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Cholecystitis is an inflammation of the gallbladder wall and nearby abdominal lining. Cholecystitis is usually caused by a gallstone in the cystic duct, the duct that connects the gallbladder to the hepatic duct. The presence of gallstones in the gallbladder is called cholelithiasis. Cholelithiasis is the pathologic state of stones or calculi within the gallbladder lumen. A common digestive disorder worldwide, the annual overall cost of cholelithiasis 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 shown an increase in cholesterol stones in the Far East. Gallstones are crystalline structures formed by concretion (hardening) or accretion (adherence of particles, accumulation) of normal or abnormal bile constituents. According to various theories, there are four possible explanations for stone formation. First, bile may undergo a change in composition. Second, gallbladder stasis may lead to bile stasis. Third, infection may predispose a person to stone formation. Fourth, genetics and demography can affect stone formation. Risk factors associated with development of gallstones include heredity, Obesity, rapid weight loss, through diet or surgery, age over 60, Native American or Mexican American racial makeup, female gender-gallbladder disease is more common in women than in men. Women with high estrogen levels, as a result of pregnancy, hormone replacement therapy, or the use of birth control pills, are at particularly high risk for gallstone formation, Diet-Very low calorie diets, prolonged fasting, and low-fiber/highcholesterol/high-starch diets all may contribute to gallstone formation. Sometimes, persons with gallbladder disease have few or no symptoms. Others, however, will eventually develop one or more of the following symptoms; (1) Frequent bouts of indigestion, especially after eating fatty or greasy foods, or certain vegetables such as cabbage, radishes, or pickles, (2) Nausea and bloating (3) Attacks of sharp pains in the upper right part of the abdomen. This pain occurs when a gallstone causes a
blockage that prevents the gallbladder from emptying (usually by obstructing the cystic duct). (4) Jaundice (yellowing of the skin) may occur if a gallstone becomes stuck in the common bile duct, which leads into the intestine blocking the flow of bile from both the gallbladder and the liver. This is a serious complication and usually requires immediate treatment. The only treatment that cures gallbladder disease is surgical removal of the gallbladder, called cholecystectomy. Generally, when stones are present and causing symptoms, or when the gallbladder is infected and inflamed, removal of the organ is usually necessary. When the gallbladder is removed, the surgeon may examine the bile ducts, sometimes with X rays, and remove any stones that may be lodged there. The ducts are not removed so that the liver can continue to secrete bile into the intestine. Most patients experience no further symptoms after cholecystectomy. However, mild residual symptoms can occur, which can usually be controlled with a special diet and medication.
II. His father died because of heart attack and her mother died of natural cause. Porac Pampanga. . Mr. his ashtma just stopped when he start drinking alcohol beverages as he said. He is also the president of their jeepney’s association. Family Health and Illness History According to Mr. which is almost 3 years ago. He also added that he had an ashtma when he was 7 years old that lasts when he is 21 years old. his religious affiliation is Roman Catholic and he is married to Mrs. Aproniano Castro is a 56 year old male. a Filipino citizen who resides at Pulong Santol. Castro that the familial disease he knows that they have in their family was the hypertension that is on his father’s side. NURSING ASSESSMENT A. vinegar and soy sauce. He seldom drinks alcohol and smoke. On his first admission into this hospital he had undergone throidectomy operation. He always sleeps around 9 in the evening and wakes up at 6 in the morning. He usually eats instant food and love eating foods which has condiment like “patis”. He had not experience any accident and injuries. He is not also choosy on the food he eats because he really eat a lots. He also love eating vegetable salads and fatty salty food. 1950 at Pulong Santol. Castro usually works for 10 to 12 hours a day usually around 7am to 7 pm. He also added that cholecystitis is prone to their family. He has day-offs but uses this day in working as the president of the jeepney association. even though his job is prone to accident particularly vehicular accident. Regarding the finances about health he is using his wife’s PHILHEALTH card to compensate the finances needed. because of one of his siblings also had acquired this disease. He is a jeepney driver bound in Porac-Angeles route. C. Personal History Mr. His wife was the one who prepares him the breakfast and the snack. Castro been admitted into this hospital (Porac District Hospital). Family Health and Illness History B. History of Past and Present Illness This is the second time Mr. Brigida M. Castro. He was born on January 22.
CBC. Upon admission he had undergone some laboratory examination such as UTZ. He just did not have his cholecystectomy done immediately due to financial problem. 2006. U/A. D. He was been diagnosed with cholecystitis with multiple cholelithiasis a month prior to admission due to severe epigastric pain and weight loss and was advised to remove his gallbladder.5 oC Physical Assessment done by the student reveals that patient is.As for his present illness.85 RR. • afebrile • with pink palpebral conjunctiva • (-) cyanosis • (+) NABS • non tender abdomen Vital Signs upon admission (February 13. Physical Examination Physical Assessment done by the attending physician reveals that patient is.130/90 RR-19 PR-84 Temp-36. 2006) BP. 2005 for his operation. When the money needed for his operation was enough he then goes to Porac District Hospital last February 13.4 oC . 2006 are as follows. FBS.According to Mr.21 Temp. Serrano. he was admitted last February 13.36. BUN. He was diagnosed and surgically operated by Dr. BP. His initial medication were H2bloc and Cefuroxime. Castro. he was admitted into this hospital because of cholecystitis.140/90 PR.Creatinine and ECG. • afebrile • with pink palpebral conjunctiva • (+) dry lips • (+) paleness • (+) dryskin • decreased skin turgor • (-) bowel movement • (-) weakness Vital Signs taken and recorded as of February 15. Chest X-ray.
until it is needed in the digestive process. and K. The wide end (fundus) points downward and forward. preventing putrefaction. upward. Digestion of fat occurs mainly in the small intestine. including fat-soluble vitamins: Vitamin A. . Structurally.5 cm (1 in) in diameter at its thickest part. the gallbladder consists of an outer peritoneal coat (tunica serosa). present in most vertebrates. empties through the biliary ducts into the duodenum to aid digestion by promoting peristalsis and absorption. The gallbladder. The purpose of bile is to. secreted by the liver and transmitted from that organ via the cystic and hepatic ducts. and an inner mucous membrane coat (tunica mucosa).III. rid the body of surpluses and metabolic wastes Cholesterol and Bilirubin. Enable intake of fat. In humans. The function of the gallbladder is to store bile. a middle coat of fibrous tissue and unstriped muscle (tunica muscularis).5 cm (about 3 in) long and 2. The body (corpus) and neck (collum) of the gallbladder extend backward. E. and to the left. it has a capacity varying from 1 to 1. by emulsifying fat into smaller droplets to increase access for the enzymes. when functioning normally. sometimes extending slightly beyond the edge of the liver. it is a pear-shaped membranous sac on the undersurface of the right lobe of the liver just below the lower ribs. ANATOMY AND PHYSIOLOGY Gallbladder. and emulsifying fat. by pancreatic enzymes called lipases. It is generally about 7. muscular organ that serves as a reservoir for bile.5 fluid ounces. D. help the Lipases to Work.
and low-fiber/highcholesterol/high-starch diets. PATHOPHYSIOLOGY Heredity Obesity Rapid Weight Loss. Bile must become supersaturated with cholesterol and calcium The solute precipitate from solution as solid crystals Crystals must come together and fuse to form stones Gallstones Obstruction of the cystic duct and common bile duct Sharp pain in the right part of abdomen Jaundice Distention of the gall bladder Venous and lymphatic drainage is impaired Proliferation of bacteria Localized cellular irritation or infiltration or both take place Areas of ischemia may occur Inflammation of gall bladder CHOLECYSTITIS . through diet or surgery Age Over 60 Female Gender Diet-Very low calorie diets.Risk factor IV. prolonged fasting.
9 g/l 5.5 g/l 27 Lymphocyte - .3-10 g/l which confirms the presence of infection. Date Ordered: February 13. 2006 Date Result In: February 13. Fasting Blood Sugar This is to measure the blood glucose levels. 2006 Results: WBC RBC Conclusion: WBC is slightly elevated based on the normal value of 4. 2006 Results: 94. Complete Blood Count (CBC) This is to determine blood components and the response to inflammatory process and streptococcal infection. 2006 Date Result In: February 13. 10. 2. Date Ordered: February 13.V. DIAGNOSTIC AND LABORATORY PROCEDURE 1.8 mg/dl Conclusion: The result is within normal range based on the normal value of < 126 mg/dl.
2006 Date Result In: February 13. casts and crystals. Leukocyte. 2006 Results: 10. WBC’s. dietary intake of CHON and the level of protein metabolism Date Ordered: February 13.glucose.7 Mg/dl Conclusions: The result is within normal range based on the normal value of mg/dl. BUN This is an indicator of renal function and perfusion. bacteria.7 mg/dl.3. 2006 Date Result In: February 13. and systematic disorders that alter urine composition. 5.0 mg/dl Conclusions: The result is within normal range based on the normal value of 0. Urinalysis Urinalysis yields a large amount of information about possible disorders of the kidney and lower urinary tract. Urinalysis data include color. pH. RBC’s. and the presence of protein. Creatinine This is the indicator of the renal function Date Ordered: February 13. 2006 Results: 1. specific gravity. ketones. . 4. bilirubin.60-1. esterase.
010 Sugar/ Albumin. 2006 Date Result In: February 10.0.negative Pus cells.0. . 2006 Results: Color.1 hpf Conclusions: The results are normal but there is a presence of pus cells in the urine which means that there is also the presence of infection.yellow Specific Gravity.Date Ordered: February 10.
Promote bedrest. patient will severity (0–10 report relieve scale). and of pain effectiveness of e. and provides a. 2. intermittent. however.pain scale of 7/10 .Cool surroundings 3.RR. of pain. and character of pain (e. Preoperative NCP 1. Facial interventions. colicky). steady. Control . patient will naturally assume least painful position. allowing patient to assume position of comfort.(+) muscle guarding .difficult y in moving as manifested by facial grimaces . Scientific Explanations Due to the presence of stones in the gallbladder it causes some obstruction in the cystic duct which in turn causes a sharp acute pain on the right part of the abdomen. Reports complications. Pain information about scale disease b.Bedrest in lowFowler’s position reduces intraabdominal pressure. RR progression/resolution. .BPNursing Diagnosis Acute pain related to inflammation and distortion of the gallbladder as evidenced by verbal reports of pain.. of pain.g.Assists in Is there a change differentiating cause on the patients. Observe and of nursing document intervention the location. c.VI. expressi ons.(+) pallor . Acute Pain Cues S O . Nursing Interventions After 4 hours 1. BP development of d. Objectives Rationale Evaluation Nursing Care Plan .30 . . Patients Care a.
deep-breathing exercises. Encourage use of relaxation techniques. visualization. . .Relief of pain facilitates cooperation with other therapeutic interventions. Administer analgesics as indicated aid in minimizing dermal discomfort. redirects attention. e. 5. 4. Make time to listen to and maintain frequent contact with patient. which can relieve pain. . . guided imagery..Helpful in alleviating anxiety and refocusing attention. may enhance coping.140/90 environmental temperature.Promotes rest.g. Provide diversional activities. 6.
a. noting adequate fluid output less than volume as Intake. will accurate record maintain of I&O. Evaluation Is there still the presence of. and capillary refill. peripheral pulses. Provide skin and mouth care . dry skin c. dry mouth d. Perform frequent oral hygiene Objectives Rationale . 2. increased evidenced by urine specific moist mucous gravity. vomiting b.Skin and mucous membranes are dry. body weakness . with decreased 3.Provides information about fluid status/circulating volume and replacement needs.2. reduces risk of oral bleeding. Maintain NI the pt.Decreases dryness of oral mucous membranes. Assess membranes and skin/mucous good skin turgor. poor skin turgor e. membranes. Fluid Volume deficient Cues S O (+) pallor (+) body weakness (+) vomiting with poor skin turgor (+) dry skin (+) dry mouth Nursing Diagnosis Fluid Volume Deficient related to vomiting Scientific Explanations Because of vomiting excessive losses through normal routes occur thus causes Fluid Volume Deficient Nursing Interventions After series of 1. .
Increase fluid intake 5. prochlorperazine (Compazine) as ordered by the physician. .g. 6. e.4. . Ascertain patient’s beverage preferences. because of vasoconstriction and reduced intracellular water. Encourage foods with high fluid content. and set up a 24hr schedule for fluid intake.Reduces nausea and prevents vomiting. elasticity. Administer antiemetics.promotes hydration. .. .Relieves thirst and discomfort of dry mucous membranes and augments parenteral replacement.
Does the patient understands and could recall all the teachings given? . b. c. Knowledge Deficit Cues S “pwede bang maulit ang sakit ko” as verbalized by the patient O Frequently asking question about his condition. Evaluation .Is there a significant changes that occur on the patients knowledge regarding. expression of concern. 2. and discharge needs Scientific Explanations There is this presence of knowledge deficit due to some unfamiliar information that causes some confusion to the client that needs to be discussed.Post-operative NCP 3. disease condition diet treatment medication self-care needs - a. . and potential complications. d. Review disease process/prognosis. Rationale .Information can decrease anxiety. thereby reducing sympathetic stimulation. Effective communication and support at this time can diminish anxiety and promote healing. Objectives After an hour of nurse-patient interaction the patient will Verbalize understanding of disease process. possible side effects.Gallstones often recur. necessitating long-term therapy. Nursing Interventions 1.Provides knowledge base from which patient can make informed choices. Encourage questions. Provide explanations of/reasons for test procedures and preparation needed. . Discuss hospitalization and prospective treatment as indicated. . self-care. e. 3. prognosis. prognosis.Prevents/limits . treatment and diet With worried gaze Nursing Diagnosis Deficient knowledge related to condition. treatment. Review drug regimen.
.. or gastric irritants (e. Instruct patient to avoid food/fluids high in fats (e. Suggest patient formation. onions. ice cream. gas producers (e. cabbage. or smoking. fried foods. butter. on straw/hard candy. carbonated beverages). beans.Promotes gas 5.. spicy foods. whole milk. pork). which can limit gum increase gastric chewing. citrus).g. caffeine.g. recurrence of gallbladder attacks. .4.g. gravies. nuts. sucking distension/discomfort..
decreasing gastric acid secretion Indication -for short term treatment of duodenal ulcer Adverse Reaction . dry mouth Nursing Consideration 1.Nausea and Vomiting . Check for doctor’s order 2. Check for doctor’s order 2. Advise patient to report abdominal pain or blood in stools or is vomiting.perioperative prophylaxis . malaise. Should not be given if positive skin test 4.b. Inform the patient about the possible side effect of the drug 4. promoting osmotic instability .competitively bedtime inhibits action of histamine on the H2 at receptor sites of parietal cells. 1. Inform the patient about the possible side effect of the drug 6. Slow IV push 5. not to be given in patients hypersensitive to drugs 3. Advised patient to take drug once daily usually at bed time 6.anti-infective .Anti-ulcer 20 mg tab at .headache. Advise patient to report any discomfort on the IV insertion site GN: Cefuroxime BN: Zinacef 02-13-06 IV 750 mg every 8o prior to OR (30 to 60 minutes before) .a 2nd generation cephalosporin that inhibits cell-wall synthesis. Name of Drug GN: H2Bloc (Pepcidine) BN: Famotidine Date Ordered 02-13-06 Drug Study Route/ Action Dosage and Frequency PO . dizziness. Instruct patient to take drug with food 5. Perform ANST prior to admission 3.
specific gravity. every 80 .endocarditis prophylaxis for GI or GU procedure or surgery . headache. U/A. Check for doctor’s order 2. Advise patient to report any discomfort on the IV insertion site 7. Perform ANST prior to admission 3. dizziness.Anti10 mg tab. malaise. BUN and creatinine levels . Check for doctor’s order 2. Should not be given if positive skin test 4. Monitor urine output. not to be given in patients hypersensitive to drugs 3.Anti-infective . Inform the patient about the possible side effect of the drug 6. depressants at 6 am Indication .headache.for depression and chronic pain Adverse Reaction . dizziness 1.Name of Drug GN: Clomipramine HCl BN: Placil Date Ordered 02-13-06 Route/ Action Dosage and Frequency PO . dry mouth Nursing Consideration 1. Inform the patient about the possible side effect of the drug GN: Gentamicin Dulfate BN: Genticin 02-14-06 IV 80 mg amp.Nausea and Vomiting. Slow IV push 5.inhibits protein synthesis .
. Use parenteral magnesium with extreme caution in patients with impaired renal function 2. Advise patient to report any discomfort on the IV insertion site GN: MgSO4 02-14-06 IV 0. Check for doctor’s order 2. Monitor renal function . dizziness Nursing Consideration 1. Slow IV push 5. Test knee jerk and patellar reflexes before each additional dose 3. Perform ANST prior to admission 3.Nausea and Vomiting.Name of Drug GN: Ampicillin BN: Omnipen Date Ordered 02-14-06 Route/ Action Dosage and Frequency IV . hypotension 1. Inform the patient about the possible side effect of the drug 6.Anti-infective 1 g amp.inhibits every 80 protein synthesis Indication .magnesium supplementation . Should not be given if positive skin test 4.endocarditis prophylaxis for GI or GU procedure or surgery Adverse Reaction . Monitor fluid intake and output 5.drowsiness. headache. check magnesium level after repeated doses 4.03% 7ml every 120 -anti-convulsant -replaces magnesium and maintains magnesium level .
Should not be given if positive skin test 4. Check for doctor’s order 2. Monitor BP.inhibits prostaglandin synthesis Indication . Monitor patient for toxicity .Anti30 mg amp. acute pain Adverse Reaction . Inform the patient about the possible side effect of the drug 6. Perform ANST prior to admission 3. inflammatory every 60 . sedation. nausea and vomiting Nursing Consideration 1.short term management of moderately severe.Name of Drug GN: Ketorolac Tromethamine BN: Toradol Date Ordered 02-14-06 Route/ Action Dosage and Frequency IV . flatulence. PR.dizziness. hypotension Nursing Consideration 1. Advise patient to report any discomfort on the IV insertion site Anesthetic drug Name of Drug GN: Lidocaine HCl Date Ordered 02-14-06 Route IV Action Anesthetic drugs Adverse Reaction -lethargy. headache. Slow IV push 5. and RR before and after giving the medication 2.
6.The ECG is an essential tool in evaluating Electrocardiography detects and amplifies the very cardiac rhythm. hepatobiliary scintigraphy .c. Electrocardiogram. 8. 2. causing the heart to contract. because of relative risk of errors in recording. 5. 7. 3. Chest X-ray. technique which uses high-frequency sound waves to create an image of the internal organs.an imaging technique of the liver. however. intravenous (IV) fluids are used for replacement. . O2 Inhalation. pain. percutaneous transhepatic cholangiography (PTC) .this is used to rule out respiratory causes of referred small electrical potential changes between different points on the surface of the body as a myocardial cell depolarize and repolarize. These measurement are not that accurate as body weight. 9. gallbladder. threatening.) .a needle is introduced through the skin and into the liver where the dye (contrast) is deposited and the bile duct structures can be viewed by x-ray.I&O measurement provide an other means of assessing fluid balance. Medical/ Surgical Management 1.a diagnostic imaging to the body into order to promote healing and health. cholangiography . Intake and Output.when the fluid loss is severe or life ultrasound (Also called sonography. Ultrasounds are used to view internal organs of the abdomen such as the liver spleen. bile ducts. This data provide insight into the cause of imbalance such as decrease fluid intake or increase fluid loss. 4.Oxygen therapies are used to provide more oxygen Intravenous Rehydration. and upper part of the small intestine.x-ray examination of the bile ducts using an intravenous (IV) dye (contrast). and kidneys and to assess blood flow through various vessels.
Cholecystotomy. 14. both horizontally and vertically.the insertion of a choledoscope into the common bile duct in order to directly visualize stones and facilitate their extraction. . muscles. CT scans are more detailed than general x-rays. with or without cholelithiasis. of the body. A tube is then placed in the gallbladder to established external drainage. and a dye is injected which will allow the internal organs to appear on an x-ray. fat. and organs.a diagnostic imaging procedure using a combination of x-rays and computer technology to produce cross-sectional images (often called slices). A CT scan shows detailed images of any part of the body. and duodenum. Cholecystectomy. then through the esophagus.a procedure that allows the physician to diagnose and treat problems in the liver. to remove a malignancy or to remove polyps. The scope is guided through the patient's mouth and throat. flexible. and pancreas. 13. The procedure combines xray and the use of an endoscope. endoscopic retrograde cholangiopancreatography (ERCP) . bile ducts. Choledochoscopy. lighted tube. A long. 12.removal of the gallbladder. A tube is then passed through the scope.the establishment of an opening into the gallbladder to allow drainage of the organ and removal of stones. computed tomography scan (CT or CAT scan) .10. 11. This is performed when the patient cannot tolerate cholecystectomy. gallbladder. including the bones. This procedure may be performed to treat chronic or acute cholecystitis. stomach. The physician can examine the inside of these organs and detect any abnormalities.
VII.140/90 PR.19 Temp.140/90 PR. Clients Daily Progress DAYS ADMISSION 2/13/06 * * BP.36.20 Temp.2 oC BP.4 oC * BP.83 RR. 1Lx 30-31 gtts/min D5NM.21 Temp.5 oC * * * * * * * * * * * * * DAY 2 2/14/16 * * * BP.84 RR.82 RR.21 Temp.188.8.131.52 oC DAY 3 2/15/16 DISCHARGE 2/16/06 Nursing Problem Acute pain Fluid Volume Deficient Knowledge Deficit Vital Signs Dx & Lab Procedures CBC U/A FBS BUN Creatinine Medical & Surgical Management Chest X-ray 12-L ECG O2 inhalation D5LRS.130/90 PR. 1Lx 30-31 gtts/min Drugs H2 Bloc .85 RR.130/90 PR.
.Cefuroxime Ketorolac Ampicillin Gentamicin MgSO4 Lidocaine Placil Diet NPO Clear liquid Soft Diet DAT Activity & Exercise FOB Sit on Bed Ambulation as Tolerated * * * * * * * * * * * * * * * * * * * * * * * * * First started and indicates the duration it was done and taken.
Encouraged patient to eat foods rich in Vitamin and Nutritious foods 3. Advised the patient to a diet as tolerated but preferably avoiding salty and fatty foods. Thursday. Encouraged patient to increase fluid intake 2. Encourage patient to avoid salty and fatty foods 4. M - DISCHARGE PLANNING Instructed the patient to continue medication as ordered 1. 2006.VIII. Mefenamic Acid 500 mg cap 3 x day (am-1pm-8pm) for 1 week E T H - Instructed the patient to do exercise as tolerated such as walking Instructed the patient to continue the medication 1. Encourage patient to have enough rest O D - Instructed to come back for follow-up check-up on February 23. Cephalexin 500 mg cap 3 x day (8am-1pm-8pm) for 1 week 2. .
Remember also the saying “Mahal ang magkasakit”. especially those foods which contains many seasonings. He was admitted in Porac District Hospital and he was diagnosed of having a cholecystitis with multiple cholelithiasis based on the diagnostic procedure conducted in him like the CBC. Since cholecystitis is the inflammation of the gall bladder which is usually accompanied by gallstones or cholelithiasis these gallstones may block the way of toxic substances that really needs to go out. Mr. the patient had recovered at once he is no longer complaining of epigastric pain. Just like on what our patient had experience he still has to collect money for the operation he had underwent causing them to have debt with different persons. FBS. The treatment usually done is the cholecystectomy. U/A.IX. Fortunately. Crea. We should try to avoid foods which are rich in salt and fats. Conclusion Our patient. We are happy to say that most of our group mates witness the operation. Due to the result the surgeon decided for a surgery to remove the gallbladder which is known as the cholecystectomy. but due to this blockage this toxic substances are not then being expelled and are just being stored in the bladder for a period of time. Though there is a saying that ”Mas masarap pag bawal” which always pertains to the food were eating we should still be conscious on our health especially if we want to live longer and also to avoid those life-threatening diseases which not only shorten our life but causes us some financial problem. This then causes inflammation of the gallbladder. . 12-L ECG. Aproniano Castro has a chief complaint of epigastric pain. X-ray and UTZ. The following day we were given the chance to visit and assess our patient’s condition. Let us not enjoy ourselves with the delicious food were eating that is rich in salts and fats but we should enjoy living because we have a healthy condition. BUN. In order to lower the risk of having this kind of condition each and every one of us must be conscious in our diet. What he was complaining is if he could already eat his food for he is on a liquid diet! And of course the pain of his operative site which is just normal for several days after undergoing the operation.
Nursing 2004 Drug Handbook.Surgical Nursing” 7th edition.client.web-health. 24th edition Doenges.htm Microsoft Encarta 2004 Nursing Care Plan Content CD-ROM . BC.html http://www.com/webhealth/topics/GeneralHealth/generalhealthsub/generalhealth/liver&gallbladder/what_gall bladder. CWCN & Jane Hokanson Hawks.com/emerg/topic97.” Nurse’s pocket guide” 9th edition.com/EMERG/topic98.PhD.com/radio/topic163. RN.htm http://www.org http://tjsamson. Online Resources www.emedicine.edu/uvahealth/adult_liver/chole. BIBLIOGRAPHY Books Joyce M.cfm http://www.virginia. pg.healthsystem. DNSc. CPSN.facs.1302-1314.htm http://www. Moorhouse. “Medical. Black.emedicine.emedicine. & Murr.X. RN.
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