Cholecystitis

ATENEO DE DAVAO UNIVERSITY
College of Nursing
IN PARTIAL FULFILLMENT OF OUR REQUIREMENTS

IN NURSING CARE MANAGEMENT 103
RELATED LEARNING EXPERIENCE
A CASE STUDY ABOUT CHOLECYSTITIS
Presented to:
MRS. GISSELLE CHARADE A. ZAMORA, R.N.
Presented by:
MR. MICAH NOEL I. PERPETUA
MR. JONI S. PURAY
MS. MA. PRINCESS H. GCCAE SANTILLAN
MS. ARNIKKA B. RUBIA
MR. RIEL R. SEGURA
BSN – 3H
GROUP 4
TABLE OF CONTENTS
PART PAGE
Acknowledgement………………………………………………………………….…
Introduction……………………………………………………………………………
Objectives…………………….……………………………………………………….
Patient’s Data………………………………………………………………………….
Genogram……………………………………………………………………………..
Family History………………………………………………………………………..
Developmental Data…………………………………………………………………...
Physical Assessment……………………….…………………………………………..
Complete Diagnosis……………………………………………………………………
Anatomy and Physiology………………………………………………………………
Etiology…………………………………………………………………………………
Symptomatology…………………………………………………………….………….
Pathophysiology…………..……………………………………………………….……
Doctor’s Order……………………………………………………………………..……
Diagnostic Examiation.………………………………………………………………….
Drug Study………………………………………………………………………………
Procedural Report……………………………………………………………………….
Nursing Theories…………………………………………………………………………
Nursing Care Plans……………………………………………………………………….
Discharge Planning……………………………………………………………………….
Prognosis…………………………………………………………………………………..
Conclusion…………………………………………………………………………………
Recommendation………………………………………………………………………….
Bibliography……………………………………………………………………………….
Acknowledgement
The student nurses would like to express their gratitude and appreciation primarily to Mr. Police for
allowing them to have his case as their study. He had been very accommodating and cooperative to them
during the entire exposure. Moreover, he was also very patient with them while providing them sufficient
information regarding him and his case.
Furthermore, they are grateful to Anna for being supportive and also for giving them an opportunity
to learn more regarding her husband’s case so that they could provide effective and efficient nursing
interventions.
The staff nurses are also acknowledged for their kind accommodation. Their humility in sharing
some of their knowledge was great help to the student nurses’ learning. Consequently, their efforts and
assistance have made the student nurses efficient in rendering nursing care towards the valued patients.
The student nurses would also like to thank Ma’am Gisselle Charade A. Zamora, R.N. for giving
them the appropriate orientation and facilitation on their first exposure to St. Joseph. She had been very
patient and understanding to them, and gave them an enjoyable and unforgettable experience that made
them further appreciate the “journey of our being.”
In addition, they would also want to express their heartfelt thanks to Sir Anselmo Lafuente, R.N.,
their substitute clinical instructor at St. Joseph ward at DMSF Hospital, for guiding and inspiring them with
his remarkable holistic teachings that encouraged them not only to be better nurses, but as well as better
individuals. May they find the right path towards God, as he wishes them to.
The student nurses would also like to thank their respective families who have always supported
and encouraged them to be confident in what they are doing; for the financial and moral support and for
understanding. Thank you for the love. The group would also like to extend their gratitude to the Perpetua
family for welcoming them into their home and for securing them enough provisions and moral support.
And above all, they are very thankful to the Almighty Father for gracing them with His wonderful
blessings. He is their ultimate strength and hope. They pray for His loving guidance as they continue their
journey in their nursing careers.

INTRODUCTION
The gallbladder is a small pear-shaped organ which aids in the digestive process. Its function is to
store and concentrate bile - a digestive liquid continually secreted by the liver. The bile in turn emulsifies
fats and neutralizes acids in partly digested food. Despite its importance in the digestion of fat, many
people are unaware of their gallbladder. Fortunately enough, the gallbladder is an organ that people can
live without. Perhaps, this fact contributes to the laxity of the majority. The gallbladder tends to be taken for
granted – ignored of the proper care and conditioning. Lifestyle together with heredity, sex, race and age
are just some factors that leave a room for gallbladder complications to occur.
This study is about cholecystitis. The most common cause of cholecystitis is gallstones (90% of the
cases). The bile becomes concentrated in the gallbladder. This later causes irritation and is probably the
leading cause of inflammation. Cholecystitis affects women more often than men and is more likely to occur
after age 40. People who have a history of gallstones are at increased risk for cholecystitis. In the
international level, cholecystitis has an increased prevalence among people of Scandinavian descent, Pima
Indians, and Hispanic populations, whereas cholelithiasis is less common among individuals from sub-
Saharan Africa and Asia. It affected 20.5 million people (1988-1994) 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)
The student nurses have chosen this case as they see it fit for the peri-operative concept as the
patient has had undergone open cholecystectomy. Moreover, despite the cholecystitis’ low incidence, they
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 they 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, they too are predisposed
to lifestyle modification – especially diet and food preferences which can contribute to the disease. With this
study, the student nurses hope to apply their learning in taking care not only of their patients but also of
themselves.
As nursing students and future nurses, they would want to understand and appreciate more on
what is happening to a patient with cholecystitis. Consequently, they are interested on what will be the
necessary management that will be given. Through this, they are hoping that they 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 them to become efficient nurses and better persons later on.
Objectives
After 5 days of data gathering, research and analysis, the student nurses shall have devised
objectives that will guide them for the proper understanding and fair interpretation of the case of their
chosen patient.
GENERAL OBJECTIVES
Cognitive
The student nurses’ first main goal is to gain knowledge through the completion of the case study
and to impart this learning to Mr. Police and to those directly and indirectly involve with the completion of
this case.
Specific Objectives under Cognitive aspect
Within the 5 days span of duty, the student nurses will be able to:
 Gather significant data from the patient’s chart which includes the doctor’s order, laboratory exams
and etc. to have complete information about the patient’s current condition.
 Research on the anatomy and physiology of the clients affected system.
 Research on the possible causes and also the symptoms the patient experienced that may suggest
the current condition of the patient.
 Research and understand the disease process of the patient’s illness.
 Determine and interpret the medical management employed including laboratory and diagnostic
procedures.
 Identify and study the drugs prescribed to the patient which affects the patient’s current situation.
Psychomotor
In this aspect, the student nurse’s goal is to apply all what they have learned during the process of
completing this case study to improve nursing care that will meet Mr. Police’s need for the improvement of
his general welfare.
Specific Objectives under Psychomotor aspect
 Conduct a thorough physical assessment and to interpret the assessment in order to give the care
the patient need.
 Formulate nursing care plans and apply them to satisfy the patient’s needs and give appropriate
nursing interventions.
 Make a discharge plan for the patient using M.E.T.H.O.D and validate the patient’s prognosis
according to categories.
Affective
With the knowledge gained and through the application of this knowledge, another goal is that the
student nurses 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 a them to have in order to become better
nurses in the future.

Specific Objectives under Affective aspect
 Establish rapport and therapeutic communication in order to gain information about the patient
which includes the medical and family health history, expectations of his condition to him gather
significant data from the patient’s chart and to his family and etc.; and for the betterment of nursing
care.
 Assume the role of being the patient’s advocate.

PATIENT’S DATA
Personal Data
Name: Mr. Police
Age: 46 years old
Sex: Male
Nationality: Filipino
Date of Birth: August 28, 1962
Place of Birth: General Santos City
Civil Status: Married
Address: Cabantian, Country Homes, Davao City
Religion: Christianity (Roman Catholic)
Educational attainment: College Graduate
Occupation: PNP
Clinical Data
Admitting Date and Time: April 27, 2009 at 10:40 am
Case Number: 01-36-90
Ward: St. Joseph (3C)
Room/ Bed: 325-5
Attending Physician: Dr. Batucan, Wolter
Chief Complaint: right upper quadrant pain
Diagnosis: Cholecystitis T/C Cholelithiasis
VS upon admission:
BP –120/90 mmHg R – 28 cpm P – 109 bpm Temp – 36.5˚C
Sources of info: Chart, Mr. Police himself, and his wife

GENOGRAM
Lolo A± Lola A± Lolo B †ħ Lola B±
Dad A B Mom 3 4 5 6
1ħ
Anna Mr. Police Step-brod Ø Step-sis

Sis Δ
Δ
BB 1 BB 2
Legend:
ħ: Hypertensive
±: Unknown cause of death
Ø: Suicide
Δ: Died of childhood illness
†: Deceased
HEALTH HISTORY
A. Family Background
Mr. Police is the eldest among Mr. Dad‘s and Mrs. Mom‘s two children. But his younger sister died
of a childhood illness at the age of three years old, he could not recall. He grew up at General
Santos City where the relatives of his mother live. When Mr. Police was a first year high school, his
parents got separated because of third party. He lived with his mother and Mrs. Mom’s live-in
partner at Davao City, while his father returned to Leyte where his other relatives live. With his
mother’s second family, he had another two siblings, Step-brod and Step-sis. Step-brod died at the
age of 18 because of suicide. He had suicide because of altered mental status due to shabu use.
Today, Step-sis has her own family at Leyte.
Because Mr. Police had been away from the relatives of his father, he does not know any
significant disease they have or had. He doesn’t also know the causes of deaths of his
grandmother and grandfather on the paternal side. On the other hand, what he only knows is that
the eldest sister of her mother has hypertension, and that his grandfather on the maternal side died
of hypertension.
Currently, Mr. Police has been married to Anna for 15 years. They met at Mandug, Davao City,
where Mr. Police had been assigned at work before. The couple had difficulty conceiving a child
because Anna has an obstetrical problem. She verbalized, “ ingon sa doctor naa man gud daw gas-
gas akoang matres.” Fortunately, nine years after their marriage, they were blessed with BB 1 who
is now a kindergarten student, aged six years old. Two years after, BB 2 followed.
B. Personal Background
Mr. Police graduated at MATS with a 4-year degree of BS-MT. But because he couldn’t find a job
with the course he had, he had six-month training to become a policeman. Currently, he had been
assigned to San Pedro Police Station for a year already. He works 24 hours straight, then have a
two-day rest.
On his rest day, he stays in their house and on the evening, goes with his friends and has a
drinking session. He enjoys watching TV, and sometimes does the cooking as he likes to. He is not
as close as the children are to Anna. But he enjoys playing with them sometimes and taking them
out on weekends. He is a “ barkadista” as his wife, Anna, describes him. He has a set of close
friends who are also policemen like him. He is a Roman Catholic, who does not always goes to
Church every Sundays but is a Sto. Niño devotee. Every January, he goes back to General Santos
City, to attend certain activities in celebrating Sto. Niño fiesta.
Mr. Police has been a smoker since he was 20 years old. His wife said he smokes three boxes of
cigarettes everyday. He has also been an alcoholic drinker since he was 13 years old. He drinks
three glasses of alcoholic drink everyday. Furthermore, he doesn’t have a regular exercise. But he
enjoyed boxing with his friends, as an exercise, which only lasted for six months (September 2008-
February 2009). He stopped because his friends also decided to stop. With regards to his diet, he
is a “meat-addict,” as Anna verbalized. Everyday, he eats meat, and could not sleep without eating
such. He also eats lots of pulutan during their drinking sessions such as laman-loob, chicaron, and
other pica-pica. Moreover, he does not eat vegetables but eats all kinds of fruits. Moreover, he has
no known drug and food allergy.

C. Effects/ Expectations of Illness to Self/ Family
Because of his condition, he had to undergo an operation which means he had to have a sick leave
from his work. Moreover, Anna also has to watch over him and she has to leave the children under
the care of her elder sister for a while. Moreover, Anna is worried of the effect of the operation to
the health of her husband. But she is hoping that because of this hospitalization, he would realize
that he should have a healthy control over his health, that he would cease drinking and smoking.
Furthermore, Anna is also expecting that her husband would regain his strength back soon.
D. History of Past Illness
Mr. Police experienced common illness such as colds, cough, and fever during his childhood. He
also had chicken pox during his childhood. However, he could not recall at what age he got the
disease and as well as the management of his chicken pox.
Five years prior to admission (2004), he was diagnosed with diabetes with an FBS result of 7.8
mmol/dL. They were having an annual check up when he discovered that he has elevated blood
sugar. He was then advised to control his diet and have a regular exercise but he was not given
any maintenance drug. Moreover, he was not compliant with the doctor’s advice.
Two years ago (2007), he was admitted to Davao Medical Center due to loss of consciousness.
Prior to that, he was experiencing palpitations, and pain on the suboccipital area (nape) associated
with headache. He had elevated blood pressure of 180/100 as he could remember during the VS
taking at the emergency room. He was admitted for one day and was diagnosed with hypertension.
He was then given Lopicard 5mg tab OD, as a maintenance anti-hypertensive medication. The
doctor advised him to cease smoking and drinking alcohol, and as well as to avoid over fatigue. He
stopped smoking, but only for two months.

E. History of Present Illness
A month prior to admission, Mr. Police experienced right upper quadrant pain associated with a
sense of bloatedness, without nausea and vomiting. The pain was tolerable so he did not seek
medical attention yet. He said he also had an increased level of pain tolerance so he also didn’t
mind to take any pain relievers. Until three days prior to admission, patient had severe right upper
quadrant pain, which was said to be intolerable. Moreover, when pressure is applied on the RUQ of
the abdomen, pain is elicited. He had also lost his appetite because of the pain. His scleras were
also slightly icteric during admission and he was positive with Murphy’s sign. So he sought
consultation at Out-Patient Department- Emergency Room at Davao Medical School Foundation
Hospital. Ultrasound revealed cholecystitis, so patient was advised admission and operation.
DEVELOPMENTAL DATA
Theories Assessment Stages Justification
Mr. Police and Anna have a good
Freud’s Psychosexual A sexual relationship. Though Mr.
Genital
Theory C Police has an erection-related
H problem, the couple are able to
Energy is directed toward
Genital (13 years and I maintain a healthy sexual relation
attaining a mature sexual
older) E with each other. Anna said that she
relationship. This stage
V understands that this might be due to
involves a reactivation of the
E Mr. Police’s diabetes, though they
pregenital impulses. These
D sometimes do not achieve sexual
impulses are usually displaced,
satisfaction. The erection-related
and the individual passes to
problem of Mr. Police does not
the genital stage of maturity.
damage the couple’s relationship. It
An inability to resolve conflicts
even made the couple more mature
can result in sexual problems,
and understanding of each other’s
such as frigidity, impotence,
sexual needs. Furthermore, Mr.
and the inability to have a
Police compensates by wooing his
satisfactory sexual relationship.
wife through romantic dinners and
being sweet with her, even in public.
Moreover, energy is directed towards
his work as a policeman, being
committed to his work and as well as
to his colleagues, who are also the
recipient of Mr. Police’s energy
towards his social relationships to
other people.
Stage 7: Generativity vs.
Erikson’s A Stagnation Mr. Police is able to send his child to
Psychosocial Theory C The middle adult years are a a private school, to ensure a high
H time of concern for the next standard of his educational needs.
Stage 7: Generativity I generation as well as Moreover, he works alone to provide
vs. Stagnation E involvement with family, the family’s financial needs. He
(Middle Adulthood V friends, and community. doesn’t allow his wife to work to make
40-65 yrs.) E Socially-valued work and sure that the children receive a direct
D disciplines are expressions of parental guidance in their growing
generativity. Simply having or years. Moreover, as he works as a
wanting children does not in policeman, he is satisfied with his
and of itself achieve service to the public through their
generativity. There is a desire protection and crime control activities.
to make a contribution to the He yearns for the community’s peace
world. If this task is not met, and order and is achieved through his
stagnation results, and the public service as a policeman.
person becomes self-
absorbed and obsessed with
his or her own needs or
regresses to an earlier level of
coping.
Mr. Police said that it is normal that in
Middle Adulthood his age, people get disease because
Havighurst’s A Developmental tasks for they are aging. Moreover, he is able
Developmental C middle adulthood include: to obtain a satisfactory occupational
Theory H  Accepting and adjusting to performance, as he stayed on his job
I physical changes for already more than 20 years
Middle Adulthood E  Attaining and maintaining already. Though his children are still
(40-65 yrs. old) V a satisfactory occupational four and six years old, he teaches
E performance them values such as honour, respect,
D  Assisting children to and honesty, for them to become like
become responsible him, a responsible citizen of our
adults country. In addition, Mr. Police said
 Relating to one’s spouse that he is blessed with their
as a person relationship because Anna is not just
 Adjusting to aging parents a wife to her, but also a friend, whom

he could confide his problems. As his
 Achieving adult social
parents are also getting old, he said
and civic responsibility
that he visits them at least once or
twice a year. He even said that wants
them to live their remaining life happy
and satisfied with it. Moreover, he
has achieved social and civic
responsibility through his public
service as a policeman.
PHYSICAL ASSESSMENT
GENERAL SURVEY
At 4 pm on April 30, 2009, physical assessment was done. Mr. Police, a 46 year old Filipino male,
was lying in bed, asleep; with an IVF # 3 D5NSS 1L at the level of 80 cc, regulated at 120 cc/hr,
infusing well at right metacarpal vein; with epidural catheter; with Jackson Pratt drain; with slightly
soaked, intact dressing at right upper quadrant of the abdomen, status post open cholecystectomy.
Patient is responsive and coherent when awaken; with complain of pain at the incision site, with a
pain scale of 6 out of 10. Patient was on NPO. He appeared endomorphic. Patient was in good
grooming, wearing clean patients gown. Respiratory distress was not noted. Aside from that, he
weighs 85 kg and stands 5’5” and has a body mass index of 31.18 which denotes that he belong to
the obese type I which ranges from 30 – 34.9.
VITAL SIGNS
BP= 120/180 mm Hg PR= 85 bpm RR= 15 cpm T= 36 °C
SKIN
Skin was warm to touch, slightly dry, rough, and with good skin turgot. Neither jaundice nor
cyanosis observed. Papules on the face observed, with nevi noted on the right side of the nose.
Patient was not cyanotic. No bruises or discolorations observed. No edema noted.
HEAD
Skull size was normocephalic. Skull and face were symmetrical with an equal distribution of hair.
Hair was black in color with fair amount of white and gray strands, short, dry, and fine. There was
no dandruff or infestation present. No lesions, lacerations, tenderness, masses and depressions
noted.
FACE
The forehead was furrowed with wrinkles. Face portrayed emotions with symmetrical movements.
No masses or involuntary movement. The face was round, with no edema, lesions, discolorations
present.
EYES
Mr. Police did not use any corrective aids such as glasses or contact lenses. Eyebrows were
evenly distributed and symmetrically aligned with no of flakes, scars and lesions noted. Eyelashes
were evenly distributed and slightly curled outward. Lid margins were clear, lacrimal duct openings
were evident at the nasal side of the upper and lower lids. Blinking reflex was present. Skin around
the eyes was intact with equal movement, with no discharges and no discolorations observed.
Eyelids close symmetrically. No edema seen in the periorbital region. Shiny smooth and pink
palpebral conjunctiva noted. No edema or tenderness over lacrimal gland observed. Eye color was
dark brown. His pupils were equal within 1-2 mm diameter in size and both have a brisk reaction to
light and uniform reaction to accommodation. Small anterior polar opacification was observed on
both eyes. Nystagmus, strabismus and lid lag were not evident.
EARS
Ears were symmetrical with same size bilaterally and color consistent with face. Pinnas were free
from lesions, masses, swelling, redness, tenderness, and discharges and were in line with the
eyes. External canals were clear with no cerumen seen. No inflammation, masses, discharges and
foreign bodies noted. Gross hearing acuity was good. No pain on the mastoid process was
reported upon palpation.
NOSE
The nose was symmetrical with no deformities, skin lesions, masses present. Nasal septum is
intact and in midline. No nasal flaring was observed. No discharges were present. No tenderness
in his sinuses upon palpation.
MOUTH
Mouth was proportional and symmetrical. Lips were rust colored and were dry with no presence of
ulcerations, sores or lesions. Teeth were yellowish in color with some dental caries noted. Right
upper first premolar tooth was absent. Tongue was in central position and moves freely with no
swelling or ulcerations observed. Gag reflex was present as evidenced by patient swallowing.
Tonsils were not inflamed. Halitosis was also noted.
NECK
Neck was symmetrical with no masses or swelling noted. No jugular vein distention was noted.
Range of motion was normal and moves easily without discomfort upon rotation, flexion, extension
and hyperextension. Thyroid was not enlarged has no nodules, masses, and irregularities upon
palpation. Trachea is symmetrical and in midline without deviation.
BREAST
Nipples were dark brown in color, inverted and in the midline. No crusting and masses noted.
Breasts were symmetrical with no edema noted. Both axilla were free of lesions rashes, and
infections. Lymph nodes were not palpable.
CHEST and LUNGS
No thorax deformity observed. Respiratory rate was 15 cycles per minute with regular breathing
pattern. Symmetrical chest expansion was observed during respiration. No use of accessory
muscles during breathing observed. Chest wall was intact; no tenderness and masses noted.
Uniform temperature also noted. No adventitious breath sounds heard upon auscultation. No
cough present. No dyspnea, hemoptysis, hiccups noted.

HEART
Apical heart beat was present upon auscultation with a point of maximal impulse at the 5th
intercostal space left midclavicular line; with cardiac rate of 85 beats per minute with a regular
rhythm. No abnormal beats, palpitations, thrills or murmurs present upon auscultation.
ABDOMEN
Abdomen was slighty enlarged and globular when patient was in supine position; with slightly
soaked, intact dressing on the right upper quadrant with Jackson Pratt drain. Pulsations were not
visible. The abdomen had hypoactive bowel sounds of two bowel sounds per minute. Tenderness
noted on the right upper quadrant near the incision site.
GENITO –URINARY
Unable to perform inspection in the genitourinary region. However, patient verbalized that he had
not noted any discharges from his genitalia nor presence of papules or ulcerations. Patient had not
yet voided since he had arrived from the OR.
BACK & EXTREMITIES
Symmetrical shoulder movement observed during respiration. Spine was located at the midline
with no discrepancies noted. Shoulders, arms, elbows and forearms were free from nodules,
deformities and atrophy. Range of motion was not limited. Neither pallor nor bone enlargements
were noted upon inspection of the upper extremities. A permanent tattoo was present on his right
deltoid area, anchor-designed. Upper extremities were not edematous. Radial and brachial pulses
were present. Hip joint and thighs were symmetrical with no deformities present. No edema noted
at both legs. No inflammation noted in the lower extremities. Range of motion was active and not
limited.
DEFINITION OF COMPLETE DIAGNOSIS
CHOLECYSTITIS
- Cholecystitis is the inflammation of the galbladder
Source: Smeltzer, S.C., Bare, B.G. Brunner & suddarth’s Textbook of Mecial-Surgical Nursing 11 th
Edition.
- Cholecystitis refers to inflammation of the gallbladder and cystic duct.
Source: Barbara Gould, Pathophysiology for the Health Professions, Third Edition, Saunders
Elsivier
- Cholecystitis refers to inflammation of the gallbladder.
Source: Carol Mattson Porth, Pathophysiology, Concepts of Altered Health Sciences
CHOLELITHIASIS
- The presence of calculi in the gallbladder
Source: Smeltzer, S.C., Bare, B.G. Brunner & suddarth’s Textbook of Mecial-Surgical Nursing !0 th
Edition.
- Cholelithiasis refers to formation of gallstones, which are masses of solid material or
calculi that forms in the bile.
Source: Barbara Gould, Pathophysiology for the Health Professions, Third Edition, Saunders
Elsivier
- Cholelithiasis, or gallstones, is caused by precipitation of substances contained in bile,
mainly cholesterol and bilirubin.

Source: Carol Mattson Porth, Pathophysiology, Concepts of Altered Health Sciences
ANATOMY AND PHYSIOLOGY
HEPATOBILLARY TREE
LIVER
A. Location and size of the liver- largest gland in the body, weighs approximately 1.5 kg; lies
under the diaphragm; occupies most of the right hypochondrium and part of the
epigastrium.
B. Liver lobes and lobules- two lobes separated by the falciform ligament
1. Left lobe- forms about one sixth of the liver
2. Right lobe- forms about five sixths of the liver; divides into right lobe proper,
caudate lobe, and quadrate lobe
3. Hepatic lobules- anatomical units of the liver; small branch of hepatic vein extends
through the center of each lobule
C. Bile ducts
1. Small bile ducts form right and left hepatic ducts

2. Right and left hepatic ducts immediately join to form one hepatic duct
3. Hepatic duct merges with cystic duct to form the common bile duct, which opens
into the duodenum
D. Functions of the liver
1. Glucose Metabolism
-after a meal, glucose is taken up from the portal venous blood by the liver and
converted into glycogen (glycogenesis), which is stored in the hepatocytes.
Glycogen is converted back to glucose ( glycogenolysis) and release as needed
into the blood stream to maintain normal level of the blood glucose.
-glucose can be synthesized by the liver through the process gluconeogenesis
2. Ammonia Conversion
-use of amino acids from protein for gluconeogenesis result in the formation of
ammonia as a by product. Liver converts ammonia to urea
3. Protein Metabolism
-Liver synthesizes almost all of the plasma protein including albumin, alpha and
beta globulins, blood clotting factors plasma lipoproteins
4. Fat Metabolism
-Fatty acid can be broken down for the production of energy and production of
ketone bodies
5. Vitamin and Iron Storage
-stores vitamin A, D, E, K
6. Drug Metabolism
7. Bile Formation
-bile is formed by the hepatocytes

-composed of water, electrolytes such as sodium, potassium, calcium, chloride,
bicarbonate, lecithin, fatty acids, cholesterol, bile salts
-collected and stored in the gallbladder and emptied in the intestine when needed
for digestion
a. Lecithin and bile salts emulsify fats by encasing them in shells to form tiny
spheres called micelles
b. Sodium bicarbonate increases pH for optimum enzyme function
c. Cholesterol, products of detoxification, and bile pigments (e.g. bilirubin) are
wastes products excreted by the liver and eventually eliminated in the feces
GALLBLADDER
The gallbladder (or cholecyst, sometimes gall bladder) is a small organ whose function in
the body is to harbor bile and aid in the digestive process.
Anatomy
 The cystic duct connects the gall bladder to the common hepatic duct to form the common
bile duct.
 The common bile romero duct then joins the pancreatic duct, and enters through the
hepatopancreatic ampulla at the major duodenal papilla.
 The fundus of the gallbladder is the part farthest from the duct, located by the lower border
of the liver. It is at the same level as the transpyloric plane.
Microscopic anatomy
The different layers of the gallbladder are as follows:
 The gallbladder has a simple columnar epithelial lining characterized by recesses called
Aschoff's recesses, which are pouches inside the lining.

 Under the epithelium there is a layer of connective tissue (lamina propria).
 Beneath the connective tissue is a wall of smooth muscle (muscularis externa) that
contracts in response to cholecystokinin, a peptide hormone secreted by the duodenum.
 There is essentially no submucosa separating the connective tissue from serosa and
adventitia.
Size and Location of the Gallbladder
The gallbladder is a hollow, pear-shaped sac from 7 to 10 cm (3-4 inches) long and 3 cm
broad at its widest point. It consists of a fundus, body and neck. It can hold 30 to 50 ml of bile. It
lies on the undersurface of the liver’s right lobe and is attached there by areolar connective tissue.
Structure of the Gallbladder
Serous, muscular, and mucous layers compose the wall of the gallbladder. The mucosal
lining is arranged in folds called rugae, similar in structure to those of the stomach.
Function of the Gallbladder
The gallbladder stores bile that enters it by way of the hepatic and cystic ducts. During this
time the gallbladder concentrates bile fivefold to tenfold. Then later, when digestion occurs in the
stomach and intestines, the gallbladder contracts, ejecting the concentrated bile into the
duodenum. Jaundice a yellow discoloration of the skin and mucosa, results when obstruction of
bile flow into the duodenum occurs. Bile is thereby denied its normal exit from the body in the
feces. Instead, it is absorbed into the blood, and an excess of bile pigments with a yellow hue
enters the blood and is deposited in the tissues.
The gallbladder stores about 50 mL (1.7 US fluid ounces / 1.8 Imperial fluid ounces) of
bile, which is released when food containing fat enters the digestive tract, stimulating the secretion
of cholecystokinin (CCK). The bile, produced in the liver, emulsifies fats and neutralizes acids in
partly digested food.
After being stored in the gallbladder the bile becomes more concentrated than when it left
the liver, increasing its potency and intensifying its effect on fats. Most digestion occurs in the
duodenum.
BILIRUBIN PRODUCTION AND ELIMINATION
Bilirubin is the substance that gives bile its color. It is formed from senescent red blood
cells. In the process of degradation, the hemoglobin from the red blood cell is broken down from
biliverdin, which is rapidly converted to free bilirubin thru biliverdin reductase. Free bilirubin, which
is not soluble in plasma, is transported in the blood attached to plasma albumin. Even when it is
bound to albumin, this bilirubin is still called free bilirubin. As it passes through the liver, free
bilirubin is released from its albumin carrier molecule and moved into the hepatocytes. Inside the
hepatocytes, free bilirubin is converted to conjugated bilrubin thru glucoronyl transferase, making it
soluble to bile. Conjugated bilirubin is secreted as a constituents of bile, and in this form, it passes
through the bile ducts into the small intestine. In the intestine, approximately one half of the
bilirubin is converted into a higly soluble substance called urobilinogen by the intestinal flora.
Urobilinogen is either absorbed into the portal circulation or excreted in the feces. Most of the
urobilinogen that is absorbed is returned to the liver to be re-excreted into the bile. A small amount
of urobilinogen, approximately 5% is absorbed into the general circulation and then excreted by the
kidneys.
Usually, only a small amount of bilirubin is found in the blood; the normal level of total
serum bilirubin is 0.1 to 1.2 mg/dL. Laboratory measurements of bilirubin usually measure the free
and the conjugated bilirubin as well as the total bilirubin. These are reported as the direct
(conjugated) bilirubin and the indirect (unconjugated or free) bilirubin.

ETIOLOGY AND SYMPTOMATOLOGY
Precipitating Factors:
Factors Present Rationale

Diet (high cholesterol, Present Increased intake of calories, refined carbohydrate,
high calorie, high sodium) cholesterol, and saturated fats has all been postulated
to cause cholesterol gallstones. Patients with
cholesterol gallstones secrete a greater fraction of
dietary cholesterol into bile than do normal subjects.
SOURCE: Harrison’s Principle of Internal Medicine,

16th Edition
Medications and Oral Absent Hypolipidemic agents (clofibrate, gemfibrozil) that
Contraceptives lower serum cholesterol by increasing biliary
cholesterol secretion increase the risk of cholesterol
gallstones by twofold to threefold.
Competitive inhibitors of 3-hydroxy-3-methylglutaryl
coenzyme A (HMGCoA) reductase (lovastatin,
simvastatin, pravastatin) decrease biliary cholesterol
saturation.
Estrogen therapy is associated with an increased risk
of developing cholesterol gallstones.
Oral contraceptive steroids increase biliary cholesterol
secretion and saturation but do not affect gallbladder
motility.
Source: Barbara Gould, Pathophysiology for the

Health Professions, Third Edition, Saunders Elsivier
Total Parenteral Nutrition Absent TPN is a powerful risk factor for gallstone formation.
Gallstones from during TPN because of decreased
gallbladder motility from lack of meal-stimulated
cholesystokinin (CKK) release, resulting in increased
fasting and residual volumes.

16th Edition
Spinal Cord Injury Absent Patients with spinal cord injury have 10% incidence of
forming gallstones within the first year after injury.
This high risk, which is 20 times normal, is believed to
be secondary to abnormal gallbladder motility and
probably biliary hypersecretion of cholesterol from the
progressive reduction in body mass.

16th Edition
Primary Biliary Cirrhosis Absent Patients with primary biliary cirrhosis have an
increased prevalence of gallstones. Stone analysis
has not been performed, but the elevated cholesterol
saturation of bile in these patients suggest that they
form cholesterol stones.

16th Edition
Diabetes Mellitus Present Despite obesity and increased total body cholesterol
synthesis and decreased gallbladder motility seen in
patients with diabetes, diabetes mellitus itself does
not appear to be an independent risk factor for
cholesterol gallstone disease.

16th Edition
Hemolytic Syndromes Absent Inherited hemolytic anemia, sickle cell disease,
sphericytosis, thalassemia, chronic hemolysis
associated with artificial heart vavles, and malaria
dramatically increase the risk of pigment stone
formation because of increased biliary secretion of
total bilirubin conjugates, especially bilirubin
monoglucoronide, at the expense of the bilirubin
diglucuronide, the predominant conjugate in healthy
individuals.

16th Edition
Ileal Disease, Resection, Absent Patients with ileal dysfunction have a strikingly
and Bypass increased risk for developing gallstones. Gallstones
develop in 30-50% of patients with ileal Chron’s
disease; the risk correlates positively with the extent
and duration of ileal dysfunction, Although ilieal
disease or resection leads to cholesterol
supersaturation and cholesterol stone formation in
some patients , careful studies now show that most
patients with ilieal dysfuncyion form black pigment,
not cholesterol stones.

16th Edition
Biliary Infection Absent Brown pigment stones are frequently found in the
intrahepatic bile ducts and are always associated with
infection by colonic organisms usually E.coli, or
parasitic infestation (Ascaris lumbricoides, or other
helminthes). Intraductal stones developing after
cholecystectomy are invariable associated with bile
stasis, biliary tree infection, and/or retained suture
material.

16th Edition
Obesity Present Obesity is strongly associated with increased
gallstone prevalence. The risk is proportional to the
increase in total body fat. Obese people synthesize
more cholesterol in both hepatic and nonhepatic
tissues, transport it to the liver, and secrete more of it
into the bile, leading to bile that is often greatly
supersaturated with cholesterol.

Rapid Weight Loss/ Absent Obese patients undergoing rapid weight loss (1-2% of
Fasting diets body weight or approximately 1-2 kg/week), either by
very low caloric dieting or gastric stapling, have a 25-
40% chance of developing gallstones within 4 months.
During rapid weight loss, biliary cholesterol saturation
increases acutely as cholesterol is mobilized from
adipose tissue and skin and secreted into bile.

16th Edition
Predisposing Factors:
Factors Present Rationale

Gender Absent Women have twice the risk as men of developing
cholesterol gallstones because estrogen increases
biliary cholesterol secretion. Before puberty this risk
is negligible, and beyond menopause the increased
risk disappears.

Advancing Age Present The incidence increases with age. Less than 5-6% of
the population under age 40 have stones, in contrast
to 25-30% of those over 80.
Source: Carol Mattson Porth, Pathophysiology,

Concepts of Altered Health Sciences
Race Absent Prevalence highest in North American Indians,
Chilean Indians, and Chilean Hispanics, greater in
Northern Europe and North America than in Asia,
lowest in Japan; familial disposition; hereditary
aspects

16th Edition
Heredity Absent Family history alone imparts increased risk, as do a
variety of inborn errors of metabolism that lead to
impaired bile salt synthesis and secretion or generate
increased serum and biliary levels of cholesterol,
such as defects in lipoprotein receptors
(hyperlipidemia syndromes), which engender marked
increases in cholesterol biosynthesis.
16th Edition
Parity/ Pregnancy Absent Pregnancy is an independent risk factor for
cholesterol gallstones. The risk increases with
increasing parity, especially with more than two
children. During pregnancy, elevated estrogen and
progesterone levels increase biliary cholesterol
secretion. Elevated progesterone also inhibits
gallbladder contractility. 40% of women develop
biliary sludge in their gallbladder and 12% of women
form their first stones during pregnancy.

16th Edition
Symptomatology
Symptoms Present Rationale

Biliary Colic/ Moderate to Present The most common symptom is in pain the right
Severe Pain upper part of the abdomen or epigastrium. This
can cause an attack of abdominal pain, called
biliary colic, which: develops quickly, is severe,
lasts about one to three hours before fading
gradually, isn't helped by over-the-counter and isn't
helped by passing wind. The pain may radiate to
the back, right scapula or shoulder. The pain often
begins suddenly following a meal. The pain of
biliary colic is caused by the functional spasm of
the cystic duct when obstructed by stones,
whereas pain in acute cholecystitis is caused by
inflammation of the gallbladder wall.

Tenderness Present Palpation of the abdomen frequently elicits
localized tenderness in the right upper quadrant
which is associated with guarding and rebound
tenderness.

Murphy’s Sign Present The patient with acute inflammation of the
gallbladder might have a positive Murphy’s sign,
which is inspiratory arrest during deep palpation in
the right upper quadrant.
SOURCE: Harrison’s Principle of Internal

Medicine, 16th Edition
Nausea and Vomiting Absent These signs and symptoms may accompany a
gallbladder attack. Pain is usually accompanied by
nausea and vomiting.

Health Professions, Third Edition, Saunders
Elsivier
Fever and chills Absent 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, also due to the irritation and inflammation
of the gallbladder wall.
Fever occurs in about one third of people with
acute cholecystitis. The fever tends to rise
gradually to above 100.4° F (38° C) and may be
accompanied by chills

fLoss of appetite and Present The pain often begins suddenly following a large or
Anorexia rich meal. People tend not to eat, especially fatty
or oily foods, in order not to experience that pain.
Fat absorption is also impaired for the lack of bile
salts, As a result, rapid loss of weight and anorexia
can occur.

Predisposing Factors: Precipitating Factors:
Gender Diet
Age PATHOPHYSIOLOGY Medications and Oral Contraceptives
Race Obesity
Heredity Rapid Weight Loss
Pregnancy Spinal Cord Injury
Primary Biliary Cirrhosis
Diabetes Mellitus
Hemolytic Syndromes
Ileal Disease, Resection and Bypass
Biliary Infection
Total Parenteral Nutrition
Liver cells secrete Liver cells Liver excrete Liver excrete Invasion Calcium enters Liver excrete
cholesterol into bile also secrete relatively high conjugated of bile passively some
along with bile salts proportion of bilirubin into bacteria along with other unconjugated
phospholipid in the cholesterol in the bile electrolytes bilirubin into
form of unilamellar bile bile
vesicles
A
Unconjugated
Residual vesicles Some of the The bacteria Bilirubin tends to
Bacterial
unilamellar hydrolyze form insoluble
hydrolysis
vesicles dissolve conjugated precipitates with
of lecithin
bilirubin calcium
Formation of Release of
mixed micelles fatty acids Formation of
Increase in Calcium
unconjugated Bilirubinate
bilirubin
The cholesterol A fatty acids forms Black Pigment
carrying capacity of complex with calcium Gallstones
the micelles and
residual vesicles is
exceeded
Attraction Bacteria
of release
Leukocytes lytic Formation of
Bile is enzyme
supersaturated with Calcium
cholesterol Bilirubinate
leukocytes
hydrolyze
Formation of bilirubin Brown Pigment
Crystals conjugates Gallstones
and fatty
acids
Nucleation of
cholesterol crystals
Cholesterol
Gallstones
Mixed Stones
CHOLELITHIASIS
Gallstone tries to go
out of the gallbladder
Obstruction of the Obstruction of the

common bile duct by cystic duct by
gallstones gallstones
(Choledocholelithiasis)
Cholestasis
Release of phospholipase Disruption of mucous
from the epithelium of the coat of the gallbladder
gallbladder epithelium
Prolong Cholestasis Absence of Bile in ↑ levels of Hydrolization of lecithin Damages mucosal cells
the duodenum bilirubin/bile into lysolecithin due to detergent action of
pigments in the
bile salts
circulation
Hepatomegaly
S/S Indigestion,
Vit ADEK
deficiency, gray
Fibrosis Irritation of the
stools
S/S jaundice, gallbladder wall
ecteric sclera,
Liver Cirrhosis pruritus, dark
urine
Release of prostaglandins
within the gallbladder wall
Fibrous nodules distorts the S/S Biliary Colic,
architecture of the liver Tenderness, Murphy’s
sign, nausea and
vomiting, fever, ACUTE M
Resistance to K elevated wbc, anorexia CHOLECYSTITIS
portal blood flow
Increase pressure
in hepatic portal
vein
IF TREATED: IF NOT TREATED
Portal Hypertension Open Cholecystectomy
Laparoscopic
Cholecystectomy
Litotripsy
Z Ursodeoxycholicacid Bacteria invade the External surface
injured gallbladder of the
through the blood, gallbladder is
lymphatic or bile ducts scarred and
form adjacent organs layered by
(Empyema of the fibrinous
gallbladder) exudates and
GOOD PROGNOSIS distended
Edema, hemorrhage and

suppuration of the
gallbladder wall
Compression of blood
vessels
Increased Intraluminal
pressure
Compromised blood flow

to the mucosa and
lymphatic stasis
Ischemia
Ulcerations of the
mucosa
Necrosis
Gangrenous
Cholecystitis
Free Perforation Localized Perforation
Adhesion to an Pericholecystic abcess

adjacent hollow
viscus (duodenum)
Cholecystoenteric
fistula formation
Gall stone induced

intestinal obstruction
(gallstone ileus);
drainage of bile into
adjacent organs; entry
of air and bacteria into
the biliary tree
As the intestine Cut off the blood

becomes supply to the
congested, its affected portion of
ability to absorb your intestine
food and fluids
decreases
Ischemia
Dehydration Necrosis
Hypovolemia Perforation in the

intestinal wall
Hypovolemic shock
Generalized Peritonitis
Sepsis
S/S fever,
Septic Shock chills,
tachycardia
DEATH
Z
Liver failure Shunting of blood into

the splenic vein Blockage or increase pressure in Increase pressure in
the portal vein causes blood to peritoneal capillaries
backflow to the different vessels
Liver is unable to located near the esophagus and
convert the protein GIT
Spleen enlarges to Fluid shifting from the
byproduct ammonia compensate
into urea portal vein to the
decreased liver peritoneal cavity
function
Splenomegaly Gastroesophageal Varices
Ammonia enters Ascites
general circulation
Increase in size Rupture Invasion of

decreases the spleen’s
bacteria from the
ability to function
Morphologic changes blood, or lymph or
properly or loss of
in astrocytes Hypovolemia through the bowel
function
wall
S/S
Asterixis Increases in blood Hypovolemic shock
Astrocytes may Spontaneous Bacterial
waste product since
undergo Alzheimer Peritonitis
spleen is not able to
type II astrocytosis properly destroy Death
RBC’s
Sepsis
S/S Fever,
Death diarrhea,
Astrocytes become abdominal pain
swollen Septic Shock
S/S
Thrombocytop
enia, anemia, Death
Development of a leukopenia
large pale nucleus, a
prominent nucleolus,
and margination of
chromatin
S/S Anorexia, Nausea,

HEPATIC Liver tenderness, Jaundice
ENCEPHALOPATHY
Cerebral edema
Increased
intracranial pressure
Brain Hernation
Hepatic Coma
DEATH
M
Chronic Cholecystitis
Increased subepithelial and

subserosal fibrosis and
proliferation of lymphocytes
and other chemical mediators
Extensive
dystrophic
calcification of the
gallbladder wall
(Porcelain bladder)
Growth of
gallbladder
carcinoma
Metastasize to the
liver
Secondary Liver
Cancer
K
DOCTOR’S ORDER
Date & Time Order Rationale Remarks

04-27-09 Pls. admit under Dr. Walter G. For proper evaluation and Done
10:40am Batucan management and care under
Dr. Batucan who is an expert on
General Surgery, Liver,
Gallbladder, Billiary and
Pancreatic Surgery.
Low fat diet Bile contains large amount of Done
cholesterol that usually remains
dissolved in the bile but when
there is oversaturation with
cholesterol, cholesterol
becomes insoluble and
crystallizes. Low fat diet serves
as a prevention and treatment
for gallstone formation.
Labs:
CompleteBloodCount, Complete blood count is the Done
PlateletCount determination of the quantity of Hemoglobin –
each quantity of each type of 172g/dL
each blood cell in a given RBC – 5.46
specimen of blood, often X10^12/L
including the amount of Hematocrit – 0.53
hemoglobin, hematocrit, and the WBC – 15.2 X
proportion of various white cells. 10^9/L
Platelet count and other blood Segmenters- 0.72
components that will help Lymphocyte-0.28
determine the underlying Platelet – 222
diagnosis. X10^9/L
Blood Typing Patient is to undergo an invasive Done

surgery which could lead to Blood type – O+
blood loss therefore blood typing
is done before blood can be
transfused on him to replace the
loss blood.
Urinalysis An indicator of health and Done
disease, it is helpful in the Yellow; cloudy
detection of renal or metabolic Rxn:6
disorders. It is an aid in Spec. gravity-
diagnosing and following the 1.030
course of treatment in diseases Glucose (-)
of the kidney and urinary system Albumin (+++)
and in detecting disorders in Pus cells 2-4/hpf
other parts of the body such as RBC 1-2/hpf
metabolic or endocrinic Mucus threads (+)
abnormalities in which the
kidneys function normally.
Chest X-ray Chest X-ray provide a good Done
outline of the heart nad major > Suggestive of an
blood vessels and ussualy can inflammatory lung
reveal a serious disease in the disease
lungs, the adjacent spaces, and compatible with
the chest wall, including the ribs. bibasal
Ordered so as to check patient’s pneumonia.
cadio-pulmonary condition Please correlate
before undergoing an invasive clinically.
surgery.
ECG ECG is a recording of the Done
electrical impulses of the heart. Normal Sinus
Such test is an important Rhythm
indicator of how well the heart is
functioning. Prior to surgery, the
heart must first be checked to
determine whether or not it can
handle the surgery.
Fasting Blood Sugar Prior to surgery, blood glucose Done
is to be checked to determine if 6.84mmol/L
the patient has a disorder in
glucose metabolism mainly
diabetes for healing tends to be
longer if one has diabetes.
Creatinine Creatinine is a breakdown DONE
product of creatine phosphate in 148umol/L
muscle, and is usually produced
at a fairly constant rate by the
body. It is mainly filtered by the
kidney, though a small amount
is actively secreted. Measuring
serum creatinine is used to
indicate renal function.
Uric Acid Measurement of uric acid is Done
most commonly in evaluation of 0.497mmol/L
renal failure, gout and leukemia.
Total Bilirubin Evaluates impairment of the liver Done
or hemolytic anemia. 33.3umol/L
Direct Bilirubin Direct and Indirect bilirubin are Done
differentiation on why there is an 7.6umol/L
Indirect Bilirubin increased bilirubin. Direct Done
bilirubin is associated with liver 25.7umol/L
dysfunction or blockage while
Indirect bilirubin is related to
destruction of red blood cells.
Alkaline Phosphatase This enzyme test is used chiefly Done
as an index of liver and bone 228U/L
disease when correlated with
other clinical findings.
Albumin The test helps in determining if a Done
patient has liver disease or 55.4
kidney disease, or if not enough
protein is being absorbed by the
body.
Attach ultrasound result Prior to admission patient had Done
undergone UTZ, attaching the Cholecystitis with
result in the chart allows better bile sludge
diagnosis and analysis for the formation and
rest of the medical team suggestive
involved in his upcoming hydrophoric
surgery. change. Cannot
entirely rule out
calculus in the
cystic duct
Refer accordingly Call doctor’s attention Done
immediately once any unusuality
occurs.
11:20am Meds:
Lopicard 5mg tab OD – c/o Patient is hypertensive, and was Done
patient’s stock ordered to continue his
maintenance medication.
04-28-09 Please refer to Dr. Torno for Prior to surgery Cadio- Done
7am Cardio-Pulmonary clearance – co Pulmonary system must first be
management diagnosed whether or not the
patient’s circulatory and
respiratory system can handle
the surgery.
Dr. Torno is an Intenist whose
specialty is cardio and pulmo.
Pls. schedule for lap Surgical removal of the Done
cholecystectomy gallbladder using a laparascope
is indicated for acute
cholecystitis.
Secure consent Securing consent ensures the Done
safety of both the medical team
and the patient. It is the
permission obtained from the
patient that he is to undergo a
surgical procedure.
Anesthesiologist: Dr. Eugene Dr. Barinaga may be the partner
Barinaga anesthesiologist of Dr. Batucan.
Start vitamin K 10g IV OD Pre-operative standard Done
operating procedure so as to
prevent excessive bleeding
during the actual surgical
procedure.
Follow up all lab results and attach Lab results are not yet available, Done
to chart thus a follow up must be made
in order for the doctors to
correlate the findings.
10am Start PLR iL @ KVO rate PLR an isotonic solution that Done
resembles blood serum used as
passage for the Vit. K IVTT that
was ordered beforehand and for
future medications. It is also
used for hydration and
electrolyte replacement.
04-28-09 Anesthesiologist: Pre-op The referral was made so as to
12:20pm Evaluation ensure a safe and successful
Thanks for this referral surgical procedure.
Patient seen and evaluated, chart Anesthesiologist made rounds to Done
review done the patient so as to establish a
therapeutic relationship prior to
the scheduled operation and to
evaluate the patient.
Anesthesia plans explained Explaining the pros and cons of Done
consequences and benefits the anesthesia allows the patient Accepted by
explained to contemplate and to have a patient
mutual understanding with the
anesthesiologist by agreeing
with what anesthesia to use.
Nothing per orem temporary at To clear the digestive tract in Done
5am after breakfast preparation for the operation to
avoid GI disturbances and
reduce the possibility of vomiting
and aspiration and the risk of
possible bowel obstruction.
Pre-meds:
Midiazolan 15mg 1tab ½ tab @ An anti-anxiety drug, given so as Done
12nn tomorrow with 30cc of water. to relieve patient’s anxiety
regarding his upcoming surgery.
Resume consent for anesthesia Consent is a written Done
understanding and a permission
from the patient that allows the
use of certain anesthesia in the
surgical procedure that he’ll
undergo.
04 -28-09 Reschedule OR tomorrow at 7am OR schedule was not indicated Done
3pm on prior orders. 7am was
ordered for it was the most
convenient time for patient, his
medical team and the OR staffs.
Inform OR, Dr. Barinaga Informing Dr. Barinaga Done
regarding the scheduled surgery
allows him time to prepare and
ready himself for the upcoming
surgical procedure.
04-28-09 IM: thank you for refer
No history of cough but with rales Patient showed signs and
at L>R symptoms of pneumonia.
CXR – pneumonia
 CAP low risk Patient was diagnosed with CAP
 HPN low risk due to the findings
 T/C DM2 above, HPN due to history of
hypertension and T/C due to
high serum glucose as shown in
his FBS.
Start Sulperazone 1.5g IV q8 Given to treat respiratory Done
infection and also serves as pre-
operative prophylaxis.
Continue Lopicard Patient may continue with his Done
maintenance medication.
04-28-09 Pls. reschedule surgery on After being seen by his internist, Done
5pm Thursday his surgeon then rescheduled
the operation maybe due to
patient having pneumonia.
Anesthesiologist: Dr Tozon Change of anesthesiologist
instead of Dr. Barinaga due to
the rescheduling of the surgery.
10pm Schedule at 7am After rescheduling the day, OR Done
finally gave the time for the
patient’s surgery.
Anesthesiologist aware The new anesthesiologist was Done
made aware of the upcoming
surgery for him to be prepared.
04-29-09 For Surgery tomorrow at 7am The scheduled procedure will be Done
10:40am once cleared carried out once the Internist
cleared the patient for surgery.
Cefoxitin (Monowell) 1amp IVTT Serves as pre-operative Done
ANST now prior to OR prophylaxis.
04-29-09 Kindly inform Dr. Batucan – Although Sulperazone and Done
1:40pm Sulperazone will serve as pre-op Cefoxitin can serve as pre-
antibiotic management discontinueoperative prophyaxis, the
Cefoxitin if ok with Dr. Batucan internist chose Sulperazone
over Cefoxitin maybe because
the former is more potent than
the latter but still it’s the
attending physician’s decision
on what drug to give.
No absolute contraindication to Surgery can now be done after
planned surgery CP ok CP clearance was done.
5pm Plan carry out above orders For abrupt implementation. Done
For open cholecystectomy instead Patient has gangrenous
of lap chole gallbladder and open
cholecystectomy is indicated for
such.
04-30-09 IntraOp
12mn NPO now Patient was put on NPO for he is Done
to undergo surgery the following
day.
Metoclopramide 1amp IVTT at Promotes gastric emptying prior Done
6am to surgery.
Ranitidine 1amp IVTT at 6am Patient was on NPO so Done
ranitidine, an H2 antagonist, was
ordered because it inhibits the
action of histamine at the H2
receptors of the parietal cells
inhibiting gastric acid secretion.
04-30-09 PostOp
To PACU For intensive monitoring after Done
the surgery and for recovery.
NPO Nothing per orem until patient Done
passes out flatus for he still has
no peristalsis and so as to avoid
aspiration.
VS q15 until stable, then q1° X Monitoring the vital signs Done
4hrs then q4° determines patient’s body’s
reaction after he had undergone
the surgery and so as for prompt
intervention for any deviations in
vital signs.
IVF D5NSS iL at 120cc/hr To replenish fluids, nutrients and Done
electrolytes.
Meds:
1. Tramadol 50mg q6 IVTT Relief of moderate to moderately Done
severe pain, serves also as a
post operative analgesia.
2. Ketorolac 30mg q8 IVTT Short-term management (up to 5 Done
days) of moderately severe
acute pain and reduces signs
and symptoms of inflammation -
redness, swelling, fever, and
pain.
3. Ranitidine 50mg q8 IVTT Ranitidine serves as post Done
surgery antacid and to prevent
ulcer of which is ketorolac’s
adverse effect.
4. Sulperazone 1.5g q8 IVTT Post operative prophylaxis Done
Epidural anesthesia: Bupivacaine Bupivacaine serves as Done
0.25% 10cc + 0.25 MSO4 OD c/o analgesia for surgery added with
Dr. Tozon magnesium sulfate so as to
prevent seizue, convulsion and
to lower the blood pressure.
Morphine precaution Ordered because morphine Done
increases biliary spasm.
I & O q shift Anesthetics and surgery affect Done
the hormones regulating fluid
and electrolyte balance
(Aldosterone and ADH), placing
the client at risk for decreased
urine output and fluid and
electrolyte imbalances.
Monitoring I & O help assess
fluid balance. Accurate
measurement of a patient's fluid
intake and output will identify
those patients at risk of
becoming dehydrated or
overhydrated. Postoperative
patients are at risk of these.
Refer accordingly Call doctor’s attention Done
immediately once any unusuality
occur
04-30-09 IVFTF: D5NSS iL at 120cc/hr To continue IVTT medication Done
5pm administration and to replenish
electrolyte and fluid loss due to
the surgical procedure.
DIAGNOSTIC EXAMINATIONS
Reference Nursing
Exam Result Clinical Indication Interpretation
Range Responsibility
Hematology (April 27, 2009)
Hemoglobin 172 M: 140-170 Hemoglobin is an Above normal Prepare the client:
F: 120 – 150 important range.
g/dL component of red -Explain that a blood
blood cells that sample will be taken
carries oxygen and from the hand or arm
carbon dioxide to and that the sample
and from tissues. will be evaluated for
The hemoglobin the presence of
determination test is infection or anemia in
used to screen for the body.
diseases associated
with anemia and in Care after test:
determining acid-
base balance. The -Observe the client
oxygen carrying for signs of anemia
capacity of the blood including pallor,
is also determined dyspnea, chest pain,
by the Hemoglobin and fatigue.
concentration.
Erythrocyte 5.46 4.0-6.0 This test is used to Within normal
-Encourage rest
X10^9/L evaluate any type of range.
periods for client
decrease or
experiencing fatigue
increase in red
related to anemia.
blood cells. These
changes must be
-Evaluate client’s
interpreted in
ability to perform
conjunction with
activities of daily
other parameters,
such as hemoglobin living.
and/or hematocrit
Hematocrit 0.53 M: 0.40 - 0.60 Measures the Within normal
-Refer to community
F: 0.38 – 0.40 percentage of RBC range.
health care services
in a blood volume.
as needed if client is
The test is
unable to meet basic
performed to help
daily needs.
diagnose blood
disorders, such as
-Obtain a dietary
polycythemia,
consult to assist the
anemia or abnormal
client and family in
dehydration, blood
choosing a well-
transfusion
balanced diet,
decisions for severe
including foods high
symptomatic
in iron and vitamin
anemias, and the
B12.
effectiveness of
those transfusions.
-Review related tests
Leukocyte 15.2 5.0 – 10.0 A white blood cell Above normal
such as hemoglobin,
X10^9/L count is a range. An
hematocrit,
determination of elevated number
reticulocyte count,
number of WBC or of leukocytes can
RBC indices, TIBC,
leukocytes/unit result from
bone marrow and
volume in a sample infectious
liver biopsies, and
of venous blood. diseases (usually
iron absorption and
The test is used to bacterial origin),
excretion studies.
detect infection or and with trauma,
inflammation and surgery, or acute
leukemia, also used leukemia.
to help monitor the
body’s response to
various treatments
and to monitor bone
marrow function,
and to determine the
need for further
tests, such as
differential count.
Differential Contains actual number of different types of leukocyte. It also evaluates
Count: the distribution and morphology of the leukocytes.
Segmenter 0.72 0.45-0.65 They are the body’s Above normal
main bacteria range, indicates
fighters by neutrophils are
phagocytosis. The found with a
test is used to number of
determine certain bacterial
viral diseases, infections,
anemia, acute inflammatory but
infections and non-infectious
inflammatory diseases (collagen
diseases. disorders,
rheumatic fever,
pancreatitis), and
with malignancies.
Lymphocytes 0.28 0.2-0.35 The largest group of Within normal
leukocytes. Evaluate range.
bacterial and viral
infection, immune
disease, leukemia,
and ulcerative colitis
Platelet Count 222 150 – 450 The smallest formed Within normal
X10^9/L elements in blood range
that promote blood
clotting after an
injury. The test is
performed to
determine if blood
clots normally,
evaluate platelet
production, and to
diagnose and
monitor a severe
increase or
decrease in platelet
count
Blood Typing O +
This blood test is Type O people Inform the patient
performed to match have red blood about the purpose or
donor blood with cells with neither significance of the
recipient who antigen, but test.
requires blood produce
transfusion. Blood antibodies against Follow up results in
typing identifies the both types of the laboratory.
inherited antigens antigens. Because Inform the patient
that compromise of this the result of the
one of four possible arrangement, type test.
blood types: A, B, O can be safely
AB, O. given to any
person with any
ABO blood type.
Hence, a person
with type O blood
is said to be a
"universal donor"
but cannot receive
blood except from
the corresponding
O type people
Reference
Exam Result Clinical Indication Interpretation Nsg Responsibility
Range
Urinalysis (April 27, 2009)
Physical Exam Prepare client:
Color Amber Yellow Urine specimens may Amber colored
vary in color from pale urine is normal but -Explain that this
yellow to dark amber. it indicates high test is to look for
The color of urine specific gravity problems with the
changes in many and a small urine and the
disease states due to amount of urine. organs that help
the presence of Specific gravity is form it.
abnormal pigment. above 1.020 and
output less than -Advise the client to
1L per day wash the peri-anal
Appearance Cloudy Clear Urine specimen may However,
area prior to
appear clear to cloudy. excretion of cloudy
collecting the
This helps to indicate urine may not be
specimen to avoid
presence of WBC, abnormal since
contamination with
RBC, bacteria, pus, the change on
secretions or stool.
phosphates, urates and urine pH may
uric acid in the urine cause precipitation
-Inform the client
composition. within the bladder
that a specimen
of normal urinary
from the first
constituents.
morning urination is
Alkaline urine may
preferred since it is
appear cloudy
usually
because of the
concentrated and
presence of
more likely to reveal
phosphates, and
abnormalities and
acid urine may
formed substances.
appear cloudy
because of urates.
Reaction 6.0 4.6 - 8 It expresses the exact Within normal -Describe the
strength of the urine as range procedure for
a dilute acid or base collecting a clean-
solution and measures catch or midstream
the free hydrogen ion specimen if
concentration in the indicated
urine.
Specific Gravity 1.030 1.010-1.035 Specific gravity is a Within normal
means by which the range
kidney’s ability to
concentrate urine is
measured.
Chemical Exam
Glucose Negative Negative Urine glucose test are Normal
used to detect
diabetes, confirming a
diagnosis of diabetes,
or monitoring the
effectiveness of
diabetic control.
Albumin +++ Negative Detection of protein in Above normal
urine provides the result.
basis for differential
diagnosis of renal
disease.
Microscopic Exam
Pus Cells 2-4/hpf Negative This is done to detect Above normal
any bacteria/ infection result, indicates
in the genitourinary patient may have
tract. an infection.
RBC 1-2/hpf 0 – 1/hpf RBCs are occasionally Finding of more
found in the urine, but than 1 or 2 RBCs
persistent findings per high powered
should be thoroughly field is an
investigated foe such abnormal
indicates serious renal condition and can
disease. indicate a renal,
systemic disease
or trauma to the
kidney.
Mucus Threads + + This is a common Normal
finding in urine since
the entire urine system
is filled with mucus.
X-ray Report
(April 27, 2009)
Chest PA
Clinical Indication: Chest X-ray is done to diagnose pulmonary disease and diseases of the
mediastinum and bony thorax. This test also gives valuable information on the condition of the
heart, lungs, gastrointestinal tract and thyroid gland.
Findings: Heart is within normal limit in size. There are infiltrates on both lung bases. Rest of the
lung fields is clear. Lateral CP sinuses are sharp.
Impression: Suggestive of an inflammatory lung disease compatible with bibasal pneumonia.

Please correlate clinically.
Interpretation: Chest X-ray was ordered so as to assess the patient’s cadio and pulmonary system
prior to surgery and it was found out that aside from having cholecystitis, patient also has
pneumonia which then needs an Internist to determine whether he can proceed with the scheduled
surgery.
Nursing Responsibilities:
- Explain to the patient that the chest x-ray will be used for screening, diagnosis and
evaluation of change in his respiratory system.
- Explain the nature of the procedure to the patient
- Instruct the patient to remove all metal objects between his neck and chest and
change to hospital gown.
- Instruct the patient to take a deep breath and exhale; then he is required to take
another deep breath but hold it while the picture is taken.
- Tell patient that the procedure takes only a few minutes.
- Inform the patient regarding the result of the test.
ECG Result
(April 27, 2009)
Rate: 25 min
PR interval: 0.10second
Rhythm: Sinus
QRS: 0.08second
Axis: +15°
QTc: 0.44seconds Position Intermediate
Interpretation: Normal Sinus Rhythm
>The electrical impulse is formed in the SA node and conducted normally.

>This is the normal rhythm of the heart.
 Inform patient on why and how the test is done. Tell him that this is not an invasive
procedure, painless and a safe test.
 Place patient in a supine position in the bed or table.
 Prepare the skin (shave if there is excess hair) by applying contact paste or prejelled
discs.
 Place the electrodes accurately.
 Inform the patient regarding the result.
Reference
Exam Result Clinical Indication Interpretation Nsg Responsibility
Range
Blood Chemistry (April 27, 2009)
FBS 6.84 4.20 – 6.40 Fasting blood sugar Above normal level, - Explain that a
mmol/L test measure the indicates diabetes. blood sample will
amount of glucose in be taken from the
the blood and to hand or arm and
detect any disorder that the sample will
of glucose be evaluating the
metabolism. amount of sugar
present in the
blood that may
indicate diabetes
and evaluate if
metabolic
derangement has
resulted by the
disease.
-Instruct the client

not to eat or drink
anything, 12 hours
prior to taking the
test. He can just
drink water.
-Administer
Omeprazole 400
mg tab, 1 tab OD
to suppress gastric
acid secretion,
preventing
hyperacidity since
the patient will be
on NPO for 12
hours.
Creatinine 148 53 – 97 Creatinine is a Above normal range, 1. Explain that this

umol/L nitrogenous waste which indicates a test is important to
product produced decreasing kidney help understand
during protein function, or muscle how well the
metabolism in disease. kidneys are
muscle tissue. The working.
test is used to
determine kidney 2. Assess fluid and
function and/or nutritional status of
damage. client for clues or
renal impairment
and other disease
causing changes in
creatinine levels.
3. Continuously
monitor fluid
balance through
daily weights and
intake and output
recordings.
4. Evaluate for
increased fluid
volume manifested
by edema,
decreased urine
out put, neck vein
distention, dyspnea
and hepatomegaly.
Total Bilirubin 33.3 2.0 – 21.0 The measurement of Above normal range, Explain the
umol/L bilirubin is important may indicate purpose and the
in evaluating liver obstructive jaundice procedure of the
function, and of which is a result of test.
hemolytic anemia. A obstruction of the
NORMAL level of common bile duct or Tell patient that
total bilirubin reules hepatic ducts due to 10ml venous blood
out any significant stones or neoplasm. is to be collected
Direct Bilirubin 7.6 0.0 – 3.4 Above normal range,
impairment in the before he eats his
umol/L may indicate
excretory function of breakfast.
choledocholithiasis.
the liver or
Indirect Bilirubin 25.7 2.0 – 17 Above normal range,
excessive hemolysis Inform patient
umol/L may indicate
of red blood cells. regarding the test
hemolytic anemia.
Differentiation of result.
bilirubin is done to
determine which of
the problems above
is the cause of the
elevation of total
bilirubin. An in
crease in indirect
bilirubin is
associated with
hemolysis while an
increase in direct
bilirubin is seen as
liver dysfunction or
blockage.
Uric Acid 0.497 0.2 – 0.4 Uric acid is formed Above normal range, Explain the
umol/L from the breakdown could be associated purpose and the
of nucleonic acids with nitrogen procedure of the
and is an end retention and with test.
product of purine increase in urea,
metabolism. creatinine and other Inform the patient
Measurement of uric non-protein regarding the
acid is most nitrogenous result.
commonly in substances in the
evaluation of renal blood. May indicate a Monitor patient’s
failure, gout and decreased renal intake and output
leukemia. function. so as to determine
if he has a
decreased renal
function.
Alkaline 228 64 – 306 U/L This enzyme test is Within normal range Explain the
Phosphatase used chiefly as an purpose and the
index of liver and procedure of the
bone disease when test.
correlated with other
clinical findings. In Inform the patient
liver disease, the regarding the
blood level rises result.
when excretion of
this enzyme is
impaired as a result
of obstruction in the
biliary tract.
Albumin 55.4 38 – 51 g/L This test can help Above normal range, Explain the
determine if a may indicate renal purpose and the
patient has liver disease. procedure of the
disease or kidney test.
disease, or if the
body is not Inform the patient
absorbing enough regarding the
protein. result.
Ultrasound Report
(04/27/09)
Ultrasound Report
(This report is based on sonographic findings and must be correlated clinically.)
The liver is normal in size and tissue attenuation with smooth external outline. No cystic or
solid parenchymal lesions demonstrated here. The intrahepatic ducts are not dilated. The width AP
diameter of the common bile duct is 0.4cm. no focal lesions noted intraluminally.
The gallbladder is significantly distended to 11.6cm to 4.1cm (length X AP dm) with

diffusely thickened walls that measures up to 1.1cm low level echoes are seen in the dependent
portion of the gallbladder. Quetionable echoes are seen in the partly obscured cystic duct.
The pancreas is obscured by overlying bowel gas preluding adequate assessment.
Impression:
> Cholecystitis with bile sludge formation and suggestive hydrophoric change. Cannot
entirely rule out calculus in the cystic duct
> Sonographically normal liver and biliar ducts
Interprertation: Based on the above findings (patient has gangrenous gallbladder), he then needs
to undergo open cholecystectomy instead of lap cholecystectomy.
 Explain the purpose and the procedure of the test.
 Inform patient that ultrasound is a noninvasive procedure.
 Instruct him not to eat solid food for the 12 hours prior to exam to allow greatest
dilation of the gallbladder.
 Inform him that water is permitted.
 Inform patient regarding the result.
DRUG STUDY
Generic Name: Amlodipine besylate
Brand Name: Lopicard
Classification: Calcium channel blocker; Antianginal; Antihypertensive
Mode of Action: Blocks the transport of calcium into the smooth muscle cells lining the coronary
arteries and other arteries of the body. Since calcium is important in muscle contraction, blocking
calcium transport relaxes artery muscles and dilates coronary arteries and other arteries of the
body. By relaxing coronary arteries, amlodipine is useful in preventing chest pain (angina) resulting
from coronary artery spasm. Relaxing the muscles lining the arteries of the rest of the body lowers
the blood pressure, which reduces the burden on the heart as it pumps blood to the body.
Reducing heart burden lessens the heart muscle's demand for oxygen, and further helps to prevent
angina in patients with coronary artery disease.
Dosage: Lopicard 5mg tab OD
Indication: Hypertension
Contraindication: Hypersensitivity to amlodipine, impaired hepatic or renal function, sick sinus

syndrome, heart block (second or third degree), lactation
Side Effects: dizziness, light-headedness, headache, fatigue, edema of the lower extremities,
flushing, nausea, vomiting, palpitations, stomach pain, drowsiness, muscle cramps, abdominal
discomforts
Adverse Effects: asthenia, arrhythmias, chest pain, yellowing of the eyes or skin, difficulty
breathing
Drug - Drug Interaction: Risk of congestive heart failure with beta-adrenergic blockers.
Increased antihypertensive effects with other antihypertensives.
Possible increased serum levels and toxicity of cyclosporine if taken
concurrently.
1. Assess patient for contraindication.
2. Assess for baseline data.
3. Administer drug without regard to meals.
4. Monitor patient’s vital signs carefully while adjusting drug to therapeutic dose.
5. Instruct patient to take drug with meals if stomach upset occurs.
6. Instruct him to take drug exactly as prescribed by his physician.
7. Tell patient that he may experience some side effects brought upon by the drug.
8. Instruct him to report intolerable side effects so management can be done.
9. Instruct him to eat frequent small meals if vomiting occurs.
10. Oral care if patient vomits.
11. Instruct him to adjust lighting, noise and temperature if he experiences headache and
report if it is intolerable so that medication may be given.
12. Instruct him to report any adverse effects that he may experience.
Generic Name: Vitamin K
BRAND NAME: Aqua-Mephyton
CLASSIFICATION: Fat soluble vitamin
MECHANISM OF ACTION: Vitamin K is essential for the hepatic synthesis of factors II, VII, IX, and
X, all of which are essential for blood clotting. Vitamin K deficiency causes an increase in bleeding
tendency, demonstrated by ecchymoses, epistaxis, hematuria, GI bleeding.
DOSAGE: Vitamin K 10g IV OD
INDICATION: Prevention of bleeding, Vitamin K malabsoption, hypoprothrombinemia
CONTRAINDICATION: Hypersensitivity, severe hepatic disease, last few wk of pregnancy
SIDE EFFECTS: Dizziness, flushing, transient hypotension after IV administration, rapid and weak
pulse, diaphoresis, erythema, pain swelling and hematoma at injection site
ADVERSE REACTION: Anaphylaxis or anaphylactoid reactions, usually after rapid IV

administration
DRUG INTERACTION:
 Cholestyramine, mineral oil: may inhibit Gi absorption of vitamin K
 Oral anticoagulants: decreased anticoagulant effect
 Antibiotics: may inhibit vitamin K production leading to bleeding
NURSING RESPONSIBILITIES :
1. Assess for contraindication.
3. Monitor protime during treatment; monitor for bleeding, pulse and BP.
4. Teach patient not to take other supplements, unless directed by prescriber, to take
this medication as directed.
5. Tell patient that he may experience side effects brought about by the drug and to
report intolerable ones so as prompt interventions be done.
6. Instruct patient to report symptoms of bleeding: bruising, nosebleeds, bleack tarry
stools, hematuria.
7. Stress the need for periodic lab tests to monitor coagulation level.
8. Instruct patient to report adverse effect that he may experience.
Generic Name: Midazolam HCl
Brand Name: Dormicum
Classification: Benzodiazepine (short-acting);Anxiolytic; CNS depressant; Anticonvulsant
Mode of Action: Acts mainly at the limbic system and reticular formation; potentiates the effects of
gamma amino butyric acid (GABA), an inhibitory neurotransmitter; anxiolytic and amnesia effects
occur at doses below those needed to cause sedation, ataxia; has little effect on cortical function.
Dosage: Midazolam 15mg 1tab ½tab at 12nn with 30cc of water
Indication: Sedation, anxiolysis, and amnesia prior to surgery
Contraindication: Hypersensitivity to benzodiazepines;psychoses, acute marrow-angle glaucoma,

shock, coma, acute alcoholic intoxication, pregnancy (cleft lip or palate, inguinal hernia, cardiac
defects, microencephaly, pyloric stenosis have been reported when used in the first trimester;
neonatal withdrawal syndrome reported in infants); neonates
Side Effects: Drowsiness, dizziness, GI upset, difficulty concentrating, fatigue, nervousness, crying,
dreams, hiccups, diaphoresis, incontinence, nausea, vomiting, diarrhea, constipation, dry mouth,
salivation, headache, light-headedness
Adverse Effects: Lethargy, apathy, disorientation, delirium, stupor, dysarthria, dystonia, tremor,
rigidity, vertigo, euphoria, vivid dreams, psychomotor retardartion, extrapyramidal symptoms,
nystagmus, bradycardia, tachycardia, urticaria, gastric disorder, jaundice, hepatic dysfunction,
paresthesias, gynecomastia, bronchospam, laryngospam, drug dependence, respiratory
depression, respiratory arrest
Drug – Drug Interaction:
 Increased CNS depression with alcohol, opioids, barbiturates, other sedatives and
anaesthetics.
 Increased respiratory depression with opiates, phenobarbital, other benzodiazepines.
 Plasma concentrations increased by CYP3A4 inhibitors such as cimetidine, erythromycin,
clarithromycin, diltiazem, verapamil, ketoconazole and itraconazole, antiretroviral agents,
quinupristin with dalfopristin.
 Midazolam concentration decreased by phenytoin, carbamazepine, phenobarbital,
rifampicin.
 Halothane, thiopental requirements may be reduced during concurrent use.
3. Monitor level of consciousness before, during and for at least 2 – 6hours after
administration.
4. Carefully monitor VS during administration.
5. Keep patient on bed for 3hours, not to permit ambulation upon administration.
6. Teach him that the drug helps him to relax and will make him sleep, and the drug is a
potent amnesiac and he will not remember what has happened on him.
7. Instruct him to take the drug exactly as prescribed.
8. Instruct him to avoid alcohol, or sleep – inducing, or OTC drugs before receiving the
drug.
9. Tell patient that he may experience side effects brought upon by the drug.
10. Instruct patient to report adverse effects that he may experience.
Generic Name: Cefoperazone Na 1 g, Sulbactam Na 0.5 g
Brand Name: Sulperazone® [vial]
Classification: Cephalosporin, antibiotic
Mode of Action: Inhibits bacterial cell wall synthesis causing cellular death
Dosage: Sulperazone 1.5g q8 IVTT
Indication: Treatment of respiratory infection caused by S. pneumoniae, H. parainfluenzae, S.

aureus, E. coli, Klebsiella, H. influenzae, S. pyrogenes; Perioperative prophylaxis; Post operative
prophylaxis
Contraindication: Hypersensitivity to cephalosporin or penicillin, or renal failure
Side Effects: diarrhea, nausea, vomiting, headache, dizziness, hypotension, abdominal pain, pain
at injectionsite, inflammation at IV site, rash
Adverse Effects: paresthesia, seizure, liver toxicity, nephrotoxicity, bone marrow depression,
leukopenia, anaphylaxis, hematuria, vasculitis, shock

 Increased nephrotoxicity with aminoglycosides
 Increased bleeding effects with anticoagulant
 Disulfiram-like reaction may occur if alcohol is taken 72hrs after drug
administration
3. Inject slowly over 3-5 minutes.
4. Have vitamin K injection readily available in case of hypoprothrombinemia.
5. Tell patient that he may experience side effects that are brought about by the drug.
9. Minimize stimuli (adjust temperature, lighting and avoid noise) if headache occurs and
if intolerable pain medication may be given as ordered.
10. Instruct patient to avoid alcohol because severe reactions could occur.
11. Tell patient to report any adverse effects that he may experience.
Generic Name: Cefoxitin Sodium
Brand Name: Monowell
Classification: Antibiotic; Cephalosporin (second generation)
Mode of Action: Bactericidal: inhibits synthesis of bacterial cell wall, causing cell death.
Dosage: Cefoxitin 1 amp IVTT ANST now prior to OR
Indication: Surgical prophylaxis
Contraindication: Hypersensitivity to cephalosporins or penicillins.
Side Effects: Nausea, vomiting, diarrhea, flatulence, anorexia, headache, phlebitis, rash, fever,
pain on injection site, dizziness, stomach upset
Adverse Effects: Lethargy, pseudomembranous colitis, paresthesias, liver toxicity, nephrotoxicity,

convulsion, leukopenia, decreased hematocrit, decreased platelet, anaphylaxis, superinfection,
Drug –Drug Interaction:

 Enhanced nephrotoxicity with aminoglycosides and loop diuretics e.g. furosemide.
 Renal excretion inhibited by probenecid.
 Increase bleeding with oral anticoagulants.
 Disulfiram-like reaction may occur if alcohol is taken within 72hours after drug
administration.
3. Have vitamin K readily available in case of hypoprothrombinemia occurs.
4. Instruct patient to avoid alcohol for 3days after drug administration because serious
reactions often occur.
5. Tell patient that he may experience some side effects brought upon by the drug.
9. Instruct him to report any adverse effects that he may experience.
Generic Name: Metoclopramide
Brand Name: Octamide PFS, Reglan
Classification: GI stimulant, antiemetic, dopaminergic blocker
Mode of Action: Stimulates the muscles of the gastrointestinal tract including the muscles of the
lower esophageal sphincter, stomach, and small intestine by interacting with receptors for
acetylcholine and dopamine on gastrointestinal muscles and nerves; decreases the reflux of
stomach acid by strengthening the muscle of the lower esophageal sphincter; stimulates the
muscles of the stomach and thereby hastens emptying of solid and liquid meals from the stomach
and into the intestines; interacts with the dopamine receptors in the brain and can be effective in
treating nausea.
Dosage: Metoclopramide 1amp IVTT @ 6am
Indication: Stimulation of gastric emptying prior to surgery
Contraindication: Hypersensitivity to metoclopramide, GI hemorrhage, mechanical obstruction or

perforation; pheochromocytoma (may cause hypertensive crisis); epilepsy
Side Effects: drowsiness, restlessness, fatigue, anxiety, insomnia, depression, sedation, nausea,
diarrhea, urinary frequency
Adverse Effects: parkinsonm-like reactions, involuntary muscle movements, facial grimacing,

dystonic reactions resembling tetanus, transient hypertension, tardive dyskinesia, myoclonus
Drug – Drug Interaction

 Decreased absorption of Cefprozil, cimetidine, digoxin from the stomach
 Increased oral bioavailability or absorption of acetaminophen, cyclosporine, ethanol,
levodopa, tetracycline
 Decreased effect on gastric emptying with anticholinergic, opioid analgesics, levodopa
 Increased risk of serious adverse effects due to excess release of neurotransmitters with
MAOIs for example, isocarboxazid (Marplan), phenelzine (Nardil), tranylcypromine
(Parnate), selegiline (Eldepryl), and procarbazine (Matulane)
3. Give direct IV dose slowly (over 1 to 2 minutes).
4. Monitor BP carefully during IV administration.
5. Monitor for extrapyramidal reactions, and consult physician if they occur.
6. Keep diphenhydramine injection readily available incase of extrapyramidal reactions.
7. Have phentolamine readily available in case of hypertensive crisis (most likely to occur
with undiagnosed pheochromocytoma).
9. Instruct patient to report involuntary movement of the face, eyes or limbs, severe
depression, severe diarrhea.
10. Provide a safe environment if restlessness, involuntary muscle movement occur.
Generic Name: Ranitidine
Brand Name: Zantac
Classification: Histamine 2 antagonist
Mode of Action: Competitively inhibits the action of histamine at the H2 receptors of the parietal
cells f the stomach, inhibiting basal gastric acid secretion and gastric acid secretion that is
stimulated by food, insulin, histamine, cholinergic agonist, gastrin, and pentagastrin.
Dosage: Ranitidine 50mg q8 IVTT
Indication: Post surgery antacid to prevent ulcer formation
Contraindication: Hypersensitivity to ranitidine, lactation.
Side Effects: headache, rash, dizziness, vertigo, constipation, diarrhea, nausea, vomiting,
abdominal discomforts, local burning or itching at IV site
Adverse Effects: malaise, insomnia, somnolence, urticaria, tachycardia, bradycardia, leukopenia,

pancytopenia, thrombocytopenia, gynecomastia, impotence, hepatitis
Drug – Drug Interaction: Increased effects of warfarin, tricyclic antidepressants

3. Tell patient that he may experience side effects brought about by the drug.
4. Instruct patient to take his meal if nausea or vomiting occurs.
5. Oral care if vomiting occurs.
6. Adjust lighting and temperature and avoid noise if he experiences headache and
instruct him to report if it is intolerable so that medication may be given.
7. Instruct him to report intolerable side effects so as prompt intervention could be done.
8. Instruct him to report adverse effects that he may experience.
Generic Name: Tramadol HCl
Brand Name: Ultram
Classification: Analgesic, centrally acting
Mode of Action: Binds to mu-opioid receptors and inhibits the reuptake of norepinephrine and
serotonin; causes many effects similar to opioids – dizziness, somnolence, nausea, constipation –
but does not have the respiratory effects.
Dosage: Tramadol 50mg q 6° IVTT
Indication: Relief of moderate to moderately severe pain; post surgery analgesia
Contraindication: Hypersensitivity to tramadol or opioids or acute intoxication with alcohol, opioids,

or psychoactive drugs
Side Effects: Nausea, constipation, dizziness, headache, drowsiness, vomiting, somnolence,

sedation, headache, dry mouth, sweating, diarrhea, rash, visual disturbances, vertigo
Adverse Effects: Confusion, anxiety, seizure, tachycardia, bradycardia, pallor, anaphylactoid

reactions

 Carbamazepine reduces the effect of tramadol by increasing its inactivation in the body.
 Quinidine (Quinaglute, Quinidex) reduces the inactivation of tramadol, thereby increasing
the concentration of tramadol by 50%-60%.
 Combining tramadol with monoamine oxidase inhibitors (for example, Parnate) or selective
serotonin inhibitors [(SSRIs, for example, fluoxetine (Prozac)] may result in severe side
effects such as seizures or a condition called serotonin syndrome.
 Tramadol may increase central nervous system and respiratory depression when
combined with alcohol, anesthetics, narcotics, tranquilizers or sedative hypnotics.
1. Assess for contraindications.
4. Instruct him to report side effects that are intolerable.
5. Control environment (temperature, lighting) if sweating or CNS effects occur.
6. Encouraged small frequent meals if vomiting occurs.
7. Oral care for dry mouth and vomiting.
8. Encourage him to increase oral fluid intake.
9. Instruct patient to report adverse effects that he may experience.
Generic Name: Ketorolac tromethamine
Brand Name: Toradol
Classification: NSAID, Nonopioid analgesic
Mode of Action: Reduces the production of prostaglandins, chemicals that cells of the immune
system make that cause the redness, fever, and pain of inflammation and that also are believed to
be important in the production of non-inflammatory pain. It blocks the enzymes that cells use to
make prostaglandins (cyclooxygenase 1 and 2). As a result, pain as well as inflammation and its
signs and symptoms - redness, swelling, fever, and pain - are reduced.
Dosage: Ketorolac 30mg q8 IVTT
Indication: For short-term management (up to 5 days) of moderately severe acute pain that
otherwise would require narcotics. It most often is used after surgery.
Contraindication: Hypersensitivity to ketorolac, renal Impariment, aspirin allergy
Side Effects: rash, ringing in the ears, headaches, dizziness, drowsiness, abdominal pain, nausea,
diarrhea, constipation, heartburn, fluid retention, somnolence, insomnia, dyspepsia, dry mucous
membrane, sweating, peripheral edema, GI pain
Adverse Effects: gastric or duodenal ulcer, renal impairment, liver failure, dysuria, bleeding, platelet
inhibition, neutropenia, leukopenia, pancytopenia, thrombocytopenia, bone marrow depression

 Increased levels of ketorolac in the body and increased side effects with
Probenecid (Benemid).
 Increase risk of lithium toxicity with lithium (Eskalith)
 Reduced kidney function with concominatnt use with angiotensin converting
enzyme (ACE) inhibitors.
 Increase risk of bleeding with anticoagulants (warfarin), aspirin
 Increased risk of nephrotoxicity with other nephrotoxins (aminoglycosides,
cyclosporine)
3. Infuse slowly as a bolus over no less than 15 seconds.
4. Administer with ranitidine to avoid ulceration.
6. Encouraged oral fluid intake to avoid dry mucous membrane.
7. Provide comfort measures if headache occurs.
8. Instruct to report intolerable side effects for prompt intervention.
9. Instruct to report signs of bleeding such as black tarry stool, weakness and dizziness
upon standing.
10. Instruct to report if he experiences adverse effects.
Generic Name: Bupivacaine
Brand Name: Bupican
Classification: Anesthesia
Mode of Action: Block the generation and the conduction of nerve impulses, presumably by
increasing the threshold for electrical excitation in the nerve, by slowing the propagation of the
nerve impulse, and by reducing the rate of rise of the action potential. The analgesic effects of
Bupivacaine are thought to be due to its binding to the prostaglandin E2 receptors, subtype EP1
(PGE2EP1), which inhibits the production of prostaglandins, thereby reducing fever, inflammation,
and hyperalgesia
Dosage: Bupivacaine 0.25% 10cc + 0.25MSO4 OD
Indication: Local or regional anesthesia; analgesia for surgery
Contraindication: Hypersensitivity to bupivacaine or other local anesthesia e.g. lignocaine, blood

clotting disorder, low blood pressure,
Side Effects: nervousness, tingling around the mouth, tinnitus, tremor, dizziness, blurred vision,
ringing of the ears, feeling of disorientation, nausea, vomiting, drowsiness, numbness of tongue,
lightheadedness
Adverse Effect: convulsion, seizures, unconsciousness, arrhythmias, tachycardia, bradycardia,

cardiac arrest, hypotensive shock, respiratory arrest, myocardial depression,
Drug – Drug Interaction: Additive effects when used with antiarrhythmic drugs
3. Monitor vital signs carefully, drug depresses the pulmonary and cardiac system.
4. Monitor for side effects.
5. Tell patient that he may experience side effects brought about by the drug and if such
is/are intolerable he must report them so as prompt interventions be done.
6. Oral care if vomiting occurs.
7. Monitor for occurrence of adverse effects, report to the anesthesiologist any signs and
symptoms of adverse effects.
8. Continue to monitor patient following discontinuation of anesthesia.
Generic Name: Magnesium Sulfate
Brand Name:
Classification: Electrolyte, Antiepilecptic, Antihypertensive, Laxative
Mode of Action: An important cofactor for enzymatic reactions and plays an important role in
neurochemical transmission and muscular excitability; prevents or controls convulsions by blocking
neuromuscular transmission and decreasing the amount of acetylcholine liberated at the end plate
by the motor nerve impulse; attracts and retains water in the intestinal lumen and distends the
bowel to promote mass movement and relieve constipation; acts peripherally to produce
vasodilation; larger doses cause lowering of blood pressure.
Dosage: Bupivacaine 0.25% 10cc + 0.25MSO4 OD
Indication: Parenteral anticonvulsant for the prevention and control of seizures, lowers BP while in
surgery
Contraindication: Hypersensitivity to magnesium sulfate, heart block, myocardial damage;

abdominal pain, appendicitis, fecal impactation, hepatitis, intestinal and biliary tract obstruction
Side Effects: weakness, dizziness, excessive bowel movement, sweating, flushing, headache,
nausea, vomiting, palpitations
Adverse Effects: fainting, magnesium intoxication, hypotension, depressed reflexes, flaccid,

paralysis, hypothermia, circulatory collapse, cardiac and CNS depression, hypocalcemia, tetany
 Potentiation of neurotransmuscular blockade produced by nondepolarizing neuromuscular
relaxants (tubocurarine, atracurium, pancuronium, vecuronium)
 CNS depression and peripheral transmission defects produced by magnesium is
antagonized by calcium.
 Reduces antibiotic activity of streptomycin, tetracycline and tobramycin when given
together.
3. Do not administer unless solution is clear and container is undamaged. Discard
unused portion.
4. Monitor knee-jer reflex before repeated parenteral administration. If it is suppressed,
do not administer the drug for it may cause respiratory center failure.
5. Administer with caution if flushing and sweating occurs.
6. Have calcium gluconate readily available if signs and symptoms of hypermagnesemia
occur.
7. Tell patient that he may experience some side effects brought about by the drug and
instruct him to report intolerable side effects so as prompt intervention be done.
8. Oral care when vomiting occurs.
9. Volume for volume replacement when excessive bowel movement and vomiting
occurs to replace the loss fluid.
10. Instruct patient to report adverse effects immediately.
Procedural Report
on Open Cholecystectomy
Surgeon: Dr. Batucan, Wolter
Operation: Open Cholecystectomy
Anesthesiologists: Dr. Togon
Date of Surgery: 04/30/09 at 7:00 am
Definition
Cholecystectomy is the excision (removal) of the gallbladder.
Discussion
Cholecystectomy may be performed to treat chronic or acute cholecystitis, with or without
cholelithiasis, or to resect a malignancy.
Note:
Cholecystectomy, performed laparoscopically, is the preferred treatment for symptomatic
gallstones unless the patient is extremely obese, there are excessive adhesions, or ductal or
vascular anomalies exist. If unexpected pathology is encountered, if acute inflammation distorts
normal tissue planes, or if there is excessive bleeding or surgical injury, the laparoscopic procedure
is promptly converted to “open” cholecystectomy.
Type of Anesthesia
 General anesthesia
 Thoracic epidural anesthesia (as an alternative)
Preparation of the Patient
Antiembolitic hose may be put on the legs, as requested. The
patient is supine; both arms may be extended on padded armboards.
A pillow may be placed under the sacrum and/ or under the knees to
avoid straining back muscles. Pad all bony prominences and areas
vulnerable to skin and neurovascular pressure of trauma. A
nasogastric tube may be inserted by the anesthesia provider. A foley
catheter is not routinely placed. An electrosurgical dispersive pad is
applied.
Skin Preparation
Begin at the intended site of incision, either right subcostal (most frequently used), right
paramedian, or medline, extending from the axilla to the pubic symphysis and down to the table on
the sides.
Procedure
The incision is right subcostal, right paramedian, or midline. The abdominal cavity is
entered in the usual manner. The gallbladder is grasped (generally with a Pean clamp). The cystic
duct, cystic artery, and common bile duct are exposed. The surgeon must be aware of anomalies
of these structures. The cystic artery is clamped (using two right-angle clamps) and ligated with a
suture passed on a long instrument or by clips (e.g., Hemoclips), as is the cystic duct. The
gallbladder is mobilized by incising the overlying peritoneum and after local dissection is removed.
The underlying liver bed may be reperitonealized. A drain (e.g., Jackson-Pratt ™) may be
employed exiting a stab wound and secured to the skin with a stitch. The wound is closed in layers.
The skin is closed with interrupted stitches, tapes, or skin staples.
Instruments, Machines and Supplies
Draping
 4 folded towels and a laparotomy sheet
Equipment
 Folded blanket or pad (for positioning)
 Sequential compression device with disposable leg wraps, if ordered
 Suction
 Ultrasound generator, if requested
 Laser (e.g., Nd: YAG laser fiber or pulsed dye) when requested
Instrumentation
 Major procedures tray
 Long Metzenbaum scissors
 Hemoclip or other ligating clip appliers
 Biliary tract tray (for common duct exploration)
 Choledochoscope when requested; if unavailable, a uteroscope or small cystoscope may
be substituted
Supplies
 Antiembolitic hose
 Basin set
 Blades, (2) #10, (1) #15, or (1) #11
 Suction tubing
 Hemoclips or similar ligating clips
 Electrosurgical pencil and cord with holder and scrape pad
 Needle magnet or counter
 Dissectors (e.g, peanut or Kittner sponges)
 Drains, e.g., Penrose 1” or suction drain (e.g., Jackson-Pratt or Hemovac™), optional
 Mushroom-tipped (retention) catheters, e.g., Pezzer or Malecot, available
 Culture tubes, one aerobic and one anaerobic
 Hemostatic agent e.g., Surgicel™, Helistat™, Thrombostat™, Avitene™, available

Nursing Responsibilities
Preoperative
 All care that is given and observations made regarding the patient (e.g., condition of skin
preoperatively) must be documented in the operative record for continuity of care and for
medicolegal reasons.
 The nurse conveys to the patient that he will act as the patient’s advocate by speaking for
him while the patient is in surgery.
 Assess health factors that affects the patient preoperatively: nutritional status, drug or
alcohol use, cardiovascular status, hepatic and renal function, endocrine function, immune
function, previous medication use, psychosocial factors, as well as the spiritual and cultural
beliefs.
 When the circulator reviews patient allergies with the patient, he ascertains that the patient
has no history of allergy to radiopaque dye.
 Inform the patient of the scheduled date and time of the surgery and where to report
 Instruct what to bring (insurance card, list of meds & allergies)
 Check the chart for patient’s sensitivities and allergies e.g. allergy to iodine. Document
allergies noted preprocedure and document alternative used.
 Instruct what to leave at home such as jewelry, watch, medications and contact lenses
 Instruct what to wear ( loose fitting, comfortable clothes and flat shoes)
 Remind the patient not to eat or drink if directed

 The patient may have fear and anxiety regarding the surgical procedure and the unfamiliar
environment. Explain nursing procedures before performing them and the sequence of
perioperative events.
 Assess and document patient’s anxiety level and level of knowledge regarding the
intended procedure. Clarify misconceptions by answering the patient’s questions in a
knowledgeable manner and refer questions to the surgeon as necessary.
 Decrease fear
 Teach deep-breathing, coughing or incentive spirometer
 Provide emotional support to the patient regarding feelings of altered body image by
providing the patient an opportunity to express her feelings.
 Respect cultural, spiritual and religious beliefs
Intraoperative
 It is imperative that the patient be positioned over the correct area on the table to ensure
accurate visualization of the biliary tract.
 A protective facial shield is suggested for those scrubbed to avoid inadvertent splashing of
contaminated fluids onto mucous membranes and eyes.
 All medications, dyes, etc., on the opening field must be labeled. Scrub person should use
a marking pen on labels to identify all solutions. All medication containers should be kept in
the room until the completion of the procedure.
 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.

 Take appropriate measures to maintain patient’s body temperature e.g., offer warm
blanket or raise room temperature as necessary.
 Keep the patient adequately covered to maintain patient’s privacy, expose only the
immediate area involved for the procedure.
 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.
 Scrub person needs to have a right angle clamp (Mixter) available throughout the
dissection of the biliary tree.
 Usually a stab wound is made in the cystic duct using a #11 blade. The incision is
extended with Pott’s scissors.
 Have T-tubes available following common duct exploration
 One syringe is filled with saline, 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)

 Use a small basin to accept the specimen
 Aerobic and anaerobic cultures may be taken of the bile or gallbladder bed.
Postoperative
 The circulator accompanies the anesthesia provider and the patient to the PACU; he/she
gives the PACU perioperative practioner a detailed intraoperative patient report regarding
the course of events as they apply to the individual.
 Assess the patient: appraise air exchanges status & note skin color; verify & identify
operative status & surgeon performed; assess neurological status (LOC)
 PACU nurse observes the patient’s breathing, monitors blood pressure and vital signs, and
documents all pertinent information.
 PACU nurse assumes the role as the patient’s advocate..
 Report for abnormalities especially for signs and symptoms of shock
 Perform safety checks – good body alignment, side rails and maintain patent airway and
cardiovascular stability
 Relieve pain and anxiety
Reference
pp. 148-153, Maxine A. Goldman 2008, Pocket Guide to the Operating Room. 3 rd edition
F.A. Davis Company.Philadelphia

Nursing Theories
Ma. Estine Levine’s Conservation Model
Levine’s conservation model provides a thoughtful basis for making effective wound
management choices in order to improve wound healing and consequently ameliorate individual
well being and quality of life. The relationship between effective wound management and positive
patient outcomes draws on Levine’s four conservation principles, about which she states:
The conservation principles address the integrity of the individual…from birth to death. Every
activity requires an energy supply because nothing works without it. Every activity must respect the
structural wholeness of the individual because well-being depends on it. Every activity is chosen
out of the abilities, life experience, and desires of the “self”’ who makes the choices. Every activity
is a product of the dynamic social systems to which the individual belongs.
The patient last April 30, 2009 was on status post cholecystectomy. Cholecystectomy was done to
remove the gallbladder. Incision was made. To have an effective wound healing and prevent
complications, vital signs was monitored. Patient was encouraged to take a rest. To regain
structure and function, the body needs to restore structural integrity through repair and healing. It is
very important to take note of the discharges, its quantity and characteristic. Aseptic technique in
wound dressing was applied to prevent possibility of infection. In addition, to promote healing,
antibiotics was also given.
Jean Watson
Dr Watson believes that a new paradigm is emerging in health care. She states that
conventional medicine has become increasingly technological, typically centering on treatment to
cure disease with medications and surgery. In contrast, the caring approach of nursing focuses on
conscious compassionate skills that help patients achieve a healthy state of mind, body, and spirit.
Dr Watson relates that caring is intrinsic to the therapeutic interpersonal relationship between the
nurse and patient. Ten primary carative factors form the structure of Dr Watson's caring theory
Psychological caring-healing therapies strive to instill hope or faith. To meet the

psychological or spiritual needs of patients, nurses traditionally incorporate humanistic, altruistic
values by using the power of prayer, spiritual beliefs, or suggestions or through a trusting
therapeutic nurse-patient relationship. The nurse's relationship and interpersonal teaching enables
the patient to provide self-care, determine personal needs, and provide opportunities for personal
growth. Therapeutic communication is implemented through nonverbal behavior and listening,
facilitating nonpossessive warmth, initiating self-understanding, and communicating with
personalized responses to develop a helping, trusting relationship
After developing a therapeutic trusting relationship, the nurse can help the patient relax
before surgery with the caring-healing therapies of holistic nursing. Being available to the patient,
listening to his concerns, and providing silence was practiced to relieve patient’s anxiety.
Medications were also given such as anxiolytic medicines to decrease anxiety.
Faye Abdellah
According to her, nursing is based on an art and science that mould the attitudes,
intellectual competencies, and technical skills of the individual nurse into the desire and ability to
help people , sick or well, cope with their health needs.
To view Abdellah’s 21 nursing problems according to Maslow’s hierarchy of needs, in the

physiologic needs, the nurse must facilitate the maintenance of a supply of oxygen to all body cells,
nutrition of all body cells, fluid and electrolyte balance, elimination, maintain good body mechanics
and prevent and correct deformities, good hygiene and physical comfort, promote optimal activity:
exercise , rest and sleep and to facilitate the maintenance of regulatory mechanisms and
functions.
Patient’s needs was attended such as proper positioning, cough and deep breathing
exercises to prevent post operative complications. Patient was on NPO, but it is very important to
increase fluid intake and eat high caloric foods to prevent dehydration and weakness due to
increased metabolic demands of the body. It is very important to take into consideration the diet
after NPO because the body is on the process of repairing.
Nursing Care Plan
Date/ Cues Need Nursing Diagnosis Objectives of Care Nursing Interventions Evaluation
Time
April 27, S: “ Sakit jud akoa C Acute Pain related to Within my 8 hr care, 1. Observe and document location, Goal met.
2009 tiyan karun O inflammation and the client will be able severity and character of pain.
(pointing at the right G distortion of tissues to: ® Assists in differentiating cause of Although pain was
3-11pm upper quadrant of N pain and provides information about not totally relieved,
the abdomen), I ® If gallstone obstruct 1. Report pain is disease progression/ resolution, the patient
mura man ug T the cystic duct, the controlled if not development of complications and verbalized, “ Na ok
gimakumot na dili I gallbladder becomes relieved. effectiveness of interventions. ok raman ko karun,
nako masabtan.”, V distended, inflamed medyo sakit pero
as verbalized by the E and eventually 2. Demonstrate the 2. Administer anticholinergics as dili na pareha
patient. infected. Inflammation use of relaxation skills indicated. ganina.” The patient
- and swelling and diversional ® Anticholinergics relieves reflex had identified
O: Grimaced face depresses the free activities as indicated spasm or smooth muscle contraction relaxing techniques
With guarding P nerve endings and for individual situation and assist in pain management. such as deep
behavior E cause the pain. The breathing exercises
Restlessness R patient may have 3. Administer smooth muscle and freeing the
Rigidity of the C biliary colic with relaxants, nitroglycerin as ordered. mind from worry
abdomen E excruciating upper ®Relieves ductal spasm. which is helpful in
RR= 32cpm P right abdominal pain minimizing pain.
Splinted respiration T that radiates to the 4. Administer Chenodeoxycholic acid.
with short and U back or right ® Chenodeoxycholic acid is a natural
shallow breathing A shoulder. bile acid that decreases cholesterol
L synthesis reducing size of gallstones.
Source:
P Porth CM. (2002). 5. Antibiotics
A Pathophysiology: ® To treat infectious process reducing
T Concepts of Altered inflammation.
T Health States.
E Philippines: Lippincott 6. Hyperlipidemic agents.
R Williams & Wilkins. ® Reduces itching or pruritus from bile
N salts in skin
7. Note response to medication and

report if pain is not being relieved.
® Severe pain not relieved by routine
measures may indicate developing
complications/ need for further
intervention
8. Promote bedrest, allowing patient to

assume position of comfort.
® Bedrest in Fowler’s position reduces
intraabdominal pressures; however,
patient will naturally assume least
painful position.
9. Use soft, cotton lines, calamine

lotion, cool or moist compress as
indicated,
® Reduces irritation/ dryness of skin
and itching sensation.
10. Control environmental

temperature, maintain a cool room
temperature.
®Cool surroundings aid in minimizing
dermal discomfort.
11. Encourage use of relaxation

techniques such as deep breathing
exercises. Provide diversional
activities such as watching television.
®Promotes rest, redirects attention,
may enhance coping.
12. Make time to listen to complaints

and maintain frequent contact with the
patient.
®Helpful in alleviating anxiety and
refocusing attention, which can relieve
pain.
Time
April S: “Wala ko kasabot S Anxiety related to Within my 4 hour 1. Be available to the patient. Goal met.
28, 2009 sa ako gibati, mura E gallbladder removal care, the client will be Maintain frequent contacts with the
ko ug nahadlok L surgery able to: patient/SO. Be available for listening Patient was able to
3-11pm karun sa ako F and talking as needed. identify ways
operasyon ug unsa - ® Anticipated surgery 1.Verbalize ® Establishes rapport, promotes reducing anxiety
ang mahitabo sa P can be a source of awareness of feelings expression of feelings. such as use of
akua panhuman E many threats. These of anxiety and health Demonstrates concern and deep breathing
ato.” R threats can produce ways to deal with willingness to help. Helpful in exercises, and
C vague feelings them. discussing sensitive subjects. anxiety was
O: Restlessness E ranging from mild reduced to a
Reports of P uneasiness to panic. 2. Report anxiety is 2. Identify patient’s perception of the manageable level, “
uncertainty and T Identifying a threat as reduced to a threat represented by the situation. Kung sige ko ug
being scared I merely surgery is too manageable level. ®Helps recognition of extent of istorya sa ako
O simplistic, personal anxiety and identification of measures ginabati ug sa ako
N threats are also that may be helpful for the individual. kaguol kay
involved. Moreover, mabwasan ang ako
S although some 3. Encourage patient to acknowledge kaguol. Magwapo
E uneasiness may be reality of stress without denial or ako ginhawa kung
L attributed to fear, the reassurance that everything will be muhinga ko ug
F remaining feelings alright. Provide information about lalom.”
- relate to anxiety. measures being taken to correct or
C alleviate condition.
O Source: ®Helps patient to accept what is
N Carpenito-Moyet. happening and reduce level of
C Nursing Diagnosis anxiety. False reassurance is not
E Application to Clinical helpful, because neither nurse nor
P Practice, 11th Ed. patient knows the final outcome.
T Lippincott Williams Information can provide reassurance/
and Wilkins, 2005 help reduce fear of the unknown.
P
A 4. Assist SO to respond in a positive
T manner to patient and situation
T ®Promotes reduction of anxiety to see
E others remaining calm. Because
R anxiety is contagious, if SO/ staff
N exhibit their anxiety, the patient’s
coping abilities can be adversely
affected.
5. Review coping mechanisms used in

the past such as recognizing or asking
for help.
®Provides opportunity to build on
resources the patient and So may
have available.
6. Acknowledge feelings as they are

expressed.
®Often acknowledging feelings will
enable patient to deal more
appropriately with situation.
7. Identify ways in which patient can

get help when needed such as calling
the attention of the members of the
health team.
® Provides assurance that staff and
students is available for assistance
and support.
8. Provide as much order and

predictability as possible in scheduling
care or activities, visitors.
®Helps patient anticipate and prepare
for difficult treatments or movements,
as well as look forward to pleasant
occurrences.
9. Instruct mental imagery or

relaxation methods such as imaging a
pleasant place, use of music, slow
breathing and meditation.
®Promotes the release of endorphins
and aids in developing internal locus
of control, reducing anxiety. May
enhance coping skills, allowing body
to go about its work of healing
10. Use therapeutic touch to help

patient remain calm.
®Aids in meeting basic human need,
decreasing sense of isolation and
assisting the patient to feel less
anxious.
Time
April S: Report of pain A Impaired physical Within my 8 hour 1. Administer medication prior to Goal partially met.
28,2009 C mobility related to care, the client will be activity as needed for pain relief.
O: Limited range of T pain at incision site. able to: ®To permit maximal effort or Patient refused to
3-11pm motion I involvement in activity. perform range of
Slowed movement V ® Pain impairs 1.Verbalize motion exercises
Decreased I mobility and activity. willingness to and 2. Change position frequently when on for a fear of
posturing change T Full function may be demonstrate bedrest; support affected body parts experiencing pain
speed Y affected and be participation in or joints with pillows. after the activity. On
- delayed. activities ®Decreases discomfort, maintains the other hand,
E muscle strength/ joint mobility, there were no
X Source: 2. Maintains optimal enhances circulation and prevents contractures and
E position of function as skin breakdown. complications
R Monks. Home health evidenced by the observed after an 8
C nursing: assessment absence of 3. Provide skin massage. Keep skin hour care with the
I and care planning. contractures and clean and dry well. Keep linens dry client.
S Elsevier Health decubitus ulcers. and wrinkle-free.
E Sciences, 2002 ®Stimulates circulation and prevents
skin irritation.
P
A 4. Encourage deep breathing and
T coughing. Elevate head of bed Turn
T side to side.
E ®Mobilizes secretions, improves lung
R expansion and reduces risk of
N respiratory complications.
5. Assist with active and passive

range of motion exercises.
®Maintains joint flexibility, prevents
contractures and aids in reducing
muscle tension.
6. Provide safe environment such as

giving assistance in sitting and
transferring from bed to chair or chair
to bed and use of wheelchair if
possible.
®Avoids accidental injuries and falls.
7. Encourage early ambulation.

Support abdomen when ambulating.
®Early ambulation prevents postop
complications. Splinting provides
incisional support/ decreases muscle
tension to promote cooperation with
therapeutic regimen.
Provide adequate rest periods in
between activities.
®To prevent fatigue.
8. Provide diversion such as talking

with the patient or watch television.
®Decreases boredom, promotes
relaxation.
Time
April S/O: N Impaired tissue Within an 8 hour care, 1. Check the incisional drain, make Goal met.
30, Incision at right U integrity related to the client will be able sure that they are free flowing.
2009 upper quadrant T surgical incision to: ® Incision site drains are used to Within the span of
with Jackson Pratt R remove any accumulated fluid and care, hemorrhage
drain I 1. Be free of bile. Correct positioning prevents back was not observed
with slightly soaked, T ® In gallbladder complications such as up of the bile in the operative area. and patient was
intact dressing at I removal surgery, a heavy bleeding at the able to demonstrate
right upper O surgeon makes a incision site. 2. Observe color and character of the behaviors to
quadrant of the N large incision (cut) in drainage. prevent skin
abdomen, A your belly to open it 2. Demonstrate ®Initially, may contain blood and breakdown through
status post open L up and see the area. behaviors to prevent blood-stained fluid, normally changing participation in the
cholecystectomy - The surgeon then skin breakdown to greenish brown (bile color) after the change of dressing
M removes your first several hours. and change of
E gallbladder by positions.
T reaching in through 3. Place patient in low or semi-fowler’s
A the incision and position.
B gently lifting it out.The ®Facilitates drainage of bile.
O surgeon will make a 5
L to 7 inch incision in 4. Change dressings as often as
I the upper right part of necessary. Clean the skin with soap
C your belly, just below and water. Use sterile Vaseline gauze,
your ribs. The zinc oxide or karaya powder around
P surgeon will cut the the incision.
A bile duct and blood ®Keeps the skin around the incision
T vessels that lead to clean and provides a barrier to protect
T the gallbladder. Then skin from excoriation.
E your gallbladder will
R be removed. 5. Observe skin, sclerae, urine for
N change in color.
®Developing jaundice may indicate
Source: obstruction of the bile flow.
http://www.nlm.nih.go 6. Note color and consistency of

v/medlineplus/ency/ar stools.
ticle/002930.htm ®Clay colored stools result when bile
is not present in the intestines.
7. Investigate increased or consistent

RUQ pain; development of fever,
tachycardia; leakage of bile drainage
from wound.
®Signs of suggestive of abscess or
fistula formation requiring medical
intervention.
8. Administer antibiotics.
®Necessary for treatment or
prohylaxis for abscess or infection.
9. Monitor laboratory studies such as

WBC
® Leukocytosis reflects inflammatory
process such as abscess formation or
development or peritonitis or
pancreatitis.
Time
April 30, S/O: Surgical H Risk for infection Within an 8 hr care, 1. Monitor vital signs. Note onset of Goal met.
2009 incision at right E related to presence of the client will be ablefever, chills, diaphoresis, changes in
upper quadrant A surgical incision to: mentation, and complaints of Within the span of
3-11pm L increasing abdominal pain. care, temperature
T ®The skin is the first 1. Be free of purulent ®Suggestive of presence of infection/ remained normal,
H line of defense drainage or erythema; developing sepsis, abscess or patient was not
against infection. Any be afebrile peritonitis. afebrile. No
P break in its continuity purulent drainage
E may allow 2. Practice good hand washing and noted.
R microorganisms to aseptic wound care.
C enter the body which ®Reduce risk of spread of bacteria.
E in turn can cause the
P infection, and since 3. Inspect incision and dressings.
T the patient had Note characteristics of drainage from
I undergone wound.
O cholecystectomy, ®Provides early detection of
N there is a break of developing infectious process and
- continuity of the skin, monitor resolution of pre-existing
H which may contribute peritonitis.
E to the development of
A future infections. 4.Administer antibiotics
L ®May be given prophylactically or to
T Source: reduce number of multiplying
H microorganisms in the presence of
Mattson Porth, infection to decrease spread and
M Essentials of seeding of the abdominal cavity.
A Pathophysiology
N Concepts of Altered 5. Use sterile gloves for wound care.
A Health Status, Practice aseptic technique.
G Lippincott Williams ®Prevents invasion of bacteria or
E and Wilkins, 2007 microorganisms at site and eventually
M prevents possible infection.
E
N 6. Instructed to maintain clean dry
T clothes preferably cotton fabric
®Skin friction caused by stiff or rough
P clothes leads to irritation of fragile skin
A and increases risk for infection.
T
T 7. Cleanse incision site with povidone
E iodine.
R ®Disinfects site and prevents
N multiplication of microorganisms which
may cause infection.
8. Instruct client not to wet incision

site.
® Microorganisms thrive at damp
areas and makes it conducive for
replication.
9. Provide a cool environment. Adjust

air conditioner as preferred by the
client.
® Hot room temperature induces
sweating which may inhibit the healing
of wound and eventually cause
moisture at the area delaying the
healing process.
Discharge Planning
Medicines:
 Tramadol
 Ketorolac
 Ranitidine
 Sulperazone
Mr. Police should comply with the medications he has been prescribed with in order to aid in the
recovery state after surgery. With regards to his medications, he must know and understand the general
knowledge of the drugs, their side effects and their adverse effects. If he experiences any adverse effects,
he needs to refer to his physician immediately.
Exercise:
Cholecystectomy actually requires time to recover. Laparoscopic cholecystectomy usually requires
only one night in the hospital. A major advantage of the procedure is that it patients can return to work in 1
to 2 weeks. But compared to open cholecystectomy, it is advised to have 4 to 6 weeks duration time for
recovery. Once home, it is possible to tire more easily than usual to begin with, so it is important to take it
easy. Strenuous exercise and lifting should be avoided. Light exercise such as walking is recommended.
Normal activities, including returning to work, can usually be resumed after about a week. Patient must
follow his surgeon's advice about driving. He shouldn't drive until he is confident that he could perform an
emergency stop without discomfort.

Treatment:
Gallbladder disease usually is treated by removing the gallbladder. Now that the patient had his
gallbladder removed, the rest is up to him. It is important to rest and let the body recover after surgery.
Consequently, to prevent other complications, he must have his lifestyle and diet modified.
Health Teachings:
 Explain to patient what to expect afterwards. As the anaesthetic wears off, there is likely to be
some pain. The anaesthetist will prescribe painkillers. Suffering from pain can slow down recovery,
so it's important to discuss any pain with the doctors or nurses.
 On discharge, the nurse must advise about caring for the stitches, hygiene and bathing, and will
arrange an outpatient appointment for the stitches to be removed, if necessary. Some people will
have dissolvable stitches, which do not need to be removed.
 Instruct patient to comply with the home medications that would be given by his physician. Remind
him to complete the full course of the antibiotic treatment.
 Encourage patient to do the recommended light exercises such as walking. Avoid doing strenuous
activities which could slow down his recovery.
 Encourage him to comply with the dietary modifications; limit the intake of saturated fat and avoid
the consumption of alcoholic beverages to prevent the occurrence of serious post-cholecystectomy
side-effects.
 Explain to patient to refer for unusualities immediately.

Out-patient Care:
Remind patients that regular check-ups are important to ensure that the patient condition is
constantly monitored by the doctor. If any of the following symptoms are noted, he should contact his
doctor:any of the wounds start to bleed
 any of the wounds become more
 painful, red, inflamed or swollen
 the abdomen swells
 pain is not relieved by the prescribed painkillers
 a fever develops.
These could be signs of an infection that may need to be treated with antibiotics
Diet:
In time, patients who have suffered cholecystectomy are exposed to a high risk of developing heart
disease, diabetes and disorders of the nervous system. This is due to inappropriate synthesis and
assimilation of vital nutrients, vitamins and minerals. In order to prevent the occurrence of serious post-
cholecystectomy side-effects, operated patients need to make drastic lifestyle and dietary changes. They
should limit the intake of saturated fat and avoid the consumption of alcoholic beverages. Also, they should
eat smaller amounts of food during a single meal. People who have had gall bladder removal surgery are
advised to eat around 5 or 6 smaller meals a day instead of 2 or 3 usual meals. Considering the fact that
the organism is unable to completely absorb important nutrients without the help of the gall bladder,
operated patients also need to take vitamin and mineral supplements and bile salts to aid the process of
digestion.
PROGNOSIS
Category Poor Fair Good Rationale

Onset of illness / A month prior to admission, Mr. Police experienced
right upper quadrant pain associated with a sense of
bloatedness, without nausea and vomiting. The pain
was tolerable so he did not seek medical attention
yet. He said he also had an increased level of pain
tolerance so he also didn’t mind to take any pain
relievers. Until three days prior to admission, patient
had severe right upper quadrant pain, which was
said to be intolerable. Moreover, when pressure is
applied on the RUQ of the abdomen, pain is elicited.
He had also lost his appetite because of the pain. His
scleras were also slightly icteric during admission
and he was positive with Murphy’s sign. So he
sought consultation at Out-Patient Department-
Emergency Room at Davao Medical School
Foundation Hospital. Ultrasound revealed
cholecystitis, so patient was advised admission and
operation.
Duration of / Though no complications aroused yet, Mr. Police did
illness not immediately seek medical attention as he had
persistent RUQ pain a month ago. He waited for the
pain to become intolerable before seeking medical
advice. Moreover, the obstruction brought about by
the cholecystitis caused his icteric sclera, which
could have been absent if he sought medical
attention earlier.
Precipitating / Only three out of eleven known precipitating factors
factors are present with Mr. Police’s case which is the
following: diet (high cholesterol, high calorie, and
high sodium), diabetes mellitus and obesity.
Attitude and / Mr. Police said he would undergo any treatment
willingness to regimen he has to as long as his condition would get
medication and better. Moreover, he let himself be admitted to the
treatment hospital and to undergo surgery as he is determined
to get well as soon as possible.
Environment / DMSFH is a hospital with an environment, very
conducive for healing. Moreover, the personnel in the
institution which includes the medical team are very
responsive to the needs of the patients.
Age / The client is almost 50 years old. The wear and tear
theory states that as one grows older, most of our
organs are already used and abused. As one ages,
one also becomes more susceptible to infections and
organ failure.
Family support / Anna is always watching over Mr. Police during his
admission. She said she will always be with Mr.
Police through his ups and downs, as he vowed him
during their wedding day. Moreover, relatives come
to Davao to visit Mr. Police, and together with them
are the encouragement and support they give Mr.
Police.
Total 0/7 3/7 4/7
Computation:
No. of categories rated POOR (1) + No. of categories rated FAIR (2) +
No. of categories rated GOOD (3) divided by TOTAL NO. OF

CATEGORIES= SCORE FOR GENERAL PROGNOSIS.
=0(1) + 3(2) + 4(3)
= 6 + 12
=18/7
=2.57
Scoring for General Prognosis:
1-1.6 =POOR
1.7-2.3 =FAIR
2.4-3.0 =GOOD
General Prognosis:
The general prognosis of the client is good. This means that the client has a good chance of
recovering from his illness.
Conclusion
Generally, the student nurse’s one week exposure and duty at the Davao Medical School
Foundation Hospital has been a memorable experience to them. The exposure had been an avenue for
further development and enhancement of their skills and capabilities in rendering care and promoting
holistic wellness to their clients. It reminded them again that nursing profession entails a deep sense of
responsibility and challenging tasks.
After five days of exposure at St. Joseph (3C) ward, the student nurses has identified and
understood the causative factors of cholecystitis, its signs and symptoms, clinical manifestations, diagnostic
studies, medical, pharmacological and nursing interventions through obtaining cues and health history in
conjunction to the disease process. They underwent extensive research in order to comprehensively
understand his condition. Upon learning his case, it challenged and motivated them to work hard to provide
the appropriate and effective nursing intervention and care.
Moreover, cholecystitis is the most common problem resulting from gallbladder stones. It occurs
when a stone blocks the cystic duct, which carries bile from the gallbladder. Predisposing factors can
include heredity, age, sex and race. With the presented factors that cannot already be modified, one has to
take action towards preventing the disease to happen. The only one who can help yourself is you alone.
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.
Our gallbladder is not to be taken for granted. There have been reports that mortality can be as
high as 15% for immunocompromised patients. Furthermore complicated cholecystitis has 25% mortality
(eg, gangrene, empyema of gallbladder).
“No matter how the disease has already reached an alarming incidence rate or not, it is
a duty of every human person to take care of his own body, not just for the sake of other people
that depend on him, but most especially for himself ~ a primary obligation that he must fulfil.”
Recommendation
Every exposure is a learning experience filled with lessons. After thoroughly studying Mr. Police’s
case, the group has come up with the following recommendations:
To the client:
Recovering after open cholecystectomy surgery doesn’t depend solely on the healthcare team.
More than anything else, there must be willingness to recover on the part of the patient. With this, he must
carry out his responsibilities in fighting his own condition. He is encouraged to verbalize his thoughts and
feelings to his medical attendants, such as his nurses, because it would be better for him to express
whatever is causing stress on his part thus, hindering his recovery or yet understand that the things that his
nurses is doing for him is for his own good and betterment in life. He is encouraged to willingly and actively
participate in therapeutic activities that will render improvement of his condition. Moreover, he should fight
his as much as he can through complying with the treatment being given to him and through continuing his
rehabilitation process so that the chances of his recovery will be greater.
To the patient’s family
Undeniably, the patient’s family plays a significant part in his battle against the disease. The family
members should be involved with his treatment as much as possible since their support motivates him to
exert more effort in the recovery process. They should not only be physically present. More than that, they
should give their emotional support to boost the patient’s morale. In addition, they are encouraged to be
oriented and educated with the basic facts about the patient’s condition so that they will understand his
condition better. Not only that, they should always asked the student nurses for assistance, advices, or
clarifications because they are always ready to lend a helping hand. Through this, they would be able to
know how to manage and meet his needs when he is discharged from the institution where he is admitted.
To the group
Maintain practicing teamwork and unity within the group so that better output will be formulated. Be
sensitive and respond to the needs of other group members. If one is done with the task, try to help the
others and contribute something that would make the work better. Being calm is always a good move. Fix
the problems in a peaceful manner. Be open-minded to suggestions and prevent intensive discussions so
that healthy relationship within the group will be maintained.
To the fellow student nurses
It is not through a single effort that you learn the entirety of a certain illness. Rather, it takes
continued research and study in order to be more updated with information that will render an insightful
understanding of what it is all about. As student nurses, you should do your best to be equipped with the
necessary knowledge that will help you in your endeavors especially when you go on duty in units where
intensive care is needed. It is through this that you can provide the quality and holistic nursing care that
patients need. You should realize that your patients are also humans, though suffering from a chronic
illness. You should always be humane in treating and approaching them so that you can be of help in the
best way you can. Nursing students of AdDU should be committed to the goal of being men and women for
others. They should not only appreciate the concepts during lecture session but should also positively
digest the experiences they get from their duties and exposures.
To the Ateneo de Davao University- College of Nursing
The AdDU- College of Nursing has been exerting much effort in providing the best exposures to its
nursing students. The faculty and staff are encouraged to continue elevating the standard of the Ateneo
Nursing Curriculum through quality training of Clinical Instructors in the advent of seminar, forums or
trainings, quality-level lectures and affiliations with various medical institutions for the students’ exposures
and duties.
To the Professional Medical World
Open cholecystectomy undeniably has its own disadvantages. The scar alone after surgery is one
of the major disadvantages. Furthermore, Minilaparotomy cholecystectomy presents exposition difficulties,
and laparoscopy requires expensive equipment and additional training. Laparotomy is more painful, causes
trauma to the abdominal wall, and requires a longer convalescence; it is also less aesthetic. Researches
and studies have been conducted to discover a new technique of minimal invasive cholecystectomy. Such
new technique presented for minilaparotomy cholecystectomy is transcylindrical. As the medical field
advances, the people’s trend as well as preference also changes. As much as possible, a cheaper, less
invasive and more aesthetic procedure is preferred. The group would like to comment on the success of the
emergence of new studies and invention. They are to look forward to further studies and improvement.
BIBLIOGRAPHY
 http://www.nottingham.ac.uk/nursing/sonet/rlos/bioproc/resources.html
 http://www.le.ac.uk/pa/teach/va/anatomy/case2/frmst2.html
 http://www.le.ac.uk/pa/teach/va/anatomy/case5/frmst5.html
 http://digestive.niddk.nih.gov/statistics
 Barbara Howard, Clinical and Pathologic Microbiology, 2 nd Edition
 Carol Porth, Pahtophysiology Concepts of Altered Health Sciences, 7 th Edition
 Pathology 3rd Edition by Stanley L. Robbins, M.D.
 Tortora et. Al., Microbiology An Introduction, 8th Edition
 Kasper et. Al., Harrison’s Principle of Internal Medicine, 16 th Edition
 Deglin, Judith H., Vallerand, April H. Davis’s Drug Guide for Nurses, 10 th ed. F.A. Davis
Company, Philadelphia, Pennsylvania,2007.
 Damjanov, I., Linder, J. Anderson’s Pathology. 10th edition USA: Mosby-
 Yearbook 1996.
 Fauci A. et al. Harrison’s Principles of Internal Medicine. 16 th edition. USA: The
o McGraw-Hill Companies 2005.
 Bullock, B. Henze, R. Focus on Pathophysiology. Philadelphia, USA:Lippincott,
o Williams and Wilkins 2006.
 Clinical Applications of Nursing Diagnoses. F.A. Davis Company, Philadelphia.
o 4th edition.
 Nutritional Therapy and Pathophysiology. Nelms, Sucher, Long. 2007. Thomson

o Brooks/Cole, The Thomson Corporation. 10 Davis Drive Belmont, CA, USA.
 Bare, Brenda G., Cheever, Kerry H., Hinkle, Janice L., Smeltzer, Suzanne C.
o Brunner & Suddarth’s Textbook of Medical- Surgical Nursing, 11 th ed. Vol.1.
o Lippincott Williams & Wilkins, 2008.
 Doenges, Marilynn E., Moorhouse, Mary Frances, Murr, Alice C. Nursing Care
o Plans 7th ed. F.A. Davis Company, Philadelphia, Pennsylvania,2006.
 Karch, Amy M. 2007 Lippincott’s Nursing Drug Guide. Lippincott Williams &
o Wilkins, 2007.
 MIMS, 108th ed. CMPMedica Asia Pte Ltd, Singapore, 2004.
 Porth, Carol M. Essentials of Pathophysiology: Concepts of Altered Health States.
o 2nd ed. Lippincott Williams & Wilkins, 2007.
 pp. 148-153, Maxine A. Goldman 2008, Pocket Guide to the Operating Room. 3 rd edition
o F.A. Davis Company.Philadelphia

Cholecystitis

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ATENEO DE DAVAO UNIVERSITY

IN PARTIAL FULFILLMENT OF OUR REQUIREMENTS

A CASE STUDY ABOUT CHOLECYSTITIS

information regarding him and his case.

them further appreciate the “journey of our being.”

journey in their nursing careers.

by the disease last 2007. (http://digestive.niddk.nih.gov/statistics)

Specific Objectives under Cognitive aspect

 Research on the anatomy and physiology of the clients affected system.

the current condition of the patient.

 Research and understand the disease process of the patient’s illness.

his general welfare.

Specific Objectives under Psychomotor aspect

the patient need.

nurses in the future.

 Assume the role of being the patient’s advocate.

Name: Mr. Police

Age: 46 years old

Date of Birth: August 28, 1962

Place of Birth: General Santos City

Civil Status: Married

Address: Cabantian, Country Homes, Davao City

Religion: Christianity (Roman Catholic)

Educational attainment: College Graduate

Admitting Date and Time: April 27, 2009 at 10:40 am

Case Number: 01-36-90

Ward: St. Joseph (3C)

Room/ Bed: 325-5

Attending Physician: Dr. Batucan, Wolter

Chief Complaint: right upper quadrant pain

Diagnosis: Cholecystitis T/C Cholelithiasis

BP –120/90 mmHg R – 28 cpm P – 109 bpm Temp – 36.5˚C

Sources of info: Chart, Mr. Police himself, and his wife

Lolo A± Lola A± Lolo B †ħ Lola B±

Anna Mr. Police Step-brod Ø Step-sis

Today, Step-sis has her own family at Leyte.

City, to attend certain activities in celebrating Sto. Niño fiesta.

no known drug and food allergy.

D. History of Past Illness

disease and as well as the management of his chicken pox.

stopped smoking, but only for two months.

consultation at Out-Patient Department- Emergency Room at Davao Medical School Foundation

 Relating to one’s spouse that he is blessed with their

as a person relationship because Anna is not just

 Adjusting to aging parents a wife to her, but also a friend, whom

the obese type I which ranges from 30 – 34.9.

BP= 120/180 mm Hg PR= 85 bpm RR= 15 cpm T= 36 °C

Patient was not cyanotic. No bruises or discolorations observed. No edema noted.

no dandruff or infestation present. No lesions, lacerations, tenderness, masses and depressions

reported upon palpation.

in his sinuses upon palpation.

Tonsils were not inflamed. Halitosis was also noted.

palpation. Trachea is symmetrical and in midline without deviation.

infections. Lymph nodes were not palpable.

CHEST and LUNGS

cough present. No dyspnea, hemoptysis, hiccups noted.

rhythm. No abnormal beats, palpitations, thrills or murmurs present upon auscultation.

noted on the right upper quadrant near the incision site.

yet voided since he had arrived from the OR.

BACK & EXTREMITIES

- Cholecystitis is the inflammation of the galbladder

- Cholecystitis refers to inflammation of the gallbladder and cystic duct.

- Cholecystitis refers to inflammation of the gallbladder.