Bulacan State University COLLEGE OF NURSING City of Malolos, Bulacan

A Case Study of

A 22 YEAR OLD MALE, DIAGNOSED WITH CALCULOUS CHOLECYSTITIS

In Partial Fulfillment of the Requirements in RLE (103-A) at the

Bulacan Medical Center (Medical Ward)

BSN 3-E (GROUP 2) Castro, Mary Joyce De Guzman, Liberty C. Fabian, Shiela Marie Ilag, Caress S. Miranda, Marife Roque, Lyra Cariza Dela Cruz, Carllae Lucille Delloro, Ephraim GABRIEL , ANER M. (Leader) Macaranas, Carmona Jane Pangan, Mary Grace S. Vidon, Jill Irish Kae

September 24, 2010

1

TABLE OF CONTENTS

I.

INTORDUCTION a. Reason why . b. Objectives .. NURSING HEALTH HISTORY a. Demographic Data . b. History of illness (present, fast and family illness ) c. Genogram ... d. Functional Health Pattern (Prior and during hospitalization) . e. Growth and Development . ANATOMY AND PHYSIOLOGY .. PATHOPHYSIOLOGY a. Schematic Diagram b. Definition of the disease . c. Signs and symptoms .. d. Precipitating factors .. e. Predisposing factors .. f. Review of system

1 3

II.

5 6 7 8-14 15-16 17-21

III. IV.

22-24 25 26 27-28 29 30
2

V. VI.

PHYSICAL ASSESSMENT . LABORATORY AND DIAGNOSTIC PROCEDURES

31-43 44-49

VII. PATIENT AND HIS CARE a. Medical Management . b. Drugs .. c. Diet d. Exercise .

50-51 52-57 58-59 60

VIII. SURGICAL MANAGEMENT a. Nursing Responsibilities (postoperative) and Clients Response 61 IX. X. XI. NURSING CARE PLAN. HEALTH TEACHING ... DISCHARGE PLANNING 62-69 70 71-72 73 74-75

XII. CONCLUSION XIII. BIBLIOGRAPHY

I.

INTRODUCTION

This is a case study of a 22 year old male nursing graduate of Our Lady of Fatima University who was rushed at Bulacan Medical Center complaining of severe pain on the right upper quadrant of the abdomen. He was admitted last August 01, 2010 at 6:45 a.m. The patient was initially diagnosed with abdominal mass to confirm calculous cholecystitis after performing laboratory and diagnostic tests, because the results shows that the patient is suffering from an inflamed gallbladder due to calculi or stones. The physician then decided to perform an emergency procedure an open cholecystectomy at 11:15 am. Calculous cholecystitis is caused by obstruction of stone in the bile duct leading to inflammation of the gallbladder. The gallbladder is an organ which aids in the digestive process. Its function is to store and concentrate bile. The bile in turn emulsifies fats and neutralizes acids in partly digested food. Despite its importance in the digestion of fat, many people are unaware of their gallbladder. Fortunately enough, the gallbladder is an organ that people can live without. Perhaps, this fact contributes to the laxity of the majority. The gallbladder tends to be taken for granted or ignored of the proper care and conditioning. Lifestyle together with heredity, sex, race and age are just some factors that leave a room for gallbladder complications to occur . The most common cause of cholecystitis is gallstones. The bile becomes concentrated in the gallbladder. This later causes irritation and is probably the leading cause of inflammation. Cholecystitis affects women more often than men and is more likely to occur after age 60. People who have a history of gallstones are at increased risk for cholecystitis. In the international level, cholecystitis has an increased prevalence among people of Scandinavian descent, Pima Indians, and Hispanic populations, whereas cholelithiasis is less common among individuals from sub-Saharan Africa and Asia. It affects 20.5 million people (1988-1994) with a mortality record of 1,077 deaths in 2002. Hospitalizations total up to 636,000 in the same year and over 500,000 have undergone cholecystectomies. In the Philippines alone, 24,913 people are affected by the disease and 139 number of reported deaths last 2007. (http://digestive.niddk.nih.gov/statistics) Calculous cholecystitis is the cause of more than 90% of cases of acute cholecystitis. In calculous cholecystitis, a gallbladder stone obstructs bile outflow. Bile remaining in the gallbladder initiates a chemical reaction; autolysis and edema occur, and the blood vessels in the gallbladder are compressed, compromising its

vascular supply. Gangrene of the gallbladder with perforation may result. Bacteria play a minor role in acute cholecystitis; however, secondary infection of bile with Escherichia coli, klebsiella species, or streptococcus is identified with cultures obtained during surgery in a small percentage of surgical treated patients. SIGNIFICANCE OF THE STUDY We, the student nurses have chosen this case as we see it fit for the peri-operative concept as the patient, who is a nursing graduate had to undergone open cholecystectomy. Moreover, despite the cholecystitis low incidence, we would like to give credit and to know more of the nature and function of the gallbladder. Much often this small organ is not given importance. Thus we are in a pursuit for knowledge to be able to impart it to others. Furthermore, this case is quite interesting since it does not always affect only females and elderly. It can affect everyone. It can be alarming since many people are confused and unaware of the symptoms presented. As teen-agers living in a fast-phased world and governed by schedules, just like NJE a nursing graduate, we too are predisposed to lifestyle modification especially diet and food preferences which can contribute to the disease. With this study, we hope to apply our learning in taking care not only of our patients but also of ourselves. As nursing students and future nurses, we would want to understand and appreciate more on what is happening to a patient with calculous cholecystitis. Consequently, we are interested on what will be the necessary management that will be given. Through this, we are hoping that we will be able to find the right plan of care and sound interventions, not forgetting the patients rights as a person. All in all, these will help us to become efficient nurses and better persons later on.

OBJECTIVES General Objective: Our first main goal is to gain knowledge through the completion of the case study and to impart this learning to those directly and indirectly involve with the completion of this case. In psychomotor aspect, our goal is to apply all what we have learned during the process of completing this case study to improve nursing care that will meet NJEs need for the improvement of his general welfare. With the knowledge gained and through the application of this knowledge, another goal is that we will be able to empathize with the current situation of the patient and to gain some values like the value of patience and calmness which is important for us to have in order to become better nurses in the future.

Specific Objectives: To determine functional health status of client with cholecystitis. Integrate knowledge of nursing care in post cholecystectomy client to formulate a quality nursing care plan. Implement appropriate nursing intervention to satisfy the patients needs. Prepare clients for understanding the purpose and significance of cholecystectomy.

Client-centered: Conduct a thorough physical assessment and to interpret the assessment in order to give the care the patient need. To identify intervention that appropriate for patients needs. Integrate psychosocial and spiritual consideration into plan of care for client with gallbladder disorder. Research and understand the disease process of the patients illness and also the possible causes and the symptoms the patient experience that may suggest the current condition of the patient.

Student-centered:

To use knowledge in assessing and understanding the manifestation of gallbladder disease. To determine the priority nursing intervention and diagnosis that we can contribute by using our knowledge that we have learned in clinical setting. To implement quality nursing care that suited for client undergone cholecystectomy Use critical thinking to evaluate the effectiveness of the nursing intervention given in meeting the needs of the patient.

II. Nursing Health History

PATIENTS PROFILE Biographic Data Name: NJE Address: 916 Ibayo, Sto Rosario, Paombong, Bulacan Birthday: December 04, 1987 Birthplace: Paombong, Bulacan Age: 22 years old Sex: Male Status: Single Occupation: None Nationality: Filipino Educational attainment: College Graduate (BS Nursing-OLFU) Religious Orientation: Roman Catholic Health Care Financing and usual source of Medical Care: Philhealth (beneficiary) Date of Admission: August 01, 2010 at 6:45 a.m. Date of operation: August 01, 2010 11:15 am. Date discharge: August 05, 2010 Chief Complaint: Abdominal pain on the right upper quadrant Initial Diagnosis: Cholelithiasis Final Diagnosis: Calculous Cholecystitis
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History of Present Illness Three months prior to admission, (May 03, 2010), NJE experienced sudden onset of pain in the right upper quadrant of the abdomen. The pain become mild to moderate and sometimes does not relieve by position. The patient noticed loss of weight, pallor, weak and easy fatigability. The patient was worried about his condition so he seeks medical attention to a private physician. The patient undergone abdominal ultrasound and the results revealed presence of gallstones. A day prior to admission (July 31, 2010 10:40 pm), patient experienced severe epigastric pain radiating to the right upper quadrant of the abdomen (pain scale of 7/10), and associated bloatedness with nausea and vomiting. There is presence of facial grimace and guarding behavior. A decrease in appetite was also experienced on that day. According to the patient, he noticed a yellowish discoloration of his skin and a clay-colored stool. By August 01, he was rushed at Bulacan Medical Center due to intolerable pain (pain scale of 9/10) accompanied by fever. Diagnostic exams were done such as Abdominal Ultrasound, Complete Blood Count, Platelet Count, Prothrombin Time and Partial Thromboplastin Time. He received IVF of D5LRS 1L regulated @ 30 gtts/min. Ultrasound revealed Calculous Cholecystitis, so the patient was advised for admission and operation. Past history of illness: NJE experienced common illness such as colds, cough, chicken fox and fever during his childhood. However, he could not recall at what age he got the disease. Her mother used cilantro for the management of his chicken pox. He had no food and drug allergy and he does not experience any injuries and accidents in the past. He received oral polio vaccine (OPV), diphtheria, pertusis and tetanus (DPT) for his immunizations. Family history of illness: The grandparents of our patient are both deceased and he cant recall the cause and the age of death. His father died on 1998 due to kidney disease and his mother was 41 yrs old and still alive. He has three siblings, he was the eldest, second to him is 19 years old, the third was 15 years old and the youngest is a 12 yr. old male. No one in his family has the same condition with him.

GENOGRAM:

FATHERS SIDE

MOTHERS DAY

55 y/o TME

45 y/o RME

44 y/o PME

41 y/o YMJ

59 y/o PMJ

55 y/o CMJ

55 y/o SMJ

22 y/o NJE LEGEND: MALE FEMALE CALCULOUS CHOLECYSTITIS DECEASED UNKNOWN CAUSE OF DEATH UNKOWN AGE

16 y/o KJE

13 y/o CJE

19 y/o HJE

PATIENT

KIDNEY DSE

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Functional Health Pattern

Prior Hospitalization

During Hospitalization

Health perception and Health management

He told us that the most important factors for a healthy life is just eating According to him, during his hospitalization, he feels weak but he is nutritious foods, having a balance diet and having enough hours of sleep. eager to get well so, he tries to follow the doctors order for fast He does not smoke but drinks alcohol frequently (2 bottles. of BAR every recovery. He takes his medicine on time. The following medicines Saturday. He does not believe in faith healer. When he is in pain he will are administered to the client as part of his regimen. take OTC drugs, when we asked him what drugs is that he told us it was mefenamic acid 500mg. Metronidazole- 500 mg TIV q8 Ranitidine 50 mg TIV q8 Celecoxib 200 mg OD Cefuroxime -750 mg TIV q8 IV Fluids D5LRS 1,000 mL regulated @ 30-31 gtts/min.

Nutritional and metabolic pattern

He likes to eat fried foods and he doesnt have any eating difficulty. During his first day of hospitalization (August 01, 2010) he was Whenever the patient is suffering abdominal pain, his appetite decreases. ordered NPO in preparation for operation and change it to General He doesnt take any vitamin supplements. According to him when he has liquid diet on August 02, 2010 post operation and on August 03, wound it heals well. He doesnt have any dentures. 2010 at 12:15pm he was instructed on a DAT diet with fat restriction to provide nutrition after the operation..

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Date

Breakfast

Lunch

Dinner Date Breakfast Lunch Dinner

July 29, 2010

1/2 cup of rice 1 fried egg 220 ml of water(1 glass)

1 cup of rice 1 piece fried pork chop 440 ml of water

1/2 cup of rice 2 pcs of fried chicken 220 ml of coffee with milk(1 cup) August 01, 2010 Nothing Orem AM SNACK: None Per Nothing Orem
AFTERNOON SNACK: None

Per Nothing Orem

Per

EVENING SNACK: None

AFTERNOON

AM SNACK: 1 order of Jollihotdog with 300 mL of coke.

SNACK:

240 ml of soft EVENING drink(RC cola) SNACK: 21 grams of Adobo Kita Cheese biscuit (2 Peanut (Sugo) Garlic packs)

August 02, 2010

30 ml of water AM SNACK: None

30 ml of water
AFTERNOON SNACK: None

30 ml of water EVENING SNACK: None

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July 30, 2010

1 cup of rice 3 pieces of fried hotdog 340 ml of water (1 glasses)

1 cup of rice 2 pcs fried chicken 220 ml of water (1 glass)

AFTERNOON

1 cup of rice 2 pieces of 2x4 inches of fried beef tapa 440 ml of water (2 glasses) EVENING SNACK: 1 pack (3 pcs) of Sky flakes 150 ml of water

August 03, 2010

Soft diet with SAP 3 tbsp of Lugaw 3o ml of water AM SNACK:

3 tbsp of Lugaw 3o ml of water

AFTERNOON SNACK:

1 piece Boiled egg 30 ml of water EVENING SNACK:

AM SNACK: SNACK: 350 ml Coke 1 pc hamburger 1 cup coffee w/ cheese 1 sliced of chicken sandwich

None None

July 31, 2010

1 cup of rice 1 slice pritong bangus 220 ml of water(1glass) AM SNACK: 1 cup coffee w/ milk

1 cups of rice 1 pc fired pork chop 440 ml of water(2 glasses)

AFTERNOON SNACK:

EVENING SNACK: NONE

None

1 pc hamburger w/cheese

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Elimination Pattern He doesnt have excessive perspiration or body odor.

He doesnt have excessive perspiration or body odor. August 01-03, 2010

Color ClayJuly 28- 31, 2010 Stool colored/ gray Amber/s Urine traw

Frequency

Consistency

Odor

Difficulty

Color

Frequency Consistency

Odor

Difficulty

Once a day

Formed

Foul

None

Stool

None

6X a day

Clear

Aromatic

None

Urine

Amber 4x a day / straw (August 02clear

Aromatic

None

vomit

Whitish

Once(July 31, 2010)

(+) food fragments

sour smell

With difficulty vomit

03,2010)

None

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Activity-Exercise Pattern

He has sufficient energy to finish his daily activities. Walking for 15 During his hospitalization he is often lying on his bed. He just listen minutes in the morning every day, except rainy days, is his form of to radio or chats with his relatives and some of the patient in the exercise, and he doesnt easily get tired. When he has free time he chats ward. As of august 03, 2010. with his friends or watch television Activity Activity Feeding Bathing Bed mobility Dressing Grooming Toileting Level Feeding 0 0 Bed mobility 0 0 0 0 Dressing Grooming Toileting 2 0 2 0 Bathing 0 2 Level

Level 0 full self care Level I-requires use of equipment Level II-requires assistance or supervision from another person Level III- requires assistance or supervision from another person or device Level IV- dependent or does not participate.

Level 0 full self care Level I-requires use of equipment Level II-requires assistance or supervision from another person Level III- requires assistance or supervision from another person or device Level IV- dependent or does not participate

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Sleep and rest pattern

The patient sleeps for about 7 hours and 30 minutes continuously from 11 The patient sleeps for about 4 to 5 hours at night. His sleep is p.m. 6:30 a.m. and he does not have any difficulty falling asleep and does disrupted due to pain felt on his incision site. He takes nap 1 hour in not take any sleeping medications. He takes nap for 2 hours in the the afternoon. afternoon.

Cognitive and Perceptual Pattern

He does not have problems in vision and hearing. According to NJE, he He does not have problems in vision and hearing as well as any had a sharp memory. He does not have any learning difficulty. learning difficulties.

Self perception and self concept

According to NJE he sees himself as a friendly person. The things that can The patient sees himself as a friendly person. When we asked him make him frustrated are when things got out of his control. Sometimes what he feels about being hospitalized he told us that he feels fine chats with his friend to lessen his frustration. The patient has a nuclear family according to members, matriarchal and he added that he wants to go home already. His mother is the one who decides about financial matters in their

Role and Relationship pattern

according to authority and neolocal according to location. He is living with family and according to him their budget is enough for his his parents. When problem arises he and the rest of the family talk to each hospitalization. other to solve it. He does not belong in any social group but he has a lot of friends in their neighborhood.

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Sexualreproductive pattern

According to the patient his sex life is complicated and admitted that he is a gay.

The patient sexual life is inactive.

Coping Stress tolerance

When the patient feels tense he chats with his friends and when he has The big change in his life is when he found out that he has gallstones. problem he usually share it with his friends to ask for their opinion to solve When he has problem he usually share it with his friends and the problem and according to him it lessen his burdens. according to him it is effective.

Values belief pattern

According to him he doesnt get easily the things he wanted, he works hard He prays at night before sleeping to ask God for good health. for it. Religion is important to him and his family. They also go to church every Sunday and ask God for guidance and good health.

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III.

GROWTH AND DEVELOPMENT

Theories

Stages Genital stage: post puberty

Justification

Resolution

Freuds Stage of Psychosexual Development

During the final stage of psychosexual development, the individual develops a strong sexual interest in the opposite sex. Where in earlier stages the focus was solely on individual needs, interest in the welfare of others grows during this stage. If the other stages have been completed successfully, the individual should now be well-balanced, warm and caring. The goal of this stage is to establish a balance between the various life areas. The formal operational stage (20 to Adulthood) During this time, people develop the ability to think about abstract concepts. Skills such as logical thought, deductive reasoning, and systematic planning also emerge during this stage.

The patient is in the genital stage but he does not developed sexual interest with the opposite sex rather than same sex. According to him he is not attracted with girls but he enjoys hanging out with them as friends.

The patient does not developed sexual interest with opposite sex.

Jean Piagets Stage of Cognitive Development

The client thinks rationally and logically. He is able to solve the problem with his family by communicating to them and vice versa.

Positive The patient thinks logically and rationally.

Young Adulthood (19 to 40 years) Ericksons Stage of Psychosocial Development Intimacy vs. Isolation Young adults need to form intimate, loving relationships with other people. Success leads to strong relationships, while failure results in loneliness and isolation. The patient share more intimately with others. He has a strong bond with his friends and family.

Positive The patient developed intimacy.

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Kohlbergs Stage of Moral Development

Level 3. Post conventional Morality Stage 5 - Social Contract and Individual Rights At this stage, people begin to account for the differing values, opinions and beliefs of other people. Rules of law are important for maintaining a society, but members of the society should agree upon these standards.

The patient understands the different roles of the society, and can distinguish what is right or wrong based on internalized rules on conscience rather than social law. He follows rules according to his willingness. According to him, he will follow all the orders of the doctor that will help to make his condition better. He also said that he does things if he knows that it is good for him and according to his willingness.

Positive The patient follows rules according to his knowledge and willingness.

Fowlers Faith development pattern

Individuative-Reflective Faith: (early 20 to adulthood) One begins to move beyond the group identity and adopt individual views; a "de-mythologizing" stage of faith; translates the symbols and images of one's tradition into personal concepts and ideas; beginning of post-conventional morality.

The patient has a religious side of him. He Positive believed in God and go to church every Sunday. To his present illness, he believed in God and to The patient develops matured sense of faith the health care provider that he can overcome his illness.

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IV.

ANATOMY AND PHYSIOLOGY

20

LIVER Largest organ in the body Lies under the diaphragm; occupies most of the right hypochondrium and part of the epigastrium. Weighing 1.5 kgs.

LIVER LOBES AND LOBULES The liver has two lobes, separated by the falciform ligament Left lobe- about one sixth of the liver Right lobe- about five sixth of the liver.

BILE DUCTS Right hepatic duct- drains bile from the right functional lobe of the liver Left hepatic duct- drains bile from the left functional lobe of the liver Common hepatic duct-is the duct formed by the convergence of the right hepatic duct and the left hepatic duct ; Length: Usually 68 cm. Approximate width:
6 mm in adults; merges with cystic duct to form common bile duct, which opens into the duodenum.

Cystic duct- is the short duct that joins the gall bladder to the common bile duct. Common bile duct- formed by the union of the common hepatic duct and the cystic duct (from the gall bladder).

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FUNCTIONS OF THE LIVER

The liver stores a multitude of substances, including glucose (in the form of glycogen), vitamin A (12 years' supply), vitamin D (14 months' supply), vitamin B12, iron, and copper.

Glucose metabolism- after meal, glucose is taken up from the portal venous blood by the liver and converted into glycogen (glycogenesis), which is stored in the hepatocytes. Glycogen is converted back to glucose (glycogenolysis) and release as needed into the blood stream to maintain normal level of the blood glucose

Ammonia conversion- use of amino acid from protein for glycogenesis results in the formation of ammonia as a byproduct. Liver converts ammonia to urea. Protein metabolism- liver synthesizes almost all of the plasmas protein including albumin, alpha and betaglobulins, blood clotting factor plasma lipoproteins. Fat metabolism- fatty acid can be broken down for production of energy and production of ketone bodies. Bile formation- bile is formed by the hepatocytes Composed of water, electrolytes such as sodium, potassium, calcium, bicarbonate, lecithin, fatty acids, cholesterol, bile salts Collected and stored in the gallbladder and emptied in the intestine when needed for digestion.

BILE Bile is the greenish-yellow fluid (consisting of waste products, cholesterol, and bile salts) that is secreted by the liver cells to perform two primary functions, including the following:

to carry away waste to break down fats during digestion

Bile salt is the actual component which helps break down and absorb fats. Bile, which is excreted from the body in the form of feces, bile gives feces its dark brown color.
22

TRANSPORT OF BILE 1. When the liver cells secrete bile, it is collected by a system of ducts that flow from the liver through the right and left hepatic ducts. 2. These ducts ultimately drain into the common hepatic duct. 3. The common hepatic duct then joins with the cystic duct from the gallbladder to form the common bile duct, which runs from the liver to the duodenum (the first section of the small intestine). 4. However, not all bile runs directly into the duodenum. About 50 percent of the bile produced by the liver is first stored in the gallbladder, a pear-shaped organ located directly below the liver. 5. Then, when food is eaten, the gallbladder contracts and releases stored bile into the duodenum to help break down the fats.

GALLBLADDER The gallbladder is a small organ whose function in the body is to store bile and aid in the digestive process. A hallow pear- shaped sac from 7- 10 cm (3-4 inches) long and 3 cm broad. It consists of a fundus, body and a neck. Fundus - the lower free and the expanded end of the Gall bladder. Body - the body of the gall bladder is the portion that is lying between that of the fundus and also the neck. The direction of the body is upwards, backwards, and to the left. Neck-it is the S shaped curve present above the body, and extends up to the cystic duct. Direction is upwards, forwards and then takes a turn and becomes downwards and backwards.
23

It can hold 30 to 50 ml of bile. It lies on the undersurface of the livers right lobe and attached there by areolar connective tissue. The cystic duct connects the gallbladder to the common hepatic duct to form common bile duct.

FUNCTION OF THE GALLBLADDER Stores bile enters to the gallbladder by way of the hepatic and cystic duct. During this time the gallbladder concentrates bile five folds to ten folds. Then later when digestion occurs in the stomach and in the intestines, the gallbladder contracts, ejecting the concentrated bile into the duodenum. Jaundice, a yellow discoloration of the skin and the mucosa, results when obstruction of bile flow into the duodenum occurs. Bile is thereby denied its normal exit from the body in the feces. Instead, it absorbed in the blood, and an excess of bile pigments with a yellow hue enters the blood and is deposited in the tissues. The gallbladder stores bile, which is released when food containing fat enters the digestive tract, stimulating the secretion of cholecystokinin (CCK). The bile, which is produced in the liver, emulsifies fats and neutralizes acids in partly digested foods.

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V. PATHOPHYSIOLOGY
Non Modifiable Factor: Heredity Modifiable and Precipitating Factor: Food preference (high cholesterol/fat)

Liver excrete relatively high proportion of cholesterol in the bile

Liver excrete conjugated bilirubin into bile

Invasion of bacteria in the gallbladder

Liver excrete some unconjugated bilirubin into bile Calcium enters bile passively along with other electrolytes

Bile is supersaturated with cholesterol

The bacteria hydrolyze conjugated bilirubin

Attraction of Leukocytes

Formation of solid Crystals

Increase in unconjugated bilirubin

Leukocytes hydrolyze bilirubin conjugates and fatty acids

Unconjugated Bilirubin tends to form insoluble precipitates with calcium 25

Crystals must come together and fuse to form stones

Formation of stones

Formation of Calcium Bilirubinate

Gallstones in the bile ducts/gallbladder (Cholesterol, brown/black pigment)

Mild to moderate pain/biliary colic in the right part of the abdomen due to functional spasm of the cystic duct; irritation of the viscera (July 30, 2010)

Obstruction of the bile ducts

26

Continues irritation of the gallbladder

Inflammation of the gallbladder

s/s

CALCULOUS CHOLECYSTITIS

s/s
Nausea and vomiting may accompany a gallbladder attack (July 31, 2010) Severe Pain/biliary colic due to inflammatory process (August 01, 2010) Fever due to elevated WBC because of bacteria invasion in the injured gallbladder (August 01, 2010)

Jaundice due to obstruction of bile flow (July 30, 2010)

Clay-colored stool may result from problems in the biliary system; due to absence of bile in the duodenum; warning signal thats something wrong with digestion (July 31, 2010)

Facial grimace (August 01, 2010)

Guarding behavior (August 01, 2010) 27

IF TREATED PHARMACOLOGIC TREATMENT o Antimicrobials o Narcotic Analgesics o Anticholinergics o Antiemetic o Gallstone solubilizer SURGICAL TREATMENT: o Open/Laparoscopic Cholecystectomy o Lithotripsy o Endoscopic papillotomy POSSIBLE COMPLICATIONS:

IF NOT TREATED

Ischemia Necrosis Rupture of gallbladder Gangrene Peritonitis Liver diseases such as Liver cirrhosis, Liver Cancer

28

CALCUOUS CHOLECYSTITIS - is the inflammation of the gall bladder resulting from an obstruction of bile outflow due to gallstones
Signs and Symptoms Rationale Biliary Colic

The most common symptom is pain in the right upper part of the abdomen or epigastrium. This can cause an attack of abdominal pain, called biliary colic, which: develops quickly, is severe, lasts about one to three hours before fading gradually, isn't helped by over-the-counter drugs and isn't helped by passing wind. The pain may radiate to the back, right scapula or shoulder. The pain often begins suddenly following a meal. The pain of biliary colic is caused by the functional spasm of the cystic duct when obstructed by stones, whereas pain in acute cholecystitis is caused by inflammation of the gallbladder wall.

Nausea and Vomiting Fever and chills

These signs and symptoms may accompany a gallbladder attack. Pain is usually accompanied by nausea and vomiting. Gallstones sometimes get trapped in the neck of the gallbladder and can cause persistent pain that lasts more than several hours and is accompanied by fever, also due to the irritation and inflammation of the gallbladder wall. Fever occurs in about one third of people with acute cholecystitis. The fever tends to rise gradually to above 100.4 F (38 C) and may be accompanied by chills

Loss of appetite and Anorexia

The pain often begins suddenly following a large or rich meal. People tend not to eat, especially fatty or oily foods, in order not to experience that pain. Fat absorption is also impaired for the lack of bile salts; As a result, rapid loss of weight and anorexia can occur.

Jaundice Clay-colored stool Nausea and vomiting Facial grimace and Guarding behavior

Due to obstruction of the bile flow. may result from problems in the biliary system; due to absence of bile in the duodenum; warning signal thats something wrong with digestion may accompany a gallbladder attack Accompanied by pain

29

Precipitating Factors: Factors Rationale Increased intake of cholesterol and saturated fats has all been postulated to cause cholesterol gallstones. Diet (high cholesterol, high fats) If there is an increased production of cholesterol, bile is being supersaturated with cholesterol, that leads in formation of crystals/stones. Hypolipidemic agents (clofibrate, gemfibrozil) that lower serum cholesterol by increasing biliary cholesterol secretion increase the risk of cholesterol Medications gallstones by two fold to three fold. Estrogen therapy is associated with an increased risk of developing cholesterol gallstone; estrogen increases biliary cholesterol secretion. Oral contraceptive steroids increase biliary cholesterol secretion and saturation but do not affect gallbladder motility. TPN is a powerful risk factor for gallstone formation. Gallstones form during TPN because of decreased gallbladder motility from lack of meal-stimulated Total Parenteral Nutrition cholecystokinin (CKK) release, resulting in increased fasting and residual volumes. Patients with spinal cord injury have 10% incidence of forming gallstones within the first year after injury. This high risk, which is 20 times normal, is Spinal Cord Injury believed to be secondary to abnormal gallbladder motility and probably biliary hypersecretion of cholesterol from the progressive reduction in body mass. Patients with primary biliary cirrhosis have an increased prevalence of gallstones. Stone analysis has not been performed, but the elevated cholesterol Primary Biliary Cirrhosis saturation of bile in these patients suggests that they form cholesterol stones. Despite obesity and increased total body cholesterol synthesis and decreased gallbladder motility seen in patients with diabetes, diabetes mellitus itself Diabetes Mellitus does not appear to be an independent risk factor for cholesterol gallstone disease. Inherited hemolytic anemia, sickle cell disease, sphericytosis, thalassemia, chronic hemolysis associated with artificial heart valves, and malaria Hemolytic Syndromes dramatically increase the risk of pigment stone formation because of increased biliary secretion of total bilirubin conjugates, especially bilirubin monoglucoronide, at the expense of the bilirubin diglucuronide, the predominant conjugate in healthy individuals.

30

Ileal Disease, Resection, and Bypass

Patients with ileal dysfunction have a strikingly increased risk for developing gallstones. Gallstones develop in 30-50% of patients with ileal Chrons disease; the risk correlates positively with the extent and duration of ileal dysfunction, Although ilieal disease or resection leads to cholesterol supersaturation and cholesterol stone formation in some Patients, careful studies now show that most patients with ileal dysfuncyion form black pigment, not cholesterol stones. Brown pigment stones are frequently found in the intrahepatic bile ducts and are always associated with infection by colonic organisms usually

Biliary Infection (bacterial)

E.coli or parasitic infestation (Ascaris lumbricoides, or other helminthes). Intraductal stones developing after cholecystectomy are invariable associated with bile stasis, biliary tree infection, and/or retained suture material. Obesity is strongly associated with increased gallstone prevalence. The risk is proportional to the increase in total body fat. Obese people synthesize more

Obesity

cholesterol in both hepatic and nonhepatic tissues, transport it to the liver, and secrete more of it into the bile, leading to bile that is often greatly supersaturated with cholesterol. Obese patients undergoing rapid weight loss (1-2% of body weight or approximately 1-2 kg/week), either by very low caloric dieting or gastric stapling, have

Rapid Weight Loss/ Fasting diets

a 25-40% chance of developing gallstones within 4 months. During rapid weight loss, biliary cholesterol saturation increases acutely as cholesterol is mobilized from adipose tissue and skin and secreted into bile.

31

Predisposing Factors: Factors Rationale Women have twice the risk as men of developing cholesterol gallstones because estrogen increases biliary cholesterol secretion. Before puberty this risk is Gender negligible, and beyond menopause the increased risk disappears. The incidence increases with age. Less than 5-6% of the population under age 60 has stones, in contrast to 25-30% of those over 80. It usually affects Advancing Age people with age of over 60 but it is more prevalent after 80 years of age. Prevalence highest in North American Indians, Chilean Indians, and Chilean Hispanics, greater in Northern Europe and North America than in Asia, lowest Race in Japan; familial disposition; hereditary aspects Family history alone imparts increased risk, as do a variety of inborn errors of metabolism that lead to impaired bile salt synthesis and secretion Heredity or generate increased serum and biliary levels of cholesterol, such as defects in lipoprotein receptors (hyperlipidemia syndromes), which engender marked increases in cholesterol biosynthesis. Pregnancy is an independent risk factor for cholesterol gallstones. The risk increases with increasing parity, especially with more than two children. During Parity/ Pregnancy pregnancy, elevated estrogen and progesterone levels increase biliary cholesterol secretion. Elevated progesterone also inhibits gallbladder contractility. 40% of women develop biliary sludge in their gallbladder and 12% of women form their first stones during pregnancy.

32

REVIEW OF SYSTEMS
LYMPHATIC

Increase WBC o There is an attraction of leukocytes due to invasion of bacteria.

GASTROINTESTINAL

Inflammation of the gallbladder o Due to obstruction of cystic duct and decrease blood flow that can cause invasion of bacteria, bacteria attracts leukocytes, phagocytosis occur that results in inflammation of gallbladder Improper emulsification of fat (problem with GIT) o Due to obstruction of bile out flow, there is an insufficient amount of bile that comes in the duodenum

INTEGUMENTARY

Jaundice
o

Due to obstruction bile outflow into the duodenum

RESPIRATORY

Short shallow breathing o Due to pain

33

PHYSICAL ASSESSMENT Name: NJE Age: 22y/o Date of assessment - August 02, 2010 T 37.2 C P 91 bpm R 31 cpm BP 110/80mmHg

GENERAL APPEARANCE Method 1. Body Built Ht. Wt. BMI Inspection and observation Proportionate, normal BMI in relation to age Proportionate Ht:56 Wt:54kg BMI:19.1 Deviation from normal due to the pain @ the incision on the right upper quadrant of the abdomen Normal Normal Findings Actual Findings Remarks

2. Posture and Gait

Inspection and observation

Relaxed, erect posture, coordinated movement

Slouched, uncoordinated movement

3. Over-all Hygiene and Grooming

Inspection and Observation

Clean and neat

Clean and neat ; no body and breath odor

Normal
34

4. Signs of Distress

Inspection and observation

No signs of distress

Present signs of distress such as facial grimace with guarding behavior

Deviation from normal due to pain at the site of incision at right upper quadrant of the abdomen

5. Obvious signs of health or illness

Inspection and observation

No signs of illness or disease

Appears weak with facial grimace and guarding behavior

Deviation from normal due to present condition; Post cholecystectomy

MENTAL STATUS

1. Level of Consciousness/ Orientation

Inspection

Conscious and coherent; Oriented to time, place and situation

Oriented to date, place and time situation

Normal

2 Emotional Status

Inspection

No facial grimace

(+) facial grimace

Deviation from normal due to pain at the site of incision at right upper quadrant of the abdomen Normal Deviation from normal due to pain at the site of incision at right upper quadrant of the abdomen.

3. Attitude

Inspection

Cooperative

Cooperative during assessment

4. Affect/mood, appropriateness of responses

Inspection

Appropriate to the situation

Responses are appropriate to the situation; irritated

35

SKIN Deviation from normal due to the effect of bilirubin that is still present at the blood streams. Deviation from normal due to water retention caused by fluid shifting from intracellular to intravascular.

1. Color

Inspection

Uniform in color

Yellowish discoloration

2. Presence of Edema

Inspection and Palpation

Absence of Edema

(+) peripheral edema

3. Presence of Lesions

Inspection

No Lesions

With incision at the right upper quadrant of abdomen Moist in Axilla and skinfolds Uniform temperature

Deviation from normal due to status post cholecystectomy Normal Normal

4. Moisture of the skin 5. Temperature

Palpation Palpation

Moist in Axilla and skin folds Uniform temperature

6. Skin Turgor

Palpation

When pinched, it springs back within 3 seconds NAILS

It springs back to previous state <3 seconds

Normal

Convex curvature, angle of nail

Convex curvature, angle of nail

36

1. Fingernail plate shape

Inspection

plate is approx. 160

plate 160

Normal

2. Fingernail and toenail bed color

Inspection

Highly vascular and pink in light skin clients

Nail beds are highly vascular

Normal

3. Fingernail and toenail texture 4. Tissue surrounding nails 5. Blanch Test of Capillary refill

Inspection and Palpation Inspection Inspection and Palpation

Smooth texture Intact epidermis Prompt return to pink or usual color within 3 seconds HEAD SKULL

Smooth texture Intact epidermis Prompt return within 3 seconds normal capillary refill

Normal Normal Normal

1. Shape

Inspection

Rounded, Normocephalic and symmetrical with frontal, parietal and occipital prominences.

Rounded, Normocephalic and symmetrical with frontal, parietal and occipital prominences.

Normal

2. Presence of nodules, masses and depressions 3. Evenness of hair growth over the scalp

Palpation Inspection and Palpation

Smooth uniform consistency, absence of nodules and masses

Smooth uniform consistency, absence of nodules and masses

Normal

Hair evenly distributed

Hair evenly distributed

Normal

37

4. Hair thinness or thickness

Inspection

Thick hair

Thick hair

Normal

5. Hair texture and oiliness

Inspection and Palpation

Silky and resilient hair

Silky and resilient hair

Normal

FACE 1. Facial Features 2. Symmetry of facial movements Inspection Inspection Symmetric or slightly asymmetric facial features Symmetric facial movements EYES EYEBROWS 1. Hair distribution 2. Alignment Inspection Inspection Inspection by asking the client to raise and lower the eyebrows Hair evenly distributed Symmetrically aligned Hair evenly distributed Symmetrically aligned Normal Normal Slightly asymmetric facial features Symmetric facial movements Normal Normal

3. Skin quality and movement

intact skin, equal movements

intact skin, equal movements

Normal

EYELASHES 1. Evenness of hair distribution Inspection Equally distributed Equally distributed Normal

38

2. Direction of curl

Inspection

Curl slightly outward EYELIDS

Curl slightly outward

Normal

Surface characteristics

Inspection

Skin intact, no discharge and discoloration

Skin intact, no discharge and no discoloration

Normal

Frequency of blinking

Inspection

Approximately 15-20 involuntary blinks per minute

18 blinks/min.

Normal

CONJUNCTIVA

BULBAR CONJUNCTIVA 1. Color, texture and presence of lesions Inspection by reverting the eyelids Transparent. Capillaries sometimes evident. No presence of lesions Transparent. Capillaries sometimes evident. No presence of lesions

Normal

PALPEBRAL CONJUNCTIVA

1. Color, texture and presence of lesions

Inspection, by retracting Shiny, smooth, pink or red in color the eyelids with thumb and index finger and asking the client to look up and down, side to

Pink in color, smooth and shiny

Normal

39

side. SCLERA

1. Color

Inspection

Sclera appears white

Slightly yellow in color

Deviation from normal due to effect of bilirubin in the blood streams

CORNEA Normal 1. Clarity and texture Inspection using a penlight PUPIL Transparent, shiny and smooth Transparent, shiny and smooth

1. Color, shape and symmetry of size

Inspection

Black in color, round equal in size EARS AURICLES

Black in color, round equal in size

Normal

1. Color, symmetry of size and position

Inspecting for position. Note the level at which the superior aspect of the auricle attaches to the head in relation to the eyes.

Color same as the facial skin, symmetrical, auricle aligned with the outer canthus of the eye.

Same color with the facial skin

Normal

40

2. Texture, elasticity and areas of tenderness

Palpation by gently pulling the auricle downward then backward and folding the pinna.

Mobile, firm and not tender.

Mobile, firm and not tender. Pinna recoils after being folded.

Normal

NOSE 1. External nose for deviations in shape, size or color and flaring or discharge from the nares.

Inspection

Symmetric; no discharge or flaring; uniform color

Symmetric; no discharge or flaring; uniform color

Normal

2. External nose for any areas of tenderness, masses and displacements of bone and cartilage

Palpation

No tenderness masses and displacements

No tenderness masses and displacements

Normal

3. Patency

Inspection (by asking the client to close the mouth and then exert pressure or the nares, and breathe through the opposite nares and repeat for the other) Observation and inspection

Air moves freely as the client breathes through the nares

Air moves freely as the client breathes through the nares

Normal

pink; clear watery discharge; No lesions and swelling

4. Mucosa

Mucosa pink; clear watery discharge; No lesions and swelling noted

Normal

5. Nasal Septum

Inspection

intact and in midline

intact and in midline

Normal

41

6. Sinuses

Palpation

Not tender MOUTH LIPS AND BUCCAL MUCOSA

No tenderness noted

Normal

1. Outer lips for symmetry of contour, color and texture Inspection Uniform pink color; soft, moist, smooth texture Uniform pink color; soft, moist, smooth texture Normal

2.Inner lips and buccal mucosa for color, moisture, texture and the presence of lesions Inspection and palpation TEETH AND GUMS Uniform color; moist, no lesions Uniform color; moist, no lesions Normal

1. Characteristics

Inspection

Smooth white tooth enamel, pink gums with moist, firm texture. Central position, smooth lateral margins; no lesions; raised papillae

Smooth white tooth enamel, pink gums with moist, firm texture Central position, smooth lateral margins; no lesions; raised papillae; moves freely

Normal

2.Tongue movement

Inspection

Normal

3. Base of the tongue, floor of the mouth and frenulum

Inspection

Smooth base of the tongue with prominent veins

Smooth base of the tongue with prominent veins

Normal

42

4. Presence of nodules, lumps or excoriated areas

Inspection and Palpation

Smooth with no palpable nodules PALATES AND UVULA

Smooth; no palpable nodules

Normal

1. Hard and soft palate for odor, shape, texture and presence of bony prominences

Inspection

Light pink, smooth soft palate; lighter pink, hard palate; no bony growths.

Light pink, smooth soft palate; lighter pink, hard palate more irregular texture; no bony growths.

Normal

2. Uvula for position and mobility

Inspection

Positioned in midline of soft palate

Positioned in midline of soft palate

Normal

TRACHEA

1. Lateral Deviations

Palpation

Central Placement in midline of neck THORAX AND LUNGS

Central Placement in midline of neck

Normal

1. Shape and symmetry of the thorax from posterior and lateral views

Inspection

Antero-posterior to transverse diameter ratio of 1:2 Ratio of 1: 2 Thumb separated 3cm Normal Normal

2. Respiratory Excursion

Palpation

Full symmetric chest expansion

43

3. Vocal (tactile) Fremitus

Palpation

Bilateral symmetry of vocal fremitus

Bilateral symmetry of vocal fremitus; equal vibration

Normal

4. Breath sounds

Auscultation

Vesicular and broncho- vesicular breath sounds

Vesicular and broncho- vesicular breath sounds

Normal

5. Breathing Pattern

Inspection

Rhythmic; effortless

Use of accessory muscles upon breathing; shallow breathing

Deviation from normal due to pain (compensatory mechanism)

ABDOMEN

1. Skin integrity

Inspection

Unblemished skin; uniform color

Impaired skin integrity with incision on the right upper quadrant

Deviation from normal due to Cholecystectomy on the right upper quadrant of the abdomen.

2. Contour and symmetry 3. Abdominal movements associated with respirations

Inspection Observation

Flat, rounded or scaphoid; symmetrical Symmetric movements

Flat; Symmetrical Symmetric movements

Normal Normal Deviation from normal due to status post cholecystectomy

4. Bowel sounds

Auscultation

Audible bowel sounds

Hypoactive bowel sounds

44

5. Areas of tenderness

Palpation

No tenderness; relaxed abdomen

Presence of tenderness

Deviation from normal due to status post cholecystectomy

MUSCLES

1. Size 2. Contractures (Softening) 3. Fasciculations and tremors 4. Muscle tonicity

Inspection Inspection Inspection Palpation Palpation

Equal in size in both sides of the body No contractures No tremors Normally firm UPPER EXTREMITIES

Equal in size in both sides of the body No contractures No tremors Firm

Normal Normal Normal Normal

1. Motor strength 2. Muscle tone

Inspection Palpation

Can perform ROM exercise for upper extremities easily Smooth and firm

Can perform ROM exercise Smooth and firm

Normal Normal

3. Presence of lesions, deformities and varicosities

Inspection

No lesions present, no deformities, varicosities may be present

No lesions, no deformities

Normal

4. Presence of edema

Inspection and Palpation

No edema

no edema noted

Normal

45

LOWER EXTREMITIES

1. Motor strength

Inspection

Can perform ROM exercise for lower extremities easily

Can slightly perform ROM

Normal Deviation from normal due to status post cholecystectomy

2. Muscle tone

Palpation

Firm muscle tone

muscle tone not firm

3. Presence of lesions, deformities and varicosities

Inspection

No lesions, varicosities may be present, no deformities

No lesions, no deformities

Normal

4. Presence of edema

Inspection and Palpation

No edema

edema noted

Deviation from normal due to water retention, the liver and kidney are compensated.

46

VI. Laboratory / Diagnostic Procedure Diagnostic Laboratory Procedures Date Ordered Result in Indication or Purpose Result Normal values Analysis and interpreta tion of the results A white blood cell count is a determination of number of WBC or leukocytes/unit volume in a sample of venous blood. The test is used to detect infection or inflammation and also used to help monitor the bodys response to various treatments and to monitor bone marrow function, and to determine the need for further tests, such as differential count. Above normal range. An elevated number of leukocyte s can result from infectious diseases (usually bacterial origin), and with trauma or surgery. -Check if theres -Use standard a doctors order precaution and for CBC sterile technique when getting specimen -Explain the procedure to the -apply pressure on the patient venipuncture site after withdrawing specimen -Label the specimen container with name, age, date and time the specimen was obtained,room no., the doctor who ordered the specimen. Prior Nursing Responsibilities During After

CBC (Complete Blood Count)

August 01, 2010

August 01, 2010

WBC

10.6

5.010.0x1 09/L

-Send the specimen to the laboratory immediately

47

Hemoglobin is an important component of red HGB blood cells that carries oxygen and carbon dioxide to and from tissues. The hemoglobin determination test is used to screen for diseases associated with anemia and in determining acidbase balance. The oxygen carrying capacity of the blood is also determined by the Hemoglobin concentration. Measures the percentage of RBC in a blood volume. HCT The test is performed to help diagnose blood disorders, such as polycythemia, anemia or abnormal dehydration, blood transfusion decisions for severe symptomatic anemias, and the effectiveness of those transfusions.

168

M: 140170 F: 120 150 g/dL

Within normal range

0.48

M: 0.40 Within - 0.60 F: 0.38 0.40 normal range

48

The smallest formed elements in blood that promote blood clotting after an injury. The test is performed to determine if blood clots normally, evaluate platelet production, and to diagnose and monitor a severe increase or decrease in platelet count A small white blood cell (leukocyte) that plays a large role in defending the body against disease. Evaluate bacterial and viral infection, immune disease, leukemia, and ulcerative colitis

PLT

268

150 450 X109/L

Within normal range

Lymphocytes 0.36

0.20.35

Above normal range

49

Prothrombin time

1. Control

13.0

12-15 sec

Within normal range

2. Activity

70-100

74.3 %

Within normal range

3. INR

0.8 1.2

1.14

Within normal range

4. Partial thromboplast in Time

35-45 sec

38.7

Within normal range

50

The gallbladder is not distended measuring 5.5 x 2.5 cm. the previously noted solitary gallstone has increase in size from 56.1 mm. wall is not thickened.

Abdominal ultrasound

August 01, 2010

August 01, 2010

To visualize abdominal structures by using non-invasive diagnostic technique in which high-frequency sound waves are passed into internal bofy structures.

>> Explain the > Patient can >> explain the purpose and the expect to procedure of the following: resume test. her/his normal activities Impression: >patient will be immediately. ask to lie on the examination > Instruct him couch next to not to eat solid ultrasound food for 12 >inform IMPRESSION machine hours prior to patient exam to allow regarding the > Solitary Cholecystitis with increase greatest dilation result of the in size gallbladder

>the area to be >Inform patient scanned will be that ultrasound exposed and a is a noninvasive clear waterprocedure. soluble gel will be applied to the skin for the transmission of sound waves into the patients body

51

>a scan probe will then be placed in contact with patients body and move over the skin to examine the tissues below. >the parient will experience no pain during the procedure >Ultrasound scans take approximately 30 min. to complete.

52

VII.

Patient and His Care A. Medical Management

MEDICAL MANAGEMENT TREATMENT

DATE ORDERED/ DATE PERFORMED/ DATE CHANGE OR DC

GENERAL DESCRIPTION

INDICATIONS/ PURPOSE

CLIENTS RESPONSE TO THE PROCEDURE No signs of dehydration.

NURSING RESPONSIBILITIES

1.) IVF (D5LRS) >Regulated @ 3031 gtts/min

Date ordered/performed August 01, 2010 Date discontinued: August 03,2010

5% Dextrose in Lactated Ringers Solution

For rehydration

PRIOR: Determined the type of solution to be infused. The rate of flow or the time over which the infusion is to be completed. Assess the vital signs, skin turgor. DURING: Prepare the infusion set. Spike the solution container. Prime the tubing. Perform aseptic technique. Initiate the infusion. Regulate the infusion. AFTER: Document relevant data. Monitor clients response. Evaluate if IV flow is consistent with what ordered. Assess the infusion site.

53

MEDICAL MANAGEMENT TREATMENT

DATE ORDERED/ DATE PERFORMED/ DATE CHANGE OR DC Date

GENERAL DESCRIPTION

INDICATIONS/ PURPOSE

CLIENTS RESPONSE TO THE PROCEDURE

NURSING RESPONSIBILITIES

Oxygen therapy (3LPM via face mask)

ordered/performed: August 01, 2010 Date discontinued: August 02,2010

- Oxygen therapy is the administration of oxygen as medical intervention. Oxygen is essential for cell metabolism, and in turn, for tissue oxygenation. -it is an administration of oxygen at concentration greater than that in room air to prevent hypoxemia and hypoxia.

-facilitate breathing -to increase oxygen saturation in tissues

-the patient relieved difficulty of breathing. -the patient demonstrate adequate oxygenation

PRIOR: Check for the doctors order including the flow rate of O2 Check and how to administer for the oxygen tank, humidifier, and flow rate meter if they are working. Place no smoking sign at the head or foot of the bed. Assess for kinks and obstruction Secure the tubing, comfortably. Observe for moisture in the mask to prevent aspiration. Observe the pressure necrosis.

DURING:

AFTER: Check for clients response to the therapy. Check for the skin irritation. Perform after care.

54

B.Drugs Date ordered, taken/given Date changed/ D/C Route of administration, dosage, frequency

Name of drug

General action, Classification, Mechanism of Action

Classification: H2 RECEPTOR

Indications/Purpose

Client response to the medication, actual side effects

Nursing Responsibilities

PRIOR INDICATION >Short-term treatment Clients response >decreased 1. Assess patient for contraindication. 2. Assess for baseline data. 3. Tell patient that he may experience side effects brought about by the drug. Side effects >abdominal pain, constipation, DURING 1. Administer the drug slowly. AFTER 1. Instruct him to report intolerable side effects so as prompt intervention could be done. 2. Instruct him to report adverse effects that he may experience.

Generic Name: RANITIDINE

Date ordered: August 01, 2010

50 mg TIV Q8

BLOCKER GENERAL ACTION >anti-ulcer MECHANISM OF ACTION >Competitively inhibits the action of histamine at the H2 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 agonist, gastrin, and pentagastrin.

Brand Name: ZANTAC

Stock Dose: 25 mg/mL

of active duodenal ulcer abdominal pain > Maintenance therapy for duodenal ulcer at reduced dosage >Short-term treatment of active, benign gastric ulcer

55

Date ordered, .Name of drug taken/given Date changed/ D/C

Route of administration, dosage, frequency General action, Classification, Mechanism of Action Indications/Purpose

Client response to the medication, actual side effects PRIOR Nursing Responsibilities

Generic Name: VITAMIN K Brand Name: Aquamephyton

Date ordered: August 01, 2010

10 mg TIV Q8

Classification: Fat soluble vitamin

GENERAL ACTION

Indication: >Prevention of bleeding,

Clients response >N/A

1. Assess for contraindication. 2. Assess for baseline data. 3. Teach patient not to take other supplements, unless directed by prescriber, to take this medication as

>hypoprothrombinemia Side effects: >anti-coagulant >N/A

MECHANISM OF ACTION

directed. 4. Tell patient that he may experience side effects brought about by the drug and to report symptoms of bleeding: bruising, nosebleeds, bleack tarry stools, hematuria. DURING 1.Slowly administer the medication AFTER 1.Instruct patient to report adverse effect that he may experience
56

>Vitamin K is essential for the hepatic synthesis of factors II, VII, IX, and X, all of which are essential for blood clotting. Vitamin K deficiency causes an increase in bleeding tendency, demonstrated by ecchymoses, epistaxis, hematuria, GI bleeding.

Date ordered, Name of drug taken/given Date changed/ D/C

Route of administration, dosage, frequency

General action, Classification, Mechanism of Action Indications/Purpose

Client response to the medication, actual side effects Nursing Responsibilities

PRIOR Generic Name: CEFUROXIMESODIUM Date ordered: August 01, 2010 750 mg TIV Q8 Classification: ANTIBIOTIC;CEPHAL OSPORIN GENERATION) Indication: >Maintenance Surgical (2ND prophylaxis Clients response >pain is felt upon administering IV push 1. Assess patient for contraindication. 2. Assess for baseline data. 3. Have vitamin K readily available in case of hypoprothrombinemia occurs. Brand Name: CEFUROXIME Stock dose: 750 mg/50 mL GENERAL ACTION: >Bactericidal MECHANISM ACTION >inhibits bacterial synthesis cell of wall, OF Side effects >no side effects DURING 1.Reconsitute 1gram with 10 or more ml of sterile water AFTER 1. Instruct patient to avoid alcohol for 3days after drug administration

causing cell death.

because serious reactions often occur. 2. Tell patient that he may experience some side effects brought upon by the drug.

57

Date ordered, Name of drug taken/given Date changed/ D/C

\Route of administration, dosage, frequency

General action, Classification, Mechanism of Action

Indications/Purp ose

Client response to the medication, actual side effects Nursing Responsibilities

Generic name: METRONIDAZOLE HYDROCHLORIDE

Date ordered: August 02, 2010

500 mg TIV Q8

Classification: >Nitroimidazole derivative

INDICATION >for preoperative

Clients response >N/A

PRIOR 1. Check for doctors order 2. Not to be given in patients

GENERAL ACTIONS:Stock dose: Brand name: FLAGYL IV 500 mg/100 mL >Anti-protozoal MECHANISM OF ACTION >Disturbs DNA synthesis in susceptible organism. bacterial >Anti-infective

prophylaxis Side effects >dark urine

hypersensitive to drugs 3. Inform the patient about the possible side effect of the drug DURING
1. Inject IV port slowly, over not less than 2 min.

AFTER 1. Advise patient to report abdominal pain.

58

Name of drug

Date ordered, taken/given Date changed/ D/C

Route of administration, dosage, frequency

General action, Classification, Mechanism of Action

Indications/Purp ose

Client response to the medication, actual side effects

Nursing Responsibilities

Classification Generic name: PARACETAMOL Brand name: > decreases body ACETAMINOPHEN temperature MECHANISM OF ACTION > Reduces fever by acting directly on the hypothalamic heatregulating center to cause vasodilation and sweating, which helps dissipate heat. Date ordered: August 02, 2010
300mg, TIV now, q4, PRN for 38C

PRIOR INDICATION >reduce body temperature Clients response >fever decreases from 38C- 37C 1. Check for doctors order 2. Not to be given in patients hypersensitive to drugs 3. Inform the patient about the possible side effect of the drug DURING 1. Inject directly slowly AFTER 1. Tell patient that he may experience some side effects brought upon by the drug

Nonopoid analgesics and antipyretic GENERAL ACTIONS

59

Date ordered, taken/given Name of drug Date changed/ D/C

Route of administration, dosage, frequency

General action, Classification, Mechanism of Action

Indications/Purpose

Client response to the medication, actual side effects

Nursing Responsibilities

PRIOR

Generic Name: CELECOXIB Brand Name: CELEBREX

Date ordered: August 02, 2010

200 mg PO FOR PAIN Stock dose: 100 mg and 200 mg

Classification: NONSTEROIDAL ANTIINFLAMMATORY DRUG

. Indication: >Management of acute pain.

Clients response >verbalized decreased pain felt

1. Take drug with food if GI upset occurs

2. Determine any GI bleed/ulcer history, sulfonamide allergy,

GENERAL ACTION >Pain reliever

Contraindications: >Contraindicated with allergies

aspirin and other NSAIDinduced asthma, urticaria, allergic type reaction 3. Monitor sign and symptoms

to sulfonamides, NSAID, or aspirin

celecoxib,

MECHANISM OF ACTION >Inhibits prostaglandin synthesis, primarily by inhibiting cyclooxygenase-2 thus decreasing inflammation. DURING

4. Assess for liver or renal dysfunction; reduce dose

1. Take with foods; decreases stomach upset AFTER

1. Tell patients that he may

experience some side effects brought about by the drug

60

C. Diet Date Started 08/01/10 General Description An instruction meaning to withhold oral foods and fluids, but for patients who will undergo surgery, the physician will allow small amount of fluid intake for oral medication Diet that allows intake of fluid or liquid forms of food only Indication/ Purposes This diet is usually ordered for preparation prior to surgery specially who will undergo general anesthesia to prevent aspiration and pneumonia Specific foods/fluids taken None Client Response Nursing Responsibilities Prior During -Strictly monitor clients behavior in following NPO. Post -Instruct the client to continue NPO as prescribed by the physician.

Type of diet

Date Change

NPO(Nothing Per Orem)

08/02/10

Feels hunger -asses the level of and thirst, understanding of appears weak the patient -Explain the importance of following strictly NPO in terms that the client can understand and then evaluate

General Liquid Diet

08/02/10

08/03/10

Before DAT diet is instructed the physician first ordered is general liquid diet to train the normal digestion and to bring back the normal digestion process

90 ml of water

Feels hunger, -Asses the level of appears weak understanding of the patient -Explain the importance of following strictly General Fluid diet in terms that the client can understand and then evaluate

-Strictly monitor clients behavior in following General Liquid diet

- General Liquid diet was instructed and maintained to train the normal digestion process.

61

-Emphasize what kind of foods the client can eat during this diet. DAT( diet as tolerated) 08/03/10 (until discharge) It is a diet that allows the patient to eat all types/kinds of foods as long as the client can tolerate it. Instructed following a general liquid diet for better source of good nutrition. Lugaw, egg and rice Pinakbet and rice Monggo and rice Sinigang na bangus and rice Relieved hunger -Asses the level of understanding of the patient -Explain that immediate shifting of foods from NPO to General Fluids to DAT without undergoing soft diet can result to constipation, thats why we need to emphasize eating first soft foods before eating any solid foods -Strictly monitor clients behavior in following DAT diet -Advised the client to take soft foods and avoid food rich in fats.

62

D. Exercise

Type of exercise

Date started

General description

Indications/purpose

Client response NURSING RESPONSIBILITY

Ambulation exercise

08/02/10

A type of exercise that requires the patient to move by feet >Walking

aids in good circulation facilitate voiding stimulate peristalsis prevent thromboembolism

The patient tolerated the exercise but he felt little bit tired

BEFORE: Ensure that the patient understand the reason for doing the exercise Assist to stand to prepare for ambulation. DURING: Assist patient while doing the exercise if necessary. Check if there is difficulty in breathing Check if he feels any pain while doing the exercise AFTER: Recheck if he feels any pain after the exercise Monitor the V/S of the patient to check if there are changes Document relevant datas.

63

VIII.

SURGICAL MANAGEMENT

The circulator accompanies the anesthesia provider and the patient to the PACU; he/she gives the PACU perioperative practioner a detailed intraoperative patient report regarding the course of events as they apply to the individual. Assess the patient: appraise air exchanges status & note skin color; verify & identify operative status & surgeon performed; assess neurological status (LOC) PACU nurse observes the patients breathing, monitors blood pressure and vital signs, and documents all pertinent information. PACU nurse assumes the role as the patients advocate.. Report for abnormalities especially for signs and symptoms of shock Perform safety checks good body alignment, side rails and maintain patent airway and cardiovascular stability

Postoperative

Relieve pain and anxiety Post operative: Patient finds it hard to sleep because of pain felt on the incision site Client appears weak

Client Response

Skin color improvement (August 03, 2010)

64

IX. NURSING CARE PLAN

Assessment

Nursing Diagnosis

Background Knowledge

Planning Short Term:

Nursing Interventions Independent 1. Observe and document

Rationale

Evaluation Goal met.

S: masakit yung tahi ko, As verbalized by the patient. O:Facial Grimace >With guarding behavior >Rigidity of the abdomen >Pain scale of 6/10 >RR= 24 cpm >With short and shallow breathing

Acute Pain related to inflammation and distortion of tissues r/t injuring agent

Cholecystectomy

After 2 hours of

1. Assists in differentiating cause of pain and provides information about disease progression/ resolution, development of complications and

After 2 hours of nursing intervention the patient pain scale was decreased from 6/10 -3/10. After 8 hours of nursing intervention the patient was

nursing intervention location, severity and the patient pain Surgical incision on scale will decrease the right lower from 6/10 3/10 quadrant of the abdomen character of pain.

Disruption of skin tissue and muscle integrity at RUQ

Long Term: After 8 hours of Nursing intervention the 2. Note location of surgical procedure

effectiveness of interventions. 2.This can influence the amount of postoperative pain experienced 3. To divert attention and reduce tension and to relieved the patient from pain.

reportedly relief of pain.

Stimulation of sensory nerve endings

patient will report relieved of pain. 3.Instruct/encourage use

PAIN

of relaxation techniques such as breathing

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exercise 4. To divert attention Source: Porth CM. (2002). Pathophysiology: Concepts of Altered Health Philippines: Lippincott Williams & Wilkins. 6. Make time to listen to complaints and maintain frequent contact with the patient. States. 5. Encourage adequate rest periods. 6. Helpful in alleviating anxiety and refocusing attention which can relieve pain. 4. Encouraged divisional activities. and to relieved the patient from pain. 5.To prevent fatigue

7. To impart 7.Discuss with significant others ways where in they can assist client and reduce precipitating factors that may cause pain knowledge to the SO regarding ways on how they can participate in alleviating the pain of the patient.

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Dependent Administer medication as prescribed.

To relieve pain.

SOURCE: Nurses pocket guide Diagnoses, prioritize interventions, and rationale, 11th edition

67

Assessment

Nursing Diagnosis

Background Knowledge

Planning

Nursing Interventions 1. Place the pt in a

Rationale

Evaluation

SHORT TERM : S: kumikirot ang sugat ko sa tagiliran as verbalized by the patient O: >Incision at right upper right quadrant of the abdomen with intact and dry dressing >Status: post operation cholecystectomy. thus impairing the integrity of the skin LONG TERM: Source: After 2-3 days of nursing intervention http://www.nlm.nih.gov/ the patient displays medlineplus/ency/articl e/002930.htm progressive improvement in wound healing. Impaired tissue integrity related to surgical incision (surgery) trauma to the skin surgical incision on the right upper quadrant of the abdomen, Within 2hrs of nursing intervention the patient verbalize understanding of condition and causative factor.

1. To prevent backaches or

Goal met: After 2hrs of nursing intervention the patient verbalized understanding of condition and causative factor.

comfortable position. muscle aches. 2. Monitor and record vital signs. Assess general condition of skin. 2. To note any significant changes that may be brought about by the disease.

3.Practiced aseptic technique for cleaning /dressing/ medicating wound 3. Healthy skin varies from individual to individual, but should have good turgor, feel warm and dry to the touch, be free of impairment, and have quick capillary refill. 4. Emphasize importance of proper nutrition and fluid intake. 4.Reduced risk for infection After 2-3 days of nursing intervention the patient displayed progressive improvement in wound healing. LONG TERM:

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5. Encourage adequate period of rest and sleep. 5. To maintain general good health and skin turgor.

6.

Promote

early 6. a.) To limit metabolic

ambulation.

demands, remain energy available for healing and meet comfort needs.

b).Promote

circulation

and

prevent excessive tissue pressure.

Sources: Nurses pocket guide Diagnoses, prioritize interventions, and rationale, 11th edition

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Assessment S: Namumula ang sugat ko sa tagiliran as verbalized by the patient. O: >Surgical incision at the right upper quadrant of the abdomen >With intact, dry dressing >Status : Post Operation Cholecystectomy

Nursing Diagnosis

Background knowledge surgical incision

Planning

Nursing Interventions

Rationale

Evaluation

Risk for infection related to increase environmental exposure to pathogen

Short term goal: After 5 hours of

1. Monitor vital signs. Note onset of fever, chills, and diaphoresis. 2.Practice good hand washing and aseptic wound care.

1. Suggestive of presence of infection/ developing sepsis.

Goal met. Short term goal: After 5 hours of nursing

traumatized tissue on the injured site

nursing intervention the patient will identify

2 .Reduce risk of spread of bacteria/ prevent cross contamination.

intervention the patient will identify intervention to prevent/ reduced the risk of infection. Long term goal:

increasing risk of infection

intervention to prevent/ reduced the risk of infection.

may result to further complication if not prevented

3. Inspect incision and dressings. Long term goal: After 1-4 days of

3. Provides early detection of developing infectious process.

After 1-4 days of nursing intervention the patient showed progress of wound healing.

Source:
Mattson Porth, Essentials of Pathophysiology Concepts of Altered

nursing intervention 5. Cleanse incision site the patient will show progress of wound healing with povidone iodine.

5. Disinfects site and prevents multiplication of microorganisms which may cause infection.

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Health Status, Lippincott Williams and Wilkins, 2007

6. Instruct client not to wet incision site.

6.Microorganisms thrive at damp areas and makes it conducive for replication

7. Provide a cool environment.

7. Hot room temperature induces sweating which may inhibit the healing of wound and eventually cause moisture at the area delaying the healing process.

8. Assess patients ability to move.

8. Immobility is the greatest risk factor in skin breakdown.

9. encourage change of position in a

9. to prevent pressure to certain parts of the body

regular basis

10. emphasize importance of adequate nutritional/ fluid Intake

10.to maintain general good health and skin turgor

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11. encourage ambulation as tolerated

11.to enhance good circulation

Dependent: >Administer medications as prescribed (antibiotics) > Prevents invasion of bacteria or microorganisms at site and eventually prevents possible infection.

Sources: Nurses pocket guide Diagnoses, prioritize interventions, and rationale, 11th edition

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X. HEALTH TEACHINGS Health Teaching Rationale

Encourage to avoid intake of foods high in fat/cholesterol.

After cholecystectomy, the liver still produce bile but in a slow trickle process, therefore if the diet is high in fat, the malabsorption of fat occurs because the minimal production of bile cannot handle the normal absorption process

Explain the importance of ambulation.

To promote good circulation

Explain to the patient the importance of deep breathing exercises/ divertional activities.

Deep breathing exercises/divertional activities help to reduce pain.

Explain to the patient the importance of splinting.

Splinting reduces the pressure in the abdomen thus reducing the pain.

Explain to the patient not to touch the incision site with bare hands.

To prevent infection.

Explain to the patient the importance of eating small frequent meals (preferably 4-6 meals) rather than to eat 3 times a day.

Since cholecystectomy is done, the liver will compensate by excreting slow and low level of bile that can cause the malabsorption of fat.

Explain the importance of proper hygiene.

Prevent the spread of microorganism/cross contamination. To reduce the risk of infection and to promote patients comfort.

Explain to the patient the importance of maintaining a clean and well ventilated environment.

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XI. DISCHARGE PLANNING Medicines: Teach the ff: to the client with regards to proper administration of the prescribed medication Cefuroxime 500 mg 3X/day (TID) Celecoxib 200 mg PRN when feeling pain.

Environment and Exercise encourage to establish a clean and well ventilated environment avoid strenuous exercise that cause tension on the affected area and further deprivation Daily activities should be spaced to provide rest periods between times of exercise

Treatment Advise to continue to take the prescribed home medication until end of the regimen or unless specified by the physician. Give relevant information about the drugs, their side effects & their adverse effects.

Health Teaching: Explain to patient what to expect afterwards. As the anesthetic wears off, there is likely to be some pain. The anesthetist will prescribe painkillers. Suffering from pain can slow down recovery, so its important to discuss any pain with the doctors or nurses. Instruct caring for the stitches, hygiene & bathing, and will arrange an outpatient appointment for the stitches to be removed. Instruct patient to comply with the home medications that would be given by his physician. Encourage the patient to do the recommended light exercises such as walking. Avoid doing strenuous activities which could slow down his recovery.
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 Encourage him to comply with the dietary modifications; limit the intake of saturated fat to prevent the occurrence of serious post-cholecystectomy side-effects. Explain to patient to refer for unusualities immediately.

Out Patient Care: Instruct to visit the physician for follow-up check up after 1 week If any of the following symptoms are noted he should contact his doctor: Diet: Instruct client to limit the intake of foods high in fat Advise the patient to eat smaller amount of foods during a single meal. Advised to eat around 5 or 6 smaller meals a day instead of 2 or 3 usual meals. If the wound become more painful, red, inflamed or swollen. If the abdomen swells If the pain is not relieved by the prescribed painkillers. If a fever develops these could be a sign of an infection that may need to be treated with antibiotics.

Spiritual/Safety: Encourage going to church and asking for guidance, encourage praying. Avoid strenuous activity.

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XII.

CONCLUSION

Generally, we, the student nurses six days exposure and duty at Bulacan Medical Center have been a memorable experience to us. The exposure had been an avenue for further development and enhancement of our skills and capabilities in rendering care and promoting holistic wellness to our clients. It reminded us again that nursing profession entails a deep sense of responsibility and challenging tasks. After a six (6) days of exposure at BMC Surgery Ward, we the student nurse has identified and understood the causative factors of cholecystitis, its signs and symptoms, clinical manifestations, diagnostic studies, medical, pharmacological and nursing interventions through obtaining cues and health history in conjunction to the disease process. We underwent extensive research in order to comprehensively understand our patients condition. Upon learning his case, it challenged and motivated us to work hard to provide the appropriate and effective nursing intervention and care. Moreover, cholecystitis is the most common problem resulting from gallbladder stones. It occurs when a stone blocks the cystic duct, which carries bile from the gallbladder. Predisposing factors can include heredity, age, sex and race. With t he presented factors that cannot already be modified, one has to take action towards preventing the disease to happen. The only one who can help yourself is you alone. With the proper knowledge about the nature of the disease as well as its preventive measures along with responsibility and sense of will, one can surely direct himself away from the complications.

- GROUP 2

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XIII. BIBLIOGRAPHY http://www.nottingham.ac.uk/nursing/sonet/rlos/bioproc/resources.html http://www.le.ac.uk/pa/teach/va/anatomy/case2/frmst2.html http://www.le.ac.uk/pa/teach/va/anatomy/case5/frmst5.html http://digestive.niddk.nih.gov/statistics Barbara Howard, Clinical and Pathologic Microbiology, 2nd Edition Carol Porth, Pahtophysiology Concepts of Altered Health Sciences, 7 th Edition Pathology 3rd Edition by Stanley L. Robbins, M.D. Tortora et. Al., Microbiology An Introduction, 8th Edition Kasper et. Al., Harrisons Principle of Internal Medicine, 16th Edition Deglin, Judith H., Vallerand, April H. Daviss Drug Guide for Nurses, 10th ed. Damjanov, I., Linder, J. Andersons Pathology. 10th edition USA: MosbyYearbook 1996. Fauci A. et al. Harrisons Principles of Internal Medicine. 16th edition. USA: The o McGraw-Hill Companies 2005. Bullock, B. Henze, R. Focus on Pathophysiology. Philadelphia, USA:Lippincott, o Williams and Wilkins 2006. Clinical Applications of Nursing Diagnoses. F.A. Davis Company, Philadelphia. o 4th edition. Nutritional Therapy and Pathophysiology. Nelms, Sucher, Long. 2007. Thomson o Brooks/Cole, The Thomson Corporation. 10 Davis Drive Belmont, CA, USA.
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Bare, Brenda G., Cheever, Kerry H., Hinkle, Janice L., Smeltzer, Suzanne C. o Brunner & Suddarths Textbook of Medical- Surgical Nursing, 11th ed. Vol.1. o Lippincott Williams & Wilkins, 2008.

Doenges, Marilynn E., Moorhouse, Mary Frances, Murr, Alice C. Nursing Care o Plans 7th ed. F.A. Davis Company, Philadelphia, Pennsylvania,2006. Karch, Amy M. 2007 Lippincotts Nursing Drug Guide. Lippincott Williams & o Wilkins, 2007. MIMS, 108th ed. CMPMedica Asia Pte Ltd, Singapore, 2004. Porth, Carol M. Essentials of Pathophysiology: Concepts of Altered Health States. o 2nd ed. Lippincott Williams & Wilkins, 2007.

pp. 148-153, Maxine A. Goldman 2008, Pocket Guide to the Operating Room. 3rd edition o F.A. Davis Company.Philadelphia

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