/Tranexamic-Acid-drugstudy

URSODEOXYCHOLIC ACID

Brand:
Generic Name: Ursodiol, UDCA
Classification:
Indications: Note: Bracketed information in the indications section
refers to uses that are not included in U.S product labeling
Mechanism of Action: AnticholelithicAlthough the exact
mechanism of ursodiol's anticholelithic action is not completely
understood, it is known that when administered orally ursodiol is
concentrated in bile and decreases biliary cholesterol saturation
by suppressing hepatic synthesis and secretion of cholesterol, and
by inhibiting its intestinal absorption. The reduced cholesterol

saturation permits the gradual solubilization of cholesterol from

gallstones, resulting in their eventual dissolution.
Adverse Effects: Ursodiol increases bile flow. In chronic cholestatic
liver disease, ursodiol appears to reduce the detergent properties
of the bile salts, thus reducing their cytotoxicity. Also, ursodiol
may protect liver cells from the damaging activity of toxic bile
acids (e.g., lithocholate, deoxycholate, and chenodeoxycholate),
which increase in concentration in patients with chronic liver
disease.
Precautions to Consider
Cross-sensitivity and/or related problems
Patients sensitive to other bile acid products may be sensitive to
ursodiol also {01} {13}.
Carcinogenicity/Tumorigenicity
Studies in rats with intrarectal instillation of lithocholic acid and
other metabolites of ursodiol and chenodiol did not show
evidence of tumorigenicity, except when these substances were
administered in conjunction with a carcinogenic agent.
Epidemiologic studies suggest that bile acids might be involved in
the pathogenesis of human colon cancer in patients who have
undergone a cholecystectomy; however, conclusive evidence is
lacking. {01} {05}
Pregnancy/Reproduction
Pregnancy
Adequate and well-controlled studies have not been done in
humans {05}.
Studies in rats at doses 20 to 100 times the human dose, and in
rabbits at doses 5 times the human dose, have not shown that

ursodiol causes adverse effects in the fetus.

FDA Pregnancy Category B.
Breast-feeding
It is not known whether ursodiol is distributed into breast
milk {05} {13}. However, problems in humans have not been
documented.
Pediatrics
Appropriate studies on the relationship of age to the effects of
ursodiol when used as an anticholelithic have not been performed
in the pediatric population. However, studies performed to date in
children and infants with cholestatic liver disease and biliary
atresia have not demonstrated pediatrics-specific problems that
would limit the usefulness of ursodiol in children. {33} {34} {40}
Geriatrics
Appropriate studies on the relationship of age to the effects of
ursodiol have not been performed in the geriatric population.
However, geriatrics-specific problems that would limit the
usefulness of this medication in the elderly are not expected. {13}
Drug interactions and/or related problems
The following drug interactions and/or related problems have
been selected on the basis of their potential clinical significance
(possible mechanism in parentheses where appropriate)not
necessarily inclusive ( = major clinical significance):
Reference/Sources: http://www.drugs.com/mmx/ursodeoxycholicacid.html

Medical & Surgical

Management
ERCP (Endoscopic Retrograde Cholangio-Pancreatography)
ERCP is a procedure that enables your physician to examine the
pancreatic and bile ducts. A bendable, lighted tube (endoscope)

about the thickness of your index finger is placed through your

mouth and into your stomach and first part of the small intestine
(duodenum). In the duodenum a small opening is identified
(ampulla) and a small plastic tube (cannula) is passed through the
endoscope and into this opening. Dye (contrast material) is
injected and X-rays are taken to study the ducts of the pancreas
and liver.
PROCEDURE
You lie on your side on a couch. The doctor will ask you to swallow
the first section of the endoscope. Modern endoscopes are quite
thin (thinner than an index finger) and quite easy to swallow. The
doctor then gently pushes it down your esophagus into your
stomach and duodenum.
The doctor looks down the endoscope via an eyepiece or on a TV
monitor which is connected to the endoscope. Air is passed down
a channel in the endoscope into the stomach and duodenum to
make the lining easier to see. This may make you feel 'full' and
want to belch.
The endoscope also has a 'side channel' down which various
tubes or instruments can pass. These can be manipulated by the
doctor who can do various things. For example:
Inject a dye into the bile and pancreatic ducts. X-ray pictures
taken immediately after the injection of dye show up the detail of
the ducts. This may show narrowing (stricture), stuck gallstones,
tumors pressing on the ducts, etc.
Take a small sample (biopsy) from the lining of the duodenum,
stomach, or pancreatic or bile duct near to the papilla. The biopsy

sample can be looked at under the microscope to check for

abnormal tissue and cells.
If the X-rays show a gallstone stuck in the duct, the doctor can
widen the opening of the papilla to let the stone out into the
duodenum. A stone can be grabbed by a 'basket' or left to be
passed out with the stools (feces).
If the X-rays show a narrowing or blockage in the bile duct, the
doctor can put a stent inside to open it wide. A stent is a small
wire-mesh or plastic tube. This then allows bile to drain into the
duodenum in the normal way. You will not be aware of a stent,
The endoscope is gently pulled out when the procedure is
finished. An ERCP can take anything from 30 minutes to over an
hour, depending on what is done.

CHOLECYSTECTOMY
Cholecystectomy (koh-luh-sis-TEK-tuh-me) is a surgical procedure
to remove your gallbladder a pear-shaped organ that sits just
below your liver on the upper right side of your abdomen. Your
gallbladder collects and stores bile a digestive fluid produced in
your liver.

Cholecystectomy may be necessary if you experience pain from

gallstones that block the flow of bile. Cholecystectomy is a
common surgery, and it carries only a small risk of complications.
In most cases, you can go home the same day of your
cholecystectomy.

Cholecystectomy is most commonly performed by inserting a tiny

video camera and special surgical tools through four small
incisions to see inside your abdomen and remove the gallbladder.
Doctors call this laparoscopic cholecystectomy. In some cases,

one large incision may be used to remove the gallbladder. This is

called an open cholecystectomy.

PROCEDURE
Placement of ports and instruments
A 1.5-cm longitudinal incision is made at the inferior aspect of the
umbilicus, then deepened through the subcutaneous fat to the
anterior rectus sheath. A Kocher clamp is used to grasp the
reflection of the linea alba onto the umbilicus and elevate it
cephalad.
A 1.2-cm longitudinal incision is made in the linea alba with a No.
15 blade. Two U stitches, one on either side of the fascial incision,
are placed with 0 polyglactin suture on a curved needle.
The peritoneum is elevated between two straight clamps and
incised so as to afford safe entry into the abdominal cavity. An 11mm blunt Hasson trocar is placed into the abdominal cavity, and
insufflation of carbon dioxide is initiated to a maximum pressure
of 15 mm Hg.
A 1.2-cm incision is made three fingerbreadths below the xiphoid
process and deepened into the subcutaneous fat. An 11-mm
trocar is advanced into the abdominal cavity under direct vision
(see the image below) in the direction of the gallbladder through
the abdominal wall, with care taken to enter just to the right of
the falciform ligament.
The table is then adjusted to place the patient in a reverse
Trendelenburg position with the right side up to allow the small
bowel and colon to fall away from the operative.

Treatment
Treating gallstones in the bile duct focuses on relieving the
blockage. These treatments may include:

stone extraction
fragmenting stones (lithotripsy)
surgery to remove the gallbladder and stones

(cholecystectomy)

surgery that makes a cut into the common bile duct to

remove stones or help them pass (sphincterotomy)

biliary stenting
The most common treatment for gallstones in the bile duct is
biliary endoscopic sphincterotomy (BES). During a BES procedure,
a balloon- or basket-type device is inserted into the bile duct and
used to extract the stone or stones. About 85 percent of bile duct
stones can be removed with BES (Attasaranya et al., 2008).

If a stone does not pass on its own or cannot be removed with

BES, doctors may use lithotripsy. This procedure is designed to
fragment stones so they can be captured or passed easily.
Patients with gallstones in the bile duct and gallstones still in the
gallbladder may be treated with cholecystectomy (gallbladder
removal). While performing the surgery, your doctor will also
inspect your bile duct to check for remaining gallstones.
If stones cannot be removed completely or you have a history of
gallstones causing problems but do not wish to have your
gallbladder removed, your doctor may place biliary stents (tiny
tubes to open the passage). These will provide adequate drainage
and help prevent future choledocholithiasis episodes. The stents
can also prevent biliary sepsis (inflammation) and infection.

Discharge Planning &

Health Teaching
M edicine
Advice patient to continue taking his prescribed
medications such as: Sultamicillin and Tramadol.
E nvironmental and Exercise
Maintain a quiet and pleasant environment to
promote relaxation.
Provide clean and comfortable environment.
Encourage walking every day.

T reatment
Continue home medications.
Teach patient about wound care.
Encourage patient to take multivitamins for
immunity.
H ealth Teaching
Provide written and oral instruction about wound
care, activity, diet recommendations, medication
and follow up visits.
Instruct patient to limit his activity for 24 to 48 hrs.
after discharge.
O ut Patient Follow Up
Patient will be advised to go back in the hospital in a
specific date to have followup checkup after
discharge.
Consult doctors for are any problems or complication
encountered.
D iet
Encourage patient to increase protein intake for
tissue repair.
Advice patient to eat smaller-than-normal amount of
at mealtime.
S piritual
Encourage patient to communicate with God.
Encourage patient to communicate with other
people.

Nursing Care Plan

DATE
AND

ASSESSME
NT

NURSING
DIAGNOSI

N
E

PLANNING

IMPLEMENTATION
/

EVALUATION

TIME
April 19,
2016
8:00 AM

S
Subjective:
Patient
verbalized
sakit ilihok
akong kilid
sa tuo.

Acute pain
related to
surgical
incision
secondary
to
cholecyste
ctomy

E
D
C
O
G
N
I
T
I
V
E

Objective:

Pain
scale
of 8

Gene
ralize
d
weak
ness
noted

Restl
essne
ss
noted

Diffic
ulty
sleep
ing
noted

P
E
R
C
E
P
T
U
A
L
P
A
T
T
E
R
N

INTERVENTION
At the end of 2-4
hours of my
care, patient will
be relieved from
pain as
evidenced by:
a.) Verbalizin
g pain
scale of 3
or below
b.) be able
to move
more
without
discomfo
rt

1.) Establish
rapport with
patient.
R: Gain trust
for
cooperation.
2.) Monitor VS.
R: To have
baseline
data.
3.) Provide
privacy to
patient.
R: Respect
for
individuals
status.
4.) Teach
patient to
do proper
handwashin
g.
R: Prevent
spread of
microorgani
sms.
5.) Note
response to
medication
and report
to
physicians if
pain is not
being
relieved.
R: Severe
pain not
relieved by
routine
measures
may
indicate
developing
complicatio
n or need
further
intervention
.
6.) Promote
bed rest
allowing
patient to

GOAL MET:
At the end of
4 hours of my
shift, patient
was able to
verbalize
pain scale of
3 and be able
to move
without
complaining
of pain.

assume
position of
comfort.
R: Reduces
irritation
and bed
sores.
7.) Instruct
patient not
to touch the
incision.
R: Avoid
infection.
8.) Instruct
patient to
do 15 min
ROM
exercises.
R:
Strengthen
muscles.
Improve
blood
circulation.

DATE
AND
TIME
April 19,
2016
8:00 AM

ASSESSME
NT

Subjective:
Patient
verbalized
Sige
matandog
akong kilid,
nahadlok ko
basin ma
unsa.
Objective:

Verba
lizati
on of
probl
em

Grim
ace

NURSING
DIAGNOSI
S
Deficient
knowledge
about selfcare
activities
related to
incision
care.

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

PLANNING

IMPLEMENTATION/
INTERVENTION

EVALUATION

After the end

of my shift,
patient
should:

1.) Establish
rapport.
R: Gain trust
and
cooperation.
2.) Monitor VS.
R: To have
baseline
data.
3.) Teach patient
proper
handwashing
technique.
R: Prevent
spread of
microorganis
ms.
4.) Discuss with
the patient
how to follow
self-care
routine.

GOAL MET:
At the end of
shift, patient
fully
understood
simple
techniques of
proper selfcare and
demonstrated
it
independently
by performing
self-care
routines and
exercises.

a.) Verbali
ze
underst
anding
of selfcare
routine
.
b.) Avoid
inappro
priate
actions
that
may
cause
irritatio
n or

face
as
obser
ved

T
E
R
N

infectio
n.

5.)

Cohe
rent

6.)

7.)

8.)

9.)

DATE
AND
TIME
April 19,
2016
8:00 AM

ASSESSME
NT

NURSING
DIAGNOSI
S

Subjective:
Naga-kulba
ko basig
magka
problema
akong

Fear/Anxie
ty related
to lack of
understan
ding of

N
E
E
D
S
E
L
F
P
E

PLANNING

After 2-4
hours of my
care, patient
will be able to
identify to
prevent or
reduce risk of

R: To help
patient cope
easier, step
by step.
Instruct
patient to
eat proper
diet.
R: Maintain
good health.
Provide
privacy for
the patient.
R: Respect
individuals
status.
Encourage
patient to
take simple
exercise.
R: Help
flexibility
and muscle
strength.
Instruct
patient to
take a rest
frequently.
R: To
maintain
good mood
and have
peace of
mind.
Provide clean
and fresh
environment.
R: Promote
mental
wellness.

IMPLEMENTATION/
INTERVENTION

1.) Establish
rapport
R: Gain trust
and
cooperation.
2.) Teach patient
proper

EVALUATION

GOAL MET:
After 4 hours of
nursing
intervention the
patient was able
to achieve
timely wound

opera.
Objective:

Facial
grima
ce
noted

Cohe
rent

Patie
nt is
coop
erativ
e to
give
infor
matio
n
relate
d to
her
condi
tion

diagnosis,
diagnostic
tests, and
treatments

R
C
E
P
T
IO
N
S
E
L
F
C
O
N
C
E
P
T
P
A
T
T
E
R
N

infections as
evidenced by:
a.) Achiev
e
timely
wound
healing
b.) Free
from
signs
and
sympto
ms of
infectio
n

3.)

4.)

5.)

6.)

7.)

handwashing
technique
R:
Handwashing
is the single
most
effective way
to prevent
infection.
Instruct on
proper wound
care.
R: For first
line of
defense
against crosscontaminatio
n.
Encourage to
eat vitamin C
rich foods like
dark leafy
greens, peas
and papaya.
R: Vitamin C
helps boost
immune
system.
Provide
privacy for
the patient.
R: Respect
individuals
status.
Wash
puncture site
with mild
soap and
water.
R: Avoid
infection that
can cause
pain.
Encourage
patient to
exercise and
not to stay in
bed majority
of time.
R: Help
flexibility and
muscle
strengthenin
g.

healing and free

from signs and
symptoms of
infection.

8.) Instruct
patient to eat
proper diet.
R: Acquire
adequate
nutrition.
9.) Instruct
patient to
sleep at least
8 hours.
R: Sleep
promotes
good mood
and wellbeing.

DATE
AND
TIME
April 19,
2016
8:00 AM

ASSESSME
NT

Subjective:
Tag
gagmay
lang
mainom
nako na
tubig.
Objective:

100m
l
previ
ous
shift:
Urine
outpu
t is
less
than
norm
al
(30ml
/hr)
Urine
color
is
deep
orang

NURSING
DIAGNOSI
S
Risk for
electrolyte
imbalance
related to
decrease
in bodily
fluid.

N
E
E
D
N
U
T
R
I
T
IO
N
A
L
M
E
T
A
B
O
L
I
C
PA
T
T
E
R
N

PLANNING

At the end of
my shift, the
patient will be
able to
maintain
electrolyte
balance as
evidenced by:
a.) Adequa
te
urinary
output
b.) Good
skin
trugor

IMPLEMENTATION/
INTERVENTION

1.) Establish
rapport
R: Gain trust
and
cooperation.
2.) Monitor VS.
R: To have
baseline
data.
3.) Instruct
patient to
drink water.
R: Avoid
dehydration.
4.) Monitor IV
Fluids.
R: Measure
intake and
output.
5.) Collaborate
with
physicians in
the fluid
therapy.
R: To have a
good
manifestation
of a patient
illness.
6.) Test skin
turgor.

EVALUATION

GOAL MET:
At the end of
my shift, patient
was able to
maintain
electrolyte
balance as
evidenced by:
a.) Good
skin
turgor.
b.) Stable
VS.
c.) Normal
Urinary
output of
30ml/hr.

Dryn
ess of
skin
noted

Dryn
ess of
lips
noted
Deep
ness
of
eyes
noted

DATE
AND
TIME
April 19,
2016
8:00 AM

ASSESSME
NT

Subjective:
Wala koy
gana
mukaon, as
verbalized
by the
patient.
Objective:

Pallor
noted

Weak
ness
noted

Fatig
ue

Did
not
eat
break
fast

R: Check
hydration.
7.) Provide
patient
privacy.
R: Respect
individuals
status.
8.) Observe for
signs of
dehydration.
R: To acquire
baseline data
9.) Administer
medication.
R: For fast
recovery.
NURSING
DIAGNOSI
S
Risk for
imbalance
nutrition
less than
body
requireme
nts related
to lack of
appetite.

N
E
E
D
N
U
T
R
I
T
IO
N
A
L
M
E
T
A
B
O
L
I
C
PA
T
T
E
R
N

PLANNING

After 2-4
hours of care,
patient will
increase
appetite as
evidenced by:
a.) Eating
her
next
meal
b.) Eating
small
snacks
in
betwee
n
meals

IMPLEMENTATION/
INTERVENTION

EVALUATION

1.) Establish
rapport
R: Gain trust
and
cooperation.
2.) Monitor VS.
R: To have
baseline
data.
3.) Encourage
patient to eat
proper diet.
R: Acquire
nutritional
needs.
4.) Instruct
patient to
rest.
R: Promote
good mood
and wellbeing.
5.) Teach proper
hygiene.
R: Risk for
crosscontaminatio
n.

GOAL MET:
After 4 hours of
nursing
intervention,
patient
verbalized:
a.) I ate half
of my
meal for
lunch.
b.) I am
more
eager to
eat.

Prognosis
CRITERIA

POOR
(1)

Duration of
Illness

FAIR
(2)

GOOD
(3)

2 Days before
operation

Onset of
Illness

Precipitating
Factors

Compliance

It takes time
for her to go to
the hospital
and know the
findings

Predisposing
Factors

Age

JUSTIFICATION

Never refuse
to take
medication
She is 39 high
risk to have
develop
gallstones
High risk to
develop
gallstone
disease.

Environment

She has a very

supportive
family,
relatives and
have a good
environment.

References
http://www.uptodate.com/contents/choledocholithiasis-clinicalmanifestations-diagnosis-and-management
https://www.nlm.nih.gov/medlineplus/ency/article/000274.htm
http://radiopaedia.org/articles/choledocholithiasis
http://www.myvmc.com/diseases/common-bile-duct-stonecholedocholithiasis-cholangitis-obstructive-jaundice/
http://www.drugs.com/mmx/ursodeoxycholic-acid.html
https://www.scribd.com/doc/201340912/Tranexamic-Acid-drug-study
Springhouse Nurses Drug Guide 2008 pg.921
Mosbys Nursing Drug Reference 2001
http://www.healthline.com/human-body-maps/gallbladder

Acknowledgement
In the process of putting this research together, we would like to
thank first and foremost, our patient and her family for trusting us
and providing us with the information needed for our case study;
the DMSF Nursing Staff, for making us feel welcome and aiding us
with whatever we needed in learning by allowing us to acquire
more information from our patients diagnosis; and to our beloved
dean, Mrs. Brenda Morales R.N M.N, our clinical instructors, Mr.
Richard Dionisio R.N. and Miss Princess Recabe R.N. who have
relentlessly encouraged us to give our best and guiding us
throughout the course. This experience has hastened our skills in
assessing our patients, writing up Nursing Care Plans, acquiring
the skill to detect the signs and symptoms of the disease before it
further develops into a stage where surgical management is
necessary. Most importantly, we now have a much more in-depth
understanding of the disease by identifying the root cause of
Choledocholithiasis. Lastly, we want to thank the time and effort
of each and every individual of our groupmates who have
contributed to making this case study to completion.