Calculous Cholecystitis

A Case Study Presented to the Faculty, Ateneo de Davao Universi ty College of Nursing

Submitted to: Daphny Grace Peneza, R.N., R.M., M.N. Clinical Instructor – Panelist for the Case Study Submitted by: Gino Gregor Palaca Marvin Rey Andrew Pepino Rio Remonde Kevin Melvin Roa Krystle Rustia BSN-3H-4a

May 25, 2010

TABLE OF CONTENTS

I.Introduction ................................................................................................... 1 II.Objectives (General & Specific) ................................................................... 3 III.Patient’s Data ................................................................................................. 6 IV.Family Background and Health History ..................................................... 7 V.Definition of Complete Diagnosis................................................................. 14 VI.Developmental Data ...................................................................................... 17 VII.Physical Assessment ...................................................................................... 26 VIII.Anatomy and Physiology .............................................................................. 34 IX.Etiology and Symptomatology ..................................................................... 37 X.Pathophysiology ............................................................................................. 47 XI.Doctor’s Order ............................................................................................... 50 XII.Diagnostic Exam ............................................................................................ 62 XIII.Drug Study ..................................................................................................... 72 XIV.Procedural Report ......................................................................................... 87 XV.Nursing Theories ........................................................................................... 94 XVI.Nursing Care Plan ......................................................................................... 100 XVII.Discharge Plan (M. E. T. H. O. D.) & Prognosis ........................................ 123 XVIII.Recommendation ........................................................................................... 130 XIX.References ...................................................................................................... 133

ACKNOWLEDGMENT

The Group 4-1 of section 3H, would like to acknowledge the contributions of the following groups and individuals to the development of this case presentation. To the Almighty God for blessing them with wisdom, competence and genuine passion and giving them the strength to finish this presentation. The group dedicates to Him the fruits of their hard-earned achievement. To the staff of the Davao Medical School Foundation Hospital-3C for being accommodating to the students and for giving them additional teachings during their exposure in the said hospital. They have also been very willing to allow the students to obtain records necessary for this presentation. To their respected clinical instructor for this rotation, Daphny Grace Peneza, R.N., R.M., M.N., for her support and guidance to the group. She has imparted knowledge that would furthermore enhance the student’s understanding of their patient’s case, thus making them ready to present this case presentation. To their client, Meg, and her family, for being open and generous enough to

disclose personal information that would be helpful for this study. The group would also like to thank them for their patience throughout the duration of the study and for giving the group the opportunity to care for Selecta and apply what they have learned. To the proponents’ respective family and friends for their prayers as well as their financial support. They have also been a source of inspiration of the students. To the members of this group for working hard and giving their efforts, time and resources in conducting the study and for the completion of the written output.

Recently. Trapped bile can irritate and inflame the walls of the bladder. surgical removal of the gallbladder is recommended. However. it is estimated that 6.gov/statistics). Bile emulsifies the fats in food. disruptive. Its function is to store bile and release it as needed for digestion. It affects women more often than men and is more likely to occur at the age of 20-50 or over 60. the digestion of fats can be seriously impaired. Maurer. The proponents are hoping that through this case study. Calculous cholecystitis is a condition wherein gallstones obstruct the gallbladder outlet leading to poor drainage of bile. Rarely do they interact with patients who had minimally invasive surgery. Moreover. In the Philippines. 040 people are affected by the disease (http://digestive. One of the common gallbladder diseases is calculous cholecystitis. people who are obese and those who had had low fat diet are at an increased risk for developing cholelithiasis. the Group 3H-4a had a patient who was diagnosed with symptomatic calculous cholecystitis and underwent laparoscopic cholecystectomy. Friedman & Brandt. However. thus leading to inflammation. 1999).3 million men and 14. 073. an extrapolated prevalence of 5. In the United States. If the gallbladder is not working as it should. They are also interested to know Page | 1 . Calculous cholecystitis is the cause of more than 90% of cases of acute cholecystitis (Feldman. breaking them to small fragments so they can be further digested and absorbed in the small intestine. The group chose this case for they see it fit for their perioperative concept.niddk. Asians are also more prone to develop pigment stones. does this mean it is of no use to the body? The gallbladder is a pearshaped organ situated underneath the liver.nih. Khare. they will be more knowledgeable and aware about such gallbladder disorder and the surgical procedure done for the said disease. recurring episodes of pain. 2006).2 million women aged 20 to74 had gallbladder disease (Everhart.INTRODUCTION One of the body organs that we can live without is the gallbladder. Gallstones that do not cause symptoms do not require treatment. if gallstones cause. Hill.

they are hoping that this study will help them become more efficient and better nurses in the future.the proper and necessary nursing management that will be given to a patient affected by the disease. As nursing students. The student nurses also hope to apply their learning in taking care not only of their patients but of themselves as well. Page | 2 . they would also like to impart their learning to their families and their community regarding the prevention and care if ever such condition will arise in the scenario. Moreover.

 Ascertain the patient’s developmental status using the theories of Robert Havighurst.  Review the anatomy and physiology of the organs affected in the patient’s disease. The group also aims to perform the necessary nursing interventions to help alleviate the patient’s condition and improve her health. Page | 3 . Within 2 weeks of exposure. Specific Objectives: The proponents also created certain aims that will help them in achieving their general objectives.  Trace the pathophysiology of the patient’s disease.  Draw the family genogram of the patient. Erik Erikson and Lawrence Kohlberg. the group should have been able to present a comprehensive case study which explains the pathology.  Obtain the doctor’s orders and make rationales for each order.  Conduct a thorough cephalocaudal assessment obtained from the client.OBJECTIVES General objective: Within 2 weeks exposure to various clinical areas.  Define the complete diagnosis of the patient by directly citing it from three different sources. the proponents aim to: Cognitive:  Gather pertinent data regarding the past and present health history of the patient through interview and assessment.  Present the etiology and symptomatology of the disease. the treatment and the appropriate medical and nursing management regarding the condition of their chosen client.

realistic.  Present specific.  Make a discharge plan for the patient with the use of M. and the specific nursing responsibilities associated with each diagnostic procedure. precipitating factors.  Broaden our scope of knowledge about the disease and the appropriate Nursing Care for the patient with the disease. attainable.  Make drug studies on each drug given to the client. explain why such drugs were ordered. age.D.O. and present important interventions in administering the drug. Psychomotor:  Find a patient who will be the subject of their case presentation. and time-bounded nursing care plans for the patient.  Provide care based on the various nursing care plans formulated by the researchers and the patient herself.H. Page | 4 .T. analyze and interpret laboratory and diagnostic procedures done on the patient and include the normal and abnormal values and findings for comparison.  Render health teachings to the patient and her significant others to promote health. measurable.  Identify three nursing theories that can be applied to the patient’s condition. correlate them with the disease process.  Correlate the different nursing theories with the nursing care plans that are presented in this case study.  Validate patient’s prognosis according to the following categories: onset of illness.. Obtain.E. willingness to take medications and treatment. environmental factors and family support. duration of illness.

 Appropriately state the bibliography of all resources used in order to prevent plagiarism and promote honesty.  Share how the disease affects those affected by it and the systems involved in its occurrence.  Show genuine concern and willingness in serving the client. Page | 5 . Share information about calculous cholecystitis and the factors that cause the development of such disease and its complications.  Be aware of the client’s progress on the succeeding interactions. Affective:  Establish rapport with the patient and significant others.

Phil Care Hospital: Vital Signs on Admission: Davao Medical School Foundation (DMSF) BP: 130/80 mmHg PR: 79 bpm RR: 19 cpm T: 37 ºC Unit: Chief Complaint: Admitting Physician: Admitting Diagnosis: Final diagnosis Surgical procedure 3C. Calinan Davao City Filipino Christian (Roman Catholic) Married Bobong 4th year high School House keeper 5ft 2inches 62 kgs.324-5 Pain at right upper quadrant Dr.PATIENT’S DATA Client’s Code Name: Age: Gender: Birth date: Address: Nationality: Religion (Denomination): Civil Status: Spouse: Educational Attainment: Occupation: Height: Weight: Health Insurance: Meg 38 years old Female November 6. Walter Batucan Acute Cholelithiasis Calculous Cholecystitis Laparoscopic cholecystectomy Page | 6 . 1971 Upper Sirib.

Her older brother died due to motorcycle accident. none of her children suffer a serious illness. So far. 30. Meg got married to Bobong in the 1998. Luigi was diagnosed with hypertension and Dora had a history of UTI. Luigi (Male. Meg graduated high school and didn’t to proceed to college because she helped her family tend their farm. She said that the family lineage of her mother also suffers from heart problems as well as kidney problems. She delivered all her children at their house with the help of ―mananabang‖. Her 3 children were delivered through Normal Spontaneous Vaginal Delivery. all were born in the Maternity clinic in Calinan. According to the patient. The client. her father and mother are still alive and they suffer from hypertension and diabetes. Bobong is the one that provides money for their daily expenses. Calinan Davao City since the marriage of Papang and Mamang. In terms of their expenses. Two of her uncles on father’s side underwent surgery. married). Bobong is a Supervisor at DABCO and has a wage of approximately 10. There was no one else in her immediate family that suffered cholecystitis aside from Meg herself. married).000 a month. and Dora (Female. Their home is near their farm. deceased).FAMILY BACKGROUND AND HEALTH HISTORY A. 28. The family has been residing in Sirib. All children of Mamang were born through Normal Spontaneous Vaginal Delivery without any complications. Meg said that they budget the Page | 7 . Meg has 3 siblings namely: Kenny (Male. They were blessed with 3 children. Her eldest child is now studying in 4th grade. cholecystectomy. and had the same condition as Meg. Family Background Meg is the second child among Mamang and Papang’s four children.

Occasionally. and pineapples in their farm. they also get their share. They plant coconut trees. Page | 8 . but she sometimes joins in the events in their community like the fiesta. Meg said that she drinks liquor very seldom. At night. She reported that she doesn’t smoke. they watch television together and this serves as their bonding time. She is not so active in terms of social organizations such as GKK (Gagmay’ng Kristohanong Katilingban). she does gardening in their backyard. she is busy taking care of Bobong and their 3 children. she helped her mother with household chores. She sometimes goes to church on Sundays together with her children. She is the one who cooks. According to her. she only consumes a half of glass or a glass of liquor occasionally. Sometimes. but still. birthday celebrations and other special occasions. cleans the house. he smokes almost one pack a day. Right now. but her husband does. they gather together with her relatives when there are fiestas. bananas. When Meg stopped going to school. The family has good relationship. she experiences fatigue from doing household chores especially since she is the only one who does the laundry.money well for them to have food and to provide the necessary daily needs and expenses. and does the laundry of the whole family. By helping tend to the 2 hectare farm of the patient’s parents. she only works in the house. Lifestyle The patient has sedentary lifestyle.

she has no allergy from any form of food. she can consume at least 3 cups of coffee. They only avail of the services of the health center very seldom. According to her. She also experienced common illnesses such as cough. In a day she can consume 4 glasses of coke. Her lunch and supper are sometimes vegetables that are found in their backyard such as ―kamunggay‖. especially junk foods. She is the one who cooks the ―baon‖ of her husband for work. Also. She said that she is not sure if she completed her immunizations. In a day. she always drinks coffee. fever. since her mother knows how to make use of different herbal medicines such as Page | 9 . She started using birth control pills since she was 36 years old. ―bulad‖. She said that their house was far from the health center so they weren’t able to avail of all of the services. Past Health History Meg and her husband preferred to have artificial family planning than natural family planning. For breakfast she usually eats. She said that before. She said “naga-diet diet man ko kay tabaan nako sa akoang lawas. she is so fond of drinking soft drinks. But she also drinks approximately 5-6 glasses of water. Every morning. she limits herself from eating fatty foods since she aimed to lose weight because she was afraid of becoming obese. ―upo‖. pero karong tuiga giundangan na nako ang pagdiet-diet”. Meg said that she eats at least two times a day in small meals. ―ginamos‖ and bread. nagsugod ko katong 36 years old pako.Meg sleeps around 9:00 o’clock at night and wakes up around 5:00 o’clock in the morning to prepare things needed of her husband. She also loves to eat salty foods. B. ―talong‖ and ―tinangkong‖. She is not fond of eating pork and beef. colds. They only treated it at home. ―okra‖. ―bagoong‖. Her mother forgot already and the records were lost. measles and even chickenpox.

Also. After three days. Meg felt mild pain at the right upper quadrant of her abdomen. She went to Isaac T. History of Present Illness On the second week of December 2009. Completion curettage was performed to her. Davao City and was asked to have ultrasound of the whole abdomen.kalabo. Because of this. She experienced measles when she was a 1-year old and had chickenpox when she was 10-year old. She was hospitalized at Robillo Hospital. After delivering her third child at the age of 36. buyo. pain recurred at a higher scale (5/10). the pain went away. Page | 10 . usually 140/90. on her 3 rd pregnancy. they sometimes bought over-the-counter drugs such as paracetamol. Meg reported that she got pregnant with her 1 st child at the age of 28. Meg started to take birth control pills until now to prevent unexpected pregnancy. she had a miscarriage and was hospitalized on the maternity clinic and underwent completion curettage. she said “dili man jud ko maabtan ug simana sa akoang kalintura ug bisan ubo”. she experienced an increased blood pressure. After 2 days. Robillo Memorial Hospital Calinan. Neozep. and tawa-tawa. she had miscarriage on the 1st week of pregnancy. However. She was advised by the doctor to undergo surgery. mayana. Bobong and Meg decided to make use of family planning. unfortunately. But after two weeks. Again. she was forced to seek medical advice. Calinan Davao City. C. She reported that in almost all her pregnancies. the result was released and they found out that there were stones in her gallbladder. She neglected it thinking that it’s nothing serious and might be just an episode of indigestion. and Medicol. cholecystectomy. gabon. With regards to how long she experienced those usual illnesses. Meg had her menarche when she was 11 years old.

unfortunately. She was instructed by the doctor to increase water intake and have a low fat diet. On May 8. She was very worried about herself because she has fear of not waking up after surgery. three days prior to admission. She just took medications that were prescribed by the doctors to alleviate the pain she felt. she wasn’t able to follow the doctor’s order and still continued with her usual lifestyle. This was characterized to be progressive pain with a pain scale of 8 out of 10. with admitting diagnosis of Acute Cholelithiasis. Meg said that she still felt the pain after the check-up but she could still tolerate it. pain recurred with a pain scale of 10 out of 10. Effects/Expectations of Illness to Self/Family Biological: When Meg knew about her condition that she needs to undergo surgery. Two days prior to admission. the patient was admitted at Davao Medical School Foundation at Surgical Ward. room 324 bed 5 under the service of Dr.the patient resisted the doctor’s advice due to fear of surgery. Batucan. She feared having complications of not having a gall bladder anymore. Page | 11 . she didn’t know what to do. 2010. admission. D. She was given medications as an alternative (the patient already forgot the name of medications prescribed). the patient again experienced right upper quadrant pain which lasted until the present condition. This prompted Meg to seek consultation. There was no radiation noted and no associated symptoms. hence. Last May 5 this year.

Also. she said that she wants to be in good condition as much as possible so that she can do her daily task in everyday life for her family. Spiritual: Still. mentally. Her husband. relatives and friends are still there giving support to her for her fast recovery. Meg wants to overcome her illness so that she can still spend time with her family and friends. and spiritually. In addition. their relatives are also extending their care and prayers for Meg because they are worried and concerned for her. and she continues to pray to Him. The client is worried about her condition because she has many plans in life together with her family.Psychosocial: Also. Furthermore. This made her decide not to go through with the surgery before. The client is also very thankful because her family. emotionally. Bobong was worried about Meg because for him. her children were worried about their mother. it makes him suffer seeing his wife suffering. who’s suffering from such condition. She believes that everything will be alright with the help of the creator. she is worried about her 3 children. who still need care and guidance from their mother. The client still has faith in the Creator. Page | 12 . Meg is still hopeful to overcome her challenges in life. They are always there and look after her in the hospital and to aid her physically. Bobong is trying his best to support his wife.

. Bobong. D Po. † Luigi.cholelithiasis a.†  Papito. Lolo. c. 7 Bebe one. . D. † Ana.Genogram Maternal Side Lola. 70 Lala. 30.old age c.Female -Male #. 60.age .diabetic K. †. 28.Heart problems †-deceased D.Kidney problem o. †. c. 38 Bebe two. o Paternal Side Mamita. 67 Jose.accident Bebe three. K Kenny. 10 Page | 13 . 64 Mamang. K. . 64 Papang.  Meg. 67 Sis.  c. . 62 . 2 Dora. a. 45. K .

com/calculi. Retrieved May 15. p. p. Calculi are usually found in the biliary and urinary tracts. Calculus (pl. Lippincott Williams & Wilkins. or gallstones. Source: Iyengar. Cholecystitis Cholecystitis is the inflammation of the gallbladder. Calculi (stones) can be divided into two groups—renal calculi and gallstones. calculi) is also called stone. they vary greatly in size.DEFINITION OF COMPLETE DIAGNOSIS Complete Diagnosis: Calculous Cholecystitis Calculous Calculi. Source: http://medical-dictionary. Source: Boyer. V. 1. Vol. In more than 90% of the cases. an abnormal stone formed in body tissues by accumulation of mineral salts. M. 11th ed. gallstones are present. Environmental.. 1347. usually form in the gallbladder from the solid constituents of bile. 2010. The majority of gallstones are composed principally of cholesterol and other calcium salts. Compositional and Methodological Aspects of Trace Elements. Elemental Analysis of Biological Systems: Biomedical. shape and composition. (2006). Brunner and Suddarth’s Textbook of MedicalSurgical Nursing.thefreedictionary. 49. Page | 14 .

the blood flow to the gallbladder may become compromised which in turn will cause problems with the filling and emptying of the gallbladder. 563. Page | 15 . Inflammation of the bladder which may be either acute or chronic. M. D. Foundations of Nursing: Caring for the Whole Person. Medical-Surgical Nursing Demystified. 832. p. A stone may block the cystic duct which will result in bile becoming trapped within the bladder due to inflammation around the stone within the duct. USA: Jones and Bartlett Publishers. An Introduction to Human Disease: Pathology and Pathophysiology Correlations. Inflammation of the gallbladder is called cholecystitis (chole = bile +cyst = bladder + itis = inflammation) Source: Crowley. There are two major types of acute cholecystitis— calculous and acalculous. 8th ed. L. USA: McGraw-Hill. Source: Digiulio. gallstones obstruct the gallbladder outlet leading to poor drainage of bile. & Jackson. Calculous Cholecystitis Acute cholecystitis is inflammation of the gallbladder.Source: White. p.. p. 288. (2010). In calculous cholecystitis.(2007). In physical exam. patients may exhibit Murphy’s sign— right upper quadrant pain elicited by palpation under the right costal margin when the patient inspires. L. Chronic cholecystitis occurs when there have been recurrent episodes of blockage of cystic duct. In an acute cholecystitis.

121-123. N. & Ahmad. USA: SLACK Incorporated. Page | 16 .Source: Ginsber. G. p. (2006) The Clinician’s Guide to Pancreaticobiliary Disorders.

Lillis. certain milestones can be identified. certain generalizations can be made about the nature of human development for everyone. and that a person must continuously learn to adjust to changing societal conditions. and Result Justification Page | 17 . the time the infant rolls over. Within each developmental level. and civic responsibility. growth and development are orderly and sequential as well as continuous and complex. walks. but. All humans experience the same growth patterns and developmental levels. Successful achievement leads to happiness and success in late tasks.DEVELOPMENTAL DATA According to Taylor. and values that determine occupational and family choices. societal disapproval. The developmental tasks arise from maturation. men and women reach the peak of their influence upon society. crawls. (Taylor. and difficulty in later tasks. or says his or her first words. whereas unsuccessful achievement leads to unhappiness. Although growth and development occur in individual ways for different people. He described learned behaviors as developmental tasks that occur at certain periods in life. a wide variation in biologic and behavioral changes is considered normal. because these patterns and levels are individualized. personal motives. for example. Robert Havighurst’s Developmental Task Theory Robert Havighurst believed that living and growing are based on learning. et al. LeMone and Lynn (2008). 2008) Stage Middle Age(30-40) Description In the middle years.

Page | 18 . psychological. And the time passes so quickly during these full and active middle years that most people arrive at the end of middle age and the beginning of later maturity with surprise and a sense of having finished the journey while they were still preparing to commence it. She is happy with her husband since she receives care and unconditional love from him.  Selecting a mate  Learning to live with a partner  Starting family  Rearing children Achieved The patient married and started a family last 1998. She works together with her husband in taking care of and rearing their children by providing their physiological. It is the period of life to which they have looked forward during their adolescence and early adulthood.at the same time the society makes its maximum demands upon them for social and civic responsibility. and emotional needs.

She is also a registered voter. she is the one managing the house.  Taking on civic responsibility Achieved The patient is doing her responsibilities as a Filipino citizen by following laws in our country such as not throwing garbage anywhere. managing the She is the one to have a house peaceful and organized home. however.The patient has no job. Meg is also responsible for budgeting their money needed to sustain them in their everyday living. and following traffic rules. She sees to it that her husband’s salary is well budgeted and not put into waste. by cleaning. washing clothes. doing other  Managing home  Getting started in occupation Achieved household chores and being a peacemaker when trouble happens among her children. Page | 19 .

the healthier development will be. Late childhood 4. Erik Erikson’s Psychosocial Development Theory Erikson emphasized developmental change throughout the human life span. He described eight stage of development: 1. That is termed psychosocial development. It is patterned to the Psychosexual Development of Sigmund Freud but more concentrated on what task and conflict should a person be able to manage in a certain age group. Maturity Page | 20 . Adolescence 6.Patient verbalized that if she were not admitted in the hospital. she would really vote in the 2010 Presidential elections. The more an individual resolves the crises successfully. Each stage consists of a crisis that must be faced. In Erikson’s theory. Early childhood 3. She also pays taxes (property tax and cedula) as part of her responsibility as a citizen. eight stages of development unfold as we go through the life span. Adulthood 8. Infancy 2. Young adulthood 7. this crisis is not a catastrophe but a turning point of increased vulnerability and enhanced potential. School age 5. According to Erikson.

she is busy taking care of her children and her husband as those are the responsibilities of a mother and wife. she often fear inactivity and meaninglessness. Self kids) and working to establish a stable environment. Stage Middle Adulthood: 25-65 years Description Result Justification The significant task is to perpetuate culture and transmit values of the culture through the family (taming the Working towards achieving goal As a wife and a mother of three children. As the children leave home. she is the one who inculcates values in the family whom she acquired from her parents. Today. She makes sure that her children will be raised with good attitude and as good Filipino Citizens. or unsuccessful. partial. which Erikson calls generativity. or the person’s relationships or goals absorption or Stagnation Basic Strengths: Page | 21 .Each stage signals a task that must be accomplished. her children are dependent and still with them. so when a person is in this stage. she still doesn’t know what her feelings will be when her children will leave home someday. The resolution of the task can be complete. As of now. Strength comes through care of others and production of something that contributes to the betterment of society. Ego Development Outcome: Generativity vs.

If a person doesn't get through this stage successfully.Production and Care changes. Creativity. Chap. Fundamentals of Nursing.com/st Page | 22 . page 352 http://www. productivity. the community and the family. she can becomes self-absorbed and stagnate.learningplaceonline. concern for others concern. Significant relationships are within the workplace. she may be faced with major life changes—the mid-life crisis—and struggle with finding new meanings and purposes. 20. or self-indulgence. of interests selfand lack commitments Kozier and Erbs.

which in turn could be broken down into six specific developmental stages. making it difficult for a person to jump forward and virtually skip an entire stage. Once a person acquires the functionalities of higher stages of moral development. Kohlberg stated that ethical behavior was based on moral reasoning. in that it is highly improbable for someone to regress backwards. based on his continued interest in how children would react to varying moral dilemmas. it will be difficult for him to lose these abilities and revert to lower levels of growth.ages/organize/Erikson. The stages are progressive. Every stage follows another.htm Lawrence Kohlberg’s Levels of Moral Development Lawrence Kohlberg outlined the different planes of moral adequacy. The levels and stages are as follows: Level 1: Preconventional Stage1: Punishment/obedience Stage2: Instrumental/relativist Level 2: Conventional Stage3: Approval Seeking Stage4: Law and order Level 3: Postconventional Stage5: Social Contract Stage6: Universal-ethical Page | 23 .

Stage Postconventional Level Stage Social Contract Description Result Justification At stage 5 social contract and utilitarian orientation. She is concerning about justice. represents person’s concern equality for all human beings. “malooy gyud ko sa mga tao nga dili matagaan ug hustisya. specifically about justice. however. 5: behavior is defined in terms of society’s law. as verbalized by the patient. while maintaining respect for self and others. correct Achieved She sees that most of the laws are correct and worth to be followed. guided by personal values and standards regardless of those Page | 24 . Laws can be changed. principle orientation. She said that she follows the rules of the country and the city she lives in. She doesn’t want nuisance in the society because she believes that to be able to live in a serene place. people must maintain and establish respect with themselves and then to others. to meet society’s needs. labaw na ng mga kabus” . Stage Stage6: Universalethical the 6. universal ethical for Working towards achieving goal She knows about universal laws.

2008) Page | 25 . (Taylor et. al. Few adults ever reach this stage of development.set by society or laws. Justice might be internalized at an even higher level than society.

General Survey The patient was received lying on bed. Patient complains of pain on the incision site and rated this pain as 6 out of 10 in the pain scale. 3C.5-cm long incisions at her epigastric and right lower rib cage areas and a 1-cm incision under her umbilicus. afebrile and without IVF.PHYSICAL ASSESSMENT Patient’s Name: Meg Age: 38 yrs. person (identified watcher correctly). She is oriented to time (verbalized it was late in the afternoon). Room 324-5 Vital Signs upon physical assessment: Temperature : Pulse Rate: Respiratory Rate: Blood Pressure: 36. 2010 Time of Assessment: 4:00 pm Location of Assessment: DMSF Hospital.6 °C 82 bpm 18 cpm 130/80 mmHg I. Each incision is covered with dry and intact dressing. place (verbalized she’s in the hospital) and Page | 26 . old Sex: Female Admitting Diagnosis: Acute Cholelithiasis Final Diagnosis: Calculous Cholecystitis Chief Complaint: right upper quadrant pain Date of Assessment: May 12. conscious. awake. coherent. Incision site is dry and intact. She has three 0.

Nail polish was removed.9 which is normal. It returns quickly to its normal state when picked up between two fingers and released. It is thick. The palms and the soles are calloused. The patient is calm. Skin Skin is fair in color. except in the palms. Hairs and Nails Upon inspection. it was observed that the patient is cooperative and has an accommodating attitude towards the student. intact and with hairs. Dandruff or flaking was not present. Skin texture is soft and fine while extensor surfaces such as the elbows have coarser skin. Other infestations. long and well-kept. Nails were long but clean. well-kept hair and clean linens and pillows. oily. Her body mass index (BMI) is 24. hair was noted to be black. II. Patient is not in respiratory distress. it was noted that patient has halitosis. comprehensible and in moderate pace. No clubbing of the nailbeds noted. were not noted. Patient appears appropriate for her stated age. Hair is also evenly distributed as evidenced by absence of bald spots. straight.reason for admission (stated that she was admitted due to right upper quadrant abdominal pain). The color of scalp is lighter than the color of skin. She stands 5 feet and 2 inches tall and weighs 62 kg. such as lice. However. Patient’s speech was audible. No edema present. III. No skin breaks present aside from the incision sites on her abdomen. She has an endomorphic body type. Through the course of the physical assessment. Skin is dry and slightly warm upon palpation. Page | 27 . Patient is in fair grooming as evidenced by unsoiled t-shirt she is wearing. Nails on both hands and feet are long but clean. soles and dorsa of the distal phalanges. Client has a capillary refill time of 2 seconds.

Client has central and peripheral vision. Iris is dark brown in color. Moreover. V. Eyelids’ surface is intact with no discharges and no discoloration but with noted eye bags on the lower surface. Bulbar conjunctiva is pale pink. Patient can move her head up and down and side to side. There were no palpated masses. equally round. even when looking straight ahead. Head Patient’s head is round and normocephalic in configuration with smooth skull contour. Facial movements are symmetrical and patient is able to perform different kinds of expression effortlessly and without any obstructions.IV. She can see things on the side of her eye. Sclera is anicteric. No edema. Facial features are symmetric as evidenced by palpebral fissures being equal in size and symmetric nasolabial folds. Pupils quickly constrict when a penlight is shone towards the pupil from a lateral position. lesions. No lid lag noted. puffiness or tenderness noted upon inspection and palpation of the periorbital area. Eyes Hairs of eyebrows are thick and evenly distributed. Eyebrows are symmetrically aligned and there’s equal movement as evidenced by the patient’s ability to elevate and lower the eyebrows. Blink reflex is present. patient was asked to follow the examiner’s Page | 28 . nodules. Pupils were black in color. deformities or fractures. like the adjacent bed. Eyelashes are equally distributed and curled slightly outward with no ectropion or entropion. No lesions noted on the face. Palpebral fissure is equal in both eyes. Cornea is transparent and without cloudiness. During ocular motility testing. 3mm in size and reactive to light and accommodation. Eyeballs are symmetrical with no bulging observed. pupils constrict when looking at near objects and dilate when looking at far objects.

Auricle is nontender upon palpation. Pinna recoils after it is folded. Both eyes move in unison. There was smooth. No nystagmus noted. She was able to correctly read the names without any difficulty. parallel movement of eyes in all direction. No lesions on the external nose structure were seen. The left and right pinna are symmetrical and aligned with the inner canthus of the eye. Patient verbalized she doesn’t use any corrective aids. External canals have minimal cerumen. There was no tenderness over the maxillary and frontal sinuses upon palpation of the cheeks and supraorbital ridges. VII. She can also hear normal voice tones as evidenced by prompt responses to questions asked. She also did not report any vision difficulty or eye pain. Ears The color of the patient’s ears is the same as her facial skin. Mastoid process is smooth and hard and no tenderness or swelling noted. VI. No sanguinous discharges noted on the meatus.finger in the six cardinal fields of gaze. Page | 29 . Nares are patent since patient is able to breathe normally on both nostrils without difficulty when one nose is closed with digital compression and patient inhaled with mouth closed. Client’s gross smell was functional as she could identify the scent of alcohol. Nose It was noted that the nostrils were symmetrical and the nasal septum is midline. Hair is noted on the nares. There were no observed discharges draining from the client’s nose. The skin behind the ear in the crevice is smooth and without breaks. To test her visual acuity. Patient was able to hear a soft whisper equally in both ears. the students asked her to read their nameplates placed about 1 ½ feet away from her.

No tenderness. moist. Thyroid also rises when patient was asked to swallow. Page | 30 . Halitosis was noted. Thyroid is not enlarged upon palpation with no nodules. Patient has no difficulty of masticating and swallowing. extension. No lymph adenopathies appreciated. Teeth are of complete set. On the other hand. pink in color and with no masses or congenital defect. and rotation of head. Range of motion is normal and no pain elicited upon flexion. moist. No gum retraction or bleeding was noted. Dental carries are evident in lower right and left molar. The patient’s gum was. No torticollis present. No ulcerations and exudates present.VIII. hard palate is much lighter and more irregular in texture. Tongue is pink. Pulsation at carotid arteries is strong and regular in rhythm. Uvula is positioned in midline of soft palate and rises when the patient says ―ah‖. Lips are cracked. Teeth are yellow in color. Trachea is symmetrical and in midline without deviation. Patient has no speech disorders. Mouth Mouth is proportional and symmetrical. Tonsils are not inflamed. firm and pinkish in color. Patient has no dentures. masses or irregularities upon palpation. slightly rough and has thin whitish color on the surface. Buccal mucosa was uniform pale pink in color and moist. No jugular vein distention noted. Soft palate is light pink in color. It is also in central position and moves freely. There are no spaces in between teeth. IX. dry. lesions or any unusualness noted. The base of tongue is smooth with prominent veins. Neck Neck is symmetrical with no masses or unusual swelling upon palpation.

Patient is not in respiratory distress. Coughing episodes were also not observed. No lesions. Point of maximal impulse is at 5th intercostal space left midclavicular line. regular and slow with a long inspiratory phase and a short expiratory phase. Patient complains of pain on the surgical site and verbalized. With no adventitious sounds. XI. There are no bulges or retraction of the intercostal spaces. Chest/Lungs Chest skin integrity is good and intact. Patient did not complain of chest pain or chest tightness. A 1-cm incision is also present just below her umbilicus. Guarding of the chest noted upon respiration due to the proximity of the incision site to the diaphragm. negative for murmurs. Abdomen Abdomen is round. A 0. Vesicular breath sounds are soft and low pitched. There were no noted deformities in the client’s thoracic area. XII. crusting and masses. Client’s respiratory rate is 18 cycles per minute. with S1 louder than S2.5-cm incision was noted at the subxyphoid area. or edema and texture is even. lungs are clear to auscultation and no crackles. Areola and nipples are dark brown in color and has no discharges. It was observed that vocal fremitus is present both at the back and front of the chest when the patient says ―ninety-nine‖. Her breathing is deep.5-cm incisions are seen at her right lower rib cage. Color of skin in abdomen is slightly lighter than the rest of the body. All four incisions are covered with dry and intact dressing.X. Page | 31 . redness. Breast Breast is conical. No dimpling or retraction. wheezes or rubs. Apical pulse is 84bpm. Another two 0. Patient has symmetrical chest wall movement. Nipples are in midline and everted pointing in the same direction. Patient has distinct heart sounds. symmetrical and skin color is lighter than exposed areas.

Page | 32 . it was noted that patient has guarded and slow movement for she feels pain on her abdomen. tenderness or nodules palpated on each joint. Patient was on DAT as ordered. The skin at the back of the patient is uniform in color. No spinal tenderness noted. osteoporosis and alike to be noted. The nails were pinkish in color without cyanosis and clubbing. it was noted that patient has normal bowel sounds—high-pitched and occurred 16 times per minute. No vaginal bleeding or any other unusual discharges noted. curly and equally distributed on the mons pubis. arms. Upon auscultation of the abdomen. elbows and forearms are free of nodules.―Nagangulngol tong gioperhan. thick in each strand. XIV. There is no swelling. She was able to sit up on bed and perform range of motion on both upper and lower extremities. XIII. radial pulse is 82bpm. Symmetrical movement of abdomen upon respiration was noted. Patient is able to ambulate freely. Patient has normal capillary refill of 2 seconds. Client’s grasping ability was moderately strong on both hands. Umbilicus is midline and inverted. Aortic pulsations are not visible. Genito-urinary Pubic hair is present. Symmetrical chest expansion with respirations noted. No edema or cyanosis was noted on both upper and lower extremities. There were no deformities or abnormalities on the bone such as scoliosis. There are no skin breaks present. deformities and atrophy. However. Abdomen is soft and there is no point tenderness. The shoulders. Pwede makahingi ug tambal para sa sakit?” Patient reported a pain scale of 6 out of 10. Back and Extremities Peripheral pulse of the patient was symmetrical and regular in rhythm. swelling. The back is also symmetrical with the spinal cord aligning from the neck down to the buttocks.

Reflexes are normal and symmetrical bilaterally in both extremities. She has a Glasgow coma scale of 15: 4 from eye opening. awake. conscious. Neurological Patient was received lying on bed. She is also alert and attentive. She verbalized her urine is amber in color. place and time. coherent and afebrile. Patient is oriented to person. She has no difficulty urinating and did not report dysuria.Patient voids freely. 5 for verbal resoponse and 6 for motor response. Page | 33 . XV.

a fluid made by the liver. the gallbladder measures approximately 8 cm in length and 4 cm in diameter when fully distended. Page | 34 .ANATOMY AND PHYSIOLOGY GALLBLADDER The gallbladder is a hollow organ that sits just beneath the liver. The neck tapers and connects to the biliary tree via the cystic duct. body. It is divided into three sections: fundus. and neck. which then joins the common hepatic duct to become the common bile duct. Its function is to store and release bile. In adults.

hormonal. it appears to function as more than a passive conduit. The cystic duct is usually 2-3 mm wide. the cystic duct is lined by a spiral mucosal elevation. called the valvula spiralis (valve of Heister) which is a series of crescentic folds of mucous membrane in the upper part of the cystic duct. bile salts. Page | 35 . Its length is variable and usually ranges from 2 to 4 cm. It can dilate in the presence of pathology (stones or passed stones). arranged in a somewhat spiral manner. cholesterol.CYSTIC DUCT The cystic duct is the short duct that joins the gall bladder to the common bile duct. The principal function of the internal spiral folds that are found in man may be to preserve patency of this narrow. tortuous tube rather than to regulate bile flow. and bilirubin. however. and neural stimuli. Although the cystic duct is unlikely to play a major role in gallbladder filling and emptying. Coordinated. Throughout its length. The duct and spiral folds contain muscle fibers responsive to pharmacologic. The cystic duct varies from 2 to 3 cm in length and terminates in the gallbladder. There is. BILE The main components of bile include contains water. proteins. graded muscular activity in the cystic duct in response to hormonal and neural stimuli may facilitate gallbladder emptying. no convincing evidence of a discrete muscular sphincter within the duct. fats.

In the absence of bile. When food is released by the stomach into the duodenum in the form of chyme. This concentration occurs through the absorption of water and small electrolytes. while retaining all the original organic molecules. the final section of the small intestine.Bile. which joins with the cystic duct from the gallbladder to form the common bile duct. Besides its digestive function. Page | 36 . The alkaline bile also has the function of neutralizing any excess stomach acid before it enters the ileum. where it is stored and concentrated to up to five times its original potency between meals. bile is prevented from draining into the intestine and instead flows into the gallbladder. Bile helps to emulsify the fats in the food. which causes the gallbladder to release the concentrated bile to complete digestion. destroying many of the microbes that may be present in the food. bile serves also as the route of excretion for bilirubin. fats become indigestible and are instead excreted in feces. a condition called steatorrhea. a byproduct of red blood cells recycled by the liver. Bile salts also act as bactericides. a muscular valve that controls the flow of digestive juices (bile and pancreatic juice) through the ampulla of Vater into the second part of the duodenum. The common bile duct in turn joins with the pancreatic duct to empty into the duodenum. is closed. If the sphincter of Oddi. the duodenum releases cholecystokinin. is produced by hepatocytes in the liver and and then flows into the common hepatic duct.

Tenth Edition 1983 page 1822 Lippincott Williams and Wilkins Handbook of Diseases Third Edition.diabetesmonitor.com/learningcenter/gallstones. Sources: Harrison’s Principles of Internal Medicine. Sources: Harrison’s Principles of Internal Medicine. Diabetes mellitus ABSENT People with diabetes generally have high levels of fatty acids called triglycerides. page 184 http://www. both of which can lead to gallstones. Page | 37 . These fatty acids increase the risk of gallstones.ETIOLOGY AND SYMPTOMATOLOGY Etiology Predisposing Factors Present/ Absent Rationale Justification Female PRESENT Women between 20 and 60 years of age are twice as likely to develop gallstones as men.htm The patient is female. The patient is not diabetic. Estrogen increases cholesterol levels in bile and decrease gallbladder movement.

Ethnicity (Native American. Sources: Harrison’s Principles of Internal Medicine. page 184 Age (20-50. In fact. She is predisposed to having pigment stones. A majority of Native American men have gallstones by age 60. page 184 The patient is 38 years old. Mexican American) (Asian) PRESENT Native Americans have a genetic predisposition to secrete high levels of cholesterol in bile. they have the highest rate of gallstones in the United States. Tenth Edition 1983 page 1823 Lippincott Williams and Wilkins Handbook of Diseases Third Edition. Asians are more genetically predisposed to having pigment stones as compared to those living The patient is Filipino. Page | 38 .Tenth Edition 1983 page 1823 Lippincott Williams and Wilkins Handbook of Diseases Third Edition. over age 60) PRESENT Many of the body’s systems and protective mechanisms become less efficient with age. Body systems and processes become sluggish. Mexican American men and women of all ages also have high rates of gallstones.

in the Western countries
Sources: Lippincott Williams and Wilkins Handbook of Diseases Third Edition, page 184 http://www.diabetesmonitor.com/learningcenter/gallstones.htm

Precipitating Factors Pregnancy

Present/ Absent

Rationale

Justification

ABSENT

Excess estrogen from pregnancy, hormone replacement therapy, or birth control pills appears to increase cholesterol levels in bile and decrease gallbladder movement, both of which can lead to gallstones. Source: http://www.fbhc.org/Patients/Modul es/gallstns.cfm

The patient is not pregnant.

Rapid weight loss

ABSENT

As the body metabolizes fat during rapid weight loss, it causes the liver to secrete extra cholesterol into bile, which can cause gallstones. Sources: Lippincott Williams and Wilkins Handbook of Diseases Third Edition, page 184 http://www.fbhc.org/Patients/Modul es/gallstns.cfm

No rapid weight loss was noted by the patient.

Page | 39

Obesity

ABSENT

The most likely reason is that obesity tends to reduce the amount of bile salts in bile, resulting in more cholesterol. Obesity also decreases gallbladder emptying. Sources: Harrison’s Principles of Internal Medicine, Tenth Edition 1983 page 1823 Lippincott Williams and Wilkins Handbook of Diseases Third Edition, page 184 http://www.fbhc.org/Patients/Modul es/gallstns.cfm

The patient is not obese.

Fasting

ABSENT

Fasting decreases gallbladder movement, causing the bile to become overconcentrated with cholesterol, which can lead to gallstones. Source: http://www.diabetesmonitor.com/lea rning-center/gallstones.htm

The patient doesn’t fast.

Hormone replacement therapy, or birth control pills

PRESENT

Excess estrogen from pregnancy, hormone replacement therapy, or birth control pills appears to increase cholesterol levels in bile and decrease gallbladder movement, both of which can lead to gallstones.

The patient has been on birth control pills since she was 36 years old.

Page | 40

Source: Lippincott Williams and Wilkins Handbook of Diseases Third Edition, page 184 http://www.diabetesmonitor.com/lea rning-center/gallstones.htm

Low Fat Diet

PRESENT

Before dietary fat can be digested, it has to be emulsified. Bile is used for this purpose. The liver makes bile continuously and stores it in the gall bladder until such time as it is needed. However, if a low-fat diet is eaten, that bile remains in the gall bladder. Gallstones are formed when the gall bladder is not emptied on a regular basis. In people who continually resort to low-fat diets, bile is stored for long periods in the gall bladder — and it stagnates. In time — and it is really quite a short time — a 'sludge' begins to form.

The patient avoids fatty foods.

Source: http://www.secondopinions.co.uk/gallstones.html

Page | 41

shoulder. distension gallbladder.Symptomatology Signs and Symptoms Present/ Absent Rationale Justification Right upper quadrant pain (may radiate to right scapula. Sources: Harrison’s Principles of Internal Medicine. Fever is a released from host cells in response to infectious or non-infections disorders. or interscapular area) “biliary colic” PRESENT patient ducts The into connected to the gallbladder came Obstruction of will cause inflammation DMSF by increased complaining produced intraluminal pressure and of RUQ pain. Tenth Edition 1983 page 1825 of the Fever (low grade) ABSENT patient nonspecific The not response that is mediated was by endogenous pyrogens febrile. Source: Carol Mattson Page | 42 . It may be brought about by prostaglandins released during inflammation.

for it is performed by asking the Murphy’s patient to breathe out and Sign. If the patient stops breathing in (as the gallbladder in moving in is tender and. The patient is then instructed to inspire (breathe during in). Normally. inspiration.Porth (2005. Pathophysiology. then gently placing the hand below the costal margin on the right side at the midclavicular line approximate location (the of the gallbladder). comes contact with the examiner's fingers) and winces with a 'catch' in breath. Seventh edition page 205) Murphy's sign (abrupt interruption of deep inspiration) PRESENT Classically Murphy's sign is The tested for during was patient positive the an abdominal examination. downward. the abdominal contents are pushed downward as the diaphragm moves down (and lungs expand). the test is Page | 43 .

A positive test also requires no pain on performing the maneuver on the patient's left hand side.com/pdf/hp_nov00_m urphy. bilirubin was Page | 44 . The inflammation of complain the gallbladder causes pain nausea and spasms of the vomiting.pdf Nausea and vomiting ABSENT Nausea and vomiting The patient sometimes occur with biliary didn’t colic.turnerwhite.considered positive. of or abdominal muscles which may make one feel nauseated. Source: Understanding Surgical Medical by Nursing Williams and Hopper page 742 Mildly elevated ABSENT Biliary obstruction causes The patient’s suppression of bile flow. Source: http://www.

Tenth Edition 1983 page 1829 Elevated SGPT and SGOT enzymes PRESENT SGOT (AST) and (ALT) is The patient’s an enzyme found mostly in lab the liver but also in the reveal heart.serum bilirubin and regurgitation of not increased. Abnormalities enzymes of liver including Page | 45 . liver disease or muscle trauma. the pancreas and of SGPT and in red blood cells. High SGOT elevations associated may with be enzymes. the muscles. pancreatitis. tests an the elevated level kidneys. Elevations may also be associated with a variety of conditions including myocardial infarction (heart attack). bile duct obstruction and more. conjugated bilirubin into the bloodstream. Sources: Harrison’s Principles of Internal Medicine.

Sources http://my.AST/SGOT and ALT/SGPT are indicative of problems such as Mirrizi syndrome. or a stone in the bile duct causing inflammation.com /apollo/sgot.asp infection/liver Page | 46 .diabetovalens.

a stone is moved and becomes impacted on the cystic duct CHOLELITHIASIS Lumen is obstructed by stones Bile stasis Page | 47 .PATHOPHYSIOLOGY Precipitating Factors: Predisposing Factors:     Female Age 38 Ethnicity Diabetes Mellitus       Bile stagnates in the gallbladder Birth control pills Low Fat Diet Pregnancy Rapid weight loss Obesity fasting Pigment solute precipitate as solid crystals Crystals clump together and form stones Gallstones Gallbladder contracts after intake of fat to release bile Upon contraction.

Chemical reaction inside gallbladder triggers the release of inflammatory enzymes (Prostaglandins) Fluids leak into gallbladder Edema Inflammation of the gallbladder Increased intraluminal pressure and distention of the gallbladder Biliary Colic (RUQ pain) Constriction of blood vessels Murphy’s Sign ACUTE CHOLECYSTITIS If not treated If treated with: Continued lack of blood supply to gallbladder Continued increase in intraluminal pressure of gallbladder Surgery. compliance to medications Necrosis Rupture of gallbladder Good prognosis Gangrene and empyema Spread of bile indigenous microorganisms peritoneal cavity Page | 48 and into Perforation of gallbladder . high fiber). proper diet (low fat.

Sepsis Death Page | 49 .

DOCTOR’S ORDER Date 5/8/10 @ 11pm Order Admit under the care of Dr. Batucan. Patient was placed in ward 324 bed 5 Done CBC A complete blood count (CBC) is a series of tests used to evaluate the composition and Done Page | 50 . this is done to prevent any further damage to the gallbladder. Labs: Done Done Remarks Done. a surgeon. Monitor VSqShift and record Monitoring vital signs is important in order to note any unusualities and to refer these as follows. Thus. for his specialties on surgical procedures (Laparoscopic cholecystectomy) Secure consent to care Consent is an agreement between client and health care provider to give proper quality care. It is also to protect the client from harmful procedures and the institution from law suits Low fat diet Doctors were not sure whether the gallstones are either cholesterol or pigment stones. Batucan Rationale Admitted under the care of Dr.

white blood cell (WBC) count. blood clots can form (thrombosis). which may obstruct blood vessels. measurement of hemoglobin and mean red cell volume. It consists of the following tests: red blood cell (RBC) count. sugar. Done Urinalysis It is done to detect urinary tract infection. and platelet count. if the number of platelets is too high. classification of white blood cells (WBC differential). protein. However.concentration of the cellular components of blood. If the number of platelets is too low. IVF infusing well Page | 51 . excessive bleeding can occur. It also measures the level of ketones. and calculation of hematocrit and red blood cell Platelet Platelet count is to determine the number of platelets. blood components and many other substances Done Venoclysis: PNSS 1L @ 100cc/hr PNSS is an isotonic solution to provide hydration since it Done.

euphoria. Done Refer any In order for the patient to be Done Page | 52 . sedation for relief of moderate to severe pain Given HNBB (Hyoscine NButyl Bromide) 20mg 1amp IVTT now It's a competitive antagonist of the actions of acetylcholine and other muscarinic agonists causing smooth muscle relaxation indicated for her abdominal pain Given MHBR Moderate high back rest is to elevate the upper portion of the body to increase lung expansion thus promoting gas exchange. This is also to prevent ascending infection that could be caused by possible rupture of the gallbladder.was found out that the specific gravity for urine is in the borderline (1. and as a medium for IVTT meds at right metacarpal vein.010). Meds: Demerol 50mg IVTT now then prn for abdominal pain Acts as agonist at specific opioid receptors in the CNS to produce analgesia. It is also to provide electrolytes.

vomiting 5/9/10 8:10am Start Cefoxitin (Monowel) 1g IVTT q8 ANST assessed and evaluated properly and be managed accordingly. to capture their size. ANST or after negative skin test is to check whether the client is not allergic to the antibiotic. For ultrasound tomorrow morning This is done to visualize internal organs. For total bilirubin. Cefoxitin may be given to the patient. Bilirubin is elvated if hepatocytes are injured and cannot metabolize or excrete bilirubin Done.unusualities: severe abdominal pain. Cefoxitin inhibits synthesis of bacterial cell wall causing cell death which acts as a perioperative prophylaxis for surgical procedures. This is also to know the condition of the gallbladder whether it ruptured or not. Results are normal Direct bilirubin. Result for skin test is negative. 2010. Patient had her ultrasound on May 11. Done. Increases in conjugated bilirubin are highly specific for disease of the liver or bile ducts Indirect bilirubin Increase in unconjugated bilirubin may be caused by Page | 53 . structure and any pathological lesions with real time tomographic images. Not able to comply.

Elevated levels may be caused by liver or heart disease Done. cholestasis. Elevation of this may possibly mean liver problems AST (aspartate aminotransferase) or SGOT is an enzyme found in high amounts in heart muscle and liver and skeletal muscle cells. and hemolysis Alkaline phosphatise High levels of alkaline phosphatise indicates liver disease SGPT (Serum glutamic pyruvic transaminase) SGPT is released into blood when the liver or heart is damaged. Done. SGOT results are also high Schedule for laparoscopic cholecystectomy on Tuesday (4/11/10) 2pm Secure consent/AC Lap Chole was to surgically remove the gallbladder with only a small incision.hepatic disease. Surgery was done on 4/11/10 @ 4pm Patient has the right to be Done. Patients SGPT results are high SGOT (Serum glutamic oxaloacetic transaminase) Done. this is to determine liver function. Page | 54 . thus. It is also found in lesser amounts in other tissues.

and for legal purposes. 5/9/10 5:00pm May have ultrasound on Tuesday 5/11/10 This was to visualize internal organs. Impression: Cholelithiasi s. Ultrasound Done Done structure and any pathological result lesions with real time tomographic images. This is also to coordinate availability of staff and surgeon Refer In order for the patient to be assessed and evaluated properly and be managed accordingly. retrieved on 5/11/10. Done. to capture their size.consented in all procedures to be done. Sonographic Page | 55 . Inform OR For the OR to know that such case will be performed and to prepare the necessary instruments and room. It is also for the anaesthesiologist to predict the operative risk and the appropriateness of the anaesthesia to be induced during operation. Anesthesia clearance is for the patient to be evaluated whether he/she is fit to undergo the operation. It is also to know whether the gallbladder has ruptured or not.

2010. making sure that the patient isn’t allergic to the anesthetic For Lap Chole tom 4pm This was to surgically remove the gallbladder with only a small incision. IVF TF: PNSS 1L @ KVO PNSS is an isotonic solution for hydration and as a medium for IVTT meds. For blood chem. Patient can undergo laparoscopic cholecystectomy since gallbladder has not ruptured yet as seen on the ultrasound result.ally normal liver and pancreas 5/10/10 1:00pm To reschedule OR tomorrow from 2pm to 4pm To inform the OR that the procedure will be moved from 2pm to 4pm Done. . such as Page | 56 Done Done Done. Patient had her surgery at 4pm of May 11. and Ultrasound tom Blood tests are used to determine physiological and biochemical states. 9:15pm Please facilitate AC AC is to assess patient’s rate of survival and check for what anesthetics is right for the patient. KVO was done since patient’s hydration was good. Done.

to hydrate before surgery in preparation for disruption of homeostasis Done Meds: Diazepam 10mg 1 Potentiates the effects of Given Page | 57 . aspiration and injury during surgery Done Assess VS prior to OR as baseline data and to detect Done any unusualities General oral hygiene Oral hygiene is the practice of keeping the mouth clean and healthy by brushing and flossing to prevent tooth decay and gum disease. mineral content. and organ function.disease. drug effectiveness. 9:30pm Pre-op orders: NPO after light breakfast (8am) NPO is to prevent peristalsis. Done IVF: D5NSS 1L @ 120cc/hr Intravenous solutions with reduced saline concentrations typically have dextrose added to maintain a safe osmolality while providing less sodium chloride.

aspiration and injury to the GI tract during surgery. thromboplasstin. Act in spinal cord and at supraspinal sites to produce skeletal muscle relaxation. PACU is a place with complete gadgets and staff for emergency purposes after post op. NPO for 4 hrs then may have SD Patient not yet fully conscious due to anesthetics. and stuart factor. thus this Done Page | 58 . proconvertin. it is also used as adjunct to General anesthesia Given Ranitidine 150mg 1tab 2am Inhibits basal gastric acid secretion and gastric acid secretion. Done Post op orders: To PACU then to room Patient must first be stabilized Done before transfer to the ward. Given 5/11/10 1:30pm NPO NPO is to prevent peristalsis.tab 2am GABA. patient was placed on NPO Vitamin K For the liver to activate clotting factors such as prothrombin.

Also this was Done Page | 59 . this was indicated due to possible intra – abdominal infections Given O2 inhalation @ 4pm until fully awake This ensures optimum oxygenation of cells gearing towards achieving balance or homeostasis. Done Meds: Etoricoxib 120mg PO 12mn Half life is 22hrs. sedation.is to prevent aspiration. causes many effects similar to opioids – analgesic Given Demerol 50mg IVTT Half life is 3-5hrs Causes analgesia. euphoria. Monitor VS q15 until stable then q30 for 2hrs then q2 Monitoring vital signs is to detect any unusualities after the operation. thus reducing pain Given Sultamicillin 375mg PO TID Inhibits synthesis of bacterial cell wall causing cell death. Etoricoxib blocks COX2 thus relieving pain and inflammation. Given Tramadol 100mg 1tab 12mn Half life is 5-7hrs Inhibits the reuptake of norepinephrine and serotonin.

Etoricoxib blocks COX2 thus relieving pain and inflammation. MHBR Moderate high back rest is to elevate the upper portion of the body to increase lung expansion thus promoting gas exchange. Deep breathing exercises for 15mins TID Post op exercise is indicated To prevent lung collapse and to eliminate anesthetic gases introduced to the body 5/12/10 11:15am May have DAT Patient may eat anything as long as it can’t harm her current condition Continue meds For the patient to complete the medication regimen and for continuity of care Done Done. Done Done Wound care Daily routine wound care is indicated in order to promote healing and/or prevent infection Done 5/13/10 9:00am MGH Patient may go home after the doctor decides if unusualities are absent Done Home meds: Etoricoxib 90mg PO BID Half life is 22hrs. Patient was informed Page | 60 . Done. prevents lung collapse.for optimum respiratory level.

up check at 5/18/10 Follow up check up is for the patient to be assessed and evaluated properly and be managed accordingly. Page | 61 .Tramadol 100mg ½ tab PO BID Half life is 5-7hrs Inhibits the reuptake of norepinephrine and serotonin. causes many effects similar to opioids – analgesic Sultamicillin 375mg PO BID Inhibits synthesis of bacterial cell wall causing cell death C/D IVF Terminate IVF when IVF is about 50cc IVF discontinued Patient to come back at 5/18/10 ff.

2-6.0 oxygen to and removes carbon dioxide from red blood cells. 2010 Test Hemoglobin Normal Result Remark Rationale Values 115. Strict asepsis should be observed Page | 62 . infection and other disorders May 8.DIAGNOSTIC EXAM CBC – a determination of red and white blood cells per cubic millimeter of blood.42 Normal Hematocrit measures the percentage of red blood cells in the total blood volume RBC 4.0.137. It helps health professional check any symptoms such as weakness.47 Normal Measures the number o RBCs per cubic millimeter Within normal range The patient may feel discomfort when blood is Within normal range Interpretation Within normal range Nursing Responsibilities There is very little risk associated with taking blood from a vein in the arm. although there is a slight risk of infection anytime the skin is broken. or bruising.360.52 0.1 4. It measures total amount of hemoglobin in the blood Hematocrit 0. fatigue.0 Normal Hemoglobin carries 155. It also helps diagnose conditions such as anemia.

organ meats. drawn from a vein. Elevated levels acute infections – tuberculosis. pneumonia. or the person may feel dizzy or faint.010. tonsillitis. Lymphocytes 20-35 21 Normal Cells present in the blood and lymphatic tissue that provide the main means of immunity for the body.0 14. meningitis. There are three types of lymphocytes: the natural Within normal range Within normal levels. clean green vegetable and fortified grains Protect the patient from potential sources of Page | 63 . WBC 5. Bruising may occur at may be caused by the puncture site. Warm packs can also be placed over the puncture site to relieve discomfort Instruct patient in dietary sources of iron such as red meat. etc. Neutrophil 55-75 74 Normal Phagocytes engulfing bacteria and cellular debris.of the whole blood. colitis. Pressure should be applied to the puncture site until the bleeding stops to reduce bruising. appendicitis. It prevents or limits bacterial infections.1 High Determines the number of circulating WBCs per cubic millimeter of the whole blood.

thymus-derived lymphocytes (T cells). The T cells and B cells are involved in specific immune responses. vitamins. Meticulous hand washing and strict asepsis are mandatory Institute isolation protective measures immediately if there is neutrophil disorder. bland diet high in protein. monitor for signs of infection. and calories. Monitor Page | 64 . and bone marrow-derived lymphocytes (B cells).killer (NK). Also instruct the patient to observe aseptic technique and to take caution most especially if immunocompromised. Monocytes 2-10 4 Normal This type of granular leukocyte functions in the ingestion of bacteria and other foreign particles Eosinophil 1-8 1 Normal Functions in allergic responses and in resisting infections. red bone marrow. Inflammatory responses involve more than one body system. lymph nodes and spleen and are able to destroy many kinds of infected body cells and tumor cells. NK cells are found in the blood. Eosinophils Within normal range Within normal range infection. Provide soft.

000-500. respiratory compromised. Encourage patient to rest between activities. Platelet 150. Platelets number from 100.000 per cubic millimeter and are important in triggering the sequence of events that leads to the formation of blood clots.0 278 Normal A test that direct count of platelets in whole blood. Encourage patient to plan ahead and save energy for the most important activities.mount on attack against parasitic invaders by attacking to their bodies and discharging toxic molecules from their cytoplasmic granules. Encourage patient to Eat Page | 65 . Within normal range the patient for worsening of the inflammatory particularly condition. Encourage patient to void or stop activities that make short of breath or make heart beat faster.0400.

a diet with adequate protein and vitamins. blood components and many other substances May 8. Drink plenty of noncaffeinated and nonalcoholic fluids. Wash hands to make sure they are clean before collecting the NURSING RESPONSIBILITIES Advise Patient to: Page | 66 . 2010 TEST Glucose RESULT Negative NORMAL <50mg/dL CLINICAL SIGNIFICANCE Glucose is the type of sugar found in blood. It is done to detect urinary tract infection. Normally there is very little or no glucose in urine. Glucose can also be found in urine when the kidneys are damaged or diseased. as in uncontrolled diabetes. or chemical examination of the urine. When the blood sugar level is very high. Urinalysis .Urinalysis is a physical. sugar. microscopic. It also measures the level of ketones. protein.

Protein Negative <30mg/dL Protein is normally not found in the urine. Urobilinogen in urine can be a sign of liver disease (cirrhosis. may cause protein to be in the urine. Clean the area around your genitals. Fever. If it is present. Bilirubin Negative <1mg/dL This is a substance formed by the breakdown of red blood cells. pregnancy. the greater the alkalinity. kidney stones. the higher the pH. the greater the toilet or urinal. If the collection cup has a lid.5-8 Urine pH is used to classify urine as either a dilute Begin urinating into acid or base solution.4 to a pH of about 6 in the urine Finish urinating into the toilet or urinal. especially kidney disease. urine. The lower the pH. a urinary Page | 67 . the acidity of a solution. and some diseases. Urobilinogen Normal <2mg/dL This is a substance formed by the breakdown of bilirubin. remove it carefully and set it down with the inner surface up. hard exercise. The glomerular filtrate of blood is usually acidified by the kidneys from a pH of approximately 7. it often means the liver is damaged or that the flow of bile from the gallbladder is blocked. Do not touch the inside of the cup with your fingers. Carefully replace and tighten the lid on the Blood Negative <510RBC/mL Red blood cells in the urine may be caused by kidney or bladder injury. pH 6 4. hepatitis) that the flow of bile from the gallbladder is blocked.

Leukocytes 25 <25WBC/m L Clarity Clear Clear Leukocyte esterase shows leukocytes in the urine. including fluid cup then return it to the lab. starvation. Bacteria.030 This checks the amount of substances in the urine. menstrual blood. Urine is normally clear. crystals. Specific gravity 1. blood. or mucus can make urine look cloudy.010-1. inflammation of the kidneys (glomerulonephritis). stool (feces). After the urine has flowed for several seconds. diabetic ketoacidosis. is present. The higher the specific gravity.tract infection (UTI). Do not touch the rim of the cup to your genital area.010 1. or anything else in the urine sample. or systemic lupus erythematosus (SLE). Nitrites in urine show a UTI is present. Page | 68 . the more solid material is in the urine. Do not get toilet paper. or severe vomiting may also cause ketones to be in the urine. Nitrite Negative Negative Bacteria that cause a urinary tract infection (UTI) make an enzyme that changes urinary nitrates to nitrites. WBCs in the urine may mean a UTI is present. A diet low in sugars and starches (carbohydrates). sperm. a kidney or bladder tumor. place the collection cup into the urine stream and collect "midstream" urine without stopping your flow of urine. Color Yellow Pale to dark Many things affect urine color. Ketone Negative <5 mg/dL Ketones in the urine may mean a very serious condition. It also shows how well the kidneys balance the amount of water in urine. pubic hair.

beets.yellow balance. or (3) the biliary tract is obstructed blocking the flow of Page | 69 . aspartate aminotransferase [AST]. and alanine aminotransferas [ALT]). Blood Chemistry . blackberries.3 REFERENCE 2. diet. and diseases. rhubarb. This may occur because (1) too much bilirubin is being produced. These tests provide valuable diagnostic cues. or blood in the urine can turn urine red-brown. 2010 TEST Total Bilirubin RESULT 8. May 9. Some medicines. serum glucose. certain kinase [CK]. Vitamin B supplements can turn urine bright yellow.0 – 21. How dark or light the color is tells you how much water is in it. medicines.0 REMARK Normal RATIONALE It occurs when bilirubin production exceeds the liver's excretory capacity.A number of tests performed on blood serum (liquid portion of the blood). It determines certain enzymes that may be present (including lactic dehydrogenase [LDH]. hormones such as thyroid hormone and other substances such as cholesterol and triglycerides. (2) hepatocytes are injured and cannot metabolize or excrete bilirubin.

0 High SGPT is released into blood when the liver or heart is damaged.conjugated bilirubin into the intestine Direct Bilirubin 0. structure and any pathological lesions with real time Page | 70 . cholestasis. to capture their size.6 0. SGOT 55.0 – 31.0 – 3. very high ALP levels can tell the doctor that the person’s bile ducts are somehow blocked Medical sonography (ultrasonography) is an ultrasound-based diagnostic medical imaging technique used to visualize muscles.0 High SGOT is an enzyme found in high amounts in heart muscle and liver and skeletal muscle cells.0 – 17. this is to determine liver function.0 – 34.2 0. and many internal organs. and hemolysis SGPT 60.4 Normal Increases in conjugated bilirubin are highly specific for disease of the liver or bile ducts Inderct Bilirubin 7. thus. Elevated levels may be caused by liver or heart disease Alkaline Phosphate 191 64 – 306 Normal When a person has evidence of liver disease . tendons.9 0.4 2.0 Normal Increase in unconjugated bilirubin may be caused by hepatic disease.

pancreas. Ultrasound has been used by sonographers to image the human body for at least 50 years and has become one of the most widely used diagnostic tools in modern medicine.tomographic images. aorta. intrahepatic ducts. 12/28/10 Impression: Isaac T. kidneys and urinary bladder Cholelithiasis Sonographically normal liver and pancreas Nursing Responsibilities: Explain the procedure and purpose of the test Provide a gown without snaps. spleen. and ask the patient to remove all jewelry Take ultrasound if the patient’s bladder is fluid filled for better results Page | 71 . Robillo Memorial Hospital 05/11/10 Impression: Davao Medical School Foundation Non-obstructive cholelithiasis Ultrasonically normal liver. paraaortic areas.

arrhythmia. Pre-op: Support for of anesthesia Contraindications: Hypersensitivity to narcotics. headache.DRUG STUDY Generic Name: Meperidine Hydrochloride Brand Name: Classification: Ordered Dose: Mode Of Action: Indications: Demerol Opioid agonist analgesic 50mg IVTT now then prn for abdominal pain Acts as agonist at specific opioid receptors in the CNS to produce analgesia. loss of appetite. hypotension. the receptors mediating these effects are thought to be the same with endorphins Relief of moderate to severe acute pain. seizure. fear. respiratory depression. palpitations. euphoria. disorientation. dizziness. tachycardia. asthma. dizziness. renal dysfunction Drug Interactions:  Potentiation of effects with barbiturate anesthetics  Severe/fatal reactions with MAOIs  Increased chances of respiratory depression. insomnia. sedation. diarrhea. sedation. tremor  CV: peripheral circulatory collapse. constipation. anxiety. hypertension. hallucinations. lethargy. agitation. dysphoria. COPD. hypotension Page | 72 . sedation. impaired visual acuity  CNS: light-headedness. pregnancy. bradycardia. vomiting. mood changes. delirium. euphoria. sedation. and coma with phenothiazines Side Effect: Adverse Effects: Nausea. drowsiness. weakness.

decreased libido  MAJOR: respiratory depression. edema  GI: nausea. urticaria. antihistamines. bronchospasm. oliguria.html www.drugs.  GU: ureteral spasm. tranquilizers  Do not take left over medications for other disorders  Keep out the reach of children  Take Demerol with food. dry mouth. anorexia.com/demerol-drug. urinary retention. sedatives. apnea. cardiac arrest Nursing Responsibilities:  Keep opioid antagonist and facilities readily available during parenteral administration  Use caution when injecting to patients with hypotension  Reduce dosage of Demerol in patients receiving phenothiazines or other tranquilizers  Reassure that addiction is unlikely to occur  Use Demerol with extreme caution in patient with renal dysfunction  Give only prescribed dosage  Avoid alcohol.htm Bibliography: Generic Name: Hyoscine N-butyl Bromide Page | 73 .com/demerol.rxlist. vomiting. constipation. shock. 2005 Lippincott’s Nursing Drug Guide www. small frequent meals  May use laxative if constipation occurs  Avoid driving or doing activities that require alertness because it could cause drowsiness and impaired visual activity. circulatory depression. respiratory arrest. Dermatologic: pruritus.

dysphoria. Hyoscine works by relaxing the muscle that is found in the walls of the stomach. respiratory arrest. paralytic ileus or pyloric stenosis. sedation. anxiety. euphoria. increased pulse. circulatory depression. hypertension. cardiac arrest  Inform patient that drug may cause blurred vision. insomnia. dizziness. vision problems. mood changes. bradycardia. diarrhea. headache. agitation. closed angle glaucoma Drug Interactions:  Anticholinergic agents  Antihistamines  Monoamine oxidase inhibitors  Tricyclic antidepressants  Competitively blocks prokinetic agents Side Effect: Nausea. Patients with prostatic enlargement. weakness. vomiting. lethargy. constipation. edema  GI: nausea. urinary retention.Brand Name: Classification: Ordered Dose: Mode Of Action: Buscopan Gastro-intestinal antispasmodic 20mg 1amp IVTT now It's a competitive antagonist of the actions of acetylcholine and other muscarinic agonists. constipation. anorexia. eye pain  CNS: light-headedness. ulcerative colitis. arrhythmia.  GU: ureteral spasm. tachycardia. rash. hallucinations. Contraindications: Hypersensitivity to hyoscine butylbromide. itching. dizziness. dry mouth. swelling of the hands or feet. trouble breathing. oliguria. Instruct patient to report if she experiences such symptom. disorientation. loss of appetite. decreased libido  MAJOR: respiratory depression. fear. shock. apnea. palpitations. intestines and bile duct (gastrointestinal tract) and the reproductive organs and urinary tract (genitourinary tract) Indications: This medication is used to relieve bladder or intestinal spasms. hypotension  Dermatologic: pruritus. delirium. dry mouth. Page | 74 Adverse Effects: Nursing Responsibilities: . tremor  CV: peripheral circulatory collapse. bronchospasm. urticaria. vomiting.

vomiting.com/hyoscine_butylbromideoral/page2. review all other significant adverse reactions and interactions  Give only prescribed dosage  Do not take left over medications for other disorders  Keep out the reach of children MIMS 113th edition 2007 http://home. Page | 75 .intekom. headache  CV: peripheral circulatory collapse.uk/medicines/100000395.  Assess for urinary hesitancy  Assess for constipation. dizziness.medicinenet. nausea.html Generic Name: Cefoxitin Sodium Brand Name: Classification: Ordered Dose: Mode Of Action: Indications: Monowel Antibiotic.html http://www.com/pharm/quatrom/q-hyosc.netdoctor. tachycardia.Bibliography:  Assess for parkinsonism and Extra-pyramidal symptoms. diarrhea Adverse Effects:  CNS:.htm http://www. lethargy.co. Cephalosphorin (2nd gen) 1g IVTT q8 ANST Inhibits synthesis of bacterial cell wall causing cell death Perioperative prophylaxis Contraindications: Hypersensitivity to cephalosphorins and/or penicillins Drug Interactions:  Increased nephrotoxicity with aminoglycosides  Increased bleeding effects with anticoagulants Side Effect: Stomach upset.  As appropriate.  Caution patient to avoid alcohol because it may increase CNS depression.

Nursing Responsibilities:

Bibliography:

bradycardia, arrhythmia, palpitations, hypertension, hypotension  GI: nausea, vomiting, diarrhea, anorexia, abdominal pain, psuedomembranous colitis  GU: Nephrotoxicity  Hematologic: bone marrow depression, thrombocytopenia  Culture infection before starting therapy  Have vitamin K available in case of hypoprothrombinemia  Discontinue if hypersensitivity occurs  Avoid alcohol while taking drug  Take only prescribed dosage  Complete antibiotic therapy, don’t skip doses  Do not use extra medicine to make up the missed dose  Do not use drug if you are allergic to penicillins and cephalosporins  Antibiotic medicines can cause diarrhea, which may be a sign of a new infection. If you have diarrhea that is watery or has blood in it, call your doctor.  Store at room temperature away from moisture, heat, and light  If you get a skin rash, do not treat yourself. 2005 Lippincott’s Nursing Drug Guide MIMS 113th edition 2007 www.drugs.com/cdi/cefoxitin.html www.revolutionhealth.com/drugs-treatments/cefoxitin

Generic Name:

Diazepam

Brand Name: Classification:

Valium Benzodiazepine, skeletal muscle relaxant
Page | 76

Ordered Dose: Mode Of Action: Indications:

10mg 1 tab 2am Potentiates the effects of GABA; Act in spinal cord and at supraspinal sites to produce skeletal muscle relaxation Relief of anxiety and tension; to lessen recall in patients prior to surgical procedures

Contraindications: Hypersensitivity to benzodiazepines, psychosis, shock, coma, alcoholic intoxication, pregnancy Drug Interactions:  Increased CNS depression with omperazole  Increased effects of diazepam with cimetidine, hormononal contraceptives  Decreased effects with ranitidine Side Effect: Adverse Effects: Drowsiness, dizziness, GI upset, difficulty concentrating, fatigue, nervousness, crying  CNS: drowsiness, sedation, depression, lethargy, fatigue, light headedness, disorientation, restlessness, tremor, stupor, psychomotor retardation, EPS, hallucinations, nasal congestion  CV: bradycardia, tachycardia, hypotension, hypertension, edema  Dependence: drug dependence  Dermatologic: uticaria, pruritus, dermatitis  GI: constipation, diarrhea, dry mouth, salivation, nausea, anorexia, vomiting, hepatic dysfunction, jaundice  GU: incontinence, retention, change in libido, menstrual irregularities  Other: phlebitis and thrombosis at injection site, hiccups, fever, diaphoresis, pain at injection site  Carefully monitor pulse, respiration rate and blood pressure during administration  Keep addiction – prone patients under careful surveillance  Ensure ready access to bathroom if GI effects occur  Provide small, frequent meals to prevent GI upset  Establish safety precautions if CNS changes occur  Monitor liver and kidney function, CBC during long term therapy  Taper dose gradually after long term therapy
Page | 77

Nursing Responsibilities:

Bibliography:

 Discuss risk of fetal abnormalities with patients desiring to become pregnant  Take drug exactly as prescribed  Do not stop drug abruptly during long term therapy  Caregiver should learn to assess seizures and monitor patient  Use of barrier contraceptive is advised while on this drug  Avoid alcohol, sleep inducing drugs 2005 Lippincott’s Nursing Drug Guide MIMS 113th edition 2007 www.drugs.com/valium.html www.medicinenet.com/diazepam/article.htm

Generic Name:

Ranitidine Hydrochloride

Brand Name: Classification: Ordered Dose: Mode Of Action:

Zantac Histamine2 antagonist 150mg 1tab

Competitively inhibits action of histamine at histamine2 receptors of the parietal cells of the stomach, inhibiting basal gastric acid secretion and gastric acid secretion that is stimulated by food, insulin, histamine, cholinergic agonists, gastrin, and pentagastrin Indications: Against ulcer brought about by NPO due to surgical procedure Contraindications: Hypersensitivity to ranitidine, lactation Drug Interactions: Increased effects of warfarin Side Effect: Constipation, nausea, vomiting, breast enlargement, impotence, headache Adverse Effects:  CNS: headache, malaise, dizziness, somnolence, insomnia, vertigo
Page | 78

 CV: bradycardia, tachycardia,  Dermatologic: rash, alopecia  GI: constipation, diarrhea, nausea, anorexia, vomiting, abdominal pain, hepatic dysfunction, jaundice  GU: gynecomastia, impotence  Hematologic: leucopenia, granulocytopenia, thrombocytopenia, pancytopenia  Local: pain at IM site, local burning pain at injection site Nursing Responsibilities: Administer oral drug with meals and hs Decrease doses in renal and liver failure Provide concurrent antacid therapy to relieve pain Avoid cigarette smoking as it decreases effectiveness  Have regular medical follow-up to evaluate response  Adjust environment (lights, temp, noise) to prevent headache  Using ranitidine may increase your risk of developing pneumonia  Avoid drinking alcohol. It can increase the risk of damage to your stomach  If you think you have taken too much of this medicine contact a poison control center or emergency room at once.  If you need to take an antacid you should take it at least 1 hour before or 1 hour after this medicine. This medicine will not be as effective if taken at the same time as an antacid.  If you get black, tarry stools or vomit up what looks like coffee grounds, call your doctor or health care professional at once. You may have a bleeding ulcer. 2005 Lippincott’s Nursing Drug Guide MIMS 113th edition 2007 www.rxlist.com/zantacwww.medicinenet.com/ranitidine/article.htm http://www.healthline.com/goldcontent/ranitidine    

Bibliography:

Page | 79

Generic Name:

Phytonadione

Brand Name: Classification: Ordered Dose: Mode Of Action:

Hema K Fat soluble vitamin; antifibrinolytic agent 1amp now Vitamin K is required for the liver to make factors that are necessary for blood to properly clot (coagulate), including factor II (prothrombin), factor VII (proconvertin), factor IX (thromboplastin component), and factor X (Stuart factor). Preoperatively: to activate clotting factors to decrease chances of bleeding during surgical procedure

Indications:

Contraindications: Hypersensitivity to benzyl alcohol, Drug Interactions: Coumarin and indanedione derivatives Side Effect: Adverse Effects: Nursing Responsibilities: No known side effects for this drug; bruising and bleeding are less likely to happen. No known adverse effects reported  Instruct patient to take only prescribed order  If a dose is missed, take as soon as remembered unless almost time for the next dose  Cooking does not destroy substantial amounts of Vitamin K  Caution patient to avoid IM injection and activities leading to injury  Patient should not drastically alter diet while taking Vitamin K  Use a soft toothbrush until coagulation effect is corrected  Advise patient to report any signs of bleeding/bruising
Page | 80

Arcoxia does not block COX-1. an enzyme in the body.Arcoxia relieves pain and inflammation with less risk of stomach ulcers compared to NSAID relief of acute pain Indications: Contraindications: Hypersensitivity to arcoxia and it’s ingredients such as etoricoxib Drug Interactions:  warfarin.Source  Patient should be advised not to take OTC drugs without advice of health care provider  Advise patient to inform health care provider of medication regimen prior to treatment or surgery  Emphasize importance of frequent lab test to monitor coagulation factors MIMS 113th edition 2007 http://www. an antibiotic used to treat tuberculosis and other infections  water pills (diuretics) Page | 81 .html Generic Name: Etoricoxib Brand Name: Classification: Ordered Dose: Mode Of Action: Arcoxia COX-2 Selective Inhibitor 120mg PO 12mn Arcoxia reduces pain and inflammation by blocking COX-2. the enzyme involved in protecting the stomach from ulcers.Other anti-inflammatory medicines (NSAIDS) block both COX-1 and COX-2.drugs.nih. a medicine used to prevent blood clots  rifampicin.nlm.com/enc/vitamin-k.html http://www.gov/medlineplus/druginfo/natural/patien t-vitamink.

hypertension  Dermatologic: rash. If you have moderate liver disease. vertigo.  For the relief of chronic musculoskeletal pain the recommended dose is 60 mg once a day. insomnia. anorexia. ACE inhibitors and angiotensin receptor blockers. jaundice  GU: gynecomastia. Blurred vision. confusion  CV: bradycardia. hepatic dysfunction.  Do not take a double dose to make up for the dose that you missed. tachycardia. a medicine used to suppress the immune system Side Effect: Adverse Effects: Nausea.  It does not matter if you take Arcoxia before or after food. a medicine used to treat a certain type of depression  birth control pills  hormone replacement therapy  methotrexate. granulocytopenia.  Take your Arcoxia at about the same time each day. urticaria  GI: constipation. Do not halve the tablet. It will also help you remember when to take the dose. vomiting. dizziness. Difficulty in sleeping. Fatigue  CNS: headache. Rash. Headache. thrombocytopenia. diarrhea. hallucinations. abdominal pain. malaise. pancytopenia  Local: pain at IM site. anxiety. swallow them with a glass of water.  If you have mild liver disease. medicines used to lower high blood pressure or treat heart failure  lithium. drowsiness. you should not take more than 60 mg every other day. local burning pain at injection site  Take Arcoxia only when prescribed by your doctor.  Taking Arcoxia at the same time each day will have the best effect.  Do not use Arcoxia for longer than your doctor says. impotence  Hematologic: leucopenia. diarrhea. Page | 82 Nursing Responsibilities: .  When taking the tablets. vomiting. nausea. Muscle cramps. you should not take more than 60 mg a day.

drugs.  Other: potential for abuse. confusion. Indications: Contraindications: Hypersensitivity to tramadol or opioids or intoxication with alcohol. anxiety.Bibliography:  If you get an infection while taking Arcoxia. MIMS 113th edition 2007 http://www. bradycardia. opioids. tachycardia. loss of appetite Adverse Effects:  CNS: sedation. noise) Responsibilities:  Limit use in patients with past or present history of Page | 83 . Arcoxia may hide fever and may make you think. mistakenly.com/arcoxia. flatulence.  Dermatologic: pruritus. dizziness. drowsiness. causes many effects similar to opioids but doesn’t cause respiratory depression Relief of moderate to severe pain. anaphylactoid reactions Nursing  Control environment ( temp.html http://arcoxia-side-effects. dreaming. tell your doctor. constipation. headache. sweating. urticaria. sedation. or psychoactive drugs Drug Interactions:  Decreased effectiveness with carbamezapine  Increased risk of tramadol toxicity with MAOIs Side Effect: Dizziness.com/ Generic Name: Tramadol hydrochloride Brand Name: Classification: Ordered Dose: Mode Of Action: Ultram Central acting analgesic 100mg 1tab PO Binds to mu-opioid receptors and inhibits the reuptake of norepinephrine and serotonin. nausea. dry mouth. that you are better or that your infection is less serious than it might be. light. impaired visual acuity. seizures  CV: hypotension. pallor  GI: nausea. vomiting.

Page | 84 . antihistamines. assistive device) Provide frequent.webmd.html http://www. positioning.medicinenet.drugs.         addiction or dependence to opioids Caution patient not to chew or crush tablet Keep opioid antagonist readily available in case of emergency Instruct post-op patients that drug suppress cough reflex Monitor bowel function and arrange laxatives for constipation Institute safety precautions (side rails.com/tramadol/article.htm Generic Name: Sultamicillin (ampicillin and sulbactam) Brand Name: Classification: Ordered Dose: Mode Of Action: Unasyn Antibiotic 375mg tab PO TID It acts through the inhibition of cell wall mucopeptide biosynthesis. small meals if GI upset occurs Provide back rubs.com/ultram. and other non pharmacological measures to alleviate pain Take drug exactly as prescribed Avoid alcohol. Ampicillin has a broad spectrum of bactericidal activity against many gram-positive and gram-negative aerobic and anaerobic bacteria. tranquilizers while taking this drug Bibliography: 2005 Lippincott’s Nursing Drug Guide http://www.aspx http://www. sedatives.com/drugs/drug-11276Ultram+Oral.

Bacteroides spp. kanamycin (Kantrex).pain. (including B. Contraindications: contraindicated in individuals with a history of hypersensitivity reactions to any of the penicillins. thrombosis at injection site  Other: superinfection. neomycin (Mycifradin.sulbactam in the UNASYN formulation effectively extends the antibiotic spectrum of ampicillin to include many bacteria normally resistant to it and to other beta-lactam antibiotics. gentamicin (Garamycin). or  an antibiotic such as amikacin (Amikin). Indications: Intra-Abdominal Infections caused by beta-lactamase producing strains of Escherichia coli. fragilis). swelling. bloating. Drug Interactions:  allopurinol (Zyloprim). sodium overload. itching. gastritis. Neo-Tab). pseudomembranous colitis.  probenecid (Benemid). swollen.  CNS: lethargy. and Enterobacter spp. fever. wheezing. black. neutropenia. hematuria. thrombocytopenia. (including K. thrush . gas. or "hairy" tongue. oliguria. vomiting. abdominal pain. hallucinations. pyuria  Hematologic: anemia. seizures  GI: stomatitis. prolonged bleeding time  Hypersensitivity: rash. CHF  Culture infected area before beginning treatment  Monitor serum electrolytes and cardiac status  Do not use this medication if you are allergic to ampicillin and sulbactam or to any other penicillin antibiotic  Antibiotic medicines can cause diarrhea. netilmicin (Netromycin). tobramycin (Nebcin. pneumoniae*). streptomycin. which may be a sign of a new infection. vomiting. nonspecific hepatitis  GU: proteinuria. Neo-Fradin. Tobi). leukopenia. If you have diarrhea that is Page | 85 Adverse Effects: Nursing Responsibilities: . or other irritation where the needle is placed. anaphylaxis  Local: pain. stomach pain. phlebitis. Klebsiella spp. diarrhea. vaginal itching or discharge. headache. Side Effect: Nausea. nausea.

com/mtm/ampicillin-and-sulbactam.  If you get a skin rash.com/files/products/uspi_unasyn. frequent meals if GI upset occurs  Do not use extra medicine to make up the missed dose. do not treat yourself. and light.  Use this medication for the entire length of time prescribed by your doctor.html Page | 86 .Bibliography: watery or has blood in it. heat.  Store ampicillin and sulbactam at room temperature away from moisture.drugs.pfizer.pdf http://www.  Provide small.com/unasyn-drug. Do not use any medicine to stop the diarrhea unless your doctor has told you to.  Seek emergency medical attention if you think you have used too much of this medicine. Tell any doctor who treats you that you are using ampicillin and sulbactam. call your doctor.rxlist. http://www.htm http://www. Your symptoms may get better before the infection is completely treated.  This medication can cause you to have unusual results with certain medical tests.

This surgery uses a laparoscope (an instrument used to see the inside of your body) to remove the gallbladder.PROCEDURAL REPORT Date of operation: Time of Operation: Time Ended: Age: Diagnosis: Operation Performed: Type of Anesthesia: Name of Surgeon: Anesthesiologist: Scrub Nurse: Circulating nurse: May 11. Dabon. Definition of Laparoscopic Cholecystectomy The surgery to remove the gallbladder is called a cholecystectomy. Lamanosa J. A laparoscope is a small. R. Napoles. A less invasive way to remove the gallbladder is called laparoscopic cholecystectomy. or cut. It is performed through several small incisions rather than through one large incision. The gallbladder is removed through a 5 to 8 inch long incision. in the abdomen.N. The surgeon can then see the gallbladder on a television screen and do the surgery with tools inserted in three other small cuts Page | 87 .N. R. This is called open cholecystectomy. R. thin tube that is put into your body through a tiny cut made just below the navel. Procedural Report A. 2010 4:48 pm 6:25 pm 38 years old Calculous Cholecystitis Laparoscopic Cholecystectomy General Endotracheal Anesthesia Dr. Walter Batucan Dr. The cut is made just below the ribs on the right side and goes to just below the waist.

Procedure (1) Merlin dissector (1) suction irrigator (1) Bovie with spatula tip (1) endoscissors (1) cholangiogram catheter unit (1) aspirating needle (1) Laparoscope (4) metallic surgical clips (1) camera (1) light source cord (1) Bovie cord 1. Instrumentations (4) folded towels (1) oral gastric tube (1) foley catheter (1) Veress needle (1) 5mm trocar/port (1) 10mm trocar/port (1)10mm right angle laparoscopic dissector (1) 5mm right angle dissector (1) Dolphin Nose Dissecting forceps (1) scoop C. Skin over surgical site is cleansed with antiseptic solution 4. reverse trendelenburg 2. Page | 88 . 5.made in the right upper part of the abdomen. Placed on supine position. The gallbladder is then taken out through one of the incisions. Placement of drapes. B. Three to four small incisions is made in the abdomen. Administration of General Endotracheal Anesthesia (GETA) 3. Carbon dioxide gas is introduced into the abdomen to the inflate abdominal cavity so that the gallbladder and surrounding organs can be more easily visualized.

2. 8.6. Nursing Responsibilities  Preoperative Phase o Secure the informed consent for legal purposes and take note of the following things: 1. Refusing to undergo a surgical procedure is a person’s legal right and privilege. 5. The nurse ascertains that the consent form has been signed before administering psychoactive drugs. 7. o Assess for drug and alcohol abuse. The skin incisions are closed with stitches or surgical staples. D. No patient should be urged or coerced to sign an operative permit. 4. Page | 89 . The gallbladder is sent to the lab for examination 9. The goal for potential surgical patients is optimal respiratory function. 7. the laparoscope is removed. The surgeon must provide a clear and simple explanation of the surgical procedure. The nurse may witness the patient’s signature. o Assess the respiratory status. When the procedure is completed. 6. If the patient needs additional information about the procedure. nurse notifies the surgeon. 10. A sterile bandage/dressing or adhesive strips is applied. The laparoscope is inserted through one of the incisions (usually at the incision below the umbilicus) and instruments will be inserted through the other incisions to remove the gallbladder. Persons with history of chronic alcoholism often suffer from malnutrition and other systemic problems that increase the surgical risk.

watch. and prepare nursing care plans to address patient’s needs o Teach deep-breathing. An important function of the preoperative assessment is to determine the existence of allergies. coughing and incentive Spiro meter to aid the patient post operatively o Encourage mobility and active body movement to avoid complications o Teach cognitive coping strategies such as imagery. A medication history is obtained from each patient because of the possibility of drug interactions o Make nursing diagnoses.o Assess the cardiovascular status. medications and contact lenses Page | 90 . o Assess the hepatic and renal functioning. fluid and nutritional needs. o Assess for the previous medication use. list of medications and allergies What to leave at home such as jewelry. Presurgical goal is optimal function of the liver and urinary system to enhance removal of medications. o Assess the immune functioning. distraction and optimistic self-recitation to reduce fear and anxiety o Explain the activities that may occur inside the operating room to reduce anxiety o Inform the patient on the following to impart knowledge on the part of the patient and to avoid delay in surgery due to noncompliance:    Scheduled date and time of the surgery and where to report What to bring such as insurance card. The goal in preparing any patient for surgery is to ensure a well functioning cardiovascular system to meet the oxygen.

  What to wear which is loose-fitting. o Acquire and document patient’s vital signs for baseline data and maintain the preoperative record o Transport the patient to the presurgical area to prepare the patient for surgery o Attend to the family needs to reduce the anxiety felt by the family o Make sure that preoperative checklist which contains the following is accomplished:                   Intraoperative phase o Position the patient: Page | 91 Lab exam results in OR services form accomplished Patient is scheduled in OR Anesthesiologist informed Medicines in Blood Typed and Matched Field of Operation prepared Sponged or bathed Diet instruction given Enema given Make-up and nail polish removed Jewelry removed Oral hygiene given Patient changed into patient’s gown Indwelling catheter inserted Pre-op meds given Medicine for OR in . comfortable clothes and flat shoes take nothing by mouth for six to 12 hours before the surgery.

side rails and maintain patent airway and cardiovascular stability o Medication Page | 92 . sponges and instruments together with the circulating nurse  Postoperative Phase o Assess patient : appraise air exchanges status & note skin color. cleanliness. sponges and instruments together with the scrub nurse o For the scrub nurse:    Setting up sterile tables Assisting the surgeon and assistant surgeon. o Skin preparation o Circulating nurse:  Manages the operating room  Protects patient’s safety and health by monitoring the activities of the surgical team  Checks and verifies the consent form  Ensures fire safety precautions. humidity and lighting of the operating room  Monitors safe functioning of the equipments  Coordinates with the surgical/ perioperative team and monitors aseptic practices  Documents operating room surgical activities  Count all needles. verify & identify operative status & surgeon performed. proper temperature. taking care of tissue specimens Count all needles. assess neurological status (LOC) o Perform safety checks – good body alignment. The patient is in a supine position reverse trendelenburg.

Emphasize the proper dosage of the medications taken.  Analgesics are administered as prescribed for pain. Encourage the client to have the prescribed diet for her condition. Educate the client about the importance of proper nutrition. o Surgical dressing is assessed periodically and reinforced when necessary. Page | 93 . o HEALTH TEACHINGS       Inform the patient about the importance of complying with the prescribed medication. Instruct to do splinting while performing deep breathing exercises to minimize pain. Antibiotics are administered to prevent infection. Encourage to have early ambulation in order to promote circulation and wound healing.

In this definition of hers. (3) eliminating body wastes. (9) avoiding dangers in the environment and avoiding injuring others. and (14) learning. needs. she recognized the need to be clear about the functions of the nurse and described the nurse's role as substitutive (doing for the person). fears.NURSING THEORIES VIRGINIA HENDERSON’S DEFINITION OF NURSING Virginia Henderson sees the nurse as concerned with both healthy and ill individuals. and using available health facilities. sick or well. (6) selecting suitable clothes. will or knowledge. discovering. supplementary (helping the person). Virginia Henderson devised her own definition as to create a proper standard of what nursing should be. or complementary (working with the person). In 1955. or satisfying the curiosity that leads to normal development and health. (2) eating and drinking adequately. (5) sleeping and resting. Henderson conceptualizes the nurse’s role as assisting sick or healthy individuals to gain independence in meeting 14 fundamental needs which is: (1) breathing normally. (12) working in such a way that one feels a sense of accomplishment. (11) worshipping according to one’s faith. (8) keeping the body clean and well-groomed to protect the integument. and to do this in such a way as to help him gain independence as rapidly as possible". to ensure safe and competent care for patients. When the Page | 94 . acknowledges that nurses interact with clients even when recovery may not be feasible. (7) maintaining body temperature within normal range. and mentions the teaching and advocacy roles of the nurses. with the goal of helping the person become as independent as possible. (10) communicating with others in expressing emotions. Her famous definition of nursing states "The unique function of the nurse is to assist the individual. (13) playing or participating in various forms of recreation. in the performance of those activities contributing to health or its recovery (or to peaceful death) that he would perform unaided if he had the necessary strength. (4) moving and maintaining a desirable position. or opinions.

Virginia Henderson also believed that it was important that nursing be based on evidence. The diet promoted by the student nurses to the client should be moderate in calories and low in fat. Employing this theory the student nurses noted that among the 14 Fundamental Needs that Henderson laid out. Having enough sleep periods was encouraged to the client by the group. The client was made comfortable and was placed in a stress free environment to minimize stressors that might further compromise the client’s health. and to this end. Page | 95 . It provides student nurses a guide on what to focus on and on giving priority on the care being provided to the client. Having enough rest and sleep is also important for the client in order for her to reach optimum wellbeing. she worked to develop an index of nursing. This diet included High fiber foods (fresh fruits and vegetables). Virginia Henderson’s theory is one of the most valuable theories that a student nurse has in his or her arsenal in providing care for the clients. She believed all nurses should have access to literature on nursing and current nursing research to help better their practices. Supervising the client in her diet was done by the student nurses in order for the client to improve her current condition. eating and drinking adequately and getting enough sleep and rest are given most priority. Whole grains (such as whole wheat bread and oats) and lean meat (such as chicken and fish). following a diet which is specified for patients with Calculous Cholecystitis is essential to improve the patient’s wellbeing. Since the ability of the body to handle fat and other fat soluble substances is impaired. The client was admitted to Davao Medical School Foundation Hospital due to right upper quadrant abdominal pain and was later diagnosed with Calculous Cholecystitis.patient was able to perform all the functions by him or herself then the patient could be considered independent and no longer required the aid of a nurse. and that research was a critical component of improving nursing practice.

and the person’s behavior reflects this feeling. Focusing on the client’s verbal and non-verbal cues as focusing on the immediate people surrounding her is essential in any medical situation for it may indicate distress or danger in one form or another.) nurse reaction. and (3. this perception leads to thought. The patient may have concerns that she will not communicate with the people around her. and because these three parts occur automatically and almost simultaneously a nurse must identify each part of the reaction to help the patient. The nurse’s first experience with the patient’s behavior is through the senses. which evokes a feeling.) patient behavior. it consists of perception. The components of Orlando’s Nursing Process Theory are (1. Nurse reaction to a patient’s behavior forms the basis for determining how a nurse acts. thought. no matter how significant. meeting this need improves the patient’s behavior. (2. may represent a cry for help because the patient who cannot resolve a need feels helpless. Given the client’s current medical status. These concerns may be hazardous to the client’s wellbeing and may further compromise her health. Nurse action is whatever the nurse says or does to benefit the patient and when performing an action.ORLANDO’S THEORY Ida Jean Orlando's theory was developed in the late 1950s from observations she recorded between a nurse and patient. the nurse is influenced by stimuli related to the patient’s needs. Orlando’s theory keeps the student nurses focus on the needs and concerns of the patient whether the client Page | 96 . and feeling. Her nursing process is based on the manner in which all individuals act and that this process is used by a nurse to meet a patient’s need for help. the group utilized Orlando’s theory as they provided care and did their work.) nurse action. The nursing process is set in motion by the patient’s behavior and all patient behavior. Orlando’s theory states that the function of the nurse is to find out and meet the patient's immediate need for help and to use the nursing process (nurse-patient interaction) to relieve a patient’s feelings of helplessness or suffering.

The student nurses paid close attention to any signs that may lead to distress that might threaten the patient’s life. nutrition.or her significant others stated it or not. and the residual stimuli which are those internal or external factors whose current effects are unclear. role function & interdependent relations during health & illness. Page | 97 . With that said. Application of the theory also helps the student nurse prepare and plan the course of action towards the situation. Callista Roy noted different stimuli that would affect a client’s adaptive response. which constitute the greatest degree of change impacting upon the person and is the stimulus most immediately confronting the person. self-concept.) Physiological mode which represents physical response to environmental stimuli & primarily involves the regulator subsystem. They also made sure to verify first what they’ve observed before planning anything. Therefore. the contextual stimuli which are all other stimuli of the person’s internal & external world that can be identified as having a positive or negative influence on the situation. The basic need is the physiologic integrity. namely the focal stimuli. Roy believed that the need for nursing care arises when the client cannot adapt to internal & external environmental demands. Learning how to interpret and validate both verbal cues and non verbal cues is essential in any hospital situation for not all cues is presented as it is. Callista Roy theorized that there are four adaptive modes: (1. This preparation leads to an appropriate intervention by the nurse that might relieve the patient of her distress or might even save the patient’s life. elimination. activity & rest and protection. the student nurses applied Orlando’s theory to aid them in interpreting the actions and behaviors of the patient. ROY’S ADAPTATION THEORY Roy’s Adaptation theory views the client as an adaptive system where the goal of nursing is to help the person adapt to changes in physiological needs. associated with oxygenation.

the proponents first identified the stressors. (3. the student nurses planned the action to be done and implemented it. By doing so. affection.) Secondary role . By providing the patient information. However failure to adapt and cope up may lead to a decline in her health status. that cause distress to the patient’s mental and emotional status. Having identified the said stressors. With that. sex and developmental stage.) Self-concept mode which relates to the basic need for psychic integrity (psychological & spiritual aspect) a. the student nurses hope that any mental and emotional Page | 98 .) Tertiary role – are temporary. (b.(c.assumed to carry out the tasks required by the stage of development & primary role. Nursing seeks to reduce ineffective responses & promote adaptive responses as output behavior of the person. Physical self – has components of body image & body sensation b. either in the client’s environment or within the client herself. (a. freely chosen & may include activities related to hobby.) Interdependence mode – identifies patterns of human value. Aside from giving information. the proponents also listened and took notice of the patient’s concerns about her admission to the hospital. which is the fear of the unknown. Personal self – has components of self-consistency. Anxiety. (4. self-ideal & moral-ethical-spiritual self. her false beliefs towards her ailments may be reduced.) primary role which determines the majority of a person’s behavior & is defined by age.(2. The proponents conceptualized that the patient’s well being depends upon her ability to adapt to her current condition. may also be alleviated through giving the patient information. love & affirmation. One of which is providing vital information about the patient’s current condition.) Role function mode which identifies the patterns of social interaction of the person in relation to others reflected by. Being able to adapt to her illness may lead to a faster recovery. Use of Roy’s Adaptation Theory guided the student nurses that the goal of nursing in this theory is the promotion of adaptive responses in relation to the four adaptive modes. Therefore it is the role of the student nurses to help the patient cope up with her ailment.

Page | 99 .stress may be reduced. This decrease in stressors hopefully will lead the patient to a faster recovery.

Risk for imbalanced body temperature related to exposure to anesthesia secondary to status post laparoscopic cholecystectomy. Impaired skin integrity related to surgical procedure: laparoscopic cholecystectomy secondary to calculous cholecystitis 3. 4. Acute pain related to presence of surgical incision secondary to status post laparoscopic cholecystectomy. Page | 100 . Risk for infection related to presence of surgical incision. 2. 5. Deficient knowledge regarding illness and treatment course related to lack of information presented.NURSING CARE PLAN 1.

Evaluation GOAL MET At the end of rendering 3 hours nursing intervention. Pain is recognized in two different forms: physiologic pain and Objective/Goal At the end of 3 hours nursing intervention. Report pain as relieved and controlled as evidenced by verbalization Page | 101 . the patient will be able to: 1. R: Tramadol is an analgesic. Monitor and assess vital signs every 2 hours.  Grimaced face noted.g Tramadol) as ordered. ngul-ngul pa. R: Vital signs are usually altered in acute pain.  Guarding I V I T Nursing Diagnosis Acute pain related to presence of surgical incision secondary to status post laparoscopic cholecystectomy.‖ Need C O G N Objective Cues:  pain scale of 6 out of 10 noted. Date 5/12/ 10 4:30 pm Cues Subjective Cues:  Verbalized ―Sakit pa akong opera. Administer analgesics (e. R: Pain is a common aftermath for every surgery after the anesthesia wore down. Report a decrease in pain intensity to a scale of 3 out of 10. Demonstrate non– 2. Acute pain related to presence of surgical incision secondary to status post laparoscopic cholecystectomy.NURSING CARE PLAN Patient’s Name: Meg Chief Complaint: pain at the right upper quadrant of the abdomen Diagnosis: Calculous Cholecystitis Age: 38 years old Ward: 3C 1. 2. It binds to mu-opioid receptors and inhibits the reuptake of Nursing Interventions 1. the patient was able to: 1.

When a patient undergoes surgery.‖ And reported a pain scale of 3 out of 10 P E R C E P T U A L experiencing a highintensity sensation.  Slow and limited movement of the upper extremities  Patient is 1 day post operative  0. norepinephrine and serotonin. Page | 102 . 3. respiratory depression. Incisions are covered with dry and intact dressing. It often acts as a safety mechanism to warn individuals of danger (e. patient maintained moderate high P resulting in incision pain. 10mm incision below the umbilicus. causes many effects similar to opioids but doesn’t cause respiratory depression. animal scratch. Clinical pain.g. tissues and nerve endings are traumatized. a burn. ―Dili na man kaayo siya sakit.g. in contrast. and also is felt in non-injured areas nearby. BP130/90. or broken glass).g.6°C. Demonstrate non– pharmacologic al methods and/or use of relaxation skills and diversional activities (e. Evaluate the effectiveness of analgesic at regular intervals after each administration. makaya na man. E clinical pain. Physiologic pain comes and goes.behavior noted.. RR-18. of client. for individual situation. as indicated. It is for moderate to severe pain.  Vital Signs: T36.5 mm incision noted on the right lower rib cage and the subxyphoid area. and is the result of pharmacological methods and/or use of relaxation skills and diversional activities. nausea and vomiting) 2. also observing for any signs and symptoms of untoward effects (e. is marked by hypersensitivity to painful stimuli around a localized site.

BP120/90. R: Allows evaluation of the severity of the pain http://www.surgeryencyc felt by the patient. back rest position. The resultant central sensitization is a type of posttraumatic stress to the spinal cord.84. she also performed diversional activities such as talking with her watcher) Vital Signs: T36. which becomes overstimulated. Monitor patient’s pain at least every hour while awake by the use of the pain scale. 4.81. That is why a patient may feel pain in movement or physical touch in locations far from the surgical site. Ongoing evaluation will assist in making necessary adjustments for effective pain management. Pain Page | 103 . A T T E R N This trauma overloads the pain receptors that send messages to the spinal cord.4°C.PR. PR. which interprets any stimulation—painful or otherwise—as unpleasant. RR-19. R: The analgesic dose may not be adequate to raise the client’s pain threshold or may be causing intolerable or dangerous side effects or both.

5.html is a subjective experience and only the patient can describe the pain she’s feeling. Instruct and demonstrate use of deep breathing exercise. R: Deep breathing increases oxygen in the body and prevents atelectasis.lopedia.com/Pa-St/PostSurgical-Pain. Also instruct patient to do splinting while doing deep breathing exercises.Splinting while Page | 104 . Deep breathing exercise also provides comfort.

Page | 105 . Maintain anatomic alignment R: Alignment helps prevent pain from malposition and it enhances comfort 7. Encourage diversional activities (TV/radio.doing deep breathing is to lessen the pain upon respiration. socialization with others. 6. Position the patient properly in bed. Elevate head of bed. mental imaging).

Provide rest periods to facilitate comfort. Assist patient in doing her activities of daily living Page | 106 .R: These highten ones concentration upon nonpainful stimuli to decrease one's awareness and experience of pain. and relaxation R: The patient's experiences of pain may become exaggerated as the result of fatigue. Adequate rest helps provide comfort 9. sleep. 8.

Page | 107 . R: Severe pain is more difficult to control and increases the client’s anxiety and fatigue. Encourage patient to report pain as soon as it starts and allow her to verbalize pain experienced or describe the pain she’s feeling.R: Helps reduce pain brought about by the exertion of force necessary to perform activities 10.

5/12/10 @ Describe wounds and observe for changes. epidermis. 2. Demonstrate behaviors/techniques to promote healing or prevent 3. PR=85. Maintain incision site and dressing intact and dry. Impaired skin integrity related to surgery: laparoscopic cholecystectomy secondary to calculous cholecystitis. carefully dress wounds. Objectives/Goals At the end of 2 days nursing intervention the patient will be able to: 1. Keep the incision site clean and dry.‖ as verbalized by the patient Need N U T R I 9:00 pm Objective: -post laparoscopic cholecystectom y (2 hrs) -disruption of the dermis. 2. Date 5/11/ 10 Cues Subjective: ―Gioperahan ko diri sa tiyan. RR=18. Remain free from infection as evidenced by normal vital signs (BP= 120/70. ®: Keeping incision site clean and dry prevents infection. the intervention. Encourage early ambulation. -with 0. It is performed through inserting a laparoscope just below the navel. Display improvement in wound healing as evidenced by intact incision site. Remain free from infection as evidenced by normal vital signs and absence of purulent discharge. and subcutaneous tissues. patient was able to: 2. 1. T I O N A L M E Rationale: Laparoscopic cholecystectomy is a less invasive way to remove the bladder.2.5 to 1 cm incisions at the epigastrium. 11:00pm ®: Establishes comparative baseline providing At the end of 2 opportunity for timely days nursing intervention. Temp=36. Assist patient in doing active and passive range of . Nursing Interventions Evaluation @ 1.6) and absence of Page | 108 3. Three additional ports are inserted by making three other incisions in the epigastrium and in the right upper Nursing Diagnosis Impaired skin integrity related to surgery: laparoscopic cholecystectomy secondary to calculous cholecystitis. it also aids in the process of wound healing. Assess dressings/ Goal Met wound every shift.

®:Proper positioning decreases tension in the operative site and promotes healing. p. complications motion exercises.Demonstrate behaviors/techni ques to promote healing or prevent complications (e. USA: Decker Inc. P A T T E R N 4. (2006). 3. Temperature: 36. Place in semi-Fowler’s position or moderate high back rest. eats a balanced diet.right lower rib cage and below the umbilicus -incisions covered with dry and intact dressing -skin slightly warm to touch.g patient washes hands after using the comfort room. and takes antibiotic medication (sultamicillin) as ordered) 6. ®: Movement stimulates circulation and assists in the body’s natural process of repair. loose-fitting clothes. 5. Advanced Therapy in Minimally Invasive Surgery.8°C T A B O L I C quadrant of the abdomen. M. Page | 109 . dry. purulent discharge. 179. Source: Talamini. ®: Early recognition of developing infection enables rapid institution of treatment and prevention of further complications. Instruct to wear clean. Monitor temperature every 4 hours.

Loose clothing reduces pressure on compromised tissues.preferably cotton fabric ®: Skin friction caused by stiff or rough clothes leads to irritation of fragile skin and increases risk for infection. Page | 110 . Protein and iron helps in repair of tissues. C. Emphasize importance of adequate nutrition and fluid intake. Vitamin C is important for immune system function and increases resistance to some pathogens. which may improve circulation/healing 7. Encourage patient to eat foods rich in protein. ®: Improved nutrition and hydration will improve skin condition. iron and vit.

purulent discharge. redness. ®: This is to involve the patient in caring for skin.8. Teach client and her significant others the importance of proper hand washing. warmth. Instruct the client to observe for signs and symptoms of complications such as elevated temperature. Instruct the client in proper postoperative skin care. or breakdown of sutures Page | 111 . 9. Proper washing of hands deter the spread of microorganisms. promoting comfort. and preventing infection or other complications. swelling near the surgical incision.

Administer antibiotics as indicated (sultamicillin) ®: May be given prophylactically or to treat specific infection and enhance healing. and report to the physician. Page | 112 . ®: Provides for prompt recognition of complications and facilitates prompt treatment.around the incision. 10.

Deficient knowledge regarding illness and treatment course related to lack of information presented. R: Adults learn best when Goal Met At the end of 2 hours nursing intervention. Assess the patient’s current knowledge of the medications and other doctor’s instructions and nursing procedures and its implications. para pud malabanan ang inpeksyon nako. Specifically ask about the physician’s explanations and the patient’s past experiences.3. the patient was able to: 1. If ever health issues Knowledge regarding and deficit At the end of 2 illness hours nursing treatment intervention.‖ 2. Initiate necessary lifestyle changes and Page | 113 Cues Need Nursing Diagnosis Objective/Goal Nursing Interventions Evaluation course related to patient will be lack of information able to: presented. and the likelihood of cure or disease control. Date & Time 05/12/ Subjective 10 cues:  Verbalized: @ ―Para asa diay ni siya (holds 6:00 pm sultamicillin tablet)?‖ Objective cues:  Frequent questioning  Incorrect T I V E C O G N I R: Knowledge is important especially in health matters. 2. 1. the likelihood of complications if these are not followed. Initiate necessary lifestyle changes and participate in treatment . Verbalize kasabot nako karon ngano ginahatagan ko ug mga ing aning tambal. Deficiency in knowledge might affect the patient’s health status. the 1. Verbalize understanding of disease process and treatment.

Ask how much the patient wants to know.verbal feedback regarding understandin g of treatment regimen. et. R: People vary in the degree of detail they find helpful.‖ P Source: A T Berman. (2008) Kozier & Page | 114 . it may result to disorders/diseases that could have been prevented if the patient had enough knowledge regarding her current health status. 2. regimen. Consider patient’s preference for information in planning and teaching. teaching builds on previous knowledge or experience. al. Those who cope participate in treatment regimen and verbalized ― Sa sunod mag-iwas na gyud ko ug mga taba kayo nga pagkaon. Lack of knowledge about health may also contribute to occurrence of anxiety. A. P E R C E P T U A L are taken for granted. Assessing recall of the physician’s explanations as well as the patient’s past experiences and exposure to health information provides an opportunity for evaluating attitudes and the accuracy and completeness of knowledge.

Pearson Prentice Hall. stress and coping with a threatening experience by avoiding it generally want to know relatively little about impending experiences. Determine learning needs. supporting the patient’s preferred learning style shows respect for individual differences.T E R N Erb’s Fundamental of Nursing Concepts. Process and Practice 8th Edition. 3. Chapter 42.When possible. Consider needs expressed by the patient and family. whereas those who cope by learning as much as possible about the threatening experience want to know a great deal. volume Two. R: Learning needs Page | 115 .

determine appropriate content. R: Too much information at one time causes confusion. Identifying predictable concerns and responses and necessary self-care activities helps the nurse fulfill learning needs of which the patient and family may be unaware. Present manageable amounts of information at any one time. Responding to expressed needs displays sensitivity to the patient’s and family’s concern. 4. Page | 116 . Learning occurs most rapidly when it’s relevant to current needs.

avoid spicy foods. 6. high fiber foods.They patient may lose sight of key points. Inform the patient about the diet specific for her condition (low fat. Inform the patient about indication of medication. 5. drug interaction and its side effects R: Allows patient to be knowledgeable about medication and avoid misconceptions. alcohol and caffeine) R: A patient who has recently had a gallbladder removed may Page | 117 .

Diarrhea and bloating occur because of two reasons. Page | 118 . When a person with gallbladder problems consumes spicy foods. unpleasant side effects such as gas and heartburn can occur. A second reason is that bacteria begins to digest the fat within the intestine and ultimately produces gas.suffer from diarrhea and bloating after consuming foods high in fat. . One reason is that fat inside the intestine absorbs more water. causing stomach upset.

Discuss to the patient and to the family the importance of complying with the medications and other doctor’s orders.7. It also lets the patient know Page | 119 . using easy-tounderstand terminology. Intricate explanations may confuse or overwhelm them. R: Medical and nursing jargon distances the patient and family members. 8. R: This lets the patient be aware of the significance of the doctor’s instructions. Provide simple explanations.

Use review and repetition judiciously. 10. Ask for feedback. considering individual factors. R: The patient may initially feel overwhelmed and insecure about learning because of the magnitude.the consequences which might occur if instructions weren’t followed. urgency or unfamiliarity of necessary adaptations to illness. Knowing the benefits of complying with the instructions encourages participation. 9. R: The unit environment Page | 120 .

like the nearest baranggay health center in their area. R: Determining learning accomplishment permits resolution of some learning needs and provides guidance for meeting others. Provide information about additional learning resources. 12. determine what learning has occurred. During and after teaching. 11. Page | 121 .and the patient’s age may contribute to a short attention span and poor retention.

R: Patients should be informed that there are health services in the health centers which are for free. so as to persuade them to avail it. Page | 122 .

) I. 2.D. Encourage the patient to report or inform the health team if any of these side effects occur. EXERCISE 1. Instruct the patient to continue drug therapy as ordered. 5. Encourage exercise in lower and upper extremities to promote good circulation. 5. 3. TREATMENT 1. Take medications as ordered. 2. 6. Alternate rest periods with activity.O. Promote regular light exercise and exercise as tolerated. Page | 123 .T. II.H. 3. MEDICATION 1. Encourage walking exercise. Inform the client about the importance of taking prescribed medications and the consequences of not following the treatment regimen. III. Provide information for better understanding regarding therapeutic regimen. 4. Inform patient about proper exercise regimen to avoid injury. Inform and explain to the client that other drugs that he is taking will probably have effects with the medication given. emphasize the right time interval of these drugs to maximize its effects and avoid further complications.DISCHARGE PLAN (M. Inform the patient as well as family the dangers of non compliance to treatment regimen. 4. Inform the patient to take medications on time or as directed for the full course of therapy even if feeling better. Moreover.E. Inform the client about the adverse effects and possible side effects of the medications. 2.

meal planning is implemented with High fiber moderate calorie. Inform the patient to exercise and do breathing exercises. Improving nutritional intake. Instruct to avoid alcoholic beverages due to a compromised hepatic system. 9. 5. especially in taking prescribed medications. 4. V. Encourage to have a restful and quiet atmosphere at home. 5. HEALTH TEACHINGS 1. Encourage patient to use relaxation skills when in pain. Encourage patient to seek emotional and social support especially to family and friends to promote strength and comfort. low fat and low salt as the primary goal. 4. Encourage patient to strictly comply with the doctor’s orders. Check with healthcare provider to evaluate progress of the condition. 3. OUTPATIENT 1. Check the condition with a healthcare provider to evaluate progress of the condition. avoiding high fat foods. Remind patient on the arrangements to be made with the physician for follow-up checkups. 10. Encourage the patient to have followed up visitations to the physician after discharge. 7. 7. Water is the best source of fluid that is needed by the body to maintain its function. 8.3. Encourage to balance diet and intake of nutritious food such as vegetables and lean meat. Discuss to the patient the complications and other problems that might arise from the condition. Encourage to have adequate hydration. 6. Instruct the patient to report to the health team promptly about any changes on health condition. Encourage patient to avoid strenuous activities. 2. Page | 124 . 6. IV.

Inform patient to avoid food such as salted. VI. smoked. 3. Encourage patient to increase nutritious foods intake by eating fresh fruits and vegetables. or canned meat. whole grain products. cured. Recommend to eat 5 or more servings of vegetables and fruits each day. Hydration is needed by the body to transport nutrients needed by the body. The diet recommended for the client is High fiber moderate calorie. Instruct to have a follow-up check up or refer to the physician if the patient is uncomfortable. low fat and low salt 2. 8. Instruct the patient and significant others to report for any irregularities. Inform to continue medication as ordered. Instruct to avoid drinking of alcoholic beverages as much as possible. Advise to try to limit meats that are high in fat and cut back on processed meats like hot dogs and bacon. 9. DIET 1. 5. 4.2. and lean meat. 7. 4. Encourage not to forget to get some type of light exercise because the combination of good diet and regular exercise will help in the maintenance of healthy weight and the feeling of more energetic. 6. Encourage to choose whole grain foods instead of white flour and sugars. Follow-up check up regularly in order to monitor and properly manage patient’s illness. Increase oral fluid intake. 3. 5. Page | 125 .

Two days prior to admission. pain recurred in a higher scale of pain (5/10). On May 8. she was forced to seek medical advice and consult at Robillo Memorial Hospital. the patient was admitted at Davao Medical School Foundation at Surgical Ward. There was no radiation noted and no associated symptoms. Patient did not comply with her doctor’s order to modify her diet (low fat. high fiber) and this led to Page | 126 . the pain disappeared.PROGNOSIS Good Fair Poor Justification Signs and symptoms of her current illness first appeared on the second week of December 2009. hence. 2010. the patient again experienced right upper quadrant pain. Because of this. On May 5. three days prior to admission. with admitting diagnosis of Acute Cholelithiasis. pain recurred with a pain scale of 10 out of 10. This was characterized to be progressive pain with a pain scale of 8 Onset of the illnesses ♠ out of 10. This prompted Meg to seek consultation. Batucan. room 324 bed 5 under the service of Dr. But after two weeks. the onset of illness of the client first started on December of 2009. Based on the data. After three days. admission. 2010.

the proponents rated the area as fair. 5 Duration of illnesses ♠ months before admission to DMSF Hospital. the proponents rated the Precipitating factors as good. she was later on able to follow instructions about her treatment regimen and cooperate with the health care team when she was admitted at Page | 127 . she was instructed to revise her diet into a low fat. Before she was brought to DMSF. patient was not able to comply with this treatment plan and this later on led to worsening of her condition. Because of the patient’s onset of illness. The client’s hepatic system has been compromised since December 2009. Given that the client has a few of the precipitating factors present and has none of the much more serious precipitating factors. high fiber diet. ♠ Willingness to take medications and treatment There. On the positive note. Because of the span of the illness of the client. the proponents rated the Duration of Illness as fair. she had a consult first at the Robillo Hospital. The precipitating factors of Calculous Cholecystitis present in the client were (1) Hormone replacement therapy.exacerbation of her illness. However. She was also instructed to drink lots of fluids. or birth Precipitating factors ♠ control pills and (2) a Low Fat Diet.

Since the patient is 38 years old. Her husband is also present and is able to provide her support as she undergoes her current condition. the proponents rated the age factor as fair. even with their financial problems. Most of the body’s protective Age ♠ mechanisms become less efficient with age.0 = Good Prognosis Page | 128 .DMSF.4-3.42 (Good Prognosis) *Scoring for General Prognosis: 1-1. 2. Because of these reasons. The proponents rated the Environmental Environment al factors ♠ factor as good for the reason that there is nothing in her environment at home or at work that can decrease her health status and further compromise her wellbeing.6 = Poor Prognosis. The client’s family is very supportive and willing to comply with the therapy in order for the patient to get well. the proponents rated the Willingness to take medications and treatment as fair. Computation: 3 4 0 Poor:(0*1)/7 = 0/7 Fair: (4*2)/7= 8/7 TOTAL Good: (3*3)/7= 9/7 Total: 17/7 or 2.3 = Fair Prognosis. 1.7-2. The patient also Family support ♠ stated that her family provides her with all the emotional support she needs. Members of her family frequently visit her in the hospital and she is able to verbalize any concern to them.

the absence of the much more serious precipitating factors. and the support of the patient’s family made the prognosis better. her willingness to take medication and treatment.Rationale for a Good Prognosis The patient has a good chance of recuperating from her current ailment as evidenced by the study done. according to the research and the calculations done by the proponents. The current status of her condition is very manageable and there is a good chance that she can recover as long as she is determined enough to achieve optimum well being. increasing the chance of her recovery from her current ailment. The onset and duration of the illness. Page | 129 . Therefore. the patient has a very good chance of recovering from her ailment.

the members of the group have realized the need of promoting and maintaining optimal health to both the patient and her significant others. the group would like to recommend the following. Just with their presence and affection can help the patient feel that she is being loved and that she can successfully surpass the challenges that are brought by her illness. and be cautious enough to know what her body needs and to recognize her limitations in complying therapeutic regimen. family problems and concerns about her health To the client’s family: The patient’s family plays an important role in the improvement of patient’s condition because they are source of strength and inspiration to deal with the disease. The family is encouraged to be sensitive enough to know the patient’s need and weaknesses that they may be able to render their support and care. The patient is encouraged to always reach for wellness. the patient is encouraged to follow the discharge plan for the betterment of her condition while at home. With these. Thus. The feeling of being secured and accepted is what also the patient needs to achieve optimal state of well being. Also. She is also recommended to have her regular follow-up checkups to evaluate her condition.RECOMMENDATION This case study about Calculous Cholecystitis gave the group more information and knowledge in making an actual management for this kind of problem. Page | 130 . To the client: The patient’s participation and willingness to be assessed and comply with the therapeutic regimen is needed for an effective management and prevention of complications. The patient is enlightened to be more open with her feelings regarding her current condition.

They should also make sure that people from far flung areas have access to medical services. clearing any scheduling matters with the students. They should be more aware about this kind of condition.To the community: The community should also be sensitive with the client’s condition. They should also disseminate vital information regarding illnesses that may affect the body’s hepatic system. They should also do proper scheduling of duties so that students wouldn’t be stressed out with their case presentations. Health workers should be sensitive to the client’s feelings and emotions. They must still respect the client even with the illness. They should also make sure that the student nurses are respected and treated well by Page | 131 . To the government: Budget for health must be increased so that patients would be able to receive adequate amount of health services from government hospitals. To professional health workers: Health care providers should be passionate about their job. Being able to access even basic medical attention may lead to a decrease in certain ailments of the genitourinary system. They must also be understanding enough and let the client feel security and acceptance. They should also continue their work even though they receive little or sometimes no salary at all. More knowledge should be acquired by the community to be able to know how to manage this kind of illness and how to prevent the occurrence of the illness within the community. giving proper care and support to their clients. They should be open for conversation to know what the client is feeling at the moment. To the College of Nursing: They should provide more exposure to the students on a consistent area to further increase their experience regarding the concept. thinking that what they’re doing is for humanitarian reasons. not treating her like she is incapable of doing her daily activities.

To the Student Nurses: Give appropriate nursing care and follow out doctor’s order properly to avoid any errors and give better care to the clients. and if able. Page | 132 . The College of Nursing should be more sensitive to the needs of the students and should be open to any comments or suggestions. They should also be honest in the data collecting done to the patient. they should make sure that their students are safe while on their duty. putting in mind that they are dealing lives. provide prophylactic treatment to avoid endangering the lives of the students. They must also be updated with current updates that could be beneficial to the nurse. They must also research about the disease to enhance their knowledge about it. Also.their superiors. the client and the rest of the healthcare team. Cooperation with the healthcare team is also essential to provide better quality care. They should treat the client as a fellow human being giving quality care and service.

A. Advanced Therapy in Minimally Invasive Surgery. Compositional Methodological Elements. Chap.(2007). Prevalence and ethnic differences in gallbladder disease in the United States. (2008) Kozier & Erb’s Fundamental of Nursing Concepts. Medical-Surgical Nursing Demystified.Fundamentals of Nursing: The Art and Science of Nursing Care. Tenth Edition 1983. G. Process and Practice 8th Edition. JE. Vol. 6th edition.  Taylor. 20. 8th ed. (2006). Khare.REFERENCES  Berman. USA: SLACK Incorporated. & Jackson. p. Page | 133 . volume Two. et. 49.  Carol Mattson Porth (2005). M. An Introduction to Human Disease: Pathology and Pathophysiology Correlations. (2006) The Clinician’s Guide to Pancreaticobiliary Disorders. al. 832. 179. p. Chapter 42. USA: Decker Inc. 11th ed. Hill. Foundations of Nursing: Caring for the Whole Person. KR. M. p. (2010). N. p. 563. USA: Jones and Bartlett Publishers.  Harrison’s Principles of Internal Medicine. L. 1. Elemental Analysis and of Biological Systems: Aspects Biomedical. Pathophysiology. 288. M. page 184  MIMS 113th edition 2007  Talamini. stress and coping  Boyer.. Gastroenterology 1999. USA: McGraw-Hill. Seventh edition. Brunner and Suddarth’s Textbook of Medical-Surgical Nursing. LeMone and Lynn (2008). of Trace Environmental. M.  Ginsber.  Digiulio. & Ahmad. Pearson Prentice Hall. V. Lillis. p. (2006). 121-123.  Everhart. Fundamentals of Nursing. 117:632.  Kozier and Erbs.  Crowley.  Iyengar. L. Maurer. p. page 352  Lippincott Williams and Wilkins Handbook of Diseases Third Edition. M. D.  Understanding Medical Surgical Nursing by Williams and Hopper page 742  White.

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