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Ateneo de Davao University

College of Nursing
Bachelor of Science in Nursing

In Partial Fulfilment for the Requirements in


Nursing Care Management [Related Learning
Experience]
- - -
Calculous Cholelithiasis

Submitted to:
Theresa Kintanar, R.N.
Ella Mae Navarro, R.N.
Clinical Instructors

Submitted by:
Lim, Stephanie Marie
Madrazo, Benedict Edmund
Mangitngit, Jeferson
Margaja, Dominique Dawn
Maulion, John Charls
Mendoza, Kathreen Glaiza
Nalzaro, Sheena Ann
Olalo, Angeli
Omandac, Alyssa

BSN 3E; Group 3; College of Nursing


February 26, 2009
TABLE OF CONTENTS

I. INTRODUCTION...............................................................................................

II. OBJECTIVES......................................................................................................

III. PATIENT’S DATA ............................................................................................

IV. FAMILY BACKGROUND/ HEALTH HISTORY ............................................

V. DEVELOPMENTAL DATA ..............................................................................

VI. DEFINITION OF COMPLETE DIAGNOSIS ...................................................

VII. PHYSICAL ASSESSMENT ..............................................................................

VIII. ANATOMY AND PHYSIOLOGY ....................................................................

IX. ETIOLOGY AND SYMPTOMATOLOGY .......................................................

X. PATHOPHYSIOLOGY ......................................................................................

XI. DOCTOR’S ORDER ..........................................................................................

XII. DIAGNOSTIC EXAM .......................................................................................

XIII. DRUG STUDY ...................................................................................................

XIV. NURSING THEORIES ......................................................................................

XV. NURSING CARE PLAN ....................................................................................

XVI. PROGNOSIS.......................................................................................................

XVII. DISCHARGE PLAN ..........................................................................................

XVIII. RECOMMENDATION ......................................................................................


I NTRODUCTION

Cholelithiasis refers to the presence of gallstones in the gallbladder which occurs

more often in women than men. Gallstones are formed within the gallbladder and can

range in size from as small as a particle to golf-ball size, depending on how long they

have been building.

A common digestive disorder worldwide, the annual overall cost of cholelithiasis

is approximately $5 billion in the United States, where 75-80% of gallstones are of the

cholesterol type, and approximately 10-25% of gallstones are bilirubinate of either black

or brown pigment. In Asia, pigmented stones predominate, although recent studies have

shown an increase in cholesterol stones in the Far East.

Gallstones are rock-like accumulations of material that take shape inside the

gallbladder. There are different types of gallstones, but cholesterol stones are the most

common. The gallbladder stores bile in the liver. The bile is composed of bile salts, bile

pigments, cholesterol, phospholipids and electrolytes. When bile contains excess

cholesterol, gallstones begin to form.

Cholesterol stones can be green, white or yellow in color and are made primarily

of cholesterol while pigment stones are somewhat dark and made of bilirubin and

calcium salts in bile. Much has been learned about how gallstones are formed and experts

believe that gallstones may be caused by a number of factors such as inherited genetic

chemistry, gallbladder movement and diet.


When bile builds up too much cholesterol, gallstones form. Furthermore, not

emptying the gallbladder enough may allow the bile to become compacted and form

stones. Increased levels of estrogen could raise cholesterol levels in bile, promoting the

formation of gallstones.

Persons with high cholesterol levels are more prone to develop Cholelithiasis.

Diets high in fats contribute to the formation of gall stones and over time the stones can

grow to considerable size, causing serious pain and discomfort.

Our patient, given the code name: Mr. R, is a hardworking supervisor for a certain

mining industry. He was admitted in DMSFH to undergo a surgery that will remove his

gall bladder. The operation he underwent was a Laparoscopic Cholecystectomy. We were

able to choose Mr. R as our case, with the help of our clinical instructor. Mr. R’s disease

is in line with our concept which is Nephrology and he was able to give us his approval

when we asked for his cooperation.

Throughout this Case Presentation, numerous data about Mr. R’s disease will be

presented for the deepened understanding of his disease, Calculous Cholelithiasis.


A CKNOWLEDGEMENT

Many people have been kind and helpful to us in finishing this case study. We

would like to extend our gratitude to the following:

First, we would like to thank the Almighty God for giving us guidance, strength

and enlightenment upon doing this case study.

Second, we would like to thank each and everyone’s parents for their support

financially, physically and emotionally.

Third, we would like to thank our dearest clinical instructor, Ms. Theresa

Kintanar, for guiding us in choosing the appropriate family for our case study and for

giving us some guidelines that could help us in acquiring necessary information.

Fourth, we would like to thank our group mates for their cooperation and

determination to finish and learn something from this case presentation.

Fifth, we would like to thank all the personnel and staff members of St. Joseph

ward, Davao Medical School Foundation Hospital for their accommodation and

assistance during our duty.

Lastly, we would like to extend our heartfelt gratitude to Mr. R. and his family for

their willingness to involve themselves openly in this case study.


O BJECTIVES
General Objectives:

To conduct a thorough and comprehensive study about Mr. R’s disease according

to the data that was gathered by conducting a series of interviews and extensive research.

Specific Objectives:

• To organize our patient’s data for the establishment of good background

information

• To analyze the family health history as well as the history of past and present

illness for the knowledge of what could be the predisposing factors that might

contribute to the patient’s illness

• To create a Genogram containing different informations that will help out in

tracing hereditary risk factors

• To evaluate our patient’s development through the use of different developmental

theories

• To differentiate the definitions of our patient’s complete diagnosis for better

understanding

• To describe the current condition of our patient through the Physical assessment

• To explain the anatomy and physiology of different organs involved and affected

during cholelithiasis

• To list several factors, signs and symptoms of cholelithiasis that are present or

absent in our patient


• To compose a flow chart showing the pathophysiology of cholelithiasis for a clear

visualization of how cholelithiasis affects a person

• To list the different orders of the physicians assigned to our patient together with

their rationale for a general knowledge of what consists of the medical

management for cholelithiasis

• To interpret the different results of our patient’s diagnostic exams together with

comparisons of normal values for the understanding of what changes during the

disease

• To classify the different drugs used by our patient so that we can identify its

functions and purposes

• To analyze the different nursing theories that can be applied to our patient

• To create Nursing Care Plans applicable to our patient

• To construct a discharge plan following the METHOD format

• To validate a prognosis according to a specific criteria.

• To compose an over-all Conclusion and recommendations about the case study

• To gather all the references used upon making this case study
P ATIENT’S D ATA

Patient's code name: Mr. R

Age: 53 yrs. Old

Address: San Mateo Laverna Buhangin, Davao City

Date of Birth: March 3, 1955

Nationality: Filipino

Civil Status: Married (living separately)

Occupation: Mining Engineer (DENR)

Sex: Male

Religion: Roman Catholic

Ward: St. Joseph 3-C

Bed no.: 325/4

Date of Admission: February 18, 2009

Time: 2:00 pm

Vital signs upon admission:

BP: 120/70 mmHg RR: 19 cpm

Temp.: 37.1 °C PR: 66 bpm

Admitting Diagnosis: Calculous Cholelithiasis

Attending Physician: Dr. Enojo

Type of Admission: Ambulatory


F AMILY B ACKGROUND

H EALTH H ISTORY

Mr. R, a 53 year-old male, was born in Bohol on March 3, 1955. He is currently

residing at B-12 L12 P1 San Mateo Laverna Buhangin, Davao City. They are 7 in the

family including his parents. He is the third child among the five children. Our patient

has completely received immunization since he was a child.

Upon interview, Mr. R said that they had a family history of the same type of

disease, which is the Diabetes Mellitus. He mentioned that within the family, they had 2

cases from his mother’s side and on his father side of the family. His aunt from his

father’s side was also diagnosed with cholelithiasis.

LIFESTYLE: ACTIVITIES

Mr. R described how his workplace is similar to his home in terms of stress. He

verbalized that there are times when he is stressed and there are others when he the

situations can let him relax.

When asked about how he usually spends his days, Mr. R was able to formulate a

schedule that would describe his activities of daily living. He would wake up at 6:00am.

The first thing he would do is take a bath. Right after taking a bath, he takes his breakfast.

After brushing his teeth, he rides his transportation service to his office. By 8:00am, he

arrives in his office. Here, he usually does paper work, participates in interviews and

meetings, records data in his office computer and, on some occasions, perform field work

as a supervisor. After work, he has the option to either go home directly (7:00pm arrival)
or have a night out with his friends from work. There are times that he chooses to go out

and drink; the most would be two times in a week. For every time that he goes out to

drink, he would consume an average of 2 bottles. If he chooses to go out and spend the

night outside the house, he’d get home by around 12:00 midnight and onwards.

LIFESTYLE: DIET

Since his grade school years, Mr. R was fond of eating all kinds of “lechon.” He

is also fond of drinking carbonated beverages and he drinks alcoholic beverages

occasionally. After he was diagnosed with Diabetes, he started eating less lechon and

more vegetables, whole grains and fish. During the interview, Mr. R was asked if he

knows any more changes in his diet. He only shrugged and said he was still unsure of

how his diet will change now that he is missing a gall bladder.

HISTORY OF PATIENT’S PAST ILLNESS

Mr. R was diagnosed of having Diabetes Mellitus type II last 1997. He was

advised by his doctor to be more particular on his diet (to eat more vegetables and fruits

and not to eat too much fatty foods) and do some exercise so that his diabetes will not get

complications. He was also diagnosed of having gallstone last 2003 at a community

hospital, which is located at Magallanes, through ultrasound on the hepato-biliary tree.

He recalls being instructed to take buscopan and co-amoxiclav after being diagnosed.

Mr. R had also mentioned that he has a history of hypertension. This wasn’t

evident during the group’s assessment on Mr. R. However, Mr. R remembers that he had

gone to several hospitals and doesn’t remember where he was diagnosed with

hypertension. Mr. R does remember this happened in the year 1995. Since then, he had

been taking anti-hypertensives like Pritor and Lipitor.


HISTORY OF PATIENT’S PRESENT ILLNESS

Mr. R started experiencing a sharp RUQ pain in the year 1994. He suspected a

disturbance in the stomach, so he took Kremil-S and Buscopan. As an additional self-

treatment for the pain, he frequently ate “lugaw” and he took a lot of rest. Eventually, the

pain went away but it came back three years later. In 1997, the year he was diagnosed

with Type 2 Diabetes Mellitus, he experienced the same sharp RUQ pain just like the one

in 1994. Knowing that his previous self-treatment was effective, he used it again, with an

additional advice from his doctor: drinking plenty of apple juice. Again, the pain went

away as expected. However, Mr. R did not know that his condition was actually getting

worse. Two years after the second incidence, the pain returned. Still not alarmed as he

was in the previous years, Mr. R still used his self-treatment for the pain in 1999. Mr. R

shared that after 1999, he experienced the pain every year already. He also shared that

every time, he used the same self-treatment.

By January 26, 2009, he experienced the worst pain of them all. He shared that his

self-treatment methods was able to ease the pain, but it surprisingly took longer than it

did before. By this time, he decided to have himself checked by a doctor. He was

admitted and undergone a surgical procedure which is Laparoscopic Cholecystectomy at

Davao Medical School Foundation Hospital after being diagnosed with Calculous

Cholelithiasis.
GENOGRAM
D EVELOPMENTAL D ATA
DEVELOPMENTAL DATA

Theorist Theory Stage Result and


Justification
Erik Erikson’s Erik Erikson Integrity Vs. Despair The patient has

Psychosocial theorized that (45 years old and above) positively achieved

Theory of development is a A person who can look this stage of

Development lifelong process and back on good times with development. He

does not end with gladness, on hard times views his life as

Source: the cessation of with self – respect, and on meaningful and

Fundamentals adolescence. Just as mistakes and regrets with fulfilling. He said


of Nursing,
3rd Edition physical growth forgiveness, will find a that he had coped
By:
Sue C. Delaune patterns can be new sense of integrity and well with the
Patricia K.
Ladner predicted, certain a readiness for whatever struggles and

psychosocial tasks life or death may bring. problems that came

must be mastered in A person caught up in old his way. He is

each developmental sadness, unable to forgive thankful because

stage. The greater themselves or others for the struggles made

the task perceived wrongs, and him a better person.

achievement, the dissatisfied with the life, Without doubt, Mr.

healthier the they’ve led, will easily R did not have any

personality of the drift into depression and regrets in all things

person. However, despair. he made whether it

failure to achieve a A positive outcome in this be bad or good.


task influences the stage is achieved if the

person’s ability to person gains a self Mr. R said that

achieve the next fulfillment of about life even though he is

task. The resolution and a sense of unity separated with his

of the conflicts at within himself and others. wife he still has a

each stage enables That way, he can accept very supportive and

the person to death with a sense of caring family.

function effectively integrity. According to him,

in society. he is very thankful

to have children

and family

members who are

always there to care

for him and to

support him no

matter what life

may give them.

He is also ready to

accept whatever

life or death may

bring him.
Lawrence Lawrence Level III: He knows and

Kohlberg’s Kohlberg’s theory Postconventional understands the

Stages of specifically In this level, the person basic social rules

Moral addresses moral lives autonomously and and laws that

Development development in defines moral values and should be followed

children and adults. principles that are distinct and he seriously


Source:
The morality of an from personal abides with it.
Fundamentals
of Nursing, individual’s identification with group According to Mr.
3rd Edition
By: decision was not values. R, when coming up
Sue C. Delaune
Patricia K. Kohlberg’s concern; Stages: with a decision he
Ladner
rather, he focused Social Contract considers the

on the reasons the Legalistic Orientation: feelings and rights

individual makes a The social rules are not of other people. He

decision. His model the sole basis for makes sure that no

states that a decisions and behavior one will be hurt

person’s ability to because the person whenever he makes

make moral believes a higher moral certain decisions.

judgments and principle applies such as Mr. R also

behave in a morally equality, justice , or due verbalized that in

correct manner process making decisions,

develops over a Universal Ethical it is important to

period of time. Principle Orientation: consider not just

Decisions and behaviors the rules in our


are based on internalized society but one’s

rules, on conscience rather feelings and

than social laws, and on perceptions as well.

self chosen ethical and Our patient was

abstract principles that are able to achieve the

universal, last stage of this

comprehensive , and level because when

consistent he and his wife

made the decision

to separate, they

chose to follow

their feelings rather

than the social

norms. Even

though it is against

the norms in our

society to separate,

they still

considered to

separate from each

other because they

believe that doing

so would be the
right thing to do.
Robert Havighurst Middle Adulthood Mr. R is currently
(30-60 years)
Havighurst’s theorized that there working as a
This stage in a person’s
Developmental are six government
life is concerned with the
Milestones developmental employee. He
achievement of the
Theory stages of life, each works in DENR as
following tasks:
with essential tasks the chief mining
 Fulfill civic and
Source: to be achieved. supervisor for
social
Fundamentals Mastery of a task in environmental and
of Nursing, responsibilities
3rd Edition one developmental safety division. He
By:  Maintain an
Sue C. Delaune stage is essential for also votes, pays his
Patricia K. economic
Ladner mastery of tasks in taxes and abides
standard of
subsequent stages. the laws.
living
A successful
 Assist
achievement of a Through his work
adolescent
task leads to as an Engineer, he
children to
happiness and to was able to earn
become
success with later enough money to
responsible,
tasks. However, send his children to
happy adults
failure leads to school. In addition,
X Relate to one’s
unhappiness in the his salary is also
partner
individual and enough to sustain
 Adjust to
difficulty with later their daily needs.
physiological
tasks.
changes Mr. R is a hands on

 Adjusting to father. He guides

aging parents and supports his

children up to now.

According to him,

the way he raised

and disciplined his

children made them

good people.

The patient was not

able to achieve the

fourth task because

he is separated with

his wife for 12

years and they do

not communicate

with each other

anymore. However,

he does not restrict

his children to

communicate with

their mother.
Our patient accepts

the changes

accompanied by

aging, especially

with the changes in

health. He accepts

and complies with

his medications

religiously.

Mr. R’s father died

of stroke in the age

of 62 years old. His

mother is still alive

and is residing at

his sister’s house in

Bohol. According

to him, even

though his mother

is in Bohol he still

continues to check

on his mother’s

condition.

D EFINITION OF C OMPLETE D IAGNOSIS


Diagnosis: Calculous Cholelithiasis

Definition

1. Calculi, or gallstones, usually form in the gallbladder from the solid

constituents of bile; they vary greatly in size, shape, and composition.

(reference: Page 1347, Textbook of Medical-Surgical Nursing, Eleventh Edition, Brunner

and Suddarth's)

2. a stonelike mass that forms in the gallbladder

(reference: Saunders Comprehensive Dictionary, 3 ed. © 2007 Elsevier)

3. a calculus formed in the gallbladder or bile duct.

(reference: Dorland's Medical Dictionary for Health Consumers. © 2007 by Saunders, an

imprint of Elsevier, Inc.)

Calculous

- describing a substance that has the hardness of stone.

- pertaining to calculus

(reference: Page 201, Mosby's Pocket Dictionary of Medicine, Nursing and Allied

Health, Fourth Edition. )

Calculus
 an abnormal stone formed in the body tissues by an accumulation of mineral salts.

Calculi are usually found in biliary and urinary tract.

(reference: Page 201, Mosby's Pocket Dictionary of Medicine, Nursing and Allied

Health, Fourth Edition.)

Calculus

 A calculus (plural calculi) is a stone (a concretion of material, usually mineral

salts) that forms in an organ or duct of the body. Formation of calculi is known as

lithiasis. Stones cause a number of medical conditions.

(reference: http://en.wikipedia.org/wiki/Calculus_(medicine)

Cholelithiasis

 the presence of gallstones in the gallbladder.

(reference: Page 256, Mosby's Pocket Dictionary of Medicine, Nursing and Allied

Health, Fourth Edition. )

• the presence of gallstones in the gallbladder

(http://wordnetweb.princeton.edu/perl/webwn?s=cholelithiasis)
P HYSICAL A SSESSMENT

Patient’s Name: Mr. R

Age: 53 years old

Sex: Male

Ward: 3C - Surgical Ward (St. Joseph Ward)

GENERAL SURVEY

Our patient, Mr. R was assessed on February 21, 2009 @ 6:00 am. He was

received lying on bed awake, conscious and coherent. He has an ongoing IVF of D5NSS

1 liter regulated at 140cc/° infusing well at R metacarpal vein at 300cc level. He weighs

72 kilograms with a height of 5’6”. He has an endomorphic body structure. Calculation of

his BMI reveals that he is overweight (25.62kg/m2) He was responsive and cooperative

when asked. The patient was 1 day post-op.

VITAL SIGNS

6:00 am

BP – 120/80 mmHg

PR – 62 beats per minute

RR – 22 breathes per minute

Temp. – 36.9°C
SKIN

Our patient has a tan complexion. He has a good skin turgor as skin goes back to

its previous state after being pinched and with a capillary refill of 2 seconds. He has dry

skin with a rough texture. Nails were properly trimmed and no traces of dirt were noted.

HEAD

Our patient’s head is normocephalic. Presence of hair was noted in the head and

in the upper and lower extremities. Lesions, bleeding and bruises were not seen upon

inspection. His hair is evenly distributed and majority of hair color is grey with several

strands of black and white hair. No signs of dandruff and lice noted.

EYES

Eyes are symmetrical with each other. The cornea is moist and white in color. The

iris appears to be black on both eyes. Pupils are equally round and reactive to light and

accommodation with a pupillary size of 2 mm. He needs reading glasses when reads

small texts. His eyebrows are thick and eyelashes are evenly distributed along the margin

of the eyelids; both eyes move in unison; no signs of scratches on both eyes and no

discharges noted.
EARS

The shape of the pinnaes is oval and with no discharges noted. Upper margin of

the pinnaes is in line with the outer canthus of the eyes. Ears are firm and non-tender.

Signs of lesions, lacerations, swelling and bruises were not seen upon inspection. He was

able to repeat a sentence when it was softly said behind his ears, which reveals that he

does not have any hearing problems.

NOSE

External surface of the nose is smooth and oily. Nasolabial folds are symmetrical.

Nostrils are also symmetrical with no flaring and discharges noted. Nasal hairs are

present upon inspection. Nasal septum is not deviated. Both nostrils are patent. No signs

of tenderness were noted. Patient was able to distinguish the smell of rubbing alcohol

while eyes were closed.

MOUTH

Lips are dry with minimal cracks. Teeth are not complete with dentures noted

upon inspection. A total of 3 cavities were also seen upon inspection of the teeth. Gums

and buccal mucosa are pinkish in color. Tongue is in the midline of the mouth. Tonsils
are not inflamed. No signs of inflammation and laceration on the uvula. Bleeding,

ulceration and swelling were not seen upon inspection. Patient was on soft diet and was

able to drink coffee and medications with no dysphagia.

NECK

The neck of our patient can move easily without any difficulty, which includes

right and left lateral, right and left rotation, flexion and hyperextension. Neck can

properly support the head. No signs of enlargement and masses on the thyroid. Carotid

pulse is palpable. No signs of swelling or enlargement of the lymph nodes. No

deformities noted.

CHEST AND LUNGS

Chest muscle expansion during inspiration and relaxation during expiration are

symmetrical and painless. There were no presence of scars and lesions. He was not in

respiratory distress. Respiratory rate is 18 cycles per minute and rhythm was regular.

Breath sounds were clear on both lungs indicating that he is free of cough or colds.

ABDOMEN

Patient’s abdomen is globular in shape, soft, and flabby. Bowel sounds are

hyperactive with 17 sounds counted within one full minute. Four intact and dry
commercially prepared dressings were seen upon inspection. One dressing was seen on

the umbilical area, another dressing was seen just below the xiphoid process, and two

other patches were seen in the upper and lower regions of the iliac. A dull pain was felt

by the patient in the umbilical area and worsens upon palpation.

GENITO-URINARY

Patient refused to be assessed on his genital area. However, patient verbalized no

pain or difficulty upon urination and defecation. Average urine output of patient was 31

cc/hr. His total output for 8 hours was approximately 250cc.

UPPER EXTREMITIES

Patient’s upper limbs, shoulders and arms were symmetrical. No tenderness noted

on the bones of the wrist and fingers. No deformities and swelling noted. He could freely

move his shoulders. No structural deviations noted.

LOWER EXTREMITIES

Both legs of the patient are symmetrical and can stretch, flex, rotate, extend and

bend without any difficulty. No signs of deformities, lesions, lacerations, bruises and

bleeding were seen upon inspection. Patient does not have any difficulty ambulating.

A NATOMY AND P HYSIOLOGY


The liver is the largest internal organ in the body, and weighs

about 3 pounds in an adult. The liver is located in the right upper

quadrant of the abdomen, just below the diaphragm. A thick capsule of

connective tissue called Glisson's capsule covers the entire surface of

the liver. The liver is divided into a large right lobe and a smaller left

lobe. The falciform ligament divides the two lobes of the liver.

Each lobe is further divided into lobules that are approximately 2 mm

high and 1 mm in circumference.

These hepatic lobules are the functioning units of the liver. Each

of the approximately 1 million lobules consists of a hexagonal row of

hepatic cells called hepatocytes. The hepatocytes secrete bile into the

bile channels and also perform a variety of metabolic functions.

Between each row of hepatocytes are small cavities called sinusoids.

Each sinusoid is lined with Kupffer cells, phagocytic cells that remove

amino acids, nutrients, sugar, old red blood cells, bacteria and debris

from the blood that flows through the sinusoids. The main functions of
the sinusoids are to destroy old or defective red blood cells, to remove

bacteria and foreign particles from the blood, and to detoxify toxins

and other harmful substances. Approximately 1500 ml of blood enters

the liver each minute, making it one of the most vascular organs in the

body. Seventy-five percent of the blood flowing to the liver comes

through the portal vein; the remaining 25% is oxygenated blood that is

carried by the hepatic artery.

The liver is responsible for important functions, including:

 Bile production and excretion

 Excretion of bilirubin, cholesterol, hormones, and drugs

 Metabolism of fats, proteins, and carbohydrates

 Enzyme activation

 Storage of glycogen, vitamins, and minerals

 Synthesis of plasma proteins, such as albumin and globulin, and clotting factors

 Blood detoxification and purification


Gallbladder: muscular organ that serves as a reservoir for bile,

present in most vertebrates. In humans, it is a pear-shaped

membranous sac on the undersurface of the right lobe of the liver just

below the lower ribs. It is generally about 7.5 cm (about 3 in) long and

2.5 cm (1 in) in diameter at its thickest part; it has a capacity varying

from 1 to 1.5 fluid ounces. The body (corpus) and neck (collum) of the

gallbladder extend backward, upward, and to the left. The wide end

(fundus) points downward and forward, sometimes extending slightly

beyond the edge of the liver.

The gallbladder (or cholecyst, sometimes gall bladder) is a small

non-vital organ which aids in the digestive process and concentrates

bile produced in the liver. The cystic duct connects the gall bladder to
the common hepatic duct to form the common bile duct. This common

bile duct then joins the pancreatic duct, and enters through the

hepatopancreatic ampulla at the major duodenal papilla.

The different layers of the gallbladder are as follows:

• The gallbladder has a simple columnar epithelial lining

• Under the epithelium there is a layer of connective tissue (lamina

propria).

• Beneath the connective tissue is a wall of smooth muscle

(muscularis externa) that contracts in response to cholecystokinin, a

peptide hormone secreted by the duodenum.

• There is essentially no submucosa separating the connective

tissue from serosa and adventitia, but there is a thin lining of muscular

tissue to prevent infection.

Function
The function of the gallbladder is to store bile, secreted by the

liver and transmitted from that organ via the cystic and hepatic ducts,

until it is needed in the digestive process. The gallbladder, when

functioning normally, empties through the biliary ducts into the

duodenum to aid digestion by promoting peristalsis and absorption,

preventing putrefaction, and emulsifying fat. Digestion of fat occurs

mainly in the small intestine, by pancreatic enzymes called lipases.

The purpose of bile is to; help the Lipases to Work, by emulsifying fat

into smaller droplets to increase access for the enzymes, Enable intake

of fat, including fat-soluble vitamins: Vitamin A, D, E, and K, rid the

body of surpluses and metabolic wastes Cholesterol and Bilirubin.

The gallbladder stores about 50mL (1.7US fluid ounces / 1.8

Imperial fluid ounces) of bile, which is released when food containing

fat enters the digestive tract, stimulating the secretion of

cholecystokinin (CCK). The bile, produced in the liver, emulsifies fats

and neutralizes acids in partly digested food.

After being stored in the gallbladder the bile becomes more

concentrated than when it left the liver, increasing its potency and

intensifying its effect on fats. Most digestion occurs in the duodenum.

Cholesterol Metabolism

Cholesterol is an extremely important biological molecule that

has roles in membrane structure as well as being a precursor for the

synthesis of the steroid hormones and bile acids. Both dietary


cholesterol and that synthesized de novo are transported through the

circulation in lipoprotein particles. The same is true of cholesteryl

esters, the form in which cholesterol is stored in cells.

The synthesis and utilization of cholesterol must be tightly

regulated in order to prevent over-accumulation and abnormal

deposition within the body. Of particular importance clinically is the

abnormal deposition of cholesterol and cholesterol-rich lipoproteins in

the coronary arteries. Such deposition, eventually leading to

atherosclerosis, is the leading contributory factor in diseases of the

coronary arteries.
E TIOLOGY AND S YMPTOMATOLOGY

PREDISPOSING
PRESENT ABSENT JUSTIFICATION
FACTORS
AGE / Mr. R is 53 years old; At his
age, the ability of his body to
heal itself is diminished,
making him more prone to
developing diseases like gall
stones.
GENDER / Although the disease is not
exclusive to one gender only,
statistics show that women
are more prone to develop gall
stones.
HEREDITY / Gallstones are very common
and thus suspected to be
hereditary. However, Mr. R’s
past illnesses (DM and
Hypertension) are found to
have hereditary causes. These
illnesses predispose him to
developing gall stones.
RACE / Statistics show that
Caucasians are more prone to
develop gallstones because
their race is exposed to
resources that provides a high
fat diet for them.
PRECIPITATING
PRESENT ABSENT JUSTIFICATION
FACTORS
Mr. R verbalized that since his
HIGH CHOLESTEROL
/ grade school years, he is fond
DIET
of eating all kinds of lechon.
OVERWEIGHT / Mr. R’s BMI was 25.62kg/m2.
HYPERTENSION / Mr. R was diagnosed with
Hypertension in 1995.
DIABETES MELLITUS II / Mr. R was diagnosed with type
2 DM in the year 1997.
NEGLIGENCE AND / Mr. R verbalized that he only
LACK OF KNOWLEDGE took Kremil-S and rest to treat
his sharp, intermittent RUQ
pain – a primary symptom of
cholelithiasis.
TREATMENT WITH / Mr. R never had the need of
ESTROGEN estrogen therapy.
ILEAL RESECTION OR / Mr. R’s ileus does not have a
ILEAL DISEASE disease had never been in
need of surgical manipulation.
SYMPTOMATOLOGY

SYMPTOMS PRESENT ABSENT JUSTIFICATION

Mr. R had intermittent RUQ pain


Pain / for a span of approximately 14
years.

Mr. R’s gall stone can only be


Biliary Colic /
found within his gallbladder.

Mr. R had never experienced


Jaundice /
jaundice.

Mr. R’s laboratory results only


Vitamin Deficiency /
revealed hypokalemia.

Mr. R verbalized that he had


Changes in Urine and
/ never experienced changes in the
Stool Color
urine and stool color.
P ATHOPHYSIOLOGY

Predisposing Precipitating Factors


Factors
-Previous Illnesses: DM and Hypertension
-Age -Overweight
-Gender -Lifestyle: Diet
-Hereditary -Negligence and lack of knowledge
-Race -Estrogen therapy
-Ileal resection or ileal disease

DM II - ↓ glucose utilization

cell hunger

polyphagia
(with high cholesterol food preference)

↑ fatty substances into the hepato biliary system

liver excretes more cholesterol in to the bile

↓ gall bladder contractility and emptying; spasm of the sphincter of Oddi

↓ bile synthesis in the liver

gall bladder stasis


bile stasis inflammation of the gallbladder

formation of a NIDUS for stone


growth

tissue injury in gallbladder

alteration in composition of bile increased reabsorption of bile


salts and lecithin

bile becomes supersaturated with cholesterol

fusion of crystals to form stones

DIAGNOSTIC PROCEDURE
interruption of bile flow
ultrasound of the hbt

Diagnosis:
CALCULOUS CHOLELITHIASIS

Medical Management Nursing Management


Surgical Management
-Anti-inflammatory - low salt, low fat Diet
Laparoscopic
-Antibiotics - Promote Exercise
Cholecystectomy
-Analgesics - Deep breathing

If treated: If not treated:

- good compliance of - poor compliance of


medication medication
- adequate financial - poor financial support
support

POOR PROGNOSIS

GOOD PROGNOSIS DEATH


D OCTOR’S O RDERS

DATE DOCTOR'S ORDER RATIONALE REMARKS

Feb. 18, Pls. admit under my service The patient is in need of DONE
2009 medical attention so he is
admitted in Davao Medical
School Foundation Hospital
Wt – 73 for preparations for the Pre-
kg operation.
Temp -
36˚C
BP-
120/80
RR-21
PR-26
HGT-120
TPRq4˚ Vital signs are recorded to DONE
obtain patients baseline data
and are useful for further
management. A temperature
higher than normal may
indicate the development of
infection. Pulse & respiration
is taken to watch out for
tachycardia - a sign of
hemorrhage & dehydration.
NPO post midnight The patient is maintained on DONE
NPO in order to prevent
aspiration from vomiting
which is one of the side
effects of anesthesia.
Labs:CBC, Blood typing, These entire lab tests are DONE
platelet count, Urinalysis, performed to screen for
Creatine,FBS,B1 B2, Alk alteration and to serve as a
phosphate, Protime, APTT, baseline data for future
Chest X-ray PA view. ECG comparison.

Schedule patient for Laparoscopic DONE


laparoscopic cholecystectomy. cholecystectomy does not
require the abdominal
muscles to be cut, resulting
in less pain, quicker healing,
improved cosmetic results,
and fewer complications
such as infection and
adhesions. The surgery must
be scheduled so that all the
necessary things could be
prepared and arranged.
Pls. secure consent. For legal purposes: to ensure DONE
that the patient knows the
majority of the operation to
be done.
Inform OR & Dr. Camarao To schedule the operation DONE
Refer to OR and Dr. Camarao Referral is done to correct DONE
unusualities as soon as
possible and to inform the
attending physician of the
patient's condition.
Refer to Dr. Pasia for CP Referral is done to correct DONE
clearance unusualities as soon as
possible and to inform the
attending physician of the
patient's condition.
Start IVF D5LR 1L to run at For replacement of fluid DONE
120cc/o prior to transport electrolytes balance
maintenance.
Give cirprobay 200mg IVTT Prevents infections by DONE
NOW 30 mins prior to OR inhibting the growth or
(ANST) action of the microorganism.

Refer accordingly Referral is done to correct DONE


unusualities as soon as
possible and to inform the
attending physician of the
patient's condition.
Feb. 18, For Na, K, Creatinine, Mg These entire lab tests are DONE
2009 performed to screen for
alteration and to serve as a
2:20pm baseline data for future
comparison.
To aware the IM-ROD about DONE
Inform IM-ROD ( re: cp the result for further
clearance ) management.
HGT now To test the amount of glucose DONE
in the blood. An abnormal
may signify further
management.
Dr. Joy Enojo

5:00pm NPO Post midnight The patient is maintained on


NPO in order to prevent
aspiration from vomiting
which is one of the side
effects of anesthesia.
Start venoclysis once NPO: For replacement of fluid DONE
D5LR 1L @ 120cc/o-hold electrolytes balance
maintenance.
For HGT monitoring q6˚ ( 5-11 Blood glucose testing can be DONE
11-5) used to screen healthy,
asymptomatic individuals for
diabetes and pre-diabetes
because diabetes is a
common disease that begins
with few symptoms.
Screening for glucose may
occur during public health
fairs or as part of workplace
health programs. It may also
be ordered when a patient
has a routine physical exam.
Screening is especially
important for people at high
risk of developing diabetes,
such as those with a family
history of diabetes, those
who are overweight, and
those who are more than 40
to 45 years old.
Continue maintenance meds c/o All medications previously DONE
Rx’s stocks. ordered by attending
physician should be
continued to hasten patient's
recovery.
Pls. do Hgt q6˚ (5-11 5-11) Blood glucose testing can be DONE
& relay to Medical ROD used to screen healthy,
asymptomatic individuals for
diabetes and pre-diabetes
because diabetes is a
common disease that begins
with few symptoms.
Screening for glucose may
occur during public health
fairs or as part of workplace
health programs. It may also
be ordered when a patient
has a routine physical exam.
Screening is especially
important for people at high
risk of developing diabetes,
such as those with a family
history of diabetes, those
who are overweight, and
those who are more than 40
to 45 years old.
Feb. 18, Start venoclysis now: PNSS For replacement of fluid DONE
2009 1L+40meqs KCL to run @ electrolytes balance
@ 120cc/o. maintainance.
5:30pm

Hold surgery temporarily. The patient had low DONE


Feb. 18, potassium levels which poses
09 11:30 as a risk in the patient’s
pm cardiac functions under
anesthesia
DONE
Pls incorporate additional 20 IV potassium is irritating to
meqs to current IVF (950cc blood vessels and
PNSS + 40 meqs KCL) and set myocardium.
rate @ 100 cc/hr.
Kalium durule 2 tabs now then DONE
1 tab t.i.d. Replaces potassium and
maintains potassium level.
Repeat serum K+ 6pm To determine if potassium DONE
tomorrow. levels are normal already
February. Will inform Dr. Malubay Informing the physician of DONE
18, 09 @ the latest news about the
11:40pm patient will mean better care
given to the patient.

Carry out IM orders. Orders from internal


medicine will help prepare
the patient

DONE
Please inform OR. To schedule the operation
and for the surgical team to
make their initial assessment
procedures on the patient
Refer Referral is done to correct
unusualities as soon as DONE
possible and to inform the
attending physician of the
patient's condition.

February. Schedule surgery on Friday To inform the nurses that a


19,2009 8am. surgical operation is being
@ 12am planned; also, to signal
preparation for pre-operative
care.

Inform OR To schedule the operation. DONE

DONE
Informing the physicians of
Inform Dr. Laminose - aware the latest news about the
patient will mean better care
given to the patient.

May have low fat, diabetic diet To prevent the patient from DONE
eating foods that may
aggravate his illness which
may lead to complications
during the upcoming
operation
refer Referral is done to correct DONE
unusualities as soon as
possible and to inform the
attending physician of the
patient's condition.
To signal the cessation of the
@11pm D/C Hgt monitoring. monitoring of the patient’s DONE
blood glucose
Februar May go ahead of surgery if K+ Patients with low potassium
y.19,200 is > or = to 3.5 levels are prone to bradycardia DONE
9@ and will worsen when
6:30 am administered with anesthetics
during surgery. A normal level
of potassium is vital for
operations

DONE
@ 7am Please carry out IM Suggestions from internal
suggestions. medicine will help prepare the
patient for his upcoming
operation
@ 2am IVF TF: PNSS 1L and 60 Daily maintenance of body DONE
meqs Kcl @ 100 cc/hr. fluids when less Na+ and Cl-
are required.

Pre-op orders:

Februar NPO post midnight The patient is maintained on DONE


y. 19, NPO in order to prevent
2009 @ aspiration from vomiting which
7:35pm is one of the side effects of
anesthesia.
V/S on call to OR Vital signs are recorded to DONE
obtain patients baseline data and
be useful for further
management.

General / oral hygiene PTOR General and Oral Hygiene is DONE


performed frequently to
promote comfort and prevent
infections. [PTOR – Prior To
Operation]

IVF: D5NSS 1L @ 120 cc/hr. D5NSS restores sodium


chloride deficit and extra DONE
cellular fluid volume.
Meds:
1. Diazepam 10mg at 6 am Diazepam- to treat anxiety, DONE
with sips of water. nervous tension, muscle spasm,
2. Ranitidine 150mg and as an anticonvulsant.
3. Nalbuphine 5mg IVTT prior Ranitidine- to treat
to transport gastroesophageal reflux disease
and gastric hypersecretory
condition; to decrease
gastric acid secretion in
which preventing the
stomach from scarring of
the lining.
Nalbuphine- to treat moderate
to severe pain
Hgt prior to OR Blood glucose levels can vary DONE
within a short period of time.
HGT prior to OR determines the
blood glucose levels right
before the operation is made.
This will ensure that other
complications will be dealt with
according to the test results
Refer Referral is done to correct DONE
unusualities as soon as possible
and to inform the attending
physician of the patient's
condition.
May have soft diet 8 hours To indicate the specific diet DONE
post-op appropriate for the patient at a
specific time. Soft diet is
ordered because the GI tract
may still be under trace effects
from the anesthesia
Post-op orders

Februar To PACU; then to ward once For close monitoring of the DONE
y.20,200 stable patient. To watch out for any
9@ signs of unusualities.
9:35 am
VS q 15 mins. until stable; Vital signs is taken to provide DONE
then q hourly. baseline data and to watch for
any unusualities.
IVF rate; D5NSS to run in 160 To prevent hypoglycemia and DONE
cc/hr. dehydration.
IVF TF: D5NSS 1L @ 140 To follow-up IVF and maintain DONE
cc/hr. replacement of fluid and
electrolyte balance.
Meds: DONE
1. Ciprofloxacin 200g IVTT q Ciprofloxacin - to fight bacteria
8 x/ more doses then shift to in the body; to prevent or slow
ciprofloxacin 400g p.o. B.I.D. anthrax after exposure.
2. Ketorolac 30g IVTT q 8 Ketorolac - to reduce pain, fever
hours x 2 more doses. & inflammation.
3. Etoricoxib 120g p.o. B.I.D. Etoricoxib - to provide
to start at 6am tomorrow x 4 analgesic effect.
doses then decrease to OD Tramadol – to alleviate
thereafter. moderate to severe pain.
4. Tramadol retard 100 g to Ranitidine - promoting healing
start at 6pm tonight T.I.D. of stomach and duodenal ulcers,
5. Ranitidine 50g IVTT q 8 and in reducing ulcer pain.
hours x 3 doses.
O2 inhalation at 2 cpm Oxygen therapy is provided to DONE
prevent patient from hypoxia.
Keep patient warm and well Warmth makes the patient DONE
thermoregulated. comfortable and alleviate
anxiety that may be helpful for
his recovery.
Deep breathing exercise for 15 To expand the lung fully and DONE
minutes, 3x a day. prevent atelectasis.
Moderate high back rest. To promote breathing and chest DONE
expansion.
May turn to sides once able. To prevent pulmonary DONE
complications as well as other
complications.
Please do Hgt monitoring q 6 To monitor the blood sugar DONE
hours; may give 4 “u” HR SQ levels of the patient
for Hgt > 240.
Watch out for any To ensure that immediate DONE
unusualities; refer accordingly. nursing interventions can be
administered to avoid
complications; Referral is done
to correct unusualities as soon
as possible and to inform the
attending physician of the
patient's condition.
@ 11pm IVF TF: D5NSS 1L @ 140 For replacement of fluid DONE
cc/hr. electrolytes balance
maintenance.

D IAGNOSTIC E XAM

Urinalysis

Name: Mr. R Feb. 18, 2009

Age/gender: 53/M 325-4

PE CE

Color: yellow Glucose: (-)

Transparency: clear Albumin: (-)

Rxn: 6.0

Specific Gravity: 1.005

Microscopic Examination

Pus cells: 0.1/hpf Uric Acid -------

RBC: 1.3/hpf calcium Oxalate ------

Epithelial cells (+) Triple phosphate -------

Mucous threads (-) Amorphous Urates

Yeast cells ------- Phosphate -------

Hyaline Cast ------ Others ------

Fine granular cast -------

Coarse granular cast -------

Oscar P. Grageda MD, FPSP, APCP


Pathologist

Date: 2/18/09

X-Ray Report

The lung fields are clear

The heart is not enlarged

Great vessels are not unusual

Diaphragm and costophrenic sulci are intact.

No other remarkable findings.

Impression: Normal Chest findings

Ultrasound Report

The liver is normal in size with mild diffuse increase in tissue attenuation. No

focal solid or cystic lesions demonstrated. The intra-hepatic ducts are not dilated. The

widest antero-posterior diameter of the common duct is about 2.4mm.

The gall bladder is adequately distended with slightly thickened walls measuring

up to 5.0mm. There is a 1.7cm intra-luminal echo exhibiting posterior sonic shadowing

but no dependent mobility in the gall bladder fundus.

Impression:

 Mild Fatty liver

 Calculous Cholecystitis
Hematology

Result Unit Reference:


Hemoglobin 133 g/dl M: 140 - 170

F: 120 - 150
Erythrocytes 4.29 10^12/L 4.0 - 6.0
Leukocyte 6.9 10^9/L 5.0 - 10.0
Segmenters 0.53 % 0.45 - 0.65
Lymphocyte (P) 0.39 % 0.20 - 0.35
Monocyte (P) 0.06 % 0.02 - 0.06
Eosinophils 0.02 % 0.02 - 0.04
Hematocrit 0.41 -- F: 0.38 - 0.4

M: 0.40 - 0.60
thrombocyte 177 10^9/L 150.0 - 450.0

Blood typing “B” Rht


Coagulation Result Form

Result Reference Range:


Protime

Patient 13.8 sec 11.5 - 14.5 sec

INR 0.99 Normal: 1.0 - 1.2

PTPA 96.4 Therapeutic: 2.0 - 3.0

Control 13.9 sec


APTT

Patient 35.6 sec 24 - 36 sec

Control 30.2 sec


APTT MIXING 1°

INCUBATION

Patient -- sec

Control -- sec
CORRECTED APTT

Patient -- sec Index: less than 12-

Control -- sec corrected

Index: less than 16-not

corrected
Date: 2/18/09

Blood Chemistry

Test Name Result Normal Value Unit


Creatinine 99.6 H 53.0 - 97.6 Mmol/l
Bilirubin T 7.6 0.0 - 18.8 Mmol/l
Bilirubin O 1.2 0.0 - 4.3 Mmol/l
Alkaline Phosphate 142 64 - 306 U/l
Magnesium 0.94 0.80 - 1.00 Mmol/l
Others:

Calcium -- 1.13 - 1.32 Mmol/l


Chloride -- 95 - 108 Mmol/l
Potassium 2.73 3.5 - 5.3 Mmol/l
Sodium 140.1 135 - 148 Mmol/l
Magnesium -- 0.8 - 1.0 Mmol/l

Normal Value LDL: 0 - 4.73 mmol/l


Normal Value Globulin 28 -31 g/l
Normal Value A/G Ratio 1.5 - 2.4 ratio

Date: 2/19/09

Blood Chemistry

Test Name Result Normal Value Unit


Glucose 5.17 4.10 - 6.40 Mmol/l
Others:

Calcium -- 1.13 - 1.32 Mmol/l


Chloride -- 95 - 108 Mmol/l
Potassium 3.91 3.5 - 5.3 Mmol/l
Sodium -- 135 - 148 Mmol/l
Magnesium -- 0.8 - 1.0 Mmol/l

Normal Value LDL: 0 - 4.73 mmol/l


Normal Value Globulin 28 -31 g/l
Normal Value A/G Ratio 1.5 - 2.4 ratio
Clinical History

Present Complaint: RVQ pain

FyHy: (+) DM- maternal (+) HPN – maternal

Past Hy: (+) DM – 10yrs.

(+) HPN – unrecalled # of years.

(-) BA

(-)FDA

Maintenance Meds:

1. Lipitor

2. Plitor

Present Illness:

18 years PTA, Patient noted abdominal pain located @ RUQ area. No consultation done.

Took antacids which offered temporary relief.

6 years PTA, (+) recurrence of RUQ pain x 5 days UTZ done revealed gallstones. Took

Herbal meds. Patient did not consent for surgery. Patient tolerated the condition, until

PTA, (+) RUQ pain, sought consultation to admission.


PE

General Appearance: awake, afebrile, NIRD, not in jaundice

EENT: pinkish conjunctivae, anicteric sclera, PERLA

C/L: regular rate and rhythm, (-) murmur

Abdomen: soft, NABs, nontender, (-) murphy’s sign.

Extremities: No limitation of movement.

Neurologic exam: no neurologic deficit.

Impression: Calculus Cholecystitis Examiner: Dr. Enigo


D RUG S TUD
Generic Name: Ranitidine hydrochloride

Brand Name: Zantac


Side
Suggested Mode of Drug Effects/ Nursing
Classifications Indications Contraindications
Dose Action Interactions Adverse Responsibilities
Reactions
Antiulcer -50 mg q 8 Competitivel
- Duodenal and - Contraindicated in Drug-drug. CNS: 1. Assess patient for
hours y inhibits
gastric ulcer patients Antacids: May vertigo, abdominal pain. Note
IVTT x 3 action of
(short-term hypersensitive to interfere with malaise, presence of blood in
doses histamine on
treatment); drug and those with ranitidine headache emesis, stool, or
the h2 at
pathologic acute porphyria. absorption. gastric aspirate.
receptor sites EENT:
hypersecretory Stagger doses,
of parietal blurred 2. Instruct patient on
conditions, such as if possible.
cells, vision proper use of the drug
Zollinger-Ellison
decreasing Diazepam:
syndrome
gastric acid May decrease Hepatic: 3. Instruct patient to
secretion. - Maintenance absorption of jaundice take the drug without
therpy for diazepam. regard to meals
duodenal or Monitor because absorption
gastric ulcer. patient closely. isn’t affected by food.
Other:
-Gastroesophageal burning and 4. Urge patient to
reflux disease Glipizide: May
increase itching at avoid cigarette
Erosive injection smoking because this
Heartburn hypoglycaemi
c effect. site, may increase gastric
esopaghitis anaphylaxis acid secretion and
Adjust
glipizide , worsen disease
dosage, as angioedema
directed. 5. Inform patient to
take drug once daily
Procainamide: prescription at bedtime
May decrease for best results.
renal clearance
of
procainamide. Alert: Don’t confuse
Monitor ranitidine with
patient closely rimantadine: don’t
for toxicity. confuse Zantac with
Warfarin: May Xanac or Zyrtec.
interfere with
warfarin
clearance.
Monitor
patient closely.
Generic Name: KETOROLAC

Brand Name: Acular, Toradol


Suggested Side Effects/
Mode of Drug Nursing
Classifications Indications Contraindications Adverse
Dose Action Interactions Responsibilities
Reactions
- Non-steroidal 30 mg q 8 - Inhibits Short-term Hypersensitivity; DRUG-DRUG - CV: 1. Obtain patient’s vital
anti- hours prostaglandin management cross-sensitivity hypertension, signs to note for signs
inflammatory IVTT x 2 synthesis by of pain (not with other NSAIDs - concurrent flushing, of hypertension.
agents more doses decreasing to exceed 5 may exist; labor, use with syncope,
an enzyme days total delivery or aspirin may pallor, edema, 2. Assess for patient’s
- Non-opioid needed for for all routes lactation; pre- or decrease vasodilation hypersensitivity
biosynthesis combined) perioperative use; effectiveness reactions especially
Analgesics known alcohol - CNS: those who have asthma,
intolerance - additive dizziness, aspirin-induced allergy,
- Analgesic, adverse GI drowsiness, and nasal polyps.
anti- effects with tremors
inflammatory, aspirin, other 3. For patient’s
antipyretic NSAIDs, - EENT: experiencing pain, note
effects potassium tinnitus, the type, location and
supplements, blurred vision. intensity of pain prior
corticosteroids Hearing loss to 1-2 hr following
or alcohol administration.
- GI: nausea,
- chronic use anorexia, 4. Instruct patient to
with vomiting, make medication
acetaminophen diarrhea, exactly as directed. If
may increase constipation, dose is missed, it
the risk of flatulence, should be taken as soon
adverse renal cramps as remembered if not
reactions almost time for next
- GU: dose.
- may decrease Nephrotoxicity:
the dysuria, 5. Advice patient to call
effectiveness hematuria, for assistance when
of diuretics or oliguria, ambulating and to
hypertensive azotemia avoid driving or any
activities requiring
- may increase - HEMA: alertness until response
serum lithium blood to the medication is
levels and dyscrasias, known.
increase the prolonged
risk of bleeding
toxicity.
- INTEG:
- increased pupura, rash,
risk if pruritus,
bleeding with sweating
cefamandole,
cefoten
cefoperazone,
valproic acid,
Generic Name: Etoricoxib

Brand Name: Arcoxia


Side Effects/
Suggested Mode of Drug Nursing
Classifications Indications Contraindications Adverse
Dose Action Interactions Responsibilities
Reactions

Non Steroidal - 120 mg synthesis of - For the - Etoricoxib is Oral myalgia 1. Check renal
Anti- P.O. BID x prostanoid treatment of contraindicated to anticoagulants, and hepatic
weight changes,
inflammatory 4 doses mediators of rheumatoid patients with known diuretics and function
chest pain,
Drugs pain, arthritis, hypersensitivity to ACE inhibitors, periodically in
fatigue,
(NSAIDs) inflammation osteoarthritis Etoricoxib, Acetylsalicylic patients on long
paraesthesia,
and fever. , ankylosing acid, term therapy.
patients with active influenza-like
Selective spondylitis, Stop drug if
peptic ulceration or Cyclosporin and syndrome &
chronic low abnormalities
clinical dose gastro-intestinal (GI) Tacrolimus,
back pain, - Dry mouth, taste occur and notify
range. COX-2 bleeding, patients Lithium,
acute pain disturbance, prescriber.
has been Methotrexate,
and gout. who have developed mouth ulcers,
shown to be oral 2. because of
signs of asthma, flatulence,
primarily contraceptives, their antipyretic
acute rhinitis, nasal constipation,
responsible for and anti-
polyps, Prednisone/Pred appetite and
the inflammatory
angioneurotic nisolone,
actions, NSAIDs
active, highly Digoxin, drugs
oedema or urticaria may mask signs
selective metabolized by
following the and symptoms of
cyclooxygenas sulfotransferases
administration of infection
e-2 (COX-2)
acetylsalicylic acid (Ethinyl
inhibitor 3. Blurred or
or other Estradiol), drugs
within and diminished vision
metabolized by
above the and changes in
CYP
color vision may
- exhibits anti- isoenzymes,
occur
inflammatory, Ketoconazole,
analgesic and 4. serious G.I.
Rifampicin, and
antipyretic toxicity,
Antacids have
activities. It is including peptic
interaction with
a potent, orally ulcer and
Etoricoxib.
Generic Name: Ciprofloxacin

Brand Name: Ciloxan, Cipro, Cipro HC Otic, Cipro I.V., Cipro XR, Proquin XR
Classification Suggested Mode of Drug Side Effects/ Nursing
Indications Contraindications
s Dose Action Interactions Adverse Reactions Responsibilities

Fluroquinolone 400mg it's action complicated avoid taking GI – nausea CNS; seizures, • Arrange
P.O. depends intra- ciprofloxacin and confusion, depression, for culture and
Antibacterial
B.I.D. upon abdominal with antacids vomiting, dizziness, drowsiness, sensitivity tests
blocking infection which contain abdominal fatigue, hallucinations, before beginning
bacterial severe or aluminium, pain, headache, insomnia, therapy
DNA complicated magnesium or constipation light-headedness,
• continue
replication bone or joint calcium. paresthesia, restlessness,
CNS – therapy for 2
by binding infection, Sucralfate, tremor
headache, days after signs
itself to an which has a high
dizziness, CV; chest pain, and symptoms of
enzyme severe aluminium
fatigue,edema, thrombophlebitis infection are
called DNA respiratory content, also
lethargy gone
gyrase, tract infection, reduces the GI;
thereby bioavailability GU – renal pseudomembranous • be aware
inhibiting the severe skin of ciprofloxacin failure colitis, diarrhea, nausea, that Proquin XR
unwinding of structure to approximately abdominal pain or is not
Skin - rash
bacterial infection 4%. discomfort, constipation interchangeable
chromosomal severe or Ciprofloxacin and dyspepsia, with other forms
DNA during complicated should not be flatulence, oral
• ensure
and after the UTI, taken with dairy candidiasis, vomiting
that patients
replication. products or GU; crystalluria, swallow ER
infectious calcium-fortified interstitiial nephritis, tablets whole; do
diarrhea, juices alone, but not cut, crush, or
typhoid fever may be taken hematologic;
chew
pyelonephritis with a meal that leukopenia, neutropenia,
nosocomial contains these • ensure
pneumonia products. that patient is
musculoskeletal;
chronic well hydrated
Heavy exercise is aching, neck pain,
bacterial tendon rupture • give
discouraged, as
prostatitis antacids at least
achilles tendon Skin; rash,
acute 2 hrs after dosing
rupture has been pruritus
uncomplicated
reported in • monitor
cystitis
patients taking clinical response;
mild to ciprofloxacin. if no
moderate cute Achilles tendon improvement is
sinusitis rupture due to seen or a relapse
ciprofloxacin occurs, repeat
use is typically culture &
associated with sensitivity
renal failure.

encourage
patient to
complete full
course of therapy
Generic Name: Diazepam

Brand Name: Valium

Classificatio Suggested Mode of Contra Drug Side Effects/ Nursing


ns
Dose Actions Indications indications Interactions Adverse Responsibilities
Reactions

Anxiolytics 10 mg PO OD A
benzodiaze
pine that preoperativ contraindicate Drug-drug CNS; Warn patient to avoid
probably e sedation d in patients drowsiness, activities that require
hypersensitive Cimetidine may slurred alertness and good
potentiates before to drug or soy decrease speech, coordination until
the effect endoscopic protein; in clearance of tremor, effects of drug are
of GABA, procedures patients diazepam and headache, unknown.
depresses
experiencing increase risk of fatigue
the CNS, muscle
shock, coma, adverse effects Warn patient not
and spasm
or acute CV; abruptly stop the drug
suppresses CNS
alcohol bradycardia, because withdrawal
the spread acute depressants may
intoxication hypotension symptoms may occur
of seizure alcohol increase CNS
activity. withdrawal depression EENT; tell patient to avoid
use cautiously
in patients diplopia, alcohol while taking the
Digoxin may blurred drug
with liver or increase risk of vision,
renal toxicity nystagmus notify patient that
impairment. smoking may decrease
Diltiazem may GI;nausea, drug's effectiveness
CNS depression constipation,
and prolong Take this medication
effects of diarrhea exactly as it was
diazepam prescribed for you. Do
GU; not take the medication
Drug-Herb incontinence in larger amounts, or
, urine take it for longer than
Kava may retention recommended by your
increase
doctor. Follow the
sedation Hepatic;
directions on your
jaundice
Drug-lifestyle prescription label.
Respiratory;
Alcohol use diazepam interacts with
apnea
may cause the plastic; therefore,
additive CNS Skin; rash introducing diazepam
effect into a container reduces
drug availability.
Smoking may
decrease
effectiveness of
drug
Generic Name: Potassium chloride

Brand Name: Kalium Durules

Suggested Mode of Drug Side Effects/ Nursing


Classifications Indications Contraindications
Dose Action Interactions Adverse Reactions Responsibilities

potassium salt 1 tab t.i.d. replaces indicated to contraindicated in Drug-drug; CNS; paresthesia of Teach patient signs and
potassium prevent patients with limbs, ;listlesness, symptoms of
ACE
and hypokalemia, severe renal confusion, hyperkalemia, and tell
inhibitors,
maintains impairment with weakness or patient to notify
digoxin,
potassium oliguria. heaviness of limbs, prescriber if they occur
potassium-
levels flaccids paralysis.
sparing Tell patient that drug is
diuretics may CV; postinfusion commonly used orally
cause phlebitis, with potassium-wasting
hyperkalemia. arrhytmias, heart diuretics to maintain
block, cardiac potassium levels.
arrest, hypotension,
Monitor ECG and
ECG changes
electrolytes levels
GI; nausea, during therapy
vomiting,
Swallow the tablets whole
abdominal pain,
with a full (8-ounce)
diarrhea.
glass of water. Do not
metabolic; chew or suck on the
hyperkalemia tablet.
Respiratory; Do not take more of it, do
respiratory paralysis not take it more often,
and do not take it for a
longer time than your
doctor ordered.
Generic Name: Nalbuphine

Brand Name: Nubain

Classifications Suggested Mode of Indications Contra Drug Side Effects/ Nursing

Dose Actions indications Interactions Adverse Responsibilities


Reactions

analgesics 5mg IVTT Unknown. adjunct to Drug-drug. CNS; Tell patient drug act as
contraindicate
Binds with balanced CNS dizziness, an antagonist and
d in patients
opiate depressants headache, may cause
anesthesi hypersensitive
receptors and sedatives sedation, withdrawal
a to drug
in the may cause vertigo, syndrome
moderate to
CNS, respiratory confusion, Advise the patient to
severe
altering depression, restlessnes avoid any activities
pain
perception hypertension, s. that requires
of and profound CV; alertness because this
emotinal sedation or bradycardi drug can cause
response coma. a, dizziness
to pain. Opoid hypotensio Explain to the patient
analgesics n, that the drug can
may decrease tachycardi cause constipation.
analgesic a, Tell the patient to
effect hypertensi report to the
Drug-lifestyle. on prescriber
Alcohol use EENT; immediately if there
may cause blurred is severe itcheness.
additive vision, dry
effects mouth
GI;
constipatio
n, nausea,
vomiting,
dyspepsia,
cramps
GU; urinary
urgency
Respiratory;
asthma
Skin;
burning,
clammines
s,
diaphoresi
s, pruritus
Generic Name: Tramadol

Brand Name: ultram


Sugge Drug Side Effects/ Nursing
sted Mode of Indicati Contraind
Classifications Interaction Adverse Responsibilitie
Action ons ications
Dose s Reactions s

Analgesics 100mg The mode of drug-drug CNS; dizziness, • Document


indicated to Hypersensitivi
P.O. t.i.d. action of headache, indications for
treat ty to tramadol.
tramadol has yet somnolence, therapy, location,
moderate to In acute Carbamezep
to be fully vertigo, seizures, onset, and
moderately intoxication ine may
understood, but anxiety, characteristics of
severe pain with alcohol, increase
it is believed to asthenia, CNS symptoms. Use a
hypnotics, tramadol
work through stimulation, pain rating scale.
centrally metabolism
modulation of confusion,
acting • Assess for
the coordination
analgesics,opi history of drug
noradrenergic disturbance,
ates, or CNS addiction, allergy
and serotonergic
psychotropic depressants euphoria, to opiates or
systems in
drug. may cause malaise, codeine, or
addition to its nervousness,
additive seizures; drug
mild agonism of sleep disorders
effects may increase the
the μ-opioid
receptor. CV; risk of
Cyclobenza vasodilation convulsions.
prine may EENT; • Monitor
increase risk visual VS, I & O, liver
of seizures disturbances and renal
function studies;
GI;
reduce dose with
Quinidine constipation,
dysfunction and
may nausea,
if over 75 yrs.
increase the vomiting, Old.
level of abdominal pain,
tramadol anorexia, • Do not
diarrhea, dry perform activities
mouth, that require
dyspepsia, mental alertness;
flatulence drug may cause
drowsiness and
GU;
impair mental or
proteinuria,
physical
urinary
performance.
frequency, urine
Alcohol may
retention
intensify drug
effect.
Musculoskeletal;
• Report
hypertonia
lack of response.
Review list side
Respiratory; effects (nausea,
respiratory dizziness,
depression constipation,
N URSING T HEORIES
BETTY NEUMAN’S Systems Model

Betty Neuman’s systems model focuses on the wellness of the client system in

relation to the environmental stressors and reactions to stressors. These stressors include

intrapersonal (occur within person, e.g. emotions and feelings), interpersonal (occur

between individuals, e.g. role expectations), and extrapersonal stressors (occur outside

the individual, e.g. job or finance pressures). The nursing interventions involved in this

theory focuses on retaining or maintaining system stability on three preventive levels: [1]

Primary prevention (includes health promotion and maintenance of wellness.), [2]

Secondary prevention (focuses on preventing damage to the central core by strengthening

the internal lines of resistance and/or removing the stressor.), and [3] Tertiary prevention

(offers support to the client and attempts to add energy to the system or reduce energy

needed in order to facilitate reconstitution).

Application to patient:

Last 2006, the patient was diagnosed of Cholelithiasis and was given medications

like pain reliever () and antibiotic (). The pain and discomfort were relieved because of

the medications given. After three years, he experienced recurrence of pain and

discomfort. This made him decide to consult his physician and agreed to the suggested

surgery, which is Laparoscopic Cholecystectomy

Our patient belongs to the tertiary prevention since he had already undergone

Laparoscopic Cholecystectomy. As a health care provider, we rendered health teachings

that would prevent him from developing the same condition. Additional information was

also given to the patient that would help hasten the healing process. Examples of health

teachings rendered to him are encouraging him to have a strict compliance of his
therapeutic regimen, to have a regular exercise and emphasizing the importance of

having a healthy and balance diet. Also, teach the patient and the family about the

importance of psychological well being in recovery.


IMOGENE KING’s Goal Attainment Theory

Imogene King’s model is a model of three interacting systems: Personal,

Interpersonal, and Social. The major elements of the theory are seen in the interpersonal

systems in which two people, who are usually strangers, come together in a health care

organization to help and be helped to maintain a state of health that permits functioning

in roles. She states that client goals are met through the transaction between nurse and

client.

Application to the patient:

As health care providers, we need to learn how to interact and establish rapport

to our patients. We must encourage them to verbalize their concerns and feelings in

order for us to provide the proper interventions necessary to their condition.

During our course of care, we were able to establish a good nurse-patient

relationship with Mr. R. Because of this, we were able to obtain information regarding

his plans after his discharge. In line with this, involved Mr. R in creating a plan of care

and exploring means of achieving this upon his discharge. We must also give him enough

information especially on prevention of illnesses so that his role as an individual will not

be affected.
LYDIA HALL’S Care, Core, and Cure Model

Lydia Hall presented her theory of nursing visually by drawing three interlocking

circles, each circle presenting a particular aspect of nursing. The circle represents care,

core, and cure. The care circle represents the nurturing component of nursing and is

exclusive to nursing. The professional nurse provides bodily care for the patient and helps

the patient to complete such basic daily biological functions as eating, bathing,

elimination and dressing. When providing this care, the nurse’s goal is the comfort of the

patient. The core circle of patient care is based in the social sciences, involves the

therapeutic use of self, and is shared with other members of the health team. The

professional nurse, by use of the reflective technique helps the patient look at and explore

feelings regarding his or her current health status and related potential changes in

lifestyle. The cure circle of patient care is based in the pathological and therapeutic

sciences and is shared with other members of the health team. The professional nurse

helps the patient and family through the medical, surgical, and rehabilitative prescriptions

made by the physician. During this aspect of nursing care, the nurse is an active advocate

of the patient.

Application to the patient:

In the care circle, we were able to ensure client safety through raising side rails

of bed to prevent patient from falling, assisting patient whenever he ambulates, and

imparting health teachings that would help him to have a speedy recovery.

In the core circle, we were able to allow the patient to explore his feelings about

his condition through letting him express his concerns and worries regarding his
condition. Through this, the patient will be motivated to make appropriate decisions in

promoting good health.

In the cure circle, we were able to perform a medical procedure that would help

the physician to determine the proper treatment that should carried-out to the patient.
N URSING C ARE P LANS
DATE/TIME CUES NEEDS NURSING OBJECTIVES NURSING INTERVENTIONS EVALUATION
DIAGNOSIS OF CARE
Feb. 21, S: C Acute pain r/t Within our 1.Observe and document location, severity (1- GOAL MET
2009 ‘’medyo O surgical tissue span of care, 10 pain scale), and character of pain(steady,
@ 5am sakit2x ang gi G trauma our patient will intermittent, colicky.) Patient was able
operahan diri N secondary to be able to: R: assists in differentiating cause of pain and to:
sa akong I laparoscopic provides information about disease
tiyan’’ as T cholelithiasis. - Follow progression/resolution, development of - minimize
verbalized by I interventio complications, and effectiveness of manipulation of
the patient. V R: Unpleasant ns to interventions. affected area and
O: E sensory and relieved 2.Promote bedrest , allowing patient to assume utilize relaxation
- Presence - emotional pain. position of comfort. techniques to
of P experience - Verbalized R: bedrest in low Fowler’s position reduces minimize pain.
patches E arising from minimal intraabdominal pressures; however, patient will -
on the R actual or pain. naturally assume least painful position. patient
operative C potential - - utilize 3.Encourage use of relaxation techniques, e.g., verbalized pain
sites. E tissue damage; comfort deep breathing exercises. scale of 3
- Grimaced P sudden or measures R: promotes rest, redirects attention, may
face T slow onset of and enhance coping.
when U any intensity techniques 4.Make time to listen to complaints and
patch on A from mild to effectively maintain frequent contact with the patient.
umbilicu L severe with an to reduce R: helpful in alleviating anxiety and refocusing
s was anticipated or or alleviate attention, which can relieve pain.
palpated P predictable pain. 5.Administer medications as indicated.
- Pain A end and R: to maintain ‘’acceptable’’ level of pain.
scale of T duration of Notify physician if regimen is inadequate to
5- T less than 6 meet pain control goal.
moderate E months. 6.Observe and document location, severity (1-
R 10 pain scale), and character of pain(steady,
N Source: intermittent, colicky.)
Nurse’s R: assists in differentiating cause of pain and
Pocket Guide, provides information about disease
Marilynn E. progression/resolution, development of
Doenges, complications, and effectiveness of
Mary Frances, interventions.
Moorhouse, 7.Promote bedrest , allowing patient to assume
Alice C. Murr position of comfort.
R: bedrest in low Fowler’s position reduces
intraabdominal pressures; however, patient will
naturally assume least painful position.
8.Encourage use of relaxation techniques, e.g.,
deep breathing exercises.
R: promotes rest, redirects attention, may
enhance coping.
9.Make time to listen to complaints and
maintain frequent contact with the patient.
R: helpful in alleviating anxiety and refocusing
attention, which can relieve pain.
10.Administer medications as indicated.
R: to maintain ‘’acceptable’’ level of pain.
Notify physician if regimen is inadequate to
meet pain control goal.
DATE/TIME CUES NEEDS NURSING OBJECTIVES NURSING INTERVENTIONS EVALUATION
DIAGNOSIS OF CARE
Feb. 21, S: C Knowledge Within our 1. Assess client's level of understanding. GOAL MET
2009 deficit span of care,
–“Dili ko O R: Facilitates planning of postoperative The patient was
@ 5am [Medications] r/t patient will be
sure kung teaching program, identifies content needs. able to:
unfamiliarity able to:
unsaon G with information - perform
nako ang resources. 2. Identify motivating factors for the necessary
akoang N individual.
diet karon –participate in interventions
I the learning R: Motivating factors will help in the correctly
na wala na
ko’y gall R: Absenc e or deficiency
process teaching process
T - verbalize
bladder.” of cognitive information understandi
3. provide information relevant to the
I situation.
O: related to specific ng of
V topic. –identify condition/disease
Patient is interferences to R: for the patient to be informed regarding
learning and her present condition. process and
S/P E
specific actions treatment.
laparoscop 4. Provide positive reinforcement.
ic - to deal with - Identify
cholecyste them R: to encourage continuation of efforts. medications
P
ctomy use to treat his
E 5. Identify information that needs to be
condition.
–exhibit increased remembered.
R
R: The client will know what specific
learning of medicines
C information will help out in remembering
taken. what is learned
E
6. Determine client's method of accessing
P information and include in teaching plans.
T R: to know teaching method to be used and to
help facilitate learning.
U
7 Provide written information and guidelines
A for client to refer to as necessary.
L R: Written information will be more reliable
for the client whenever information will be
P forgotten
A 8. Begin with information that client already
T knows and move to what the client does not
know.
T
R: This will ensure that the client will not
E have a hard time learning new things

R 9. Provide information about additional


learning resources.
N
R: to assist client with further learnings and

promote learning at own pace.


DATE/TIME CUES NEEDS NURSING OBJECTIVES NURSING INTERVENTIONS EVALUATION
DIAGNOSIS OF CARE
Feb. 21, O: N Impaired skin Within our 1. Identify underlying condition/ Goal Met:
2009 Disruption U integrity r/t span of care, pathology trauma. (e.g. surgical incision)
Patient was able
@ 5am of skin T tissue damage the client willR: Identifies impairments and allows for
to:
layers R secondary to be able to identification of appropriate
(epidermis I laparoscopic interventions.
- participate in
and dermis) T cholecystectomy - display 2. Note changes in skin color, texture,
prevention
due to I procedure. timely healing and turgor.
measures and
laparoscopic O of skin R: changes in the integument to
treatment
procedure. N lesions/ determine skin integrity
program.
A R: Altered wounds/ 3. Determine depth of damage to
L epidermis and/ pressure sores integument system (epidermis, dermis,
- verbalize
or dermis. without and underlying tissues.)
- feelings of
complication. R: this will help client’s recovery. To
increased self-
Source: Nurse’s note underlying complications for further
M esteem and
Pocket Guide, - Maintain management.
E ability to manage
Marilynn E. optimal 4. Note odors emitted from the skin/ area
T situation.
Doenges, Mary nutrition/ of injury.
A Frances, physical well- R: this will determine occurrence of
B Moorhouse, being. gangrene
O Alice C. Murr 5. Note presence of compromised vision,
L hearing, or speech.
I R: Skin is a particularly important
C avenue of communication for these
people and, when compromised, may
P affect responses.
A 6. Keep the area clean/ dry, carefully
T dress wounds, support incision, prevent
T infection, and stimulate circulation to
E surrounding areas.
R
N R: to assist body’s natural process of
repair.

7. Use appropriate barrier dressings,


wound coverings, drainage appliances,
and skin-protective agents for open/
draining wounds.

R: to protect the wound and/ or


surrounding tissues.

8. Provide skin care every 8 hours and


prn. Change wet clothing and linens prn

R: Helps to promote circulation and


reduces potential for skin breakdown.

9. Provide optimum nutrition and


increased protein intake.

R: to provide a positive nitrogen balance


to aid in healing and to maintain general
good health.

10. Assist the patient in understanding


and following medical regimen and
developing program of preventive care
and daily maintenance

R: Enhances commitment to plan,


optimizing outcomes.
DATE/TIME CUES NEEDS NURSING OBJECTIVES NURSING INTERVENTIONS EVALUATION
DIAGNOSIS OF CARE

Feb. 21, Objective: N Altered nutrition Within our 8 1.Monitor vital signs eb. 21, 2009 @
2009 less than body hours span of 6:00am
>loss of appetite U requirements related care, the ®serves as a baseline data
@ 5am as evidenced by to impaired fat patient will be
untouched meals T digestion due to able to 2.Monitor IVF
and as verbalized obstruction of bile achieve relief Goal met:
by the patient R ® To maintain the fluid and electrolytes
flow. of nausea and balance in the patient’s body
and his I vomiting.
significant 3. Monitor Intake and output. The patient was
others. T able to
®To determine any unusualties for demonstrate
>the patient has I immediate medical management.
undergone achievement in
laparascopic O relief of nausea
4. Assess for abdominal distention, and vomiting.
cholecystectomy. frequent belching, guarding, and
N reluctance to move.
A ®Nonverbal signs of discomfort
L associated with impaired digestion, gas
pain.
-
5. Consult with patient about
M likes/dislikes, foods that cause distress,
and preferred meal schedule.
E
®Involving patient in planning enables
T patient to have a sense of control and
encourages patient to eat.
A
B 6. Provide a pleasant atmosphere at
mealtime; remove noxious stimuli

®useful in promoting appetite/reducing


O nausea.
L 7. Keep comments about appetite to a
minimum
I
®Focusing on problem creates a
C negative atmosphere and may interfere
with intake.

P 8. Provide oral hygiene before meals.

A ®A clean mouth enhances appetite.

T 9. Offer effervescent drinks with meals,


if tolerated.
T
®May lessen nausea and relieve gas.
E
10. Ambulate and increases activity as
R tolerated.

N ®Helpful in expulsion of flatus,


reduction of abdominal distention.
Contributes to overall recovery and
sense of well-being and decreases
possibility of secondary problems
related to immobility.
DATE/TIME CUES NEEDS NURSING OBJECTIVES NURSING INTERVENTIONS EVALUATION
DIAGNOSIS OF CARE
Feb. 21, O: H Risk for Within our 1. Monitor vital signs and patient for presence of GOAL MET
2009 infection r/t span of care, fever and chills.
@ 5am - surgical E abdominal patient will be
incision incision done able to: R: Fever, tachycardia, and tachypnea may indicate The patient was
noted on A secondary to presence of infection. able to:
abdomen laparoscopic
as possible L 2. Stress proper hand washing techniques between -demonstrate
procedure. technique
portal of - identify therapies/clients.
T interventions
entry for es, lifestyle
pathogenic to prevent/ R: A first-line defense against nosocomial infections/
H changes to
organisms. R: At reduce risk of cross-contamination.
increased infection. promote safe
risk for being 3. Cleanse incisions or change dressings as environ
P invaded by needed/indicated.
ment.
pathogenic R: Dressings help protect the area to reduce further
E organisms. - achieve -stay afebrile.
timely wound injury.
R healing. -and achieve
4. Administer/ monitor medication regimen and note timely
C Source: client’s response.
wound healing.
Nurse’s R: to determine effectiveness of therapy/ presence of
E
Pocket side effects.
P Guide,
Marilynn E. 5. Use sterile or strict aseptic technique for all
T Doenges, dressing changes.
Mary
I Frances, R: .Abdominal incision makes the patient susceptible
Moorhouse, to infection.
O Alice C.
6. Instruct patient/ family regarding signs and
N Murr symptoms to observe for, such as demarcated area
changes, redness, change or presence of drainage,
- and so forth
H R: May indicate presence of infection or that tissue
necrosis is extending.
E
7. Instruct patient/family regarding maintaining
A proper nutrition, with increased protein intake.
L R: adequate nutrition is required for maximum
T wound healing.

H 8. Instruct patient on all medications and procedures.

R: Promotes knowledge and helps to facilitate


compliance with medical regimen.
M

T
P ROGNOSIS
Poor Fair Good
Category Justification
(1) (2) (3)
1. Duration It's been 14 years since the

of Illness first sign of pain
As soon as the pain got really
2. Onset of worse, he immediately sought

Illness medical treatment, but he
could have done this earlier
3. 2 out of 3 predisposing factors
Predisposin  are present; his susceptibility
g Factors to the disease is unavoidable.
4.
His lifestyle could have been
Precipitatin
 adjusted and hid disease could
g
have been avoided altogether
Factors
5.
Willingness
Patient verbalized that this
to take the
 experience has taught him
medications
valuable lesson in keeping
or
healthy and preventing
compliance
illnesses by taking his
to
medication religiously
treatment
regimen
Patient verbalized that his
6.
home environment and work
environmen
 place only give him
t
manageable stress.
During our interview Mr. R's
nephew was present; his son
7. family was also expected to visit in

support the morning; Mr. R was also
observed to answer two phone
calls from two of his siblings.
3 + 2 + 9 = 14
14/7 = 2

Calculatio 3x1 1x2 3x3 =


Ranges:
ns =3 =2 9
1.0 – 1.5 = Poor
1.5 – 2.5 Fair
2.5 – 3.0 = Good

Mr. R has a FAIR prognosis.

His disease could have been totally avoided just by a change in lifestyle and diet.

Mr. R could have paid attention to his weight gain and the rising issues about obesity and

what diseases it could bring about. And most of all, Mr. R should have had his RUQ pain

checked by a doctor early on. If the gall stones were still during its early stages, they

could have been removed by Mr. R taking medications and an invasive procedure could

have been avoided. However, the usual prognosis of post laparoscopic cholecystectomy

patients is usually very good. Having smaller incisions brings about lower risks for

infections. Early ambulation is readily done which then will bring about early recovery.

Mr. R has also been educated on the changes in his lifestyle that he could do in order for

him to have a good life ahead of him even if he doesn’t have a gall bladder anymore.
D ISCHARGE P LAN
MEDICATION

• Explain each purpose of the medication

® Knowledge about what medications will make the client become aware of

what he is taking and for the family to participate more in the client’s treatment.

• Inculcate to the client to comply all the medications prescribed at the ordered

dosage, route and at the ordered time.

® Taking the drugs at the ordered dose, route and time limits the chance for

toxicity and ensure its effectiveness.

• Instruct client not to take over-the-counter drugs without doctor’s knowledge.

 Non-prescribed drugs may have an antagonistic effect or synergistic effect in

any drug therapy.

• Explain the side effects or adverse reactions of each medication. Instruct the client

and family to watch out for it and to report it immediately as soon as possible to

the physician.

® Explaining the side effects will let the client and family identify what harmful

effects to expect and for them to distinguish the adverse reaction to medication for

them to report it to their physician immediately.

• Advice client to take medications with food if not contraindicated or to take

medicine one hour before meals or one hour after meals.


® Some medications are irritating to the gastric mucosa.

• Let patient complete the whole course of the drug therapy.

This can help the patient alleviate the problem and be able to experience the full

therapeutic effect of the medication.


EXERCISE

• Instruct client to avoid strenuous activities for at least a week or a month until

fully recovered.

Activities that require great muscle strength should be avoided to prevent injury

and muscle strain.

• Encourage early ambulation.

Walking is good exercise and could promote circulation, hence, proper healing.

• Promote exercise to the client especially ROM.

® This will promote good physical health.

• Advise patient to have adequate rest and sleep.

To gain back the lost strength and be able to return to its normal state thus allow

ample time for healing.

• Practice deep breathing exercise.

This will help alleviate any pain or discomfort that patient will encounter

TREATMENT

• Explain the need of treatment after discharge and must take it seriously so as to

prevent such complications to the patient


 To make the client and family aware that the treatment does not only end at

hospital but needs to be continued at home to make the client responsible towards

medication.

• Explain to the family the condition of the patient and give them factual

information about the illness.

To have better understanding of the patient’s condition and to be able to know

what intervention they should give that could not alter the effect of the therapy.
HYGIENE

• Encourage having proper hygiene like taking a bath, meticulous hand washing,

and brushing of teeth every after meal.

 Hygiene promotes comfort and cleanliness to the patient. It also increases the

sense of wellness, which is very much needed in the therapeutic process.

• Encourage patient to continue hygienic measures practiced at present such as

changing clothes everyday and changing of underwear as often as necessary,

keeping the nails neatly trimmed, maintaining own supplies/items for personal

necessities.

Keeping all practiced measures is necessary in consistent maintenance of proper

hygiene. Owning personal accessories for hygiene purposes keep client away

from contamination and infectious diseases.

• Provide a calm, clean, and accepting environment.

 Calm, clean and non threatening environment may lessen the occurrence of

possible infection and would be a good place for healing.


OUTPATIENT ORDER

• Inform the patient that follow-up check-up is important to have continuous

monitoring and care even after attainment of the course medical therapy.

 Through constant visits as out patient, the physician would still monitor the

progress of the therapeutic intervention availed by the patient.

• Advice the client and the family to carry out follow-up diagnostic examinations

® This is to evaluate the therapeutic response of the patient to the treatment.

• Instruct the family to report any unusual signs and symptoms experienced by the

patient.

This will help detect early signs and symptoms of recurrence of the disease.

DIET

• Encourage client to eat a variety of nutritious foods like fruits and vegetables once

instructed by the physician.

To maintain and promote a healthy body.

• Instruct client to take vitamins as ordered.

To boost the body’s defense mechanism.


• Encourage patient to increase oral fluid intake.

This hydrates the body for normal functioning and maintain acid-base balance.

• Advise client not to skip meals and have a regular eating pattern/schedule.

Regular interval of meals is the basic principle of a good dietary plan.

• Tell patient not to eat foods contraindicated by the physician.

To prevent the occurrence of complications.

• Instruct patient to avoid drinking liquors and smoking

® To also avoid illness to be triggered.


R ECOMMENDATION