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College of Nursing

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RELATED LEARNING EXPERIENCE (105)

CASE STUDY ABOUT ACUTE CHOLECYSTITIS

Presented to:
Mr. Clark Joy Barias R.N. MAN
R.L.E Coordinator

Presented by:

DOLLY JOY SALOMES

BSN IV A

March 5, 2010
I Patient profile
Biographical Data
Name: Mr. X

Age: 46 years old

Sex: Male

Nationality: Filipino

Date of Birth: August 28, 1962

Place of Birth: General Santos City

Civil Status: Married

Address: Lucban Quezon

Religion: Christianity (Roman Catholic)

Educational attainment: High School Graduate

Occupation: Driver

Admitting Date and Time: January 8 at 10:40 am

Case Number: 083981

Attending Physician: Dr. Emmanuel Yap

II History
A, Nursing history
I chief complain: Right upper quadrant pain
II admitting diagnoses: Cholecystitis T/C Cholelithiasis
III physical Examination

Hair, head and face:

Skull size was normocephalic. Skull and face were symmetrical with an
equal distribution of hair. Hair was black in color with fair amount of white and
gray strands, short, dry, and fine. There was no dandruff or infestation present. No
lesions, lacerations, tenderness, masses and depressions noted. The forehead was
furrowed with wrinkles. Face portrayed emotions with symmetrical movements. No
masses or involuntary movement. The face was round, with no edema, lesions,
discolorations present

Eyes:
Pupils are equal and round reactive to light and accommodation (PERRLA)

Nose:
 The nose was symmetrical with no deformities, skin lesions, massses present.
Nasal septum is intact and in midline. No nasal flaring was observed. No discharges
were present. No tenderness in his sinuses upon palpation.

Ears:
Ears were symmetrical with same size bilaterally and color consistent with
face. Pinnas were free from lesions, masses, swelling, redness, tenderness, and
discharges and were in line with the eyes. External canals were clear with no
cerumen seen. No inflammation, masses, discharges and foreign bodies noted. Gross
hearing acuity was good. No pain on the mastoid process was reported upon
palpation.

Mouth and Throat:

Mouth was proportional and symmetrical. Lips were rust colored and were dry
with no presence of ulcerations, sores or lesions. Teeth were yellowish in color with
some dental caries noted. Right upper first premolar tooth was absent. Tongue was in
central position and moves freely with no swelling or ulcerations observed. Gag
reflex was present as evidenced by patient swallowing. Tonsils were not inflamed.
Halitosis was also noted.
Neck and Lymph nodes:
Neck was symmetrical with no masses or swelling noted. No jugular vein
distention was noted. Range of motion was normal and moves easily without
discomfort upon rotation, flexion, extension and hyperextension. Thyroid was not
enlarged has no nodules, masses, and irregularities upon palpation. Trachea is
symmetrical and in midline without deviation.

Skin:
Skin was warm to touch, slightly dry, rough, and with good skin turgot. Neither
jaundice nor cyanosis observed. Papules on the face observed, with nevi noted on
the right side of the nose. Patient was not cyanotic. No bruises or discolorations
observed. No edema noted.

Nails:
Pink nail bed and trimmed

Thorax and Lungs:

No thorax deformity observed. Respiratory rate was 21 cycles per minute with
regular breathing pattern. Symmetrical chest expansion was observed during
respiration. No use of accessory muscles during breathing observed. Chest wall was
intact; no tenderness and masses noted. Uniform temperature also noted. No
adventitious breath sounds heard upon auscultation. No cough present.

Cardiovascular:
With cardiac rate of 75 beats per minute with a regular rhythm. No abnormal
beats, palpitations, thrills or murmurs present upon auscultation.

Axilla:
No assessment done

Abdomen:
Abdomen was slighty enlarged and globular when patient was in supine
position; with slightly soaked, intact dressing on the right upper quadrant. Pulsations
were not visible. The abdomen had hypoactive bowel sounds of two bowel sounds
per minute.

Extremities:
 Symmetrical shoulder movement observed during respiration. Spine was
located at the midline with no discrepancies noted. Shoulders, arms, elbows and
forearms were free from nodules, deformities and atrophy. Range of motion was
not limited. Neither pallor nor bone enlargements were noted upon inspection of the
upper extremities. Upper extremities were not edematous. Radial and brachial pulses
were present. Hip joint and thighs were symmetrical with no deformities present. No
edema noted at both legs. No inflammation noted in the lower extremities. Range of
motion was active and not limited.

IV final diagnoses. Acute cholecystitis

B, Present Health history
Symptom (PTA)

Pt prior to admission, Mr X experienced right upper quadrant pain associated

with a sense of bloatedness, without nausea and vomiting. The pain was tolerable so
he did not seek medical attention yet. He said he also had an increased level of pain
tolerance so he also didn’t mind to take any pain relievers. Until three days prior to
admission, patient had severe right upper quadrant pain, which was said to be
intolerable. Moreover, when pressure is applied on the RUQ of the abdomen, pain is
elicited. He had also lost his appetite because of the pain. His scleras were also
slightly icteric during admission and he was positive with Murphy’s sign. So he
sought consultation at Out-Patient Department- Emergency Room at Tayabas
Community Hospital. Ultrasound revealed cholecystitis, so patient was advised
admission and operation.

C, Past Health History

I Hospitalization

Mr. x experienced common illness such as colds, cough, and fever during his
childhood. He also had chicken pox during his childhood. However, he could not
recall at what age he got the disease and as well as the management of his chicken
pox.

Two years ago (2007), he was admitted to Davao Medical Center due to loss
of consciousness. Prior to that, he was experiencing palpitations, and pain on the
suboccipital area (nape) associated with headache. He had blood pressure of 180/100
as he could remember during the VS taking at the emergency room. And his
diagnosed with hypertension.

II Surgical management
None
III allergies
None

D family Health History

 Grandfather Grandmother
Grandfather Grandmother
unknwon unknown Hypertension

Father Mother

Step-brod died at the age of 18 because o

Youngerand
Patient X . Hypertension sister
choloAnna died of car accident at age of six years

Mr. X is the eldest among Mr. Dad‘s and Mrs. Mom‘s two children. But his younger
sister Anna died of car accident at the age of six years old; He grew up at General Santos
City where the relatives of his mother live. When Mr. X was a first year high school, his
parents got separated because of third party. He lived with his mother and Mrs. Mom’s live-
in partner at Davao City, while his father returned to Leyte where his other relatives live.
With his mother’s second family, he had another two siblings, Step-brod and Step-sis. Step-
brod died at the age of 18 because of suicide. He had suicide because of altered mental
status due to shabu use. Today, Step-sis has her own family at Leyte.

Because Mr. X had been away from the relatives of his father, he does not know any
significant disease they have or had. He doesn’t also know the causes of deaths of his
grandmother and grandfather on the paternal side. On the other hand, what he only knows is
that the eldest sister of her mother has hypertension, and that his grandfather on the maternal
side died of hypertension.

IV Nutrition
A 24 hrs food result (PTA)
Meal Type and amount of food usually taken
 Breakfast I cup of rice and fried egg
Morning snack Coke and sandwich
Lunch 2 cap of rice and sinegang
Dinner 2 cap of rice and adobong baboy

B Regular Routine of diet (weekly)

Monday Tuesday Wednesday Thursday Friday Saturday Sunday

Breakfast I cup of I cup of I cup of I cup of I cup of I cup of I cup of

rice, 1 cup rice, 1 cup rice, 1 cup rice, 1 cup rice, 1 cup rice, 1 cup rice, 1
of coffee of coffee of coffee of coffee of coffee. of coffee cup of
and hotdog and tocino and fried and fried Corne and coffee
egg chicken beef maling and
Lunch 2cup of rice 2 cup of 2 cup of 2 cup of 2 cup of 2 cup of 2cup of
and rice and rice and rice and rice and rice and rice and
sinegang adobong pinangat langkang monggo sisig
na baboy manok gulay kalderita

Dinner I cup of rice I cup of I cup of rice I cup of I cup of I cup of I cup of
and rice and and maling rice and rice and rice and rice and
corne beef tinola pansit
Langka Fried Sinegang
gulay chicken

• Food likes; all kinds of adobong

• Cheese curls; boy Bawang
• Allergies ; none
C Intake and output
Frequency Problem difficulty Usual remedy
Bowel movement Twice a day None none
Urination 4* a day None Morning

D habits
Playing computer games, basketball, and cooking foods
V Disease Entity
A Definition
Cholecystitis is an inflammation of the gallbladder wall and nearby abdominal
lining. Cholecystitis is usually caused by a gallstone in the cystic duct, the duct that
connects the gallbladder to the hepatic duct. The presence of gallstones in the
gallbladder is called cholelithiasis. Cholelithiasis is the pathologic state of stones or
calculi within the gallbladder lumen. A common digestive disorder worldwide, the
annual overall cost of cholelithiasis is approximately $5 billion in the United States,
where 75-80% of gallstones are of the cholesterol type, and approximately 10-25%
of gallstones are bilirubinate of either black or brown pigment. In Asia, pigmented
stones predominate, although recent studies have shown an increase in cholesterol
stones in the Far East.

Gallstones are crystalline structures formed by concretion (hardening) or accretion

(adherence of particles, accumulation) of normal or abnormal bile constituents.
According to various theories, there are four possible explanations for stone
formation. First, bile may undergo a change in composition. Second, gallbladder
stasis may lead to bile stasis. Third, infection may predispose a person to stone
formation. Fourth, genetics and demography can affect stone formation.

Risk factors associated with development of gallstones include heredity, obesity,

rapid weight loss, through diet or surgery, age over 60, Native American or Mexican
American racial makeup, female gender where gallbladder disease is more common
in women than in men. Women with high estrogen levels, as a result of pregnancy,
hormone replacement therapy, or the use of birth control pills, are at particularly high
risk for gallstone formation. Diet with very low calorie diets, prolonged fasting, and
low-fiber/high-cholesterol/high-starch diets all may contribute to gallstone
formation.

Sometimes, persons with gallbladder disease have few or no symptoms. Others,

however, will eventually develop one or more of the following symptoms; (1)
Frequent bouts of indigestion, especially after eating fatty or greasy foods, or certain
vegetables such as cabbage, radishes, or pickles, (2) Nausea and bloating (3) Attacks
of sharp pains in the upper right part of the abdomen. This pain occurs when a
gallstone causes a blockage that prevents the gallbladder from emptying (usually by
obstructing the cystic duct). (4) Jaundice (yellowing of the skin) may occur if a
gallstone becomes stuck in the common bile duct, which leads into the intestine
blocking the flow of bile from both the gallbladder and the liver. This is a serious
complication and usually requires immediate treatment.

The only treatment that cures gallbladder disease is surgical removal of the
gallbladder, called cholecystectomy. Generally, when stones are present and causing
symptoms, or when the gallbladder is infected and inflamed, removal of the organ is
usually necessary. When the gallbladder is removed, the surgeon may examine the
bile ducts, sometimes with X-rays, and remove any stones that may be lodged there.
The ducts are not removed so that the liver can continue to secrete bile into the
intestine. Most patients experience no further symptoms after cholecystectomy.
 However, mild residual symptoms can occur, which can usually be controlled with a
special diet and medication.
B Etiology
When the outflow of bile from the gallbladder is obstructed, it becomes
distended. This distension causes a compromise of blood flow and lymphatic
drainage. This eventually leads to mucosal ischemia and finally necrosis. In 2000,
the ability of endotoxin to cause necrosis, hemorrhage, areas of fibrin deposition, and
extensive mucosal loss was demonstrated. Later, endotoxin was shown to have the
capacity to abolish the gallbladder’s ability to contract in response to cholecystokinin
(CCK), worsening gallbladder stasis and accelerating the process of infection. (Bile
cultures are often positive for bacteria, but bacterial proliferation may be a more
appropriate description of the overall process.)

C Epidemiology

➢ Frequency
An estimated 10-20% of Americans have gallstones, and as many as one third of
these people develop acute cholecystitis. Cholecystectomy for either recurrent biliary
colic or acute cholecystitis is the most common major surgical procedure performed
by general surgeons, resulting in approximately 500,000 operations annually.

Cholelithiasis, the major risk factor for cholecystitis, has an increased prevalence
among people of Scandinavian descent, Pima Indians, and Hispanic populations,
whereas cholelithiasis is less common among individuals from sub-Saharan Africa
and Asia.

➢ Mortality/Morbidity
Most patients with acute cholecystitis have a complete remission within 1-4 days.
However, 25-30% of patients either require surgery or develop some complication.
Patients with acalculous cholecystitis have a mortality rate ranging from 10-50%,
which far exceeds the expected 4% mortality rate observed in patients with calculous
cholecystitis. Emphysematous cholecystitis has a mortality rate approaching 15%.
Perforation occurs in 10-15% of cases.

➢ Race
Pima Indian and Scandinavian people have the highest prevalence of cholelithiasis
and, consequently, cholecystitis. Populations at the lowest risk reside in sub-Saharan
Africa and Asia. In the United States, white people have a higher prevalence than
black people.

➢ Sex
Gallstones are 2-3 times more frequent in females than in males, resulting in a higher
incidence of calculous cholecystitis in females. Elevated progesterone levels during
pregnancy may cause biliary stasis, resulting in higher rates of gallbladder disease in
pregnant females. Acalculous cholecystitis is observed more often in elderly men.

➢ Age
The incidence of cholecystitis increases with age. The physiologic explanation for
the increasing incidence of gallstone disease in the elderly population is unclear. The
increased incidence in elderly men has been linked to changing androgen-to-estrogen

ratios

D Anatomy of Origin
 HEPATOBILLARY

LIVER

A. Location and size of the liver- largest gland in the body, weighs approximately 1.5
kg; lies under the diaphragm; occupies most of the right hypochondrium and part of
the epigastrium.
B. Liver lobes and lobules- two lobes separated by the falciform ligament
1. Left lobe- forms about one sixth of the liver
2. Right lobe- forms about five sixths of the liver; divides into right lobe proper,
caudate lobe, and quadrate lobe
3. Hepatic lobules- anatomical units of the liver; small branch of hepatic vein
extends through the center of each lobule
C. Bile ducts
1. Small bile ducts form right and left hepatic ducts
2. Right and left hepatic ducts immediately join to form one hepatic duct
3. Hepatic duct merges with cystic duct to form the common bile duct, which
opens into the duodenum
D. Functions of the liver
1. Glucose Metabolism
-after a meal, glucose is taken up from the portal venous blood by the liver
and converted into glycogen (glycogenesis), which is stored in the
hepatocytes. Glycogen is converted back to glucose (glycogenolysis) and
release as needed into the blood stream to maintain normal level of the blood
glucose.

-glucose can be synthesized by the liver through the process gluconeogenesis

2. Ammonia Conversion
-use of amino acids from protein for gluconeogenesis result in the formation
of ammonia as a by product. Liver converts ammonia to urea

3. Protein Metabolism
-Liver synthesizes almost all of the plasma protein including albumin, alpha
and beta globulins, blood clotting factors plasma lipoproteins

4. Fat Metabolism
-Fatty acid can be broken down for the production of energy and production
of ketone bodies
 5. Vitamin and Iron Storage
-stores vitamin A, D, E, K

6. Drug Metabolism
7. Bile Formation
-bile is formed by the hepatocytes

-composed of water, electrolytes such as sodium, potassium, calcium,

chloride, bicarbonate, lecithin, fatty acids, cholesterol, bile salts

-collected and stored in the gallbladder and emptied in the intestine when
needed for digestion

a. Lecithin and bile salts emulsify fats by encasing them in shells to form tiny
spheres called micelles
b. Sodium bicarbonate increases pH for optimum enzyme function
c. Cholesterol, products of detoxification, and bile pigments (e.g. bilirubin)
are wastes products excreted by the liver and eventually eliminated in the
feces
GALLBLADDER

The gallbladder (or cholecyst, sometimes gall bladder) is a small organ whose
function in the body is to harbor bile and aid in the digestive process.

Anatomy
• The cystic duct connects the gall bladder to the common hepatic duct to form the
common bile duct.
• The common bile romero duct then joins the pancreatic duct, and enters through the
hepatopancreatic ampulla at the major duodenal papilla.
• The fundus of the gallbladder is the part farthest from the duct, located by the lower
border of the liver. It is at the same level as the transpyloric plane.

Microscopic anatomy

The different layers of the gallbladder are as follows:

• The gallbladder has a simple columnar epithelial lining characterized by recesses
called Aschoff's recesses, which are pouches inside the 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.
Size and Location of the Gallbladder

The gallbladder is a hollow, pear-shaped sac from 7 to 10 cm (3-4 inches) long and 3
cm broad at its widest point. It consists of a fundus, body and neck. It can hold 30 to 50 ml
of bile. It lies on the undersurface of the liver’s right lobe and is attached there by areolar
connective tissue.

Structure of the Gallbladder

Serous, muscular, and mucous layers compose the wall of the gallbladder. The
mucosal lining is arranged in folds called rugae, similar in structure to those of the stomach.

Function of the Gallbladder

 The gallbladder stores bile that enters it by way of the hepatic and cystic ducts.
During this time the gallbladder concentrates bile fivefold to tenfold. Then later, when
digestion occurs in the stomach and intestines, the gallbladder contracts, ejecting the
concentrated bile into the duodenum. Jaundice a yellow discoloration of the skin and
mucosa, results when obstruction of bile flow into the duodenum occurs. Bile is thereby
denied its normal exit from the body in the feces. Instead, it is absorbed into the blood, and
an excess of bile pigments with a yellow hue enters the blood and is deposited in the tissues.

The gallbladder stores about 50 mL (1.7 US 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.
BILIRUBIN PRODUCTION AND ELIMINATION

Bilirubin is the substance that gives bile its color. It is

formed from senescent red blood cells. In the process of
degradation, the hemoglobin from the red blood cell is broken down
from biliverdin, which is rapidly converted to free bilirubin thru
biliverdin reductase. Free bilirubin, which is not soluble in plasma,
is transported in the blood attached to plasma albumin. Even when
it is bound to albumin, this bilirubin is still called free bilirubin. As
it passes through the liver, free bilirubin is released from its albumin
carrier molecule and moved into the hepatocytes. Inside the hepatocytes, free bilirubin is
converted to conjugated bilrubin thru glucoronyl transferase, making it soluble to bile.
Conjugated bilirubin is secreted as a constituents of bile, and in this form, it passes through
the bile ducts into the small intestine. In the intestine, approximately one half of the bilirubin
is converted into a higly soluble substance called urobilinogen by the intestinal flora.
Urobilinogen is either absorbed into the portal circulation or excreted in the feces. Most of
the urobilinogen that is absorbed is returned to the liver to be re-excreted into the bile. A
small amount of urobilinogen, approximately 5% is absorbed into the general circulation and
then excreted by the kidney

VI Pathophysilogy
Risk factor
• Heredity
• Obesity
• Rapid Weight Loss, through diet or surgery
• Age Over 60
• Female Gender
• Diet-Very low calorie diets, prolonged fasting, and
low-fiber/high-cholesterol/high-starch diets.
 Thecholesterol
Bile must become supersaturated with solute precipitate from solution
and calcium as solid
Crystals crystals
must come together and fuse to form

Gallstones

Obstruction of the cystic duct and common bile duct

Sharp pain in the right part of abdomen Jaundice

Distention of the gall bladder Cause of Fever

Venous and lymphatic drainage is impaired

ProliferationLocalized Areas
of bacteriacellular irritation or infiltration or bothof ischemia
take place may occur

Inflammation of gall bladder

The operation of making an opening in the gall bladder, as for the rem
CHOLECYSTITI

Cholecystotomy

Surgical Incision

Disruption of skin, tissue and muscle integrity Destruction of

skin layers

Destruction of Skin Layers

Broken skin and
Stimulation of sensory nerve endings traumatized tissue
 Impaired Skin
Broken Skin and traumatized tissue integrity
Pain

Increased risk for environmental exposure to pathogens

Risk for Infection

VII management
A Medical Management

Abdominal Ultrasound is an imaging procedure used to

examine the internal organs of the abdomen, including the liver,
gallbladder, spleen, pancreas, and kidneys. The blood vessels that
lead to some of these organs can also be looked at with
ultrasound.
The procedure usually takes less than 30 minutes.

cholecystectomy is performed
to treat cholelithiasis and
cholecystitis. In cholelithiasis,
gallstones of varying shapes
and sizes form from the solid
components of bile. The
presence of stones, often
referred to as gallbladder
disease, may produce symptoms
of excruciating right upper
abdominal pain radiating to the right shoulder. The
gallbladder may become the site of acute infection and
inflammation, resulting in symptoms of upper right abdominal
pain, nausea and vomiting. This condition is referred to as
cholecystitis. The surgical removal of the gallbladder can
provide relief of these symptoms

B Nursing Management
• All care that is given and observations made regarding the patient (e.g., condition of
skin preoperatively) must be documented in the operative record for continuity of
care and for medicolegal reasons.
 • The nurse conveys to the patient that he will act as the patient’s advocate by
speaking for him while the patient is in surgery.
• Assess health factors that affects the patient preoperatively: nutritional status, drug or
alcohol use, cardiovascular status, hepatic and renal function, endocrine function,
immune function, previous medication use, psychosocial factors, as well as the
spiritual and cultural beliefs.
• When the circulator reviews patient allergies with the patient, he ascertains that the
patient has no history of allergy to radiopaque dye.
• Inform the patient of the scheduled date and time of the surgery and where to report
• Instruct what to bring (insurance card, list of meds & allergies)
• Check the chart for patient’s sensitivities and allergies e.g. allergy to iodine.
Document allergies noted preprocedure and document alternative used.
• Instruct what to leave at home such as jewelry, watch, medications and contact
lenses
• Instruct what to wear ( loose fitting, comfortable clothes and flat shoes)
• Remind the patient not to eat or drink if directed
• The patient may have fear and anxiety regarding the surgical procedure and the
unfamiliar environment. Explain nursing procedures before performing them and the
sequence of perioperative events.
• Assess and document patient’s anxiety level and level of knowledge regarding the
intended procedure. Clarify misconceptions by answering the patient’s questions in a
knowledgeable manner and refer questions to the surgeon as necessary.
• Decrease fear
• Teach deep-breathing, coughing or incentive spirometer
• Provide emotional support to the patient regarding feelings of altered body image by
providing the patient an opportunity to express her feelings.
• Respect cultural, spiritual and religious beliefs
Notify your physician to report any of the following:
• fever and/or chills

• redness, swelling, or bleeding or other drainage from the incision site(s)

• increased pain around the incision site(s)

• abdominal pain, cramping, or swelling

• pain behind the breast

VIII laboratory/ diagnoses procedure

A Blood Analysis
DIAGNOSTIC NORMAL ACTUAL NURSING NSG.
RESULT RESULT RESPONSIBILITY
IMPLICATION

WBC 5.0-10.0 12.9 g/l slightly elevated >Instruct patient to

indicates infection increase intake of
Vitamin C and increase
fluid intake

>Administer antibiotic as
ordered

Lymph # 3.0-4.0 1.6x1069/L High-indicates >Instruct patient to

stress, pain and acute increase intake of
systemic infection Vitamin C and increase
fluid intake

>Monitor signs of
infection such as elevated
Body Temp.

>Administer antibiotic as
ordered

Mid # 0.1-0.9 0.7x10^9/L Normal

Gran # 5.0-7.0 8.0 g/l Slightly elevated >Monitor signs of

indicates infection infection such as elevated
Body Temp.

>Administer antibiotic as
ordered

HGB 120-160 131g/L Normal

RBC 4.04-5.48 4.99x10^12/L Normal

B Urinalysis
 NORMAL ACTUAL Implication Nursing Responsibility

COLOR Light or pale Light Yellow Normal

Yellow

CHARACTER Clear Slightly turbid Abnormal • Instruct patient to

increase fluid intake

ALBUMIN (-) (-) Normal

REACTION 4.6-8 6.5 pH Normal

SPECIFIC 1.010-1.025 1.010 Normal

GRAVITY

PUS CELL 0 2-4 Slightly elevated • Instruct patient to

presence of increase fluid intake
infection • Administer antibiotic
as ordered

SQUAMOUS (-) (+) Abnormal • Instruct patient to

increase fluid intake
• Administer antibiotic
as ordered

BACTERIA (-) (+) Abnormal • Instruct patient to

increase fluid intake
• Instruct patient to
increase intake of
Vitamin C
• Administer antibiotic
as ordered

X Discharge Plan.

M - Instructed the patient to continue medication as ordered

1. Cephalexin 500 mg cap 3 x day (8am-1pm-8pm) for 1 week

 2. Mefenamic Acid 500 mg cap 3 x day (am-1pm-8pm) for 1 week

E - Instructed the patient to do exercise as tolerated such as walking

T - Instructed the patient to continue the medication

H - 1. Encouraged patient to increase fluid intake

2. Encouraged patient to eat foods rich in Vitamin and Nutritious foods

3. Encourage patient to avoid salty and fatty foods

4. Encourage patient to have enough rest

O - Instructed to come back for follow-up check-up on January 15, 2010, Friday.
Remind patients that regular check-ups are important to ensure that the patient
condition is constantly monitored by the doctor. If any of the following symptoms
are noted, he should contact his 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

D - Advised the patient to a diet as tolerated but preferably avoiding salty

and

fatty foods.
1, Acute pain r/t disruption of skin, tissue and muscle integrity secondary to Surgical incision
ASSESSMENT NURSING PLAN NURSING RATIONALE EVALUATIO
N
DIAGNOSIS INTERVENTION
Acute pain r/t Cholecystoto After 8 hrs of ➢ Assess location, ➢ To assess the etiology or Goal met:
disruption of skin, my nursing characteristic, onset, duration, precipitating factors
Subjective tissue and muscle intervention frequency , quality and Patient reported
integrity ↓ the patient severity of pain that her pain
“masakit ang was lessened
sugat ko" as secondary to Surgical Incision will report ➢ Note location of surgical
Surgical incision that her pain incision from a pain
verbalized by the scale of 5/10 to
patient ↓ is lessen from ➢ Perform assessment each time ➢ As this can influence the
(Cholecystotomy a pain scale of pain occurs, note and amount of post-op experience 1/10 after 8
) Disruption of 5/10 to 1/10. investigate changes from ➢ To rule out worsening of hours of nursing
skin, tissue and previous reports underlying condition or intervention.
muscle integrity ➢ Monitor V/S development of complication
Objective ↓ ➢ Provide quiet environment
and encourage adequate rest
• with pain Stimulation of period ➢ V/S are usually altered in acute
scale of sensory nerve ➢ Encourage use of relaxation pain
5/10 endings technique and diversional ➢ To prevent fatigue
• with facial activities
grimaces ↓
• weak Pain
appearanc ➢ To encourage sense of control
➢ Provide additional comfort and improve coping
e measures such as back rub,
• guarding activities/helps control or
changing patient’s position, alleviate pain
behavior change linen as necessary

➢ To relieve general discomfort

2, Acute Pain, r/t disruption of skin, tissue and muscle integrity secondary to Surgical incision

ASSESSMENT NURSING PLAN NURSING RATIONALE EVALUATION

 DIAGNOSIS INTERVENTION

➢ Assess location, ➢ To assess the

Subjective Acute Pain, r/t Cholecystotomy After 8 hrs of characteristic, etiology or Goal met:
disruption of skin, nursing onset, duration, precipitating
” masakit ang sugat tissue and muscle ↓ intervention the Patient reported
ko pag gumaglaw ako’ frequency , quality factors that her pain was
integrity secondary Surgical Incision patient will and severity of pain
as verbalized by the to Surgical report that her lessened from a
patient incision ↓ pain is lessen pain scale of
from a pain 5/10 to 1/10 after
Objective (Cholecystotomy) Disruption of skin, ➢ Note location of 8 hours of
scale of 5/10 to ➢ As this can
• Facial grimace tissue and muscle 1/10. surgical incision nursing
integrity influence the intervention.
upon moving amount of post-
• patient puts her ➢ Perform assessment
↓ each time pain op experience
hand above ➢ To rule out
surgical incision Stimulation of occurs, note and
investigate changes worsening of
when moving sensory nerve underlying
• Slowed movement endings from previous
reports condition or
• weak appearance development of
• Inability to ↓
complication
ambulate or walk Pain ➢ V/S are usually
without assistance ➢ Monitor V/S altered in acute
from others pain
T: 36.2 °C ➢ To prevent
➢ Provide quiet fatigue
P: 69 bpm environment and
encourage adequate
R: 19 cpm rest period ➢ To encourage
➢ Encourage use of sense of control
BP: 120/80 mmHg relaxation and improve
technique and coping
diversional activities/helps
activities control or
alleviate pain

➢ Provide additional
comfort measures ➢ To relieve
such as back rub, general
changing patient’s discomfort
position, change
linen as necessary

➢ Administer ➢ To maintain
analgesic as acceptable level
ordered of pain

➢ Instruct patient’s
significant others to
help patient divert
pain into other
things
3, Impaired Skin Integrity r/t disrupted skin layers secondary to surgical incision

ASSESSMENT NURSING ANALYSIS PLAN NURSING RATIONALE EVALUATION

DIAGNOSIS INTERVENTION
Subjective Impaired Skin Cholecystotomy After 8 hrs of ➢ Inspect/assess incision ➢ Redness or Goal Met
Integrity r/t nursing site for redness, swelling swelling indicates
”Medyo na disrupted skin layers ↓ intervention or signs of evisceration wound infection (-) Scratching on
ngangate tong secondary to the patient will the incision site
sugat ko” as Surgical Incision after 8hours of
surgical incision avoid
verbalized by the ↓ scratching at nursing
patient ➢ Keep the incision site ➢ To assist body’s intervention.
the incision clean and dry, carefully natural process of
Destruction of skin site
layers change the dressing infectio
➢ To promote
Objective ↓ healing and
• disrupted ➢ Regularly clean the prevent infection
Broken skin and
skin layers traumatized tissue wound aseptically
• wound area
is warm to ↓ ➢ Preventing skin
touch ➢ Minimize skin irritation irritation
• (+)slight Impaired Skin eliminates a
• swelling at integrity potential source of
the incision microorganism
site entry
➢ They aid in skin
V/S: healing
T: 36.2 °C
➢ Instruct patient to
P: 69 bpm increase intake of foods ➢ Provides for early
rich in protein, minerals detection of
R: 19 cpm and vitamins developing
BP: 120/80 ➢ Assess for presence or infectious process
absence of local wound
4. Risk for infection related to presence of surgical incision

ASSESSMENT NURSING PLAN NURSING RATIONALE EVALUATION

DIAGNOSIS INTERVENTION
 ➢ Monitor vital signs. Note ➢ Suggestive of presence of
S/O: “Surgical Risk for Surgical After 8 hours of onset of fever, chills, infection/ developing Goal Met :
incision at right infection related Procedure nursing intervention diaphoresis, changes in sepsis, abscess or
upper quadrant” to presence of the occurrence of after 8hours of
(Cholecystotomy infection will be mentation, and complaints of peritonitis. nursing
as verbalized by surgical incision increasing abdominal pain.
the patient ) prevented as intervention
evidenced by no • (-) chills,
s/sx of infection ➢ Practice good hand washing • (-)
Objective ↓ ➢ Reduce risk of spread of diaphoresis
will appear like and aseptic wound care.
Surgical Incision diaphoresis, chills, bacteria • (-) report of
• disrupted skin
abdominal pain and increasing
layers
↓ fever. abdominal
• wound area is ➢ Inspect incision and
warm to ➢ Provides early detection pain
Destruction of dressings. Note • afebrile with
touch Skin Layers characteristics of drainage of developing infectious
• (+)slight process and monitor a body temp
from wound. of 36.9°C
• swelling at ↓ resolution of pre-existing
the incision peritonitis.
site Broken Skin and
• WBC is traumatized tissue
slightly
elevated,12 ↓ ➢ Administer antibiotics ➢ May be given
prophylactically or to
V/S: Increased risk for reduce number of
environmental multiplying
T: 36.2 °C
exposure to microorganisms in the
P: 69 bpm pathogens presence of infection to
R: 19 cpm ↓ decrease spread and
seeding of the abdominal
BP: 120/80 mmHg Risk for Infection cavity.
5. Anxiety related to Surgical incision.
 Assessment Nursing Plan Nursing Interventions Rationale Evaluation
Diagnosis

Subjective Within my 4 hour ➢ Be available to the ➢ Establishes rapport, promotes

Natakot ako sa care, the client patient. Maintain expression of feelings.
operasyon baka Anxiety related Inflammation of
will be able to: frequent contacts with Demonstrates concern and
kong anu ang mag to upcoming gall bladder
yari sa akin. surgical the patient/SO. Be willingness to help. Helpful in
operation. available for listening discussing sensitive subjects
Objective and talking as needed
CHOLECYSTITIS 1.Verbalize
➢ Restlessness awareness of ➢ Identify patient’s ➢ Helps recognition of extent of
surgical operation perception of the anxiety and identification of
Reports of feelings of
uncertainty (Cholecystotomy) anxiety and health
threat represented by measures that may be helpful
and being ways to deal with the situation for the individual.
scared them. ➢ Encourage patient to ➢ Helps patient to accept what is
acknowledge reality of happening and reduce level of
Anxiety to
scheduled surgical stress without denial anxiety. False reassurance is
operation or reassurance that not helpful, because neither
T: 36.2 °C 2. Report anxiety everything will be nurse nor patient knows the
P: 69 bpm is reduced to a alright. Provide final outcome. Information can
R: 19 cpm manageable level.
BP: 120/80 information about provide reassurance/ help
mmHg measures being taken reduce fear of the unknown.
to correct or alleviate
condition. ➢ Promotes reduction of anxiety
➢ Assist SO to respond to see others remaining calm.
in a positive manner to Because anxiety is contagious,
patient and situation if SO/ staff exhibit their
anxiety, the patient’s coping
abilities can be adversely
affected.
➢ Review coping ➢ Provides opportunity to build
C. PHARMACOLOGIC
 Name of Drug Route/ Dosage Action Indication Adverse Reaction NURSING RESPONSIBILITY Pharmacokinetics
and Frequency
GN: H2Bloc PO - Anti-ulcer -for short term - headache, dizziness, 1. Check for doctor’s order 45% Absorbed after
(Pepcidine) treatment of malaise, dry mouth 2. Know the 10 Rights in drug oral and IM
20 mg tab at - competitively duodenal ulcer administration administration.
bedtime inhibits action of 3. not to be given in patients
BN:Famotidine histamine on the H2 hypersensitive to drugs
at receptor sites of 4. Inform the patient about the
parietal cells, possible side effect of the drug
decreasing gastric 5. Instruct patient to take drug
acid secretion with food
6. Advised patient to take drug
once daily usually at bed time
7. Advise patient to report
abdominal pain or blood in
stools or is vomiting.
GN: Cefuroxime IV - anti-infective - perioperative - Nausea and Vomiting 1. Check for doctor’s order Approximately 50% of
prophylaxis 2. Know the 10 Rights in drug serum cefuroxime is
750 mg every 8o - a 2nd generation administration bound to protein. Serum
prior to OR (30 to cephalosporin that 3. Perform ANST prior to pharmacokinetic
BN: Zinacef
60 minutes inhibits cell-wall admission parameters for CEFTIN
before) synthesis, 4. Should not be given if positive Tablets and CEFTIN for
promoting osmotic Oral. absorbed from the
skin test
instability gastrointestinal tract and
5. Slow IV push
rapidly hydrolyzed by
6. Inform the patient about the nonspecific esterases in
possible side effect of the drug the intestinal mucosa
7. Advise patient to report any and blood to
discomfort on the IV insertion cefuroxime.
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