College of Nursing

A Grandcase Presentation On:


In partial fulfillment of Requirement for: RELATED LEARNING EXPERIENCE

Submitted by: Alvarez, Jennifer N. Aquino, Joanna Rose P. Aquino, Karla mae Banez, Ivy Z. Camemo, Jinky G. Cabero, Elaine Lourdes F. Mercader, Juan Miguel F. Neri, Martin Jaren Reyes, Farida Paula S. Reynoso, Sean Rupert Samson, Rona Angelika Togonon, Phillippe

Group 14

NURSING PROCESS ASSESSMENT A. General Data Patient’s Initials: RVH Address: Paranaque City Age: 33Y1M Sex: Female Date of Birth:November 19, 1976 Civil Status: Married Occupation: N/A B. Chief Complaints

Informant: RVH (client herself) Date of Admission: Jan. 5, 2010 No. of days in hospital: 4

The patient experienced abdominal pain in the right upper quadrant with the pain scale of 8/10, as 10 being the highest. She describes it as a stabbing, intermittent pain that occurs for almost 3 to 4 hours with an interval of 5 minutes. The pain radiates to the subscapular region and to the right shoulder. The onset of pain is often after a meal or in the evening. Associated symptoms are nausea and vomiting. C. History of Present Illness

December 22, 2009 patient RVH felt pain on the right upper quadrant of the abdomen with the pain scale of 8/10 as 10 being the highest. The pain was still tolerable that time so she didn’t take any medication. The same amount of pain re-occur last December 25-27, 2009 , she self medicate and took Buscopan 5mg for relief. December 28, 2009 the pain is progressively increasing and it already radiated on her shoulder and most often on her scapular area so she decided to have a check-up at Medical Center Paranaque. Ultrasound was done and it revealed Sludge filled gall bladder with lithiasis and diffused wall thickening, rule out acute cholecystitis. She was then scheduled for Laparoscopic Cholecystectomy on January 6, 2010 because the gallstone is already in the neck of the gallbladder. December 30, 2010 the stabbing pain worsens especially after eating. She was advised to take Etoricoxib 12 mg/tab every time the pain will occur. January 3-4 she already experienced nausea and vomiting. January 5, 2009 when she was admitted to her room, the pain became severe with pain scale of 8/10. D. Past History Childhood Illnesses Chickenpox (9 years old) Asthma (birth – 6 years old) Mumps (10 years old) Adult Illnesses None Immunization Complete Previous Immunization Cervical Cancer Vaccine (2009) Operations Cesarean birth on second child (2005) Cesarean birth on third child (2009) Injuries None Medications prior to confinement Vitamin C –OD 500 mg Clusivol -OD 500mg Allergies None

E. Systems Review 1. Health Perception-Health Management Pattern According to the client, her general health these past few months has been fair even though she has had coughs and colds. The client also mentioned, “Pag may sipon ako o ubo, calamansi juice lang muna iniinom ko pero pag grabe na yung sipon, pag hindi ko na kaya umiinom na ko ng gamot.” She takes over-the-counter drugs such as Robitussin or Solmux and takes it twice a day and her colds/coughs will usually be relieved after five to seven days. She performs monthly breast self examination and mentioned that there were no tenderness and masses felt. She is now regularly taking Vitamin C(500mg) and Clusivol MultiVitamins (500 mg ) for her supplements 1 tablet per day. During her confinement, the client’s perception about her health has changed. She also said, “Feeling ko hindi na ako ganun kahealthy gaya ng dati kase ang laki na ng tinaba ko pagkatapos ko ipanganak yun last baby ko” She also mentioned that she is always bothered because of the pain she feels due to the incision. The client looks tired and not well rested. During the interview, the client feels pain. “Masakit pa rin dito sa may opera sakin.” as verbalized by the client. When she was asked to rank her pain from 0 -10, as 10 being the highest. She rates it as 8. She said that her movement is limited because of the pain. 2. Nutrition Metabolic Pattern DAY 1 January 2, 2010 2 slices of loaf bread 2 boiled egg 1 cup of coffee 1 plate of Caesar salad 1 glass of water DAY 2 DAY 3 January 3, 2010 January 4, 2010 1 bowl of cereal 1 cup of coffee 1 glass of orange juice 1 bowl of oatmeal 1 plate of chicken macaroni salad 1 glass of water ½ cup of mushed potato 2-3 cubes of steamed beef 1 glass of water


The table above is the client’s daily food intake prior to confinement. As told by the client, she eats twice a day which consumes breakfast and dinner. She does not eat in between. She does not eat rice either. She also mentioned that she usually drinks six to eight glasses of 210 cc of water every day and about a glass of soda once a week. She also mentioned that she does not have any dental problems and does not wear dentures. After pregnancy the client noticed that she gained a lot of weight (from 120 lbs she became 160 lbs), but she didn’t bother to decrease her food intake because she is still breastfeeding. After 4 months she was alarmed when she realized that she is still overweight (140 lbs). She abruptly shifted her diet to salads, bread, steamed beef and white meats. “iniiwasan ko na yung matataba at maalat, dati kasi mahilig talaga ako sa mga pagkain tulad ng barbecue at porkchop madalas mga apat na beses sa isang linggo ” as verbalized by the client During the confinement, the client is on NPO. Upon waking up after the surgery, she felt hungry and thirsty but did not drink or eat anything due to physician’s order. 3. Elimination Pattern Prior to hospitalization, the client mentioned that she urinates four to five times daily which is usually yellow in color. She defecates once a day which is semi-solid formed and brown in color. “Hindi naman masakit pag umiihi ako.” As verbalized by the client. She does not take any laxatives either. She also mentioned that she does not perspire excessively except when she is exercising. The client feels ease and comfort during urinating and defecating During hospitalization the client usually urinates 11 times a day with a total of 1400 cc output which is dark yellow in color. On the first day of post operation, the client still does not

defecate. On the second day, her bowel movement has returned, she defecates semi solid in characteristic and brownish in color. 4. Activity – Exercise Pattern Before confinement, the client said that she exercises regularly which is done everyday. She said, “Every day nanonood ako ng instructional dvd tapos ginagaya ko din.” She also said that playing with her children is also part of her exercise regimen. She does not do any household chores because they already have a helper to do the cooking, cleaning, laundry and everything else. Whenever her children are at school, she takes her youngest child to the mall and strolls around. She also watches television most of the time. Her whole family goes to church and attends mass every Sunday and they will have their dinner afterwards. During confinement, the client’s movement is limited due to the pain at the incision site. “Nahihirapan ako gumalaw ngayon kase kumikirot yun tahi ko” as verbalized by the client. When asked to rate the pain that she feels, ten being the highest, “mga 8 out of 10 ganun” as verbalized by the client. 5. Cognitive – Perceptual Pattern Prior to hospitalization, the client had her last eye check up last year and make known by the ophthalmologist that her vision is 20/20. She does her eye check-up once a year. She does not have any hearing difficulties either. She also said that she is a fast learner. “Pag may ituro o basahin lang ako, naiintindihan ko naman agad. Yun nga yung exercise videos, kagaya nun madali ko naman masundan. She does not find it hard to make important decisions in her life because she and her husband talks about it; and most of the time, her husband is the one who decides. She also said that she has a good memory because she can easily remember things and recall past events. According to the client, her vision and hearing did not change during hospitalization. The only difference that she mentioned is that she is not able to concentrate on other things anymore. “Mas iniintindi ko kasi itong sakit na nararamdaman ko” as verbalized by the client. 6. Sleep Rest Pattern Before confinement, the client sleeps for about four to eight hours every day. She sleeps at around 10:00 pm – 2:00 am and wakes up at around 6:00 – 8:00 am. She does not take afternoon naps. She does not experience any nightmares but she does wake up at night to drink water or urinate. She also said that she does not have snoring problems. She always feels wellrested upon waking up. During confinement, the client said that she’s having difficulty in sleeping due to the pain at the incision site. “Nagigising gising ako kasi nga masakit yung tahi. Hindi ako makatulog ng maayos kaya madalas nangihihina ako.” the client verbalized. She also mentioned that she was disturbed by the monitoring procedures of the health care provider. 7. Self-Perception Pattern Before hospitalization, the client describes herself as a jolly, friendly and relaxed person. “Sobrang masaya ko at kami ng asawa ko kasi may bago kaming baby.” She also said that she is conscious about her physical appearance because she gained weight. “Feeling ko ang taba taba ko ang taba taba ko na” The client also mentioned that as much as possible, she does not want to get mad. “Naiinis lang ako kapag pinagchichismisan ako ng mga taong nakapaligid sa kin. Syempre sino bang hindi mainis di ba?” She also said that she does not lose hope because her husband is always there for her and she believes that God will never let her down. During hospitalization, the client said that even though she is worried about her situation, her children inspires her and makes her happy. “Pag naiisip ko mga anak ko, naiisip ko I am a good mother and confident ako sa pagpapalaki ko sa kanila kahit na malaking responsibility

super saya ko talaga”.But then she still worries about her physical appearance “Sobrang tumaba ako nung nagbuntis ako ayoko ng ganto”.

8. Roles - Relationships Pattern The client has a nuclear type of family which is composed of her husband, two daughters and a son. Her husband works as a businessman, and as the breadwinner of the family, he provides everything especially the financial aspect. She said that her husband’s salary is enough to provide for them. The client is a housewife and takes care of their children. “Minsan kapag hindi ako nagsshoshopping or nasa mood ako, pupunta ako sa business namin. Kapag hindi naman, after ko asikasuhin mga anak ko, nanonood lang ako tv sa bahay. Hintayin ko lang sila makauwi.” The client mentioned that she and her husband always talk especially when it comes to major decisions in life. “Lagi naming pinaguusapan lahat before kami magdesisyon syempre.” She also said that she and her husband have a good relationship with each other and with everybody else in the house. The client also mentioned that she has a lot of friends and they meet occasionally. During confinement “madalas nandito ang asawa at anak ko pagkatapos sa trabaho ng asawa ko dinadala nya mga anak naming sa ospital, makita ko lang sila para bang nagiginhawaan na ako” as verbalized by the informant. 9. Sexuality – Reproductive Pattern According to the client, she had her menarche when she was 12 years old. She also said that her period lasts for about four to five days. She consumes three to four sanitary pads a day which were fully soaked and bright to dark red in color. She does not experience dysmenorrhea or headache during her period. The client also said that she and her husband are both sexually active. She also mentioned that they do not use any family planning method. 10. Coping-Stress Tolerance Pattern Prior to hospitalization, the client said that a major change in her life this past year is giving birth to her new baby. “Having a new, healthy baby is really a blessing to me and to the family” as verbalized by the client. She also said that there is no crisis going on within her family. Whenever they have problems concerning with their children they fix it right away. “ hindi namin tinatapos ang araw na may problema kami” She also believes that her husband is the most helpful person in talking things over. “He’s not just my husband, but also my best friend. I really think na importante yung ganun.” The client also mentioned that she is relaxed most of the time. “Lagi din ako nagsisimba at nagpepray kaya alam ko na hindi rin ako mahihirapan sa buhay dahil kay God.” During hospitalization, that client said that she is not stressed out about her surgery because she believes that everything will be fine. “Hindi naman ako takot dito or natatakot sa opera, nabobother lang talaga ko sa sakit ng tahi yun lang.” She also said that she also follow her physician’s orders because she wants to get well immediately. The client said that her husband and her chidren helps her in getting well. “makita ko lang sila ayos na ko” as verbalized by the patient. 11. Values-Belief Pattern The client believes that she generally gets the things she wants in life. “Not just materially, pero like yung gusto ko pa ng another baby, yun binigay din Nya. Sa ngayon kasi bata pa naman mga anak ko, syempre gusto ko makapagtapos sila ng pagaaral at syempre magandang buhay. Gusto din naming magvacation as a family siguro magbeach sa summer.” The client is a Roman Catholic and her whole family attends mass every Sunday night. She believes that religion and her relationship in God is very important. “Hindi pwedeng hindi ako magdasal bago matulog sa gabi,” the client verbalized.

F. Family Assessment NAME RELATION AGE RH MH JMH HH G. Husband Daughter Son Daughter 42 11 4 10mos


OCCUPATION Businessman, PhD none none none

EDUCATIONAL ATTAINMENT College Graduate Grade 5 Preschool -

Heredo – Familial Illness • Maternal – Diabetes Mellitus, Hypertension • Paternal – Hypertension


Developmental History AGE 33 years old TASK GENERATIVITY V. STAGNATION PATIENT’S DESCRIPTION The client has established her own family and is financially stable to raise her kids. She also talks with her husband especially when major decisions have to be made. “Lagi naming pinaguusapan lahat before kami magdesisyon syempre.” The client has a husband and her own family. She can freely express her feelings as a woman and is happily married. She and her husband are both sexually active and do not use any family planning method. “Pareho kasi kami ng husband ko na mahilig sa bata kaya okay lang madaming babies.” The client does not have a hard time in making decisions. She has a good memory and can easily recall things. She is a fast- learner. “Pag may ituro sa kin or basahin naalala ko

THEORY Psychosocial Theory by Erik Erikson

Psychosexual Theory by Sigmund Freud

33 years old


Cognitive Theory by Jean Piaget

33 years old


Moral Theory by Lawrence Kohlberg

33 years old


Spiritual Theory by James Fowler

33 years old


kaagad, especially pag nagcoconcentrate ako.” The client is aware that people have different opinions and that respect should still be given to them. “Kahit na madami tao pinagchichismisan ako, nakakainis pero I try not to mind them.” The client is a Roman Catholic and has her own point of view when it comes to religion. She goes to church every Saturday night with her family. “Hindi ako makatulog kapag hindi nagdadasal.”

I. PHYSICAL EXAMINATION Date and time of history taking: January 7, 2010 (0900H) Height: 5’3” Actual Height:5’3”
Body Mass Index: BMI = Weight in kg. ___________________ (Height in meters) ² BMI = 64 kgs. ___________________ (1. 60 m) ² BMI = 24.8 kgs/m²= indication of within the normal range

Weight: 64kgs

Desirable Body Weight (Tannhauser’s Method of DBW Computation) DBW = DBW = DBW = Height in cm – 100cm; get 10% of remainder; subtract the answer from the remainder 160 cm – 100cm = 60 60x 10% = 60 64 – 6 58kg

Vital Signs BP: 130/90 mmHg RR: 25cpm PR: 87 bpm T: 37 oC

General appearance: - Endomorph - Client is clean in her overall hygiene - No breath or body odor - Cooperative and able to respond - Understandable and clear tone of speech - Client’s organization of thought makes sense - Able to maintain attention span - Restless appearance -Jackson Pratt Drain was attached to the RUQ incision site (5mm)

A. Skin I: -

Light to deep brown in color Dark pigmentation on areas of skin folds (neck, elbow, inguinal, armpit) Hair is evenly distributed on the patient’s skin Free from lesions No edema

P: - Good skin turgor - Smooth and moist skin Warm to touch Uniform temperature on all areas No palpable nodules or masses

B. Nails I: P: -

Well rounded, convex curvature Pinkish in color Short and clean nails Nail bed approximately 160 degrees Intact epidermis Smooth texture Good capillary refill (2 seconds)

C. Skull and Face I: - Normocephalic - Symmetric facial features and movements - Upright and still


Hair is black in color - Head has no masses and deformities - Absence of nodules and masses - No pain upon palpation

D. Eyes I: P: -

Eyebrow is evenly distributed and skin is intact Eyebrows are symmetrically aligned Eyelashes are equally distributed and curled slightly outward Eyelids are intact, no discharges, no discoloration, or excessive tearing Pupils: equal in size, round, black in color, and clearly visible Eyelids close symmetrically Sclera is white in color No tenderness felt in her eyes No edema in lacrimal and nasolacrimal duct

E. Ears I: - Color is same with the facial skin, symmetrical - Aligned with the outer canthus of eye - Ear canal is pinkish, clean, with scanty amount of cerumen - No discharges - No swelling on both ears P: - Pinna recoils after it is folded - No tenderness

F. Nose I: - Symmetric and straight - No discharge or flaring - Uniform in color - Nasal septum intact in midline - Pink mucosa P: - No areas of tenderness, inflammation and lumps upon palpation. - Non-tender and absence of masses on frontal and maxillary sinuses.

G. Mouth and Oropharynx I: - Light pink and smooth lips - Able to purse lips - No dentures - Symmetry of contour - Moist, pinkish mucosa - No bleeding, swelling and inflammation of gums - Uvula positioned midline of soft palate - Tongue midline without deviation, moves freely, no tenderness - Light pink in color, no swelling, symmetrical tonsils H. Neck I: - Head is centered - Able to move with no difficulty

- Able to slightly resist force - Proportion to body structure - Coordinated smooth movements - Thyroid gland not visible - No discomforts - No swelling P: - No vein engorgement and scars - Lymph nodes not palpable I. Spine I: - Spine lies straight without lateral deviation. P: - No presence of tenderness masses and lumps.

J. Thorax / Lungs I: - Symmetrical chest expansion - Quiet, rhythmic and effortless respirations - Respirations of 22 cycles per minute. -Spontaneous, non-labored breathing. Pa: - Skin is intact and uniform in temperature - No tenderness - No masses Per: - Not performed A: - Absence of adventitious sounds

K. Cardiovascular / Heart I: - No visible pulsations - Jugular veins not distended P: - No lifts or heaves - Carotid artery has symmetrical pulse volume - No pulsations on aortic and pulmonic areas L. Breast -The patient refused to have a physical examination in her breast but according to the patient “she doesn’t notice any mass or nodules when doing breast self examination. M. Abdomen I: - Contour was round and bilaterally symmetrical Position of umbilicus was midline and inverted - Incisions found on in the RUQ, one just right of the midline, slightly below the xiphoid and coastal margin, and the other midway to umbilicus, one laterally in the anterior axillary line above the iliac crest at the coastal margin, in midclavicular line slightly above the level of umbilicus and 2 cm below the rib. A: - bowel sound heard in 8 times per minute. Pe: - Not performed Pa: - Not performed N. Extremities: I: - Uniform in color - Equal size of muscle on both sides of the body - IV is attached on right metacarpal; intact with no signs of infection - Lower extremities are flaccid

P: -

Able to move upper extremities No tremors or contractures Absence of tenderness on the upper and lower extremities

N. Genitals - The patient refused to have a physical examination in her genital area on the day of interview, but according to the patient, she has no rashes or skin lesions in the area. The patient doesn’t have difficulty in urinating and no tenderness felt in the area.

G. Rectum and Anus - The patient refused to have a physical examination in her rectum and anus on the day of interview, but according to the patient, she has no rashes or skin lesions in the area. The patient doesn’t have difficulty in defecating and no tenderness felt in the area.

II. PERSONAL AND SOCIAL HISTORY Habits: Swimming, Billiard, Tennis Vices: None Lifestyle: Active Social affiliation: None Rank in the family: Mother Travel: None Educational attainment: College Graduate

Client’s usual day like: According to the client, she wakes up at around 6-8 in the morning. She eats her breakfast and prepares her children to go to school. When her husband is at work, and her children are at school, she exercises. She watches instructional dvds . Afterwards, she watches television or goes shopping if she feels like it. She stays at home most of the time. She goes to church with her family every Sunday evening. After dinner, she helps her children do their home works. She sleeps at around 10 in the evening to 2 in the morning after watching tv. III. ENVIRONMENTAL HISTORY The patient lives in an exclusive village. Their lot measures about 810 square meters and they have a 3-storey house with seven rooms, nine bathrooms, one pool, and one garden. They have 5 maids in their house who works for them. They also have one dirty kitchen and two dining area. The windows are adequate for ventilation because they feel the air every evening. They buy Distilled drinking water to a store near them. They use Nawasa for cooking, washing clothes bathing and other water activities. They have electricity and they are a subscriber of Meralco. In terms of storage of food, they have a refrigerator. If there are any left over every lunch, they just place the food on the table covered. For their garbage disposal, they have two big drums enough to occupy and cover their trash. Four times a week, the garbage is being collected. They don’t practice recycling but practices segregation of biodegradables and non biodegradables. IV. OB/GYNE HISTORY Menarche: 12 years old When: Grade 6 Amount and Characteristics: 2-3 pads of napkin per day Duration: 4-5 days Associated Symptoms: None

Deliveries: G: 3 OB Score: T: 3

P: 3 P: 0

A: 0

L: 3

V. PEDIATRIC HISTORY -Not applicable VII. LABORATORY RESULTS December 28, 2009 ULTRASOUND Examination/s: HDT/ Pancreas Ultrasound Findings: The liver is normal in size and echopattern. No focal lesions seen. The intrahepatic duct and common bile duct are not dilated, the latter measuring 3.96 mm. The gall bladder measures 3.3 cm in widest transverse diameter. An echogenic, shadowing focus measuring 1.4 cm is noted in the gallbladder neck. The rest of the lumen is then filled with medium to high level echoes. Wall is diffusely thickened. Pancreas is normal in size and echogenecity with no discrete lesion seen in it. IMPRESSION: Sludge filled gall bladder with lithiasis and diffuse wall Thickening, rule out cholecystitis Normal sonogram of the liver and pancreas LABORATORY URINALYSIS January 5, 2010 COLOR NORMAL VALUE Light straw to dark amber Clear 4.8 – 7.8 1.005 – 1.030 RESULT INTERPRETATION

Light Yellow Clear 6.8 1.009


(-) (-)

(-) (-)

- Urine is diluted. There is no indication of lack of body fluids, no excess body fluid or presence of blood, drugs and food. - Normal, - Within the normal range, no indication of acidity and alkalotic. - Within the normal range, no indication of dehydration and high fluid intake, diabetes insipidus or hyperglycemia - Absence of diabetes - Does not indicate presence of glomerulonephritis and hypertension. - Above the normal range, indication of urinary tract infection - Above the normal range, indication of cystitis, trauma to the kidney, renal disease, renal calculi, lupus nephritis, excess aspirin, anticoagulant, sulfonamides, menstrual contamination.


0.2 hpf 0-1 hpf

0-8 0–5


Occasional Occasional


Squamous Fasting Blood Glucose Urea Nitrogen

71 – 116 mg/dl 7.98 – 20 mg/dl

Few 111.27 11.93

Creatinine Total Cholesterol Triglycerides HDL

0.60 – 1.30 mg/dl 0.00 – 200.00 mg/dl 50 – 150 mg/dl 32.69 – 75 mg/dl 65.38 – 173.85 mg/dl 2.86 – 6.10 mg/dl 0.00 – 41.00 U/L 0.00 – 37.00 U/L 42.00 – 98.00 U/L 0.00 – 1.30 mg/dl 0.00 - 0.50 mg/dl 0.00 – 0.80 mg/dl 25 – 125 U/L

0.89 182.69 53.64 29.63

LDL Uric Acid ALT/SGPT AST/SGOT Alkaline Phosphate Total Bilirubin

178.92 3.98 13.00 16.90 92.00 0.46

Conjugated Bilirubin Unconjugated Bilirubin Amylase

0.14 0.32 83.50

-Within normal range, no indication of pre diabetes and diabetes - Within normal range, no indication of malnutrition, kidney problems, too much protein intake and increased protein breakdown in the body. - Within the normal range, the body has adequate metabolism of muscle mass - Within the normal range, there is no indication atherosclerosis and coronary artery disease. - Within the normal range, adequate energy to the heart and skeletal muscle. - below the normal range, the cholesterol is not properly removed in the body and transported to the liver. - above the normal range, the cholesterol is not properly transported to various cells. -Within the normal range, there is no indication of gout or kidney disease - Within the normal range, there is no indication of liver disease. - Within the normal range, there is no indication of acute MI and liver damage. - Within the normal range, there is no indication of liver and bone damage - Within the normal range, there is no indication of liver damage and or abnormal breakdown of red blood cells. - Within normal range, there is no indication of liver disease. - Within the normal range, there is no indication of liver disease. -Within the normal range, there is no indication of pancreatitis

COMPLETE BLOOD COUNT January 5, 2010 Hemoglobin

120 – 150 gm/L


- Within the normal range, adequate oxygen-carrying protein and deliver it to the body tissue

Hematocrit RBC Count WBC Count Platelet Count RBC INDICES MCV MCH MCHC RDW DIFFERENTIAL COUNT Lymphocytes

0.37 - 0.47 4 – 5.4 4.5 – 11 200.00 – 400.00

0.38 4.45 12.9 Adequate

- Within the normal range, adequate proportion of total blood volume made up of red blood cell. -Within the normal range, adequate oxygen transport in blood to all cells in the body. - Above the normal range, may indicate presence of infection, leukemia, or tissue necrosis -Within the normal range, has a good clotting process.

83 – 101 fL 27 -31 pg 315 – 345 g/L 39 – 46 fL

85.6 28.1 328 43.1

- Within the normal range, the size of the RBC is normocytic. - Within the normal range, average weight of the hemoglobin in RBC. - Within the normal range, average hemoglobin concentration per unit volume of RBC,s - Within the normal range, average width differences of RBC’s.

0.20 – 0.35


- Within the normal range, there is no indication of chronic and viral infections.

PROTHROMBIN TIME Patient ACTIVE PARTIAL PROTHROMBIN TIME Patient 12.00 – 15.00 secs 13.0 - Within the normal range, adequate oral anti coagulant

20-30 secs.


Within the normal range, adequate clotting factor and platelet.

January 6, 2010 CHEST PA FINDINGS: Hazed densities observed in both lung zones (due to breast shadow vs. pneumonic process) The cardiac shadow is not enlarged. Other chest structures are unremarkable


Drugs Date Ordered: 1/7/10 Generic Name: Etoricoxib Brand Name: Arcoxia Classification: Analgesics / anti inflammatory Dosage: 120 mg/tab OD prn *POST OP

Indication - Relief of acute pain.

Action - NSAIDs work by blocking the action of a substance in the body called cyclooxygenase. Cyclo-oxygenase is involved in producing prostaglandins, in response to injury or certain diseases. These prostaglandins cause pain, swelling and inflammation. Because NSAIDs block the production of these prostaglandins, they are effective at relieving pain and inflammation.

Side effect/ adverse reaction Immune system disorders, nervous system disorders, cardiac disorders, respiratory, thoracic and mediastinal disorders, GI disorders, hepatobiliary disorders, skin and subcutaneous tissue disorders, renal and urinary disorders.

Nursing Considerations - Assess for pain of osteoarthritis, rheumatoid arthritis; gouty arthritis; check ROM, inflammation, characteristics of pain. - Monitor blood counts before and during therapy; uric acid. - Assess for hypersensitivity to medication. - Monitor kidney and liver function tests

Patient Teaching - Teach patient that the drug must be continued for prescribed time to be effective. - Inform patient to avoid NSAIDs, sulfonamides. - Advise patient to rehydrate prior to therapy; take with a full glass of water to enhance absorption. - Caution patient to report bleeding, bruising, fatigue, malaise; report GI symptoms: black tarry stools, cramping. - Teach patient to check with physician to determine when the drug should be discontinued before surgery. - Advise patient to notify physician of pregnancy is planned pr suspected - Advise patient to inform physician if using drugs such as aspirin, fluconazole, furosemide, lithium, warfarin, ACE inhibitors, anticoagulants, antineoplastics, glucocorticoids, and thiazide diuretics.

Drugs Date Ordered: 1/5/10 Generic Name: Nalbuphine Brand Name: Nubain Classification:

Indication - Relief of moderate to severe pain; for pre – operatively analgesia, supplement to balanced anesthesia, surgical anesthesia, obstetrical anesthesia.

Action *Binds with opiate receptors in CNS: ascending pain pathways in limbic system, thalamus, midbrain, hypothalamus, altering perception of and emotional response to pain. Relieves pain.

Side effect/ adverse reaction Sedation, drowsiness, sweating, nausea, dry mouth and dizziness, headache, vomiting.

Nursing Considerations - Assess patient’s underlying condition before therapy obtains drug history. Assess pain characteristics before administration and after treatment. - Monitor vital signs after

Patient Teaching - Discuss in detail all aspects of the drug therapy: reason for taking drug and expected result. - Discuss with patient that dizziness, drowsiness, confusion are common. Instruct patient to change position slowly to prevent orthostatic hypotension and avoid getting up




Side effect/ adverse reaction Palpitations, bradycardia, tachycardia, orthostatic hypotension, headache, nervousness, drowsiness, weakness, dizziness, confusions, insomnia, fever, excitability, restlessness, tremor, allergic reactions, urticaria, rash, flushing, nasal congestion, altered taste, xerostomia, nausea, vomiting, dyspagia, constipation, heartburn, bloated feeling; paralytic ileus, urinary hesitancy and retention, impotence, bronchospasm, suppression of lactation, decreased sweating.

Nursing Considerations - Obtain patient’s history of underlying condition and reassess regularly. - Monitor cardiac rate, rhythm, and character. Watch for tachycardia, it may cause ventricular fibrillation. - Monitor ECG for ectopic ventricular beats, PVC, tachycardia, in cardiac patients. - Monitor respiratory status: rate, rhythm, cyanosis, wheezing, dyspnea, engorged neck veins. - Monitor allergic / hypersensitivity reaction: rash, urticaria. - Monitor inputoutput ratio; check for urinary retention and daily output in elderly or postoperative patients. - Monitor for bowel sounds - Monitor for increased intraocular pressure.

Patient Teaching

Date Ordered: 1/5/10 Generic Name: Atropine Brand Name: Classificatio n: Antidotes Dosage: .5 R arm Im *INTRA-OP

Administration prior to anesthesia to reduce or prevent secretions of respiratory tract.

Inhibits acetylcholine at parasympathetic neuro effector junction, blocking vagal effect on the heart (SA node), exocrine glands, smooth muscles, and urinary bladder. Drug increases heart rate, dries secretions, decreases sweating and salivation in low doses. Mydriasis (dilatation of the pupil) and cycloplegia (failure to accommodate for close vision) occur at moderate doses. Motility of GI and GU systems are affected at high doses.

- Advise patient not to perform strenuous activity in high temperatures due to danger of heat stroke. - Instruct patient to take as prescribed and not to skip doses. - Instruct patient to report blurring of vision, loss of sight; troubled breathing, sweating, flushing, chest pain, allergic reactions, constipation, and urinary retention. - Advise patient not to drive, operate machines, or perform other hazardous activities, atropine may cause dizziness, drowsiness, or blurred vision. Alcohol may also cause dizziness and drowsiness. - Advise patient not to take OTC drugs products without approval of physician.

XI. Ongoing Appraisal On January 5, 2010 a 33 year old female was admitted to the ward at exactly 3:30 AM with chief complaint of abdominal pain at the right upper quadarant under the service of her attending physician.. She was conscious and coherent and has prolonged and non labored breathing. Initial vital signs were taken. The attending physician was informed of the admission. At exactly 3:40 AM IVF of D5NM IL @ 3ogtt/min was started to run for 8 hours. ECG and chest X-ray was done. Laboratory tests such as FBS, BUN, UREA, LIPID PROFILE, SGOT, SGPT, URIC ACID, CBC, UA, PTT, ALKALINE PHOSPHATE, and TOTAL BILE were requested by the attending physician.

At exactly 3:50 am initial dose of HNBB 1 amp IV given. The consent of the patient was obtained and wheeled to the room of choice. At exactly 4:25 AM Nubain 1 amp IV given. January 6, 2010 of 4 am IVF #2 D5NMIL at 30 gtt/min was infused. Vital signs were continuously monitored. The consent was signed for the procedure laparoscopic cholecystectomy. At exactly 3:30 pm above IVF was consumed and replaced. At exactly 8:10 pm the NOD was inquired by her anesthesiologist to continue the pre op meds. The patient was advised to be on NPO post midnight. At exactly 9 pm Prevacid 30 mg mg 1 tab was given. At exactly 1 am the patient complained of stomach pain with pain scale of 9/10. She was then seen and examined by Dr. Reyes, He administered Nubain 1 amp IV. The patient verbalized relief of pain On her second day, January 6, 2010 at 0630H, the client’s IVF was changed to fast drip 300cc of the present IVF of D5NM for 6 hours. Then, the client was brought to the operating room for the scheduled laparoscopic cholecystectomy. Procedural report: • The patient is asked to void prior entering the OR • The pulse oximeter was attached with intial BP of 180/50 pr of 62 O2 fo 100% • The general anesthesia intubation was inducted by Dr. Dizon • Viewing monitors are then placed at the side of the OR bed. • The patient is in a supine position in a slight to moderate reverse tredelenburg position • The skin preparation and drape was done. • An incision was done through an insertion of needle followed by placement of the operating trocar into the abdomen • A trocar is placed at the umbilicus and a laparoscope is introduced • Three additional trocars are placed in the upper abdomen under direction vision for insertion of operating instruments. • Insufflation of carbon dioxide was done With this technique: • The hepatocystic triangle is dissected, exposing the cystic duct, cystic artery, infundibulum of the gallbladder, junction of the gallbladder and the cystic duct • After careful dissection, the surgeon ligates and divided the cystic duct and artery with suture loops and clips • The inflamed gallbladder is then removed through the use of sterile elastic plastic container and withdrawn through the periumbilical incision • Dessuflation of the carbon dioxide • The incision was then sutured • The site was cleansed with hydrogen peroxide. • Dressing at the incision sites was done by the surgeon After the operation, the client was monitored every 15 mins for 2 hours at the recovery room until her vital signs were stable. The client remained at NPO and was advised to stay flat on bed because of the anesthesia given to her. The client was advised also to do deep breathing exercise and ambulate to for faster healing. The client was allowed to wet her lips with ice chips but still at NPO. The physician ordered to maintain NPO, continue her activities and was encouraged to do deep breathing exercises. Still, the client was advised to continue her deep breathing exercises and to ambulate more often to promote healing at the incision site. Tepid sponge bath was done to keep the client comfortable. At exactly 2 pm the above IVF was consumed and replaced with the # 1 PNSS IL x 30 gtt/min. the client was advised to have an NPO. At exactly 3 pm Etoricoxib (arcoxia) 60 mg 1 tab was started. The patient was advised to turn to side to side. At exactly 8 pm Sullamicillin (Unasyn) 375 mg 1 tab was started. At exactly 10 pm the above IVF was consumed and replaced with D5NSS 1L x 8 hours and regulated at 30 gtt/min. The JP was drained with 15 cc of brownish discharge of bile and kept in negative pressure. The patient still complains of the pain at the post operative site. On January 7, 2010. The IVF was regulated to KVO @ 700 cc level. The patient was senn and examined by the physician andshe was then advised to ambulate. At exactly 1 pm change of dressing was done by the physician . Negative flatus and BM was also noted.

On January 8, 2010 she was seen by her attending physician and ordered MGH. The ordered meds was still continuously given. The return of bowel movement and positive flatus was also noted. At exactly 4pm the patient was discharged. XII. DISCHARGE PLAN Prior to discharge the nurse should assess the patient’s physical and psychological conditions. The patient should be assessed for: Normal vital signs. The knowledge of the patient to perform interventions when needed. Encourage client to take her medications. Follow the given schedule and dose of taking the drugs. Explain to her how the drugs should be taken. Encourage patient to exercise regularly. Inform her of what exercise she can perform. Encourage patient to follow the treatment plan given to her. Educate the patient on what to do when there is no nurse/caregiver around. Set a date on when the patient would come back for a checkup as ordered. Inform the patient on what diet to follow.

MEDICATION Medications should be taken regularly as prescribed, on exact dosage, time and frequency, making sure that the purpose of the medications is fully disclosed by the health care provider and to ensure that medications are taken safely. Client or relatives must need to know the possible side effects and adverse reactions. Drugs should be continuously taken at the desired dose and duration -Unasyn 375 mg 1 tab BID x 7 days -Arcoxia 120mg 1 tab OD for pain EXERCISE Ambulation and activity must gradually increase after the procedure to prevent problems such as bowel and urine incontinence. Cholecystectomy actually requires time to recover. Laparoscopic cholecystectomy usually requires only one night in the hospital. A major advantage of the procedure is that it patients can return to work in 1 to 2 weeks. But compared to open cholecystectomy, it is advised to have 4 to 6 weeks duration time for recovery. Once home, it is possible to tire more easily than usual to begin with, so it is important to take it easy. Strenuous exercise and lifting should be avoided. Light exercise such as walking is recommended. Normal activities, including returning to work, can usually be resumed after about a week. TREATMENT Gallbladder disease usually is treated by removing the gallbladder. Now that the patient had her gallbladder removed, the rest is up to her. It is important to rest and let the body recover after surgery. Consequently, to prevent other complications, she must have her lifestyle and diet modified. HEALTH EDUCATION 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 it's important to discuss any pain with the doctors or nurses. On discharge, the nurse must advise about caring for the stitches, hygiene and bathing, and will arrange an outpatient appointment for the stitches to be removed, if necessary. Some people will have dissolvable stitches, which do not need to be removed. Instruct patient to comply with the home medications that would be given by her physician. Remind her to complete the full course of the antibiotic treatment.

Encourage patient to do the recommended light exercises such as walking. Avoid doing strenuous activities which could slow down his recovery. Encourage her to comply with the dietary modifications; limit the intake of saturated fat and avoid the consumption of alcoholic beverages to prevent the occurrence of serious postcholecystectomy side-effects. Explain to patient to refer for unusualities immediately. OPD Follow up check up after one week Remind patients that regular check-ups are important to ensure that the patient condition is constantly monitored by the doctor. DIET In time, patients who have suffered cholecystectomy are exposed to a high risk of developing heart disease, diabetes and disorders of the nervous system. This is due to inappropriate synthesis and assimilation of vital nutrients, vitamins and minerals. In order to prevent the occurrence of serious post-cholecystectomy side-effects, operated patients need to make drastic lifestyle and dietary changes. They should limit the intake of saturated fat and avoid the consumption of alcoholic beverages. Also, they should eat smaller amounts of food during a single meal. People who have had gall bladder removal surgery are advised to eat around 5 or 6 smaller meals a day instead of 2 or 3 usual meals. Considering the fact that the organism is unable to completely absorb important nutrients without the help of the gall bladder, operated patients also need to take vitamin and mineral supplements and bile salts to aid the process of digestion. SIGNS AND SYMPTOMS: If any of the following symptoms are noted, he should contact her doctor: any of the wounds start to bleed Any of the wounds become more • painful, red, inflamed or swollen • the abdomen swells • pain is not relieved by the prescribed painkillers • A fever develops. These could be signs of an infection that may need to be treated with antibiotics