Cholecystectomy

- Data

OPERATING ROOM
Related Learning Experience Case Scenario
Date: August 16,17,18,23,24,25,30,31, 2021
Monday, Tuesday and Wednesday
Mode: Online/Asynchronous)

Patient A is a man 37 years of age who arrives in the PACU following surgical removal of his
gallbladder. Surgical intervention using the laparoscopic approach is successful.

Patient A's airway and ability to maintain respiratory stability is evaluated immediately. His
respiration is 16 breaths per minute, and his heart rate is 78 beats per minute. Oxygen is being
administered at 2 liters via nasal cannula. A pulse oximeter is placed on his left forefinger, and his
oxygen saturation is measured at 95%. The patient is arousable but easily drifts off to sleep.

- How it is diagnosed
Abdominal ultrasound. This test is the one most commonly used to look for signs of gallstones.
Abdominal ultrasound involves moving a device (transducer) back and forth across your stomach
area. The transducer sends signals to a computer, which creates images that show the structures
in your abdomen.
Endoscopic ultrasound (EUS). This procedure can help identify smaller stones that may be
missed on an abdominal ultrasound. During EUS your doctor passes a thin, flexible tube
(endoscope) through your mouth and through your digestive tract. A small ultrasound device
(transducer) in the tube produces sound waves that create a precise image of surrounding tissue.
- Signs & Symptoms
Intense, sudden pain in the upper right part of your belly.
Pain (often worse with deep breaths) that spreads to your back or below the right shoulder blade.
Nausea.
Vomiting.
Fever.
Yellowing of the skin and eyes (jaundice)
Loose, light-colored bowel movements.
Belly bloating.
 PATHOPHYSIOLOGY
(Book Based)

The pathophysiology cholecystitis for the book base starts with risk factors associated
with development of gall stones including genetics, obesity and rapid weight loss through diet or
surgery. Developing gallstones begin in three factors, first is the bile must become supersaturated
with cholesterol and calcium, second the crystal must come together and fuse to form stones and
the last factor the solute precipitates from solution as solid crystal. After developing gallstones,
the obstruction of the cystic duct and common bile duct have two possible signs and symptoms.
Sharp pain in the right part of the abdomen and jaundice. Due to obstruction the gallbladder will
begin to enlarge and may result the venous and lymphatic drainage is impaire, proliferation of
bacteria, localize cellular irritation or infiltration and areas of ischemia may occur eventually it
can cause inflammation of the gallbladder and may result cholecystitis.

- Lab procedure / Results

1. Complete Blood Count
This is to determine components and response to inflammatory process and streptococcal
infection.
Complete Blood Count
Complete Blood Count (CBC) is a group of tests that
evaluate the cells that circulate in the blood. Variety of
complications can be detected with the test such as infection,
anemia, and leukemia.

Cell Result of the patient Normal Range

White blood cell 10.7 x 10⁹/L 4 - 11 x 10⁹/L

Red blood cell 4.9 x 10¹²/L 4.5 - 6.5 x 10¹²/L

Hemoglobin 147 g/L 130 - 180  g/L

Hematocrit 45% 42% - 54%

Platelet 295 10⁹/L 150 - 450 x 10⁹/L

Table x. Complete Blood Count
The table shows the laboratory result of the patient for a
complete blood test that contains the white blood cells, red
blood cells, hemoglobin, hematocrit, and platelets. In addition,
the patient’s results have reverted back to the normal range that
signifies there are no further infections.
- Date & Time Admitted & Discharged
Patient A was admitted to the hospital on August 16, 2021 9:53 Am and he had his surgery at 3
pm. The operation last 2 hours without any problem. He was discharged after 5 days in the
hospital as the doctor to him to do so.
- History of Illness
According to Patient A that the familial disease he knows that they have in their family was the
hypertension that is on his father’s side. His father died because of heartattack and her mother
died of natural cause. He also added that cholecystitis is prone to their family, because of one of
his siblings also had acquired this disease
- Type of Surgery (Operation performed)
Cholecystectomy
The gallbladder is a small organ under your liver. It is on the upper right side of your belly or
abdomen. The gallbladder stores a digestive juice called bile which is made in the liver. Open
(traditional) method. In this method, 1 cut (incision) about 4 to 6 inches long is made in the
upper right-hand side of your belly. The surgeon finds the gallbladder and takes it out through
the incision.

- Drugs taken pre-op & post-op (Drug Study)

This includes prescription-strength nonsteroidal anti-inflammatory drugs (NSAIDs) and opioid
painkillers like codeine, hydrocodone and morphine.
DRUG STUDY
GENER MECHANISM INDICA CONTRAINDIC ADVERSE NURSING
IC OF ACTION TIONS ATIONS REACTION  CONSIDERATIO
NAME N
This drug For This drug CNS: BEFORE:
Morph interacts Adults is confusio ●Ensure there
ine with :  contraindic n, is a
sulfa opioid ated in sedation physician’s
te receptor Oral clients , order before
sites, (Table with: dizzines giving the
primarily t):   Hypers s, drug.
Pregn in the 5-30 ensiti dysphori ● Check and
ancy limbic mg vity a, verify the
Risk system, (q4hrs to euphoria right drug's
Categ thalamus, p.r.n) drug, , name or
ory: and 20 mg tartra floating label, route,
C spinal (QID zine, feeling, dosage, time,
cord. or bisulf hallucin frequency and
This BID) ites, ations, expiration
interacti 200 mg or headache date.
on alters (QID)  alcoho , ● Verify the
neurotran l  nightmar right patient
smitter  Acute es  and check or
release, Intrav bronch review the
altering enous: ial CV: client’s
perceptio -2 to asthma  hypotens history to
n of and 10  Upper ion, drug
tolerance mg/70 airway bradycar interactions,
for pain. kg obstru dia  medications
(p.r.n ction  previously
slowly EENT: given or diet
 Respir
over blurred and also
atory
4-5 vision, client’s
depres
mins.) diplopia allergies.
sion 
-0.1 , ●Inform the
to 1  GI miosis  client about
mg/ ml obstru the side
in ction, effects and 
GI:
dextro paraly adverse
nausea,
se 5% tic reactions of
vomiting
in ileus the drug like
,
water constipa dizziness,
delive tion, nausea and
red by dry vomiting,
contro mouth  constipation,
lled- urinary
infusi GU: retention and
on urinary respiratory
device retentio depression.
. n  ●Before
giving the
Respirat medication,pe
ory: rform skin
apnea, testing to
respirat ensure the
ory client has no
depressi allergy to
on, the drug.
respirat ●Give the
ory client enough
arrest  autonomy to
refuse to
Skin: medication
flushing after
, thoroughly
itching, explaining
sweating  the effects.
DURING:
Other: ●For oral
physical intake, tell
or patient he
psycholo may crush
gical immediate-
drug release form
dependen and mix with
ce, drug food or
toleranc fluids.
e ● Tell
patient he
may open
sustained-
release
capsule,
sprinkle
entire
contents of
capsule onto
a small
amount of
food (such as
applesauce),
and consume
immediately. 
●Stress
importance of
not chewing,
crushing, or
dissolving
pellets.
●Advise
patient not
to crush or
break
extended-
release form.
Instruct him
to swallow it
whole.
● Advise
patient to
take drug at
the first
sign of pain,
because
continuous
dosing is
more
effective
than p.r.n.
dosing.
● Monitor
vital signs.
Contact
prescriber if
respiratory
rate is 10
breaths/minut
e or less. 
● Assess pain
character,
location, and
intensity.
● Monitor
fluid intake
and output.
Stay alert
for urinary
retention. 
● Monitor
bowel
elimination
pattern. If
constipation
occurs,
intervene as
appropriate. 
● Assess
neurologic
status.
Implement
safety
measures as
needed to
prevent
injury.
AFTER:
●Evaluate the
client for
any any
adverse
reactions and
record the
implemented
care.
●Inform
client that
drug may
cause
constipation
or urinary
retention.
Encourage
high-fiber
diet and high
fluid intake.
● Stress
importance of
taking drug
only as
prescribed.
Point out
that drug may
cause
psychological
or physical
dependence.
● Caution
client to
avoid driving
and other
hazardous
activities
until he
knows how
drug affects
concentration
, vision, and
alertness.
● Teach
client and
caregiver
about
appropriate
 safety
measures to
prevent
injury.
● Caution
client to
avoid alcohol
and other CNS
depressants
during and
for 24 hours
after
therapy.
● As
appropriate,
review all
other
significant
and life-
threatening
adverse
reactions and
interactions,
especially
those related
to the drugs,
tests, and
behaviors
mentioned
above.

CHAPTER IV

Nursing Care Plan

ASSESSMENT OUTCOME PLANNING INTERVENTIO EVALUATI
 NURSIN IDENTIFI N ON
G CATION
DIAGNOS
IS
Constip Within 8
Subjective: ation hours of Short- Independent Short-
related nursing term: : term:
“Masakit ang to interven
tiyan ko.” surgery tions, After 8  Determ After 8
 as the
As manifes patient hours of ine hours of
verbalized ted by will be nursing stool nursing
by the difficu able to interven color, interven
client. lty in return tion, consis tions,
bowel to the tency, the
  movemen normal patient freque patient
ts patterns will be ncy, was able
Objective: of bowel able to and to
function return amount return
·         to . to
ing.
Abdominal normal normal
pain, patterns Rationale: patterns
cramping of bowel assists in of bowel
function identifying function
·         causative
ing. ing.
Altered or
bowel   contributin  
sounds g factors
Long and Long
  term: appropriate term:
Vital signs interventio
After 24 ns. After 24
taken as hours of hours of
follow: nursing nursing
 
interven interven
Temp: 36.5
tions,  Auscul tions,
RR: 16cpm the tate the
patient bowel patient
PR: 76bpm returns sounds returns
to . to
BP: normal normal
140/90mmHg patterns Rationale: bowel
of bowel bowel function
Weight: function sounds are ing,
110kg ing, generally showed
will decreased its
Height: 1.7m show in normal
normal constipatio bowel
bowel n. sounds,
sounds, and no
and no   signs of
signs of abdomina
pain.  Encour l pain.
age
fluid  
intake
of
  Goa
2500- l
3000ml was
/day met
within .
cardia
c
tolera
nce.

Rationale:
assists in
improving
stool
consistency
.

 Recomm
end
avoidi
ng gas
formin
g
foods
(e.g.,
lentil
s,
brocco
li,
cabbag
e, and
milk)

Rationale:
decrease
gastric
distress
and
abdominal
distension

 Discus
s use
of
 stool
soften
ers,
mild
stimul
ants,
and
bulk-
formin
g
laxati
ve.
Monito
r
effect
ivenes
s.

Rationale:
facilitates
defecation
when
constipatio
n is
present.

 Encour
age to
eat
high-
fiber
rich
foods
(beans
,
wheat-
bread,
pasta,
and
brown
rice.

Rationale:
to enhance
easy
 defecation.

Collaborati
ve:

 Consul
t with
a
dietit
ian to
provid
e a
well-
balanc
ed
diet
high
in
fiber
and
bulk.

Rationale:
fiber
resists
enzymatic
digestion
and absorbs
liquids in
its passage
along the
intestinal
tract and
thereby
produces
bulk, which
acts as a
stimulant
to
defecation.

- History of the case

The gallbladder is a small organ under your liver. It is on the upper right side of your belly or
abdomen. The gallbladder stores a digestive juice called bile which is made in the liver.
- Health teachings
-Ask someone to drive you to your appointments for the next week. Don’t drive until you are no
longer taking pain medicine and can step on the brake pedal without hesitation.
-Don’t worry if you feel tired for the first couple of weeks after your surgery. Fatigue is
common:
-Nap when you feel tired.
-Get plenty of rest.
-Walk around the house, do office work, climb stairs, or ride in a car if you feel able to do so.
-Don’t do any strenuous physical activities, heavy lifting (nothing heavier than 10 pounds or 4.5
kg), or sports for 4 weeks after surgery.
-Eat your normal diet. If your healthcare provider advises a low-fat diet, ask for menus and other
diet information.
-If you are constipated, discuss a bowel regimen with your provider. Pain medicines can be
constipating. Increased fiber and a stool softener are often helpful.
-Gently wash the skin around your incision daily with mild soap and water.
-If there is a gauze dressing on your incision, change it daily or as often as needed to keep it dry
and clean.
-You may take a shower (even if there is a surgical drain in place), unless your healthcare
provider gives you different directions.
-Don’t sit in a bathtub, swimming pool, or hot tub until the incision is closed and any surgical
drains are removed.

- Anesthesia Taken (Type)

Endotracheal general anaesthesia (GA) is the anaesthetic technique of choice for laparoscopic
cholecystectomy (LC). Regional anaesthesia too (spinal/epidural/combined spinal epidural) has
been reported as a sole technique for performing LC as an alternative to GA for LC.
- Course of Disease
-Cholecystitis happens when a digestive juice called bile gets trapped in your gallbladder.
-In most cases, this happens because lumps of solid material (gallstones) are blocking a tube that
drains bile from the gallbladder.
-When gallstones block this tube, bile builds up in your gallbladder. This causes irritation and
pressure in the gallbladder. It can cause swelling and infection.
-The gallbladder stores bile. Gallstones are formed in your gallbladder. They are made from bile.

Other causes of cholecystitis include:

Bacterial infection in the bile duct system. The bile duct system is the drainage system that
carries bile from your liver and gallbladder into the first part of your small intestine (the
duodenum).
Tumors of the pancreas or liver. A tumor can stop bile from draining out of your gallbladder.
Reduced blood supply to the gallbladder. This may happen if you have diabetes.
Gallbladder sludge. This is a thick material that can’t be absorbed by bile in your gallbladder.
The sludge builds up in your gallbladder. It happens mainly to pregnant women or to people who
have had a very fast weight loss.