Bulacan State University City of Malolos, Bulacan College of Nursing



This is a case study of a 64 year old male client who were rushed at Lubao Clinic at Lubao, Pampanga complaining of severe pain on the right upper quadrant of the abdomen. After performing abdominal ultrasound, the result shows that he has Cholecystolithiasis/cystitis and choledocholelithiasis with secondary biliary ectacia. He was then diagnosed with cholecystocholedocholithiasis and was referred by Dr. G to Dr. PB of Bulacan Medical Center. He was admitted at Bulacan Medical Center last August 27, 2010 at 12:32 p.m. and was scheduled for cholecystectomy with billiary exploration. Cholecystocholedocholithiasis is presence of gallstone in both gallbladder and common bile duct, in turn leading to bile obstruction and gallbladder irritation. Gallstones are crystalline bodies formed within the body by accretion (increase by natural growth) or concretion (formation of stone-like substance) of normal or abnormal bile components, it can occur anywhere within the biliary tree, including the gallbladder and common bile duct. The bile is a fluid produced by the liver that aids in digestion of lipids and neutralizing of partly digested foods, it is stored in the gallbladder and upon eating it is discharged to the duodenum (the first part of the small intestine) by passing to a duct called common bile duct. The gallbladder is an organ which aids in the digestive process. Its function is to store and concentrate bile. The common bile duct is a tube-like structure that is formed by the union of the common hepatic duct and the cystic duct. Its primary function is conduction of concentrated bile from the gallbladder to the duodenum. Cholecystectomy is a surgical removal of gallbladder. Fortunately, the gallbladder is an organ that people can live without. Despite of the importance of gallbladder in the digestion of fat, many people are unaware of it. That is why they often neglect to take care of their gallbladder. And biliary exploration is done to search for any gallstone present in the biliary tree. Cholecystocholedocholithiasis can affect both men and women but it is more prevalent in women at the age of 40 years old. People who have a history of gallstones are at increased risk for having this kind of disease. In the international level, gallstones are prevalence among people of Scandinavian descent, Pima Indians, and Hispanic populations, whereas gallstones are less common among individuals from sub-Saharan Africa and Asia. It affected 20.5 million people (19881994) with a mortality record of 1,077 deaths in 2002. Hospitalizations total up to 636,000 in the same year and over 500,000 have undergone cholecystectomies. In the Philippines alone, an extrapolated prevalence of 5,073,040 people are affected by the disease last 2007. (http://digestive.niddk.nih.gov/statistics)

No unanimous consensus has been achieved regarding the ideal management of cholecystocholedocholithiasis. The treatment of gallbladder and common bile duct stones may be achieved currently according to a two-step-protocol (endoscopic sphincterotomy associated with laparoscopic cholecystectomy) or by a one-step laparoscopic procedure, including exploration of the common bile duct and cholecystectomy. Endoscopic sphincterotomy is reported to have considerable morbidity/mortality and common bile duct stone recurrence rates, whereas laparoscopic common bile duct clearance is a demanding procedure, which to date has not spread beyond specialized environments. (http://pubget.com/paper/19466493#)

Significance of the study We, the student nurses have chosen this case as we see it fit for the peri-operative concept as the patient has had undergone cholecystectomy with billiary exploration and cholechoduodenostomy. Moreover, despite the Cholecystocholedocholithiasis low incidence, we would like to give credit and to know more of the nature and function of the gallbladder. Much often this small organ is not given importance. Thus we are in a pursuit for knowledge to be able to impart it to others. Furthermore, this case is quite interesting since it does not always affect only females and elderly. It can affect everyone. It can be alarming since many people are confused and unaware of the symptoms presented. As teen-agers living in a fast-phased world and governed by schedules, we too are predisposed to lifestyle modification especially diet and food

preferences which can contribute to the disease. With this study, we hope to apply our learning in taking care not only of our patients but also of ourselves. As nursing students and future nurses, we would want to understand and appreciate more on what is happening to a patient with Cholecystocholedocholithiasis. Consequently, we are interested on what will be the necessary management that will be given. Through this, we are hoping that we will be able to find the right plan of care and sound interventions, not forgetting the patient s rights as a person. All in all, these will help us to become efficient nurses and better persons later on.

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

Specific Objectives: y y Conduct a thorough physical assessment and to interpret the assessment in order to give the care the patient need. Research and understand the disease process of the patient s illness and also the possible causes and the symptoms the patient experienced that may suggest the current condition of the patient. y y y Integrate knowledge of nursing care in post Cholecystectomy with biliary exploration client to formulate a quality nursing care plan. Implement appropriate nursing intervention to satisfy the patient s needs. Use critical thinking to evaluate the effectiveness of the nursing intervention given in meeting the needs of the patient.

BM 64 years old Male October 28. 2010 12:32 PM Cholecystocholedocholithiasis . Pampanga Married Head of the family Filipino Roman Catholic Philhealth and SSS August 27. Cruz Lubao.PATIENT S PROFILE BIOGRAPHIC DATA NAME: AGE: SEX: BDAY: ADDRESS: STATUS: Position in the family: Nationality: Religion: Care Financing: Date of Admission: Time of Admission: Final Diagnosis: Mr. 1945 Sta.

BM consult a doctor at Lubao. CHIEF COMPLAINT A. Mr. Mr. NURSING HEALTH HISTORY A. and he undergone abdominal ultrasound.II.Until August 27.4 C) on that day.. 2010. PB. PB to present the referral slip of Dr. hematology. PT and PTT. . He was scheduled for cholecystectomy with billiary exploration and cholechoduodenostomy. he noticed a yellowish discoloration on his skin. He also had a fever (38. Laboratory exam were done such as. He was reffered to Dr. B. 2010. He was worried about his condition so he seeks medical attention. 2010. 2009). Three days prior to admission (August 24. Clinic. G. ciprofloxacin 500mg tab and tramadol 50 mg tab. By august 22. By August 25. A.1 Chief complaint on admission The patient verbalized that he experienced pain in the right upper quadrant prior to admission. Wala na akong nararamdaman na sakit sa tahi ko as verbalized by the client. he experienced intolerable pain of 10/10. dark urine and clay-colored stool. G of Lubao Clinic and some medications were prescribed to him such as omeprazole20 mg capsule. Createnine. BM experienced tolerable pain in the right upper quadrant of his abdomen with a tolerable pain of 6/10. The result shows Cholecystolithiasis/cystitic choledocholelithiasis with secondary biliary ectacia and he was diagnosing of having cholecystocholedocholithiasis. Sobrang sakit sa itaas na kanang bahagi ng aking tiyan as verbalized by the client. 2010). PB of Bulacan Medical Center by Dr. He does not seek medical attention yet and he does not take any medication. he exhibited nausea and vomiting resulting in a decrease in appetite but still he was not able to consult Dr. he went to Bulacan Medical Center to consult Dr. He received IVF of D5Lr 1L regulated at 30gtts/min. HISTORY OF PRESENT ILLNESS One month prior to admission (August.2 During the interaction The patient verbalized that he doesn t feel any pain during actual assessment. CBC.

A2 died due to pulmonary tuberculosis. A5 has diabetes mellitus while A6 and A7 both have rheumatoid arthritis. While his grandmother died due to lung cancer. B1 and B2 as well as patient s father died due to lung cancer. D. A year ago. He has a history of smoking cigarettes and drinking alcohol beverages but he stopped 22 years ago. asthma and hypertension. diabetes mellitus. lung cancer. C4 died due to cardiovascular accident. The patient stated that his grandmother on maternal side and his grandfather on paternal side died due to natural death. C6 died due to liver cancer and C8 has rheumatoid arthritis. His grandfather on maternal side died due to DM complications. A3 died due to lung cancer while patient s mother died due to cardiovascular accident. rheumatoid arthritis. the eldest(C1) died due to meningitis. cardiovascular accident. FAMILY HISTORY OF ILLNESS The patient has a familial disorder of hypertension. C7 and C9 are hypertensive. The patient also stated that he can t remember the immunizations he received. And B8 died due to complication of hypertension (heart attack). this is not the first time he has been hospitalized. Gatchalian. PAST HISTORY According to the patient. He has 8 siblings. He does not have any allergies to any kind of medication or food. liver cancer and asthma. . B5 died due to cardiovascular accident.C. As far as the client concerned. On the paternal side. C2. C5. he undergone prostatectomy at Manila Doctors Hospital facilitated by Dr. Patient (C3) has DM.


FUNCTIONAL HEALTH PRIOR DURING PATTERN I. During admission. the patient stated that being a healthy person is During admission. 2010 BREAKFAST y 1 cup of rice y ½ milk fish (pangat) y 150mL of water LUNCH y 1 cup of rice y 1 cup of milk fish (sinigang) y 360 mL of water y 1 pc of regular banana DINNER y 1 cup of rice AUGUST 27. The client s fluid intake was around 1000-1500mL of foods offered by the hospital. Health Prior to admission. AUGUST 24. he eats balanced some of the doctor s order in terms of the foods that are not allow for him to eat. the patient s usual food preferences are vegetables. 2010 BREAKFAST y 120mL of hot coffee y 2 pcs of pandesal(regular) y 1 pc of fried egg LUNCH y 1 cup of rice y ½ fried milk fish y 1 small bowl of chopseuy y 360mL of water DINNER y 1 cup of rice y 1 fried of fish(galunggong) . His skin is dry but does not have any lesions or other skin is 600-700mL of water. After the surgery her daily fluid intake water per day. Nutritional and Metabolic Pattern Prior to admission. And to keep himself healthy. problems. Health and nutritious foods and regular exercise as well. the usual foods that the patient eats are the fish and seafood. the patient stated that its hard for him to follow Perception and being free from diseases. Management Pattern II.

2010 BREAKFAST y 120mL of hot coffee. 2010 BREAKFAST y 1 cup of rice y 2pcs boiled eggplant y 2pcs of fish (sardines) y 240mL of water LUNCH y 1 cup of rice y 1 pc of fried tilapia y 300mL of water DINNER y 1 cup of rice y 1pc gigi fish (pangat) y 150mL y 1pc of regular banana AUGUST 26.y y 1 fried of gigi fish 175mL of water y y 1 small bowl of milk fish (sinigang) 240mL of water AUGUST 28. BREAKFAST y 2pcs of pandesal (regular) y 120mL of water BREAKFAST y 1 cup of rice y 1 pc of boiled egg y 150 mL of water LUNCH y 1 cup of rice y 1 small cup of pakbet y 240mL of water DINNER y 1 cup of rice y 1 small fried chicken y 150mL of water AUGUST 29. 2010 AUGUST 25. 2010 .

the patient defecated once a day. The stool was pale in color. acolic stool (3 days prior). Elimination Pattern Prior to admission. he noticed a darkcolored urine 3days before admission. and firm. Color Frequen cy Consiste ncy Formed Odor Difficulty Stool Claycolored 1x/day Foul none Urine Urine Dark9x/ day Clear aromatic none Darkcolored 7x/day clear Aromatic None . firm.y 4pcs of hot pandesal(regular) LUNCH y 1 cup of rice y 4 pcs of crabs y 3 pcs of big shrimp y 280mL of water DINNER y 1 cup of rice y 2 pcs of banana (regular) III. and the stool was brown in color. He does not perspire excessively and no body odor problems. The patient urinates 7 times a day because of the infused intravenous fluid and oral fluid intake. The patient urinates 9 times a day depending on how much his fluid intake was. Color Frequency Consistenc y Stool Claycolored/g ray 1x/day Formed foul Odor difficu lty None LUNCH y 1 cup of rice y 1 small cup of pakbet y 200 mL of water DINNER y 1 cup of rice y 1 small fried chicken y 120 mL of water During admission. According to him. The patient said that defecation is not hard for him. the patient defecates once a day.

During hospitalization.assistance from other person and devices 4. Activity Exercise Pattern 0 Full self care. the patient didn t have enough energy to do his task. His only form of exercise was early ambulation and some active and passive range of motion. the patient had sufficient energy to do his entire task and still he can manage their farm independently. 1 use of equipment 2 assistance from other person 3.dependent Prior to hospitalization. Activity Level Activity Level Feeding Bathing Bed mobility Dressing Grooming Toileting 0 0 0 0 0 0 Feeding Bathing Bed mobility Dressing Grooming Toileting 0 2 0 2 2 2 .colored vomit None vomit None IV.

he had 8 hours of continuous sleep a day. The patient also their age. making. Sleep Rest Pattern Prior to hospitalization. they can t practice sexual intercourse due to They can t participate on sexual activity due to their age. According to the patient. he has only 6 hours of sleep and it s not slept at 9PM and wake as early as 5AM. Role Relationship Pattern XI. They belong to the nuclear type of family. Self Perception and Self-Concept Pattern Prior to hospitalization. He took naps in the afternoon continuous like before due to surrounding. the client stated that he had no hearing difficulty Pattern difficulty and his memory were still intact because he can still remember and his memory were still intact because he can still remember the the information being asked to him. VIII.V. stated that they used to take care of their grandsons and daughters and just enjoying their remaining time. They belong to the nuclear type of family. she During hospitalization. information being asked to him VII. SexualityReproductive Pattern The patient is the head of the family. He usually sleeps at 10 PM and awakens at 4AM. VI. they both played the role in The patient is the head of the family. Cognitive Perceptual Prior to hospitalization. at least 30-1hour. the client stated that he had no hearing Prior to hospitalization. the patient described himself as a good person The patient described himself as a good person but during the and approachable. they both played the role in decision decision making. . occurrence of the disease he easily get irritated and he feels moody most of the time.

triggered his feelings the patient went to farm to get some fresh air and to feel relax. to made them a better and stronger individual. . Her The patient stated that he doesn t feel any tension during this time because wife was the most helpful person in taking things over.X. The client believed that all things that happening to their family have purpose from GOD. to made them a better and stronger individual. He is taking his he feel safe and secured coz they can easily contact a doctor if there s any home medication to cope with it most of the time. Value-Belief Pattern The client believed that all things that happening to their family have purpose from GOD. But if some stress problem encounter. Faith in GOD is the thing that made them hold to problems even if it was very difficult to handle. Her husband was the most helpful person in taking things over. Coping Stress Tolerance Pattern According to the patient he feels tense every time he feels dizzy. XI. Faith in GOD is the thing that made them hold to problems even if it was very difficult to handle.

and can distinguish what is right or wrong based on internalized rules on conscience rather than social law. GROWTH AND DEVELOPMENT THEORY STAGES NORMAL FINDINGS ACTUAL FINDINGS RESOLUTION Freud s psychosexual theory Genital phase (13 years and older) At this point. He is married and has 3 Positive (+) the development of relationship and children. BM and his wife were remains sweet to each other. I must follow rules because my conscience tells me . she will follow the entire doctor s order that will help to make his condition better. Post conventional Stage Stage 6 Universal ethical principle orientation. Mr. learned to desire members of the opposite sex and to fulfill instincts to procreate and thus ensure the survival of the human species.III. He also . and hopeless with self satisfaction in activities. Erikson s Psychosocial theory Stage 8 Ego Integrity vs. worth worthiness. meaningless satisfaction and worthiness. BM follows rules according to his different roles of the knowledge and willingness. and importance. Higher Law and conscience orientation. society. According to him. BM has a feeling of self sense of dignity. Orientation to internal discussion of conscience but without clear rationale or universal principle. Mr. also have his own family. Kohlberg s Moral Development theory . BM has a sense of self Positive (+) Mr. Mr. Despair Feeling of self acceptance. Mr BM understands the Positive (+).

Mr. it is still a must for him to pray and thank God for his graces and ask guidance for his current condition.said that he does things if he knows that it is good for him and according to his willingness. BM said that even if he Positive (+). Mr. He integrates other perspectives does not always go to about faith into own definition of truth. BM can think reasonably. ideal images and prejudices built deeply into the selfsystem by virtue of one's nurture within a particular social class. this involves a critical recognition of one's social unconsciousthe myths." Importantly. solution and learn to think and reason in abstract terms. and to reason in the logically for the possible abstract. There must be an opening to the voices of one's "deeper self. religious tradition. . church regularly. Fowlers spiritual development theory Conjunctive faith Here there must also be a new reclaiming and reworking of one's past. ethnic group or the like.adulthood) Able to see relationships Mr. BM said that he thinks Positive (+). Piaget s cognitive development Formal operations (12 .


5 kgs. Weighing 1. . Approximate width: 6 mm in adults. y y Cystic duct. occupies most of the right hypochondrium and part of the epigastrium. Length: Usually 6 8 cm. Common bile duct. which opens into the duodenum.is the short duct that joins the gall bladder to the common bile duct.about five sixth of the liver. LIVER LOBES AND LOBULES y y y The liver has two lobes.about one sixth of the liver Right lobe.drains bile from the right functional lobe of the liver Left hepatic duct. merges with cystic duct to form common bile duct.drains bile from the left functional lobe of the liver Common hepatic duct-is the duct formed by the convergence of the right hepatic duct and the left hepatic duct .formed by the union of the common hepatic duct and the cystic duct (from the gall bladder). BILE DUCTS y y y Right hepatic duct. separated by the falciform ligament Left lobe.LIVER y y y Largest organ in the body Lies under the diaphragm.

use of amino acid from protein for glucogenesis result in the formation of ammonia as a by product. and copper. y Glucose metabolism. y y Fat metabolism.bile is formed by the hepatocytes Composed of water. blood clotting factor plasma lipoproteins. iron. calcium. Glycogen is converted back to glucose (glycogenolysis) and release as needed into the blood stream to maintain normal level of the blood glucose y Ammonia conversion. Bile formation. Liver converts ammonia to urea. vitamin B12. BILE Bile is the greenish-yellow fluid (consisting of waste products. y Protein metabolism. lecithin. bile salts Collected and stored in the gallbladder and emptied in the intestine when needed for digestion. including glucose (in the form of glycogen). alpha and betaglobulins.fatty acid can be broken down for production of energy and production of ketone bodies. bicarbonate. which is stored in the hepatocytes.liver synthesizes almost all of the plasmas protein including albumin. vitamin D (1 4 months' supply). fatty acids. cholesterol. glucose is taken up from the portal venous blood by the liver and converted into glycogen (glycogenesis). potassium. electrolytes such as sodium.FUNCTIONS OF THE LIVER y The liver stores a multitude of substances. cholesterol. including the following: y y to carry away waste to break down fats during digestion .after meal. and bile salts) that is secreted by the liver cells to perform two primary functions. vitamin A (1 2 years' supply).

These ducts ultimately drain into the common hepatic duct.10 cm (3-4 inches) long and 3 cm broad. Then. a pear-shaped organ located directly below the liver. TRANSPORT OF BILE 1. which runs from the liver to the duodenum (the first section of the small intestine). When the liver cells secrete bile.shaped sac from 7. GALLBLADDER y y y The gallbladder is a small organ whose function in the body is to store bile and aid in the digestive process. it is collected by a system of ducts that flow from the liver through the right and left hepatic ducts. About 50 percent of the bile produced by the liver is first stored in the gallbladder. 4. However.Bile salt is the actual component which helps break down and absorb fats. body and a neck. 3. The common hepatic duct then joins with the cystic duct from the gallbladder to form the common bile duct. 2. Fundus . the gallbladder contracts and releases stored bile into the duodenum to help break down the fats. when food is eaten. bile gives feces its dark brown color. Bile. not all bile runs directly into the duodenum. 5. A hallow pear.the lower free and the expanded end of the Gall bladder. . It consists of a fundus. which is excreted from the body in the form of feces.

ejecting the concentrated bile into the duodenum. which is produced in the liver.the body of the gall bladder is the portion that is lying between that of the fundus and also the neck. results when obstruction of bile flow into the duodenum occurs. it absorbed in the blood. The cystic duct connect the gallbladder to the common hepatic duct to form common bile duct. a yellow discoloration of the skin and the mucosa. Jaundice. FUNCTION OF THE GALLBLADDER Stores bile that enters it by way of the hepatic and cystic duct. and to the left.y Body . which is released when food containing fat enters the digestive tract. . The bile. The direction of the body is upwards. y Neck-it is the S shaped curve present above the body. the gallbladder contracts. and an excess of bile pigments with a yellow hue enters the blood and is deposited in the tissues. It lies on the undersurface of the liver s right lobe and attached there by areolar connective tissue. Bile is thereby denied its normal exit from the body in the feces. The gallbladder stores bile. Then later when digestion occurs in the stomach and in the intestines. During this time the gallbladder concentrates bile five folds to ten folds. Direction is upwards. forwards and then takes a turn and becomes downwards and backwards. backwards. Instead. stimulating the secretion of cholecystokinin (CCK). y y y It can hold 30 to 50 ml of bile. emulsifies fats and neutralizes acids in partly digested foods. and extends up to the cystic duct.

V. PATHOPHYSIOLOGY Predisposing Factors Precipitating Factors Advancing age (age 40 and above) Biliary infection (bacteria) Diet (high cholesterol/fat) Decreased gallbladder motility Liver excrete conjugated bilirubin into bile along with bile salts and cholesterol Liver excrete relatively high proportion of cholesterol in the bile Release of inadequate amount of bile to break down/digest fats Invasion of bacteria Bile is supersaturated with cholesterol Significant increase of cholesterol in the circulating blood Bacteria hydrolyze conjugated bilirubin Formation of solid Crystals that is insoluble Liver excrete relatively high proportion of cholesterol in the bile Increase in unconjugated bilirubin Crystals fuse together to form stones .

2010) .Bile is supersaturated with cholesterol Unconjugated Bilirubin tends to form insoluble precipitates with bile salts and cholesterol Formation of solid Crystals Formation of stones Crystals must come together and fuse to form stones Stones in bile ducts (choledolithiasis) and gallbladder (cholelithiasis) Mild to moderate pain/biliary colic in the right part of the abdomen due to functional spasm of the cystic duct. 2010) Dark-colored urine (August 24. irritation of the viscera (August. warning signal that s something wrong with digestion (August 24. due to absence of bile in the duodenum. 2009) Obstruction of the bile ducts Clay-colored stool may result from problems in the biliary system. 2010) Jaundice due to obstruction of bile flow (August 24.

2010) Decrease in appetite (August 25. 2010) Severe Pain/biliary colic due to inflammatory process (August 22. 2010) .Continues irritation of the gallbladder Inflammation of the gallbladder CHOLECYSTOCHOLEDOCHOLITHIASIS Fever due to elevated WBC because of bacteria invasion in the injured gallbladder (August 25. 2010) Nausea and vomiting may accompany a gallbladder attack (August 25.

Signs and Symptoms Rationale Biliary Colic The most common symptom is in pain the right upper part of the abdomen or epigastrium. The fever tends to rise gradually to above 100. As a result.Cholecystocholedocholithiasis . warning signal that s something wrong with digestion . Fever Gallstones sometimes get trapped in the neck of the gallbladder and can cause persistent pain that lasts more than several hours and is accompanied by fever. The pain often begins suddenly following a meal. The pain may radiate to the back. in turn leading to bile obstruction and gallbladder inflammation. is severe. also due to the irritation and inflammation of the gallbladder wall. due to absence of bile in the duodenum. in order not to experience that pain. Fever occurs in about one third of people with acute cholecystitis. People tend not to eat. lasts about one to three hours before fading gradually. The pain of biliary colic is caused by the functional spasm of the cystic duct when obstructed by stones. isn't helped by over-thecounter and isn't helped by passing wind. whereas pain in acute cholecystitis is caused by inflammation of the gallbladder wall. called biliary colic. This can cause an attack of abdominal pain.4° F (38° C) and may be accompanied by chills Loss of appetite The pain often begins suddenly following a large or rich meal. which: develops quickly.presence of gallstone in both gallbladder and common bile duct. Jaundice Clay-colored stool Due to obstruction of the bile flow may result from problems in the biliary system. Fat absorption is also impaired for the lack of bile salts. especially fatty or oily foods. rapid loss of weight and anorexia can occur. right scapula or shoulder.

bile is bring supersaturated with cholesterol. . in contrast to 25-30% of those over 80. high fats) Rationale Increased intake of cholesterol and saturated fats has all been postulated to cause cholesterol gallstones. Less than 5-6% of the population under age 60 has stones. and/or retained suture material. biliary tree infection. Intraductal stones developing after cholecystectomy are invariable associated with bile stasis. Predisposing Factor Factor Advancing Age Rationale The incidence increases with age. It usually affects people with age of over 40 but it is more prevalent after 60 years of age. It is primarily due to decreased gallbladder motility of older person that may result in releasing of inadequate amount of bile to help digest fats. or parasitic infestation (Ascaris lumbricoides. or other helminthes).coli. Biliary Infection (bacterial) Brown pigment stones are frequently found in the intrahepatic bile ducts and are always associated with infection by colonic organisms usually E.Precipitating Factors Factors Diet (high cholesterol. If there is an increased production of cholesterol. that leads in formation of crystals/stones.

for technique when getting date and time specimen >apply pressure on the specimen was obtained. The test is used to detect infection or inflammation and also used to help monitor the body¶s response to various treatments and to monitor 5. DIAGNOSTIC AND LABORATORY RESULTS Diagnostic Laboratory Procedures Date Ordered Result in August 27. 2010 Indication or Purpose Result Normal values Analysis and interpretation of the results prior NORMAL -Check there¶s doctor¶s order CBC -Explain the Nursing Responsibilities during After HEMATOLOGY August 27.5. the doctor who after -Send the specimen to the laboratory immediately ordered procedure to patient the the venipuncture site the specimen.10..6 x109/L 3. age.0 x109/L if -Use standard -Label a precaution and specimen the sterile container with name. withdrawing specimen .VI.room no. 2010 A white blood WBC cell count is a determination of number of WBC or leukocytes/unit volume in a sample of venous blood.

17 x1012/L 3. carry oxygen from the lungs to the cells of organs in the body and transport carbon dioxide from those cells back to the lungs.bone marrow function. Red blood cells. and to determine the need for further tests.805.80 x1012/L Within normal range . such as differential count. When the values of the RBC 4. which are made in the bone marrow.

Hemoglobin is an important component of red blood cells that carries oxygen and carbon dioxide to and from tissues. the patient is said to be polycythemic. the patient is said to be anemic. When the values increase above this range. The hemoglobin HGB 119 g/L 110-165 g/L Within normal range .RBC count and hemoglobin decrease below the established reference range.

determination test is used to screen for diseases associated with anemia and in determining acid-base balance.352 LL/L .500 LL/L Within normal range . such as HCT 0.350. The test is performed to help diagnose blood disorders. The oxygen carrying capacity of the blood is also determined by the Hemoglobin concentration Measures the percentage of RBC in a blood volume.

anemia or abnormal dehydration. evaluate platelet PLT 302 150 ± 310 X109/L Within normal range .polycythemia. The smallest formed elements in blood that promote blood clotting after an injury. and the effectiveness of those transfusions. blood transfusion decisions for severe symptomatic anemias. The test is performed to determine if blood clots normally.

99 sec 95% 10-14 sec 70-100% Within normal range Within normal .6 17. immune disease.2010 Prothrombin time Activity 13.production. and to diagnose and monitor a severe increase or decrease in platelet count A small white blood cell (leukocyte) that plays a large role in defending the body against disease.048. and ulcerative colitis PT AND PTT Lymphocytes 21.0 Within normal range August 28.2010 August 28. leukemia. Evaluate bacterial and viral infection.

her/his normal activities immediately.14 Within normal range Within normal range Partial 35-45 thromboplastin sec Time Abdominal ultrasound To visualize abdominal structures by using noninvasive diagnostic technique in which highfrequency sound waves are passed into internal body structures. Instruct examination him not to couch next to >inform patient eat solid ultrasound regarding the food for 12 machine result hours prior to exam to allow greatest dilation of the >the area to be will scanned be exposed and a clear soluble watergel .range INR 1.20 1. 38.7 >> Explain >> IMPRESSION > Cholecystolithiais/cystitis >Choledocholithiases with secondary biliary ectacia Explain >> Patient can expect resume to the purpose the following: and the >patient will be ask to lie on > the procedure of the test.

will be applied to the skin for the transmission of sound waves into the patient¶s body >a scan probe will then be placed contact in with patient¶s body and move over the skin to the below.gallbladder >Inform patient that ultrasound is a noninvasive procedure. >the will experience no pain during parient examine tissues .

. to complete.the procedure >Ultrasound scans take approximately 30 min.

Document relevant information.VII. phlebitis) for amount of fluid infused 3. rate of IV flow. Explain the procedure to the client. phlebitis. date and time of discontinuing the infusion. In changing the IV container. how much has infused. 4. Inspect for IV tubing patency 3. inflammation. amount of solution. how much fluid remains to be infused. PATIENT AND HIS CARE MEDICAL MANAGEMENT TREATMENT DATE ORDERED/ DATE PERFORMED GENERAL DESCRIPTION INDICATIONS/ PURPOSES CLIENTS RESPONSE TO THE TREATMENT IVF (PNSS 1L) Date ordered: August 30. . Assess the client s response to the IV. bleeding. AFTER 1. type solution used. Assess IV site for fluid infiltration. and condition of the IV insertion site. flow rate. ideal for the initial correction of extracellular fluid y Used as a means of route for medications y Ideal for patient needs fluid replcement The client is well hydrated NURSING RESPONSIBILITIES FOR IV THERAPY PRIOR 1. 2. obtain the correct solution container. 2. rate of flow of infusion. 2010 Non-pyrogenic intravenous fluid. Review physician s order for IV infusion (type of solution. amount to be administered. Check for physician s order for discontinuing IV infusion therapy 2. Assessed for venipuncture site (if there is bleeding. 2010 Date discontinue: September 2. if there are medicine to be added / time to be completed) DURING 1.






IVF 5% Dextrose in Lactated Ringer s Solution

Date ordered: August 29, 2010 Date shifted: August 30, 2010

-hypertonic solution that contains some form of carbohydrate and varying amount of electrolytes

- Treatment for persons needing extra calories who cannot tolerate fluid overload. - Treatment of shock. -For rehydration -To increase the blood volume

Client exhibits natural fluid and electrolyte balance. Client does not experience any dehydration

5. Use aseptic technique when changing IV solution container, apply new IV tag.

NURSING RESPONSIBILITIES PRIOR 1. Explain the procedure to the client. 2. Review physician s order for IV infusion (type of solution, amount to be administered, rate of flow of infusion, if there are medicine to be added / time to be completed) DURING 1. Assess the client s response to the IV, rate of IV flow, how much has infused, how much fluid remains to be infused, and condition of the IV insertion site. 2. Inspect for IV tubing patency 3. Assess IV site for fluid infiltration, phlebitis, bleeding. 4. In changing the IV container, obtain the correct solution container, flow rate, amount of solution 5. Use aseptic technique when changing IV solution container, apply new IV tag. AFTER 1. Check for physician s order for discontinuing IV infusion therapy 2. Assessed for venipuncture site (if there is bleeding, inflammation, phlebitis) for amount of fluid infused 3. Document relevant information, type solution used, date and time of discontinuing the infusion

MEDICAL MANAGEMENT TREATMENT Oxygen therapy (3-6L/min) facial mask

DATE ORDERED/ DATE PERFORMED Date ordered: August 30,2010 Date discontinued: August 30,2010




-Administration of oxygen at a concentration greater than that found in the environmental atmosphere. -Facial mask is used to provide moderate oxygen support and higher concentration of oxygen and humidity

-post anesthesia recovery

No response from the patient because he is -to increase amount of oxygen sedated. in the blood ,reduces the extra work of the heart, and decreases shortness of breath -To maintain adequate ventilation.

NURSING RESPONSIBILITIES PRIOR 1. Check for the doctor s order including the flow rate of O2 and what kind of O2 therapy would be used. 2. Assess patient s vital signs. 3. Explain the procedure to the patient. 4. Fill the humidifier with plain NSS. 5. Check the oxygen tank, humidifier, and flow rate meter if they are working properly. 6. Place a no smoking sign at the head of the bed. DURING 1. Assess for kinks and obstructions in the tube. 2. Secure the tubing, comfortably and the device used. 3. Always check the humidifier. It should be always filled with water. 4. Observe for moisture in the mask to prevent aspiration. 5. Observe for pressure necrosis. 6. Take note for any presence of irritation at the nares. AFTER 1. Check for client s response to the therapy. 2. Do after care on all the materials. 3. Check for skin irritations.

Medical Management Treatment Catheterization

Date Ordered/Performed Date ordered: August 31,2010 August 31,2010

General Descriptions


Client Response

Foley Catheter (3 way FC)

Urinary catheterization, or "cathing" for short, a plastic tube known as a urinary catheter is inserted into a patient's bladder via their urethra. Retained by means of a balloon at the tip which is inflated with sterile water. The balloons typically come in two different sizes: 5 cc and 30 cc. which are commonly made in silicone rubber or natural rubber.

Catheterization allows the Bladder distension is patient's urine to drain freely from relieved. the bladder for collection, or to inject liquids used for treatment or diagnosis of bladder condition. Providing relief for persons with an initial episode of acute urinary retention, allowing their bladder to regain its normal muscle tone

NURSING RESPONSIBILITIES PRIOR 1. Verify the doctor s orders for the type of catheter to be used. 2. Explain procedure to the client. 3. Asses the time the client last voided, the client s age, developmental stage and sex. DURING 1. Monitor for indication of obstruction, infection, or complications before the catheter is changed. 2. Monitor and record the output. 3. Perform catheter care. AFTER 1. Checked for the doctor s orders for removal of catheter. 2. Reassess the patient to determine the response to catheterization. 3. Document the time, date the catheter is removed. 4. Document significant findings.

Medical Management Treatment Penrose Drain

Date Ordered/Performed General Descriptions Date ordered: August 31,2010 Date Discontinue: ---


Client Response

Is consists of a soft rubber tube placed in a wound area, to prevent the build up of fluids. Promoting drainage of blood, pus and other fluids helps reduce the risk of infection and keeps the patient more comfortable.

- Prevent the area from accumulating fluid, such as blood, which could serve as a medium for bacteria to grow in. - Removes fluid from a wound area.

Assess the wound area by checking for signs of infection and drainage. 2. Secure a large safety pin on the tube outside the wound 3. Clean the area around the drain and incision. Record the amount. Position the patient to a comfortable position 2. Always check the dressing if it is damp 4. Apply a new dressing change or gauze after this. A large safety pin is placed on the tube outside the wound to maintain its position. AFTER 1. . Review the physicians order for the drain 2. Make sure the drain is patent or free of any blockage. Place a dressing over the Penrose drain to contain drainage. Assist the physician while doing the procedure 3. Explain the procedure to the client 3. Place the bed at an appropriate and comfortable working height NURSING RESPONSIBILITIES DURING 1. 5. color.PRIOR 1. consistency. and odor of any drainage.

5g (vial) TIV 750mg TIV q8 Classification: second.2010 9:50am August 30. 2010 1. dosage. Classification.DRUG STUDY Date ordered. Mechanism of Action Indications/ Purpose Client response to the medication. promoting osmotic instability. 2010 12:30pm Date given: August 30.Reduce incidence generation of certain postcephalosporin operative infection undergoing surgical procedures General action: treating or preventing bacterial infections by stopping the growth of bacteria Prior: -verify physician s order -check expiration date -check for hypersensitivity to cefuroxime or other cephalosporin -assess condition of the patient -explain possible side effect -check for any discoloration of the drug -check the IV site (for inflammation. actual side effects Nursing Responsibilities Generic Name: cefuroxime Brand Name: Date ordered: August 29. taken/given Name of drug Date changed/ D/C Route of administration . frequency General action. 2010 Date changed: September 2. redness or swelling) During: 500mg tab TID Mechanism of action: Inhibits cell-wall synthesis. .

usually bactericidal -administer as prescribed -administer over 3 to 5 minutes -do not take a double dose to make up for a missed one After : -monitor for adverse effect -report loose stools or diarrhea promptly -document administration of the drug .


inhibits prostaglandins and leukotriene synthesis Short-term Pain was relieved management of pain (up to 5 days) of moderately severe acute pain.Assess for baseline data. . frequency General action. .Tell patient that he may experience side effects brought upon by the drug. During: -provide comfort measures -administer the drug slowly After: . . relieve pain Mechanism of action: Anti-inflammatory and analgesic activity. weakness and dizziness upon standing.Instruct to report signs of bleeding such as black tarry stool. -Instruct to report intolerable side effects for prompt intervention . Mechanism of Action Indications/ Purpose Client response to the medication.Provide comfort measures if headache occurs. dosage.2010 Date given: August 30. taken/given Name of drug Date changed/ D/C Route of administration. actual side effects Nursing Responsibilities Prior: Generic Name: Ketorolac Brand Name: Toradol Date ordered: August 30. Classification. . 2010 30 mg TIV Classification: NSAID General action: Analgesic.Date ordered. No actual side It is most open effects used after surgery.Assess patient for contraindication.

Classification.Monitor for occurrence of adverse effects After: -Monitor vital signs carefully. -Monitor for side effects. binds serotonin receptors. lacks antiseizure. . dosage. but the clinical significance is unclear During: . 2010 Classification: Anxiolytic General action: Management of short term relief of symptoms of anxiety.Date ordered. frequency General action. or muscle relaxant properties. drug depresses the pulmonary and cardiac system. . actual side effects Nursing Responsibilities Generic Name: Buspirone HCl Brand Name: Buspar Date ordered: August 30. Mechanism of Action Indications/ Purpose Client response to the medication.Assess for baseline data.Tell patient that he may experience side effects Mechanism of action: Mechanism of action not known. taken/given Name of drug Date changed/ D/C Route of administration .Oral care if vomiting occurs.2010 Date given: August 30. Prior: . .Assess for contraindication. . sedative.

Mechanism of Action Indications/ Purpose Client response to the medication.Do not open foil-wrapped powders and tablets before use. .Avoid licorice. large amounts cause both hypokalemia and Na+ retention During . 2010 Discontinue: August 29.Instruct patient to avoid salt substitutes or low-salt milk or food unless approved by health care professional. taken/given Name of drug Date changed/ D/C Route of administration .2010 Date given: August 28.Do not use salt substitute unless specifically ordered by Dr.Do not self prescribe laxatives. frequency General action. Classification. . .Date ordered. dosage. actual side effects Nursing Responsibilities Prior: Generic Name: Potassium chloride Brand Name: Kalium durules Date ordered: August 28. 2010 2 tab BID Classification: Potassium salt General action: maintains potassium levels Mechanism of action: Replaces potassium and maintains potassium levels Indicated to prevent hypokalemia . Chronic laxative use has been associated with diarrhea-induced K+ loss .

unusual fatigue. . return to regular dose schedule. tarry. if not.Notify Dr.A missed dose should be taken as soon as remembered within 2 hr.Instruct patient to report dark. or bloody stools. of persistent vomiting because losses of K+ can occur . .After . or tingling of extremities. weakness.

Vitamin K deficiency causes an increase in bleeding tendency. Vitamin K malabsoption. pulse and BP -Instruct patient to report adverse effect that he may experience. nosebleeds. actual side effects Prior: Nursing Responsibilities Generic Name: Vitamin K Brand Name: Aqua-Mephyton Date ordered: August 28. VII. Prevention of bleeding. GI bleeding. demonstrated by ecchymoses. bleack tarry stools. dosage.Date ordered. and X. 2010 10mg 1 amp IM q8 Classification: Fat soluble vitamin General action: Plays an important role in blood clotting Mechanism of action: Vitamin K is essential for the hepatic synthesis of factors II. .2010 Date given: August 28. . taken/given Name of drug Date changed/ D/C Route of administration . Mechanism of Action Indications/ Purpose Client response to the medication.Assess for contraindication. all of which are essential for blood clotting. During: . frequency General action. hematuria. . hematuria. hypoprothrombinemia . epistaxis. IX. -Instruct patient to report symptoms of bleeding: bruising.Tell patient that he may experience side effects brought about by the drug and to report intolerable ones so as prompt interventions be done.monitor for bleeding. Classification.do not to take with other supplements After: .assess for baseline data.

Assess patient s blood pressure before starting therapy and regularly and pulse rate. Do not stop taking this drug without consulting your health care provider. 2010 50mg tab STAT Classification: Antihypertensive General action: Reduce blood pressure level Mechanism of action: Selectively blocks the binding of angiotensin II to specific tissue receptors found in the vascular smooth muscle and adrenal gland. suggest using barrier birth control while using losartan.Take drug without regard to meals. Mechanism of Action Indications/ Purpose Client response to the medication. After: . . frequency General action.Ensure that patient is not pregnant before beginning therapy. actual side effects Prior: Nursing Responsibilities Generic Name: losartan Brand Name: Cozaar Date ordered: August 29. Classification.2010 Date given: August 29. this action blocks the vasoconstriction effect of the reninangiotensin system as well as the release of aldosterone leading to Treatment of hypertension. alone or in combination with other antihypertensive agents .Obtain baseline liver and renal function before therapy and regularly assess kidney function BUN and creatinine.Assess for hydration status: mucous membranes and skin turgor . . dosage. taken/given Name of drug Date changed/ D/C Route of administration .Date ordered. During: .

Report fever.Tell patient to avoid sodium substitutes because it may contain potassium which can cause hyperkalemia -Teach patient to avoid sunlight or wear sunscreen because photosensitivity may occur.Monitor patient closely in any situation that may lead to a decrease in blood pressure. dizziness.decreased blood pressure. . . . . chills. pregnancy.

peripheral resistance and cardiac oxygen consumption and depresses rennin secretion. Beta-blocker General action: Reduce blood pressure level Mechanism of action: A selective beta blocker that selectively blocks beta 1 receptors.circulation problems. do not stop suddenly. actual side effects Nursing Responsibilities Generic Name: metoprolol Brand Name: Neobloc Date ordered: August 27. frequency General action. decreases cardiac output. -Avoid activities that require mental alertness until drugs effect realized. dosage. -Do not crush or chew. taken/given Name of drug Date changed/ D/C Route of administration. liver or kidney disorders. swallow tablets whole. may preclude drug therapy.emphysema. After: -Do not discontinue the drug abruptly. depression. Hypertension and chronic angina pectoris Prior: -Monitor V/S for baseline data. Mechanism of Action Indications/ Purpose Client response to the medication. -Continue with diet. -Assess for asthma. Classification. regular exercise and weight loss in the overall plan to control BP . During: -Take with food. -Take at same time each day.2010 Date given: August 27 2010 50mg tab PO BID Classification: Anti-hypertensive drug.Date ordered.

After: -Do not engage in activities that require mental alertness such as operating machinery and driving. inhibits sympathetic cardioaccelerator and vasoconstrictor centers.2010 75mg tab SL PRN >160/100 mmHg Classification: Antihypertensive General action: Reduce blood pressure level Mechanism of action: Stimulates CNS alpha2-adrenergic receptors. used alone or as part of combination therapy Not taken Prior: . Classification. actual side effects Nursing Responsibilities Generic Name: clonidine Brand Name: Catapres Date ordered: August 29. and decreases sympathetic outflow from the CNS.Take this drug exactly as prescribed. During: . frequency General action. dosage. -If taken PO. take last dose of the day at bedtime to ensure overnight control of BP. -Note evidence of alcohol. . Mechanism of Action Indications/ Purpose Client response to the medication.Assessment hypersensitivity to clonidine or severe coronary insufficiency. Do not miss doses. Monitor V/S especially the BP. y Hypertension. cerebrovascular disease. recent MI. taken/given Name of drug Date changed/ D/C Route of administration .Date ordered. drug or nicotine addiction.

rash. changes in vision. blanching of fingers. in the morning. .Report urinary retention.-Do not discontinue the drug abruptly. -Record weight daily. .

2010 300mg IV q 4 >37. Mechanism of Action Indications/ Purpose Client response to the medication. actual side effects Nursing Responsibilities Generic Name: Paracetamol Brand Name: Acetaminophen Date ordered: August 31. frequency General action.5 C Classification: non-opioid analgesic General action: produce analgesia by blocking pain impulses Mechanism of action: inhibits synthesis of prostaglandin that may serve as mediators of pain primarily in the CNS or other substances that sensitize pain receptors to stimulation For fever and mild pain Not taken Prior administration: -Verify physician s order -check for the expiration date -check hypersensitivity to the drug -explain for possible side effect -assess the type. location and intensity of pain PO-assess for vomiting During administration: -administer as prescribed IV-slowly administer at least over 3-5 minutes PO-take with food . taken/given Name of drug Date changed/ D/C Route of administration . Classification.Date ordered. dosage.

-take with full glass of water After administration: -assess for pain relief -monitor and report for side effects -document administration of the drug .

urticaria.2010 200mg cap BID Classification: Nonsteroidal Anti.I bleed . Classification. aspirin and other NSAIDinduced asthma. frequency General action. allergic type reaction y Monitor sign and symptoms y Assess for liver or renal dysfunction. primarily by inhibiting cyclooxygenase-2 thus decreasing inflammation. actual side effects Nursing Responsibilities Generic Name: celecoxib Brand Name: celebrex Date ordered: September 2. decreases stomach upset AFTER y Monitor CBC and electrolytes y Determine any G. Mechanism of Action Indications/ Purpose Client response to the medication. dosage. Indication: -Acute and longterm treatment of signs and symptoms of rheumatoid arthritis and osteoarthritis -Management of acute pain -Treatment of primary dysmenorrhea PRIOR y Determine any GI bleed/ulcer history. taken/given Name of drug Date changed/ D/C Route of administration .Date ordered.2010 Date given: September 2. reduce dose DURING y Take with foods.inflammatory Drug General Action Pain Reliever Mechanism of Action -Inhibits prostaglandin synthesis. sulfonamide allergy.

which is responsible for catalyzing an early step in the synthesis of cholesterol.Advise patient to avoid drinking more that 1 qt/day of grapefruit . frequency General action. exercise. During: . . taken/given Name of drug Date changed/ D/C Route of administration. In patients with coronary heart disease (CHD) or at high risk of CHD. and cessation of smoking. 3hydroxy-3methylglutarylcoenzyme A (HMG-CoA) reductase. and alcohol). Mechanism of Action Indications/ Purpose Client response to the medication. Mechanism of action: Inhibit an enzyme.Instruct patient to take medication as directed and not to skip doses or double up on missed doses. dosage. Prior: -Obtain base line data of the patient. cholesterol. Classification.Date ordered. actual side effects Nursing Responsibilities Generic Name: Simvastatin Brand Name: Zocor 80mg 1/2 tab OP OD Classification: Anti-hyperlipedimia General action: Catalyzes the early ratelimiting step in the synthesis of cholesterol. carbohydrates. An adjunct to diet when the response to a diet restricted in saturated fat and cholesterol and other nonpharmacologic measures alone has been inadequate. -Instructed patient that this medication should be used in conjunction with diet restrictions (fat.

Advise patient to wear sunscreen and protective clothing to prevent photosensitivity reactions (rare). -Emphasize the importance of follow-up exams to determine effectiveness of the drugs. tenderness.Instruct patient to notify health care professional if unexplained muscle pain.juice during therapy. . After: . or weakness occurs. .

Mechanism of Action Indications/ Purpose Client response to the medication. a small increase in serum potassium levels. a powerful vasoconstrictor. taken/given Name of drug Date changed/ D/C Route of administration. dosage. frequency General action. .2010 Date given: Classification: Angiotensin-converting enzyme (ACE) inhibitor Antihypertensive General action: Reduce level of blood pressure Mechanism of action: Blocks ACE from converting angiotensin I to angiotensin II. increased prostaglandin synthesis also may be involved in the antihypertensive action. 2010 Capoten Treatment of hypertension alone or in combination with thiazide-type diuretics Prior: -assess history of allergy to drug -inform the patient for possible side effects During: -Administer 1 hour before meal -monitor patient closely for drop in BP Post: . and sodium and fluid loss. Classification.Date ordered.mark patient's chart with notice that captopril is being taken -instruct to consult health care provider if light-headedness or dizziness occurs. actual side effects Nursing Responsibilities Generic Name: captopril Date ordered: August 30. decreased aldosterone secretion. Brand Name: August 30. leading to decreased blood pressure.

. taken/given Name of drug Date changed/ D/C Route of administration.2010 Date given: August 27 2010 80mg tab OD Classification: Antidiabetic.Inform the patient about the possible side effects that he/she can feel upon administration of drug During -avoid using alcohol while taking these drug -instruct to swallow extendedrelease tablets whole -do not crush. Glumetza. frequency General action.Check doctors order for latest dosage. actual side effects Nursing Responsibilities Generic Name: Metformin Brand Name: Fortamet.cut or chew After -monitor urine or serum glucose levels frequently to determine effectiveness of drug -instruct to do not discontinue drug without the doctors order. frequency & route.Date ordered. . Classification. Mechanism of Action Indications/ Purpose Client response to the medication. and increases peripheral uptake and utilization of glucose. Riomet Date ordered: August 27. oral.ExtendedRelease form used to treat type 2 diabetes as initial therapy. decreases intestinal absorption of glucose. -Improve glycemic control in clients with type 2 diabetes. dosage. Glucophage.assess for history of allergy to drug . Biguanide General Action: Antidiabetic Mechanism of Action: Decreases hepatic glucose production. . Prior .

DIET Type of diet NPO(Nothi ng Per Orem) Date Started General Description An instruction meaning to withhold oral foods and fluids but for patients who will undergo surgery the physician will allow before intake of medication Diet that allows intake of fluid or liquid forms of food only Indication/ Purposes This diet is usually ordered for preparation prior to surgery specially who will undergo general anesthesia to prevent aspiration pneumonia Before DAT diet is instructed the physician first ordered general liquid diet to train the normal Specific foods/fluids taken none Client Respons e Feels very hungry and thirsty Nursing Responsibilities During Post -Strictly monitor clients behavior in following NPO diet -Educate the client of what kind of food he can eat after NPO diet Date Change Prior -asses the level of understanding of the patient -Explain the importance of following strictly NPO diet in terms that the client can understand and then evaluate General Liquid Diet -Asses the level of understanding of the patient -Explain the importance of following strictly General Fluid diet in terms that the -Strictly monitor clients behavior in following General Liquid diet -Educate the client of what kind of food he can eat after General Liquid diet .

digestion and to bring back the normal digestion process DAT (diet as tolerated) (until discharge) It is a diet that allows the patient to eat all types/kinds of foods as long as the client can tolerate it Instructed following a general liquid diet for better source of good nutrition client can understand and then evaluate -Emphasize what kind of foods the client can eat during this diet. -Asses the level of understanding of the patient -Explain that immediate shifting of foods from NPO to General Fluids to DAT without undergoing soft diet can result to constipation thats why we need to emphasize eating first soft foods before eating any solid foods -Strictly monitor clients behavior in following DAT diet -Educate the client of what kind of food he can now eat that he can tolerate ACTIVITY AND EXERCISE .

Assist client to sit on bed DURING: .Assist patient while doing the exercise if necessary.Monitor the V/S of the patient to check if there is changes ACTIVE ROM An exercise accomplished by the patient without assistance. Activities include turning from side to side and from back to abdomen and moving up and down on bed.Check if he feels any pain after the exercise . .Check if there is difficulty in breathing .Check if he feels any pain while doing the exercise AFTER: .Ensure that the patient understand the reason for doing the exercise .TYPE OF EXERCISES DATE STARTED GENERAL DESCRIPTION INDICATION AND PURPOSE -Helps keep joint and muscle as healthy as possible -Increases muscle strength CLIENT RESPONSE TO EXERCISE NURSING RESPONSIBILITY PRIOR: . .

SURGICAL MANAGEMENT Open Cholecystectomy with Biliary Exploration Choledochoduodenostomy .TYPE OF EXERCISES DATE STARTED GENERAL DESCRIPTION INDICATION AND PURPOSE y aids in good circulation facilitate voiding stimulate peristalsis prevent thromboembolis m CLIENT RESPONSE TO EXERCISE The patient tolerated the exercise but he felt little bit tired NURSING RESPONSIBILITY AMBULATION A type of exercise that requires the patient to move by feet Act of travelling by foot y y Walk from place to place y PRIOR: -Assess patients ability to tolerance the procedure -Assess the patient if she needs assistance performing the procedure -Explain the procedure to the client DURING: -Assess the client if needed -Encourage client to ambulate independently if she is able. but walk beside the client -Be alert for signs of activity intolerance AFTER -Assess vital signs -Document significant findings VIII.

or to resect a malignancy. The injection is usually made in the lumbar spine below the level at which the spinal cord ends (L2). Instrumentation/ Device Number Size Comments Type of operation Laparoscopic cart . there are excessive adhesions. If unexpected pathology is encountered. giant stones. Spinal anaesthesia is easy to perform and has the potential to provide excellent operating conditions for surgery below the umbilicus. chronic respiratory failure. Type of Anesthesia Spinal Anesthesia Block . if acute inflammation distorts normal tissue planes. Choledochoduodenostomy is also useful for preventing cholangitis caused by recurrent stones in patients with chronic disease. the laparoscopic procedure is promptly converted to open cholecystectomy. or ductal or vascular anomalies exist. with or without cholelithiasis. perfomed laparospically. Note: Cholecystectomy. Main indication for biliary obstruction either benign or malignant.is induced by injecting small amounts of local anaesthetic into the cerebro-spinal fluid (CSF). is the preferred treatment for symptomatic gallstones unless the patient is extremely obese. or if there is excessive bleeding or surgical injury.Definition: A cholecystectomy is the surgical removal of the gallbladder A choledochoduodenostomy is the surgigal creation of a passage uniting the common bile duct and the duodenum. and diabetes.Indicated mainly in patients with recurrent stones. or concominant common bile stricture and stones. Choledochoduodenostomy may be performed for a biliary bypass operation are benign biliary strictures and malignant obstruction of the biliary system caused by pancreatic or biliary ductal carcinomas. Discussion: Cholecystectomy may be performed to treat chronic or acut cholecystitis. such as chronic heart failure.

5 and 10 mm diameter Available in various shapes according to surgeon s preference. we prefer to use a 30° 5 mm diameter laparoscope Selection of graspers should allow surgeon choice appropriate to thickness and consistency of gallbladder wall.High-intensity halogen light source (150 300 watts) High-flow electronic insufflator (minimum flow rate of 106 L/min) Laparoscopic camera box Videocassette digital video and still image recorder (optional) Digital still image capture system (optional) Laparoscope Atraumatic grasping forceps 1 2-4 3. insulation is required One curved and one straight scissors with rotating shaft and insulation. additional microscissors may be helpful for incising cystic duct Either disposable multiple clip applier or 2 manually loaded reusable single clip appliers for small and medium-to-large clips. insulation is unnecessary Used to extract gallbladder at end of procedure Should have a rotatable shaft.510mm 2-10mm Available in 0° and angled views. instrument should have channel for suction and irrigation controlled by trumpet valve(s). insulation required Cord should be designed with appropriate connectors for electrosurgical unit and instruments being used Large-tooth grasping forceps Curved dissector Scissors 1 1 2-3 10mm 2-5mm 2-5mm Clip appliers 1-2 5-10mm Dissecting electrocautery hook or spatula 1 5mm High-frequency electrical cord 1 .

the adhesion was released. facilitates retrieval of spilled stones 5mm 14gauge A cholecystectomy with choledochoduodenostomy was performed with patient under Spinal Anesthesia Block in supine position. A 2. these are often unncessary with newer disposable trocars and may be built into some reusable trocars Allows use of 2 3 mm instruments and ligating loops in 5 mm trocars 1-2 1 1 1-2 1 1 5mm 5mm Allow passage of catheter and clamping of catheter in cystic duct Used if initial trocar is inserted by percutaneous technique Allow atraumatic grasping of bowel or gallbladder Useful for aspirating gallbladder percutaneously in cases of acute cholecystitis or hydrops Useful for preventing spillage of bile or stones in removal of infl amed or friable gallbladder. a right subcostal incision was made.Suction-irrigation probe 1 5-10mm 10-to-5 mm reducers 2 5-to-3 mm reducer Ligating loops Endoscopic needle holders Cholangiogram clamp with catheter Veress needle Allis or Babcock forceps Long spinal needle Retrieval bag 1 Probe should have trumpet valve controls for suction and irrigation. may be used with pump for hydrodissection Allow use of 5 mm instruments in 10 mm trocar without loss of pneumoperitoneum. so that it can be approximated to the common bile duct without tension. and the area of the hepatoduodenal ligament was dissected.5 cm longitudinal incision is made in the distal common bile duct as close as possible to the area of stenosis or obstruction in .0. A right subcostal incision is usually performed.The duodenum is widely mobilized by generous Kocher maneuver.2. The cholecystectomy was performed in the usual manner.

In patients with a stricture. The duodenum is opened longitudinally for a distance of 2. Sutures is placed to approximate the ductal and duodenal mucosa.patients with benign disease. the bile duct is divided and the stricture excised.2. The duodenum and duct are joined by a posterior or row of interrupted 3-0 silk sutures. A final row of interrupted 3-0 silk sutures completes the anterior row of anastomosies.0.5cm and a second row of interrupted 3-0 or 4-0 chromic catgut. A T-tube is used in patients with thin walled ducts or difficult anastomosies. .

either right subcostal (most frequently used). The gallbladder is mobilized by incising the overlying peritoneum and after local dissection is removed. Hemoclips). Jackson-Pratt ) may be employed exiting a stab wound and secured to the skin with a stitch. The gallbladder is grasped (generally with a Pean clamp). extending from the axilla to the pubic symphysis and down to the table on the sides. The abdominal cavity is entered in the usual manner. Skin Preparation: Begin at the intended site of incision. An electrosurgical dispersive pad is applied. or medline. tapes. or skin staples. and common bile duct are exposed.. The patient is supine. The skin is closed with interrupted stitches.g. as is the cystic duct. A foley catheter is not routinely placed. Pad all bony prominences and areas vulnerable to skin and neurovascular pressure of trauma.. A drain (e. The underlying liver bed may be reperitonealized. The cystic artery is clamped (using two right-angle clamps) and ligated with a suture passed on a long instrument or by clips (e. or midline. condition of skin preoperatively) must . A pillow may be placed under the sacrum and/ or under the knees to avoid straining back muscles.g.Preparation of the Patient: Antiembolitic hose may be put on the legs.g. as requested. right paramedian. NURSING RESPONSIBILITY Preoperative y All care that is given and observations made regarding the patient (e. right paramedian. The wound is closed in layers. The cystic duct. The surgeon must be aware of anomalies of these structures. cystic artery. Procedure Draping: y 4 folded towels and a laparotomy sheet Procedure: The incision is right subcostal. both arms may be extended on padded armboards.. A nasogastric tube may be inserted by the anesthesia provider.

Document allergies noted preprocedure and document alternative used. endocrine function. hepatic and renal function. Explain nursing procedures before performing them and the sequence of perioperative events. watch. Assess health factors that affects the patient preoperatively: nutritional status. drug or alcohol use. 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.g. immune function. 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. When the circulator reviews patient allergies with the patient. Respect cultural. psychosocial factors. medications and contact lenses Instruct what to wear ( loose fitting. allergy to iodine. Inform the patient of the scheduled date and time of the surgery and where to report Instruct what to bring (insurance card.y y y y y y y y y y y y y y y be documented in the operative record for continuity of care and for medicolegal reasons. spiritual and religious beliefs Intraoperative y It is imperative that the patient be positioned over the correct area on the table to ensure accurate visualization . previous medication use. he ascertains that the patient has no history of allergy to radiopaque dye. 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. list of meds & allergies) Check the chart for patient s sensitivities and allergies e. Instruct what to leave at home such as jewelry. cardiovascular status. Decrease fear Teach deep-breathing. as well as the spiritual and cultural beliefs. 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.

Scrub person needs to have a right angle clamp (Mixter) available throughout the dissection of the biliary tree.y y y y y y y y y y y y y y y y y y y y y of the biliary tract. Instruments used on the gallbladder are isolated in a basin (considered contaminated) Prevent musculoskeletal injuries to team members by employing ergodynamic measures when positioning the patient. on the opening field must be labeled. Scrub person should use a marking pen on labels to identify all solutions. Have T-tubes available following common duct exploration One syringe is filled with saline. offer warm blanket or raise room temperature as necessary... expose only the immediate area involved for the procedure. Usually a stab wound is made in the cystic duct using a #11 blade. Strictly follow the principles of surgical asepsis Keep surgical conscience Count all instruments and sharps with circulating nurse before and after the procedure Know the name and use of the instrument Never pile the instruments on top of each other Know the name and use of the instrument and handle the instrument individually Hand the surgeon the correct instrument Pass the instrument firmly and decisively Be careful in handling of sharp instruments at all times The scrub person sets up the instruments on the back table for the surgeon. etc. and a second syringe is filled with radiopaque dye diluted to half strength (labeled accordingly) Scrub person takes care to make certain that the saline or dye catheters are devoid of air bubbles (which can be confused for calculi) . Take appropriate measures to maintain patient s body temperature e. All medications. dyes. A protective facial shield is suggested for those scrubbed to avoid inadvertent splashing of contaminated fluids onto mucous membranes and eyes.g. All medication containers should be kept in the room until the completion of the procedure. The incision is extended with Pott s scissors. Keep the patient adequately covered to maintain patient s privacy.

side rails and maintain patent airway and cardiovascular stability Relieve pain and anxiety Client Response Pre operative: y Patient complaint of pain on right upper quadrant y Feeling of fear to the procedure. assess neurological status (LOC) PACU nurse observes the patient s breathing.. NURSING CARE PLAN ASSESSMENT NURSING DIAGNOSIS BACKGROUND KNOWLEGDE PLANNING NURSING INTERVENTION RATIONALE EXPECTED OUTCOME . PACU nurse assumes the role as the patient s advocate. Intra Operative: y Patient is sedated Post operative: y Patient finds it hard to sleep because of pain felt on the incision site y Client appears weak Skin color improvement from jaundice to slight jaundice as of August 24. Assess the patient: appraise air exchanges status & note skin color.y y Use a small basin to accept the specimen Aerobic and anaerobic cultures may be taken of the bile or gallbladder bed. Report for abnormalities especially for signs and symptoms of shock Perform safety checks good body alignment. 2009 IX. verify & identify operative status & surgeon performed. and documents all pertinent information. y y Postoperative y y y y y The circulator accompanies the anesthesia provider and the patient to the PACU. monitors blood pressure and vital signs. he/she gives the PACU perioperative practioner a detailed intraoperative patient report regarding the course of events as they apply to the individual.

Long term goal: After 1-2 days of nursing intervention the patient vital sign was on normal range especially the temperature. Vitamin C boosts immune system and resistance to infection. Exogenous pyrogen Short term goal: (expose to foreign After 30 minutes of microorganism) nursing intervention the patient temperature will Bacterial invasion decrease from 39. interleukins and interferons) y Encourage to wear hypothermic clothing Promote bed rest y y y y Promote inatake of caloric rich food and rich in vitamin C Hypothalamus signals increase in heat production Dependent: y Administer medication as ordered by the To decrease body temperature through evaporation To provide comfort To regain loss energy due to illness process To adapt on the increasing metabolism of the client during fever. Objective: y cold clammy skin y hot flsh y warm to touch y v/s as follows: T.2 o C to 37. y Fever To decrease body temperature . Long term goal: After 1-2 days of nursing intervention the patient vital sign will be on normal range especially the temperature.38.3*C PR.5 oC.5 oC.2 o C to 37. Independent: y Provide tepid sponge y bath y Release of substances (activation of TNF.22 cpm Elevated body temperature related to Infection.Subjective: Nilalamig ako as verbalized by the client.77 bpm RR. Short term goal: The patient temperature was decrease from 39.

patient was verbalized an understanding of the condition and y y . prioritize intervention and rationale. Lippincott Williams and Wilkins 2007 Source: Nurses pocket guide Diagnoses.physician Mattson Porth. DIAGNOSIS Impaired skin integrity related to inadequate primary defences (surgical incision) SCIENTIFIC BACKGROUND Surgical incision on the right upper quadrant and epigastric area of the abdomen PLANNING Short term: After 3 hours of nursing intervention the patient will y INTERVENTION Place in a comfortable position Monitor and record vital y RATIONALE To prevent back aches or muscle aches To note any significant EVALUATION Short term: Goal met. ASSESSMENT Subjective: nangangati yung tahi ko . as verbalized by the client. 11th Edition. Essentials of Pathophysiology Concepts of Altered Health Status.

medicating wound Emphasize importance of proper nutrition and fluid intake Encourage adequate period of rest and sleep y changes that may be brought about by the disease Reduce risk for infection causative factor. y y y y Promote early ambulation To maintain general good health and skin turgor To limit metabolic demands.nih.nlm. impairing the integrity of the skin y y Practiced aseptic technique for cleaning.gov/med patient displays lineplus/ency/article/002930.Objective y Moist intact dressing at the right lower quadrant. Thus. progressive improvement in htm wound healing. y Feeling of itchiness y Destruction of skin surface Trauma to the skin verbalize understanding of condition and causative factor. remain energy available for healing and meet comfort needs Promote circulation and prevent excessive tissue pressure. Long term: Goal met. patient displays progressive improvement in wound healing. dressing. Source: . y signs Long term: After 2 days of nursing intervention the Source: http://www.

11th Edition. patient was verbalized an . ASSESSMENT DIAGNOSIS SCIENTIFIC BACKGROUND Surgical Incision PLANNING INTERVENTION RATIONALE EVALUATION Subjective: Ø Risk for infection related to inadequate primary Short term: After 2 hours of nursing intervention Independent: y Monitor Vital signs. Note onset y Suggestive of presence of Short term: Goal met. prioritize intervention and rationale.Nurses pocket guide Diagnoses.

y y Emphasise importance of adequate . infection or developing sepsis. Prevent invasion of bacteria or microorganism at site and eventually prevents possible infection. y s/p cholecystecto my with biliary exploration. Microorganism thrives at damp areas and makes it conducive for understanding to prevent or reduce risk of infection. Lippincott Williams and Wilkins 2007 of fever. y y Dependent: y Administer medications as prescribed (antibiotics). y y Cleanse incision site with povidone iodine. without any Essentials of complication. patient was able to demonstrate techniques to promote timely wound healing without any complication. Provide early detection of developing infectious process. Traumatized tissue on the injured site Increasing risk of infection the patient will verbalize understanding to prevent or reduce risk of infection. Reduce risk of spread of bacteria or prevent cross contamination. Pathophysiology Concepts of Altered Health Status. chills and diaphoresis. Inspect incision and dressing. Long term: Goal met. Practice hand washing and aseptic wound care. y y Instruct not to wet incision site. Disinfect site and prevent multiplication of microorganism which may cause infection. y y Long term: May result to further After 2 days of complication if not nursing intervention the patient will be prevented able to demonstrate techniques to promote timely wound healing Mattson Porth. Objective y Presence of an incision site on right lower quadrant.defences (surgical incision).

11th Edition.y nutritional and fluid intake. ASSESSMENT DIAGNOSIS SCIENTIFIC BACKGROUND Lack in information resources PLANNING INTERVENTION RATIONALE EVALUATION Subjective: hindi ko nga alam kung paano ako nagkaron ng bato Deficient Knowledge related to unfamiliarity After 4 hours of nursing intervention the y Determine ability or readiness and y Individual may not be physically. patient was verbalized an understanding of . y replication. Encourage ambulation as tolerated. y To enhanced good circulation. Maintain general good health and skin turgor. Goal met. prioritize intervention and rationale. Source: Nurses pocket guide Diagnoses.

. cultural influences. Reinforces learning process. condition or disease process or treatment. religion. Can allows interest and limits sense of being overwhelm. Clarifies expectation of teacher and learner. allows to proceed at own pace. Provide mutual goal setting and learning contracts. y y y barriers to learning. Begin with information already know and move to what does not y emotionally or mentally capable. y To facilitate learning. and level of education. Feeling of unawareness Objective y Unawareness Deficient Knowledge patient will verbalize understanding of condition or disease process or treatment. Provide positive reinforcement. y y y y y y y Can encourage continuation of effort. Note personal factors such as age. May need to help SO to learn. with information resources. Provide written information or guidelines and self learning modules. Identify support persons or SO requiring information.sa apdo e as verbalized by the client.

ASSESSMENT DIAGNOSIS SCIENTIFIC BACKGROUND Verbalization of willingness to follow home PLANNING INTERVENTION RATIONALE EVALUATION Subjective: pauwi na ako.know. meron na lang Readiness for enhance therapeutic Short term After 4hours of nursing y Verify client s knowledge/understandi ng of therapeutic y Provides opportunity to assure accuracy Short term Goal met. patient was assumed responsibility .

Promotes sense of self-esteem and confidence to continue efforts for managing treatment regimen. Assist in implementing strategies for monitoring progress/ responses to therapeutic regimen. patient was remain free of preventable complications/progres sion of illness. Acknowledge individuals efforts/ capabilities to reinforce movement toward attainment of desired outcomes. as verbalized by the client. Long term Goal met. Long term After 2 days of nursing intervention the patient will remain free of preventable complications/pr ogression of illness. regimen management health maintenance Objective y Willingn ess to follow Assumes responsi bility in maintain ing health Readiness for enhance therapeutic regimen management intervention the patient will assume responsibility for managing treatment regimen. y and completeness of knowledge base for future learning Understanding the process enhances commitment and the likehood of achieving the goals. y y Provides positive reinforcement encouraging continued progress toward desired goals Problem proactive problem solving X. HEALTH TEACHINGS HEALTH TEACHING RATIONALE .akung iinuming gamut sa amin. regimen y Identify steps necessary to reach desired goal y y y y y Accepts clients evaluation of own strengths/ limitations while working together to improve abilities.

3. the liver still produce bile but in a slow tickle process. Prevent the spread of microorganism/ cross contamination XI. Explain to the patient the importance of eating small frequent meals (preferably 4-6 meals) rather that to eat 3 times a day. 4. the liver will compensate by excreting slow and low level of bile that can cause the malabsorption of fat. the malabsorption of fat occurs because the minimal production of bile cannot handle the normal absorption process To promote good circulation.1. Explain to the patient the importance of deep breathing exercises/ divertional activities. Since cholecystectomy is done. Splinting reduces the pressure in the abdomen thus reducing the pain. After cholecystectomy. therefore if the diet is high in fat. To prevent infection 5. Explain to the patient the importance of splinting. Explain to the patient the importance of maintaining a clean and well ventilated environment. Explain the importance of proper hygiene To reduce the risk of infection and to promote patient s comfort. Encourage to decrease intake of foods high in fat/ cholesterol. Explain the importance of ambulation. 7. Deep breathing exercises/ divertional activities help to reduce pain. Explain to the patient not to touch the incision site with bare hands. 2. DISCHARGE PLANNING MEDICINES: . 6. 8.

their side effects and their adverse effects Teach the following to the client with regards to proper administration of the prescribed medication -right patient -right assessment -right drug -right documentation -right time -right to educate -right dose -right to evaluate -right route -right to refuse ENVIRONMENT AND EXERCISE y y y Encourage to establish a clean and well ventilated environment Avoid strenuous exercise that cause tension on the affected area and further deprivation Daily activities should be spaced to provide rest periods between times of exercise TREATMENT y y Advise to continue to take the prescribed home medication until end of the regimen or unless specified by the physician Instruct him to visit physician to follow-up check-up HEALTH TEACHING y y y y y Explain to patient what to expect afterwards. Avoid doing strenuous activities which could low down his recovery Encourage him to comply with the dietary modifications. Instruct patient to comply with the home medications that would be given by his physician. there is likely to be some pain.y y y Instructed to continue home medication Give relevant information about the drugs. limit the intake of saturated fat to prevent the occurrence of serious post-cholecystectomy side effects . The anesthetist will prescribe pain killers. Encourage the patient to do the recommended light exercises such as walking. hygiene and bathing and will arrange an outpatient appointment for the stitches to be removed. Suffering from pain san slow down recovery. so it s important to discuss any pain with the doctors or nurses Instruct caring for the stitches. As the anesthetic wears off.

CONCLUSION . XII. encourage praying Avoid strenuous activity. Advised to eat around 5 to 6 smaller meals a day instead of 2 to 3 usual meals SPIRITUAL/SAFETY y y Encourage going to church and asking for guidance.y Explain to the patient to refer for unusualities immediately OUT PATIENT CARE y y Instruct to visit the physician for follow-up check-up If any of the following symptoms are noted he should contact his doctor -if the wound become more painful. inflamed or swollen -if the abdomen swells -if the pain is not relived by the prescribed painkillers -if a fever develops these could be a sign of an infection that may need to e treated with antibiotics DIET y y Should limit the intake of foods high in fat Should eat smaller amount of foods during a single meal. red.

clinical manifestations. After 3 days of exposure at BMC Medical Ward. its signs and symptoms. ³No matter how the disease has already reached an alarming incidence rate or not. which carries bile from the gallbladder. diagnostic studies. The only one who can help yourself is you alone. Moreover. pharmacological and nursing interventions through obtaining cues and health history in conjunction to the disease process. It reminded us again that nursing profession entails a deep sense of responsibility and challenging tasks. Predisposing factors can include heredity. We underwent extensive research in order to comprehensively understand our patient¶s condition. it challenged and motivated us to work hard to provide the appropriate and effective nursing intervention and care. it is a duty of every human person to take care of his own body.Generally. we. medical. the student nurse¶s 3 days exposure and duty at Bulacan Medical Center have been a memorable experience to us. cholecystitis is the most common problem resulting from gallbladder stones. but most especially for himself ~ a primary obligation that he must fulfill. With the presented factors that cannot already be modified. we the student nurse has identified and understood the causative factors of cholecystitis. sex and race. Upon learning his case. BIBLIOGRAPHY . The exposure had been an avenue for further development and enhancement of our skills and capabilities in rendering care and promoting holistic wellness to our clients. not just for the sake of other people that depend on him. It occurs when a stone blocks the cystic duct. age. With the proper knowledge about the nature of the disease as well as its preventive measures along with responsibility and sense of will. one can surely direct himself away from the complications.´ XIII. one has to take action towards preventing the disease to happen.

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

2008. Murr.. 2007 Lippincott¶s Nursing Drug Guide. 11th ed. 2007. Pocket Guide to the Operating Room. 2007. Davis Company. Goldman 2008. Lippincott Williams & Wilkins. Nursing Care o Plans 7th ed. Mary Frances. Lippincott Williams & o Wilkins.A.Surgical Nursing. Pennsylvania. Singapore. Essentials of Pathophysiology: Concepts of Altered Health States. 3rd edition F. CMPMedica Asia Pte Ltd. 148-153. y Karch. F. 2004. Davis Company. Marilynn E. Amy M. o 2nd ed.o Brunner & Suddarth¶s Textbook of Medical. o Lippincott Williams & Wilkins. 108th ed.2006.A. Philadelphia. Carol M. y Doenges. y pp. Moorhouse. Porth. y y MIMS. Maxine A. Vol.1. Alice C.Philadelphia .

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