I. INTRODUCTION 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-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, DietVery low calorie diets, prolonged fasting, and low-fiber/high-cholesterol/highstarch 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.

II.

Patient’s Profile Patient’s Name: Mr. Cholengty Attending Physician: Dr. Espiritu Room Number: 401 C Age: 47 Sex: Male Civil status: Married Citizenship: Filipino Religion: Roman Catholic Address: Caroyroyan,Pili, Camarines Sur Date Admitted: February 9, 2009 Chief Complaint: Right upper quadrant pain for several months. During Admission: conscious, coherent, on wheel chair Neuro Vital Signs: Eyes: 4 Pupils’ size: L:2-3 mm R: 2-3 mm Pupils Reactive to Light Verbal Response: 5 Motor Response: 6 BP: 1840/100, CR: 68 bpm, RR: 20 cpm, T: 36.3 NURSING ASSESSMENT Personal History

III. A.

Mr. Cholengty is a 47 year old male, a Filipino citizen who resides at Caroyroyan, Pili, Camarines Sur. He was born on December 2, 1962; his religious affiliation is Roman Catholic. He is currently employed in the Air Force of the Philippines (Philippine Army). He was admitted on MSH-Our Lady of Perpetual Unit last February 9, 2009(Monday) with a chief complaint of Right upper quadrant pain for several months. He also mentioned that the severity of pain started to bother him since August 2005. When he tried to eat oily and salty foods, he experienced an upsetting pain which decreased his appetite and feels nauseated and vomits. He had a history of drinking alcoholic beverages and consumes 1 cigarette pack/day. On December 23, 2009, he went to seek for medical check up and undergone ultrasound at Plaza Medica. The findings were as follows: Ultrasound: ** Normal liver parenchyma and intra-hepatic ducts. ** Well distended gallbladder with multiple polyps and lithiases. **No free fluid noted

He was diagnosed and surgically operated by Dr. It is generally about 7.According to Mr. present in most vertebrates. Structurally. Potassium and ALT. Gallbladder. History of Past and Present Illness This is the second time Mr. Cholengty that the familial disease he knows that they have in their family was liver disease in the case of his brother. Cholengty been admitted into this hospital. He had not experience any accident and injuries. a middle coat of fibrous tissue and unstriped muscle (tunica muscularis). even though his job is prone to accident. 2009. upward. Sodium. .5 cm (about 3 in) long and 2. His father died because of heart attack and her mother died of natural cause. The body (corpus) and neck (collum) of the gallbladder extend backward. He also added that cholecystitis is prone to their family. In humans. it is a pear-shaped membranous sac on the undersurface of the right lobe of the liver just below the lower ribs.5 fluid ounces. he was admitted last February 09. ANATOMY AND PHYSIOLOGY C. which is almost 29 years ago. and an inner mucous membrane coat (tunica mucosa). because of one of his siblings also had acquired this disease. Family Health and Illness History According to Mr. The wide end (fundus) points downward and forward.Creatinine.B. and to the left. He was been diagnosed with cholelithiases with multiple polyps two months prior to admission due to right upper quadrant pain. Sales last February 10. On his first admission into this hospital he had undergone fistulectomy operation. the gallbladder consists of an outer peritoneal coat (tunica serosa). 2009. upon admission he had undergone some laboratory examination such as Chest X-ray. sometimes extending slightly beyond the edge of the liver. Cholengty. CBC. He was admitted into this hospital because of cholelithiases. muscular organ that serves as a reservoir for bile. IV. it has a capacity varying from 1 to 1.5 cm (1 in) in diameter at its thickest part.

secreted by the liver and transmitted from that organ via the cystic and hepatic ducts. including fat-soluble vitamins: Vitamin A. Enable intake of fat. The purpose of bile is to. and K. The gallbladder. preventing putrefaction. E. until it is needed in the digestive process. and emulsifying fat. empties through the biliary ducts into the duodenum to aid digestion by promoting peristalsis and absorption. by pancreatic enzymes called lipases. help the Lipases to Work. when functioning normally. Digestion of fat occurs mainly in the small intestine. . D. rid the body of surpluses and metabolic wastes Cholesterol and Bilirubin.The function of the gallbladder is to store bile. by emulsifying fat into smaller droplets to increase access for the enzymes.

Bile must become supersaturated with cholesterol and calcium The solute precipitate from solution as solid crystals Crystals must come together and fuse to form stones Gallstones Obstruction of the cystic duct and common bile duct Sharp pain in the right part of abdomen Jaundice Distention of the gall bladder Venous and lymphatic drainage is impaired Proliferation of bacteria Localized cellular irritation or infiltration or both take place Areas of ischemia may occur Inflammation of gall bladder CHOLECYSTITIS . PATHOPHYSIOLOGY Heredity Obesity Rapid Weight Loss. and low-fiber/highcholesterol/high-starch diets. through diet or surgery Age Over 60 Female Gender Diet-Very low calorie diets.Risk factor V. prolonged fasting.

Creatinine This is the indicator of the renal function Date Ordered: February 09.046% Hemoglobin .9. minor aches and pains.1% Conclusion: Complete Blood Count is within the normal range. DIAGNOSTIC AND LABORATORY PROCEDURE 1.44.42% MONO-.58% LYM -3. For post-operative pain. MORPHIN SO4 0.Medications NAME OF DRUGS/DOSAGE ZEPTRIGEN 1gm IV q80 (8AM-4PM-12MN) V. Active duodenal ulcer and GERD. 2009 Date Result In: February 09.371% BASO-. Date Ordered: February 09. Complete Blood Count (CBC) This is to determine blood components and the response to inflammatory process and streptococcal infection. .367% EOS-.14. Used fro the control of moderate to severe pain and as an adjunct to anesthesia.79K/uL NEU -5. 10cc per EC q 120 x 3 doses (4PM-4AM) OMEPRON 40mg IV OD (6AM) PONSTAN SF 500MG 1 CAP TID (8AM-1PM-8PM) PARACETAMOL 500MG Q40 VI. CLASSIFICATION Antibiotic Analgesic and Antipyretic Antacid and Antiulcerant Antirheumatic. 2009 Results: WBC .03% sol. 2. For relief of fever. 2009 Date Result In: February 09. 2009 Results: 84umol/L Conclusions: The result is within normal range based on the normal value of 58-110. Antiinflammatory Analgesic Analgesic and Antipyretic INDICATION Treatment for urinary tract infection.5g/dl Hematocrit .

6. The left hemidiaphragm and chest bones are intact. Potassium Date Ordered: February 09. GORDON’S ASSESSMENT I. . Sodium Date Ordered: February 09.0mmol/L Conclusion: The result is within normal range based on the normal value of 3. **No free fluid noted. 2009 Date Result In: February 09. 5. 2009 Date Result In: February 09. 7. The right hemidiaphragm is elevated.0. 2009 Result: 46 U/L Conclusion: The result is within normal range based on the normal value of 21-72. 2009 Result: 4. 2009 No active infiltrate noted nor pneumothorax seen. ALT Date Ordered: February 09.6-5. 2009 Results: 144mmol/L Conclusion: The result is within normal range based on the normal value of 137-145. ** Well distended gallbladder with multiple polyps and lithiases. 4. 2009 Date Result In: February 09. The heart is not enlarged. Clinical coyrrelation and further evaluation is recommended. Ultrasound ** Normal liver parenchyma and intra-hepatic ducts. Perception and Management  Chief Complain of: right upper quadrant pain for several months.3. 2009 Date Result In: February 09. Impression: Consider Subdiaphragmatic lesion. Chest X-Ray Date Ordered: February 09.

Tagalog and English  Has abdominal discomfort V. Awaken when pain is felt. Health Maintenance  Follow the physician strictly VIII.  Has no bowel movement C. Elimination  With Foley Catheter draining at 300-740 per shift. III. and generally chooses experiences that optimize wellness.  Ask for advice to his friends in times of problems  Watch TV to divert his attention  The patient’s family exhibits the desire and readiness for enhanced health and growth in relation to the client. . Other pertinent data A. Activities of daily living  Takes a bath regularly  Brush his teeth at least three times a day VI. Cognitive/Perception  Speaks Bicol.diet is tolerated  eats three times a day. Nutrition/Metabolic  Diet. Mobility  With regular exercise IV. understands and is aware of the presence of illness  complies with nursing interventions II. fond of eating fatty and salty foods  dry oral mucous membrane  skin is dry and cool  has vices B. Coping /Stress Tolerance  Smokes whenever he feels stressed. Beliefs or Values  Seldom attends mass  Seldom reads Bible  Roman Catholic  Uses cell phone for communication VII.  Family members move in the direction of a health-promoting and enriching lifestyle that supports and monitors treatment programs. Sleep/Rest  Usually sleeps between 11-12 midnight and wakes up between 6-7 am.

M DISCHARGE PLANNING Instructed the patient to continue medication as ordered 1.7. 74bpm. IX.  A husband for 17 years. Significant others perform assistive and supportive behaviours with satisfactory results. 21cpm  BP: 140/100 mmHg  Skin pale  Pale conjuctiva  Facial edema  drowsy  Dry oral mucous membrane  Cracked lips  Nonproductive cough  Abdominal pain (pain scale = 5/10)  Decreased peristaltic sound heard upon auscultation  Muscle twitching  (+) Trousseaus’s sign VII. Philippine Army.  The patient is the second child of three. Sexuality/Reproductive  Married Competencies:  Has many friends  Alteration in physical ability Nursing Physical Assessment  Age: 47  TPR: 36. Self-Perception and Self-Concept 1. Cirok 500mg/cap 2x a day (10am-10pm) for 7 days. Patient’s General Appearance  Pale palpebral conjunctiva  Dry lips  Drowsy 2.  A father of 2 children. Emotional Aspect  Anxious when he was hospitalized  Can focus on questions X. . Role/ Relationship  The patient has a good and sound relationship with her relatives who are taking care of him.  The patient is a graduate of Air Force of the Philippines.

. E walking T H - Ponstan SF 500mg/cap 3x a day (8am-1pm-8pm) for 2 days then as necessary. Instructed the patient to do exercise as tolerated such as Instructed the patient to continue the medication 1.2. Encouraged patient to increase fluid intake 2. Encourage patient to have enough rest O Instructed to come back for follow-up check-up on February 20. Encouraged patient to eat foods rich in Vitamin and Nutritious foods 3. D Advised the patient to a diet as tolerated but preferably avoiding salty and fatty foods. 2009. Encourage patient to avoid salty and fatty foods 4.

.

Patients Care a. and provides information about disease progression/resolu tion. BP130/80 - pain scale of 5/10 .RR. Acute Pain Cues S “Dai naman grabe ang namamati kong kulog. -Suited position for a patient having a gallbladder disorder. however. Facial grimace s not noted c. Nursing Intervention s 1. Scientific Explanation s Due to the presence of stones in the gallbladder it causes some obstruction in the cystic duct which in turn causes a sharp acute pain on the right part of the abdomen. severity (0–10 scale).Positioned the patient in a semi Fowler’s. and effectiveness of interventions. Objectives After 4 hours of nursing intervention the patient will report relieve of pain. Pain scale of 2/10 b. RR-25 d. . Nursing Care Plan 1.(+) muscle guarding . colicky). Observed and document location.Promoted bedrest. steady.Bedrest in lowFowler’s position reduces intraabdominal pressure. intermittent.(+) pallor . patient Evaluation a. development of complications. tama lang” as verbalized by the client. 3.30 . O Nursing Diagnosis Acute pain related to inflammation and distortion of the gallbladder as evidenced by presence of stones in the common bile duct. allowing patient to assume position of comfort..Assists in differentiating cause of pain.difficult y in moving as manifeste d by facial grimaces .VIII. Rationale . and character of pain (e.g. 2.

Relief of pain facilitates cooperation with other therapeutic . may breathing enhance coping. techniques. which can relieve pain. 6. surroundings aid in minimizing 5.Helpful in alleviating anxiety and refocusing attention. 4... . deepattention. Make time to listen to and maintain frequent contact with patient.BP140/90 will naturally assume least painful position. Control environmental . Administered analgesics as indicated .Cool temperature.Promotes rest. 7. Provide diversional activities. Encouraged dermal discomfort. exercises. redirects e. use of relaxation .g.

interventions. .

Decreases dryness of oral mucous membranes. Provide skin and mouth care . 2. Nursing Intervention s 1. increased urine specific gravity. Assess skin/mucous membranes. poor skin turgor e. reduces risk of oral bleeding. Fluid Volume deficient Cues S  O (+) pallor (+) body weakne ss (+) vomitin g with poor skin turgor (+) dry skin (+) dry mouth Nursing Diagnosis Fluid Volume Deficient related to vomiting Scientific Explanations Because of vomiting excessive losses through normal routes occur thus causes Fluid Volume Deficient Objectives After series of NI the pt. dry mouth d.2. with decreased 3. body weakness - - . dry skin c. . Perform frequent oral hygiene Rationale . noting output less than Intake. vomiting b. peripheral pulses.Skin and mucous membranes are dry. Evaluation Is there still the presence of. Maintain accurate record of I&O.Provides information about fluid status/circulati ng volume and replacement needs. will maintain adequate fluid volume as evidenced by moist mucous membranes and good skin turgor. and capillary refill. a.

4. . and set up a 24hr schedule for fluid intake. Encourage foods with high fluid content. because of vasoconstricti on and reduced intracellular water. Increase fluid intake 5.. e.Relieves thirst and discomfort of dry mucous membranes and augments parenteral replacement. prochlorperazi ne (Compazine) as ordered by . Administer antiemetics.promotes hydration.Reduces nausea and prevents vomiting.elasticity.g. Ascertain patient’s beverage preferences. 6. . .

.the physician.

Does the patient understan ds and could recall all the teachings given? . Discuss hospitalization and prospective treatment as indicated. Review drug regimen. Effective communication and support at this time can diminish anxiety and promote healing. a. disease condition diet treatment medicatio n self-care - . thereby reducing sympathetic stimulation.Provides knowledge base from which patient can make informed choices. prognosis. b. Review disease process/progn osis.Information can decrease anxiety. 3. . treatment and diet With worried gaze Nursing Diagnosis Deficient knowledge related to condition. Knowledge Deficit Cues S “pwede bang maulit ang sakit ko” as verbalized by the patient O Frequently asking question about his condition. d. c. necessitating long-term therapy. Provide explanations of/reasons for test procedures and preparation needed. and discharge needs Scientific Explanatio ns There is this presence of knowledge deficit due to some unfamiliar information that causes some confusion to the client that needs to be discussed. e. self-care. . Encourage questions. Nursing Interventions 1.Is there a significant changes that occur on the patients knowledg e regarding. treatment. and potential complication s.Post-operative NCP 3. possible side Rationale . Evaluation . Objectives After an hour of nursepatient interaction the patient will Verbalize understandin g of disease process. prognosis. 2.Gallstones often recur. expression of concern.

beans. spicy foods. gravies.g. sucking on straw/hard candy.. ice cream. 4. . pork). Suggest patient limit gum chewing.Prevents/limits recurrence of gallbladder attacks. needs . or gastric irritants (e. butter.effects. cabbage... 5. nuts. citrus).Promotes gas formation. Instruct patient to avoid food/fluids high in fats (e. onions.g.g. or smoking. which can increase gastric distension/discom fort. caffeine. carbonated beverages). fried foods. gas producers (e. whole milk. .

Sign up to vote on this title
UsefulNot useful

Master Your Semester with Scribd & The New York Times

Special offer for students: Only $4.99/month.

Master Your Semester with a Special Offer from Scribd & The New York Times

Cancel anytime.