Southern Luzon State University

College of Allied Medicine

Lucban, Quezon

CASE ANALYSIS: ACUTE

CHOLECYSTITIS

Presented by:

Mabait, Ivan Karl D.

Mendoza, Maria Alessandra A.
Ros, Lyka Atheena M.
BSN3 (GROUP 2)

SURGERY AREA
Case Analysis # 4 – ACUTE CHOLECYSTITIS

GG is a 49-year-old High school teacher. He has been admitted to the hospital because of his
acute pain in his abdomen and back. When discussing his health history, the patient states
that he has hypertension and gout. The patient reported no prior episodes of pain in his
abdomen and his posterior right
side. He reported having sudden
sharp pain in those areas and
cramping. Patient stated he quit
smoking two years ago, denies the
use of recreational smoke and
drinks occasionally, specifically
two beers on weekends. He is 5 feet
8 inches tall and weighs 205
pounds; his oral temperature is 37.7
C, pulse 72 bpm, respirations 18
bpm, blood pressure
150/82mmHg; On physical examination, his abdomen was tender to palpation.

Furthermore, he presented redness, swelling, and tenderness in the metatarsophalangeal joint

of the first toe of the right foot. He had a fever as demonstrated by his high temperature, and
his labs were abnormal; specifically, his white blood cell count was above average. After this
finding, the provider ordered a computed tomography (CT) scan of his abdomen, and the
results showed acute cholecystitis. Therefore, the provider ordered two antibiotics to
eliminate the infection and pain medications to reduce the patient’s pain.

Definition

Acute cholecystitis is inflammation of the gallbladder that develops over hours, usually
because a gallstone obstructs the cystic duct.

Acute Calculous Cholecystitis

When bile becomes trapped in the gallbladder, acute cholecystitis occurs. The most
common complication of cholelithiasis is acute cholecystitis. Matter of fact, cholelithiasis is
present in 95% of patients with acute cholecystitis. When a stone becomes lodged in the cystic
duct and obstructs it for an extended period of time, acute inflammation occurs. Stasis of bile
results in the release of inflammatory enzymes.

The damaged mucosa secretes more fluid than it absorbs into the gallbladder lumen.
The resulting distention releases additional inflammatory mediators (e.g., prostaglandins),
aggravates mucosal damage and induces ischemia, all of which contribute to the perpetuation
of inflammation. Bacterial infection is possible. When left unchecked, the vicious circle of
fluid secretion and inflammation results in necrosis and perforation.

If the acute inflammation subsides but recurs, the gallbladder becomes fibrotic and
contracted, unable to concentrate bile or empty normally—all of which are characteristics of
chronic cholecystitis.

Acute Acalculous Cholecystitis

Acalculous cholecystitis is cholecystitis without stones. It accounts for 5 to 10% of
cholecystectomies done for acute cholecystitis. The exact cause of AAC is unknown but
thought to be induced by reduced blood flow to the gallbladder (ischemia), infectious disease,
or lack of gallbladder stimulation (not eating) causing biliary stasis (bile immobility).
 The mechanism probably involves inflammatory mediators released because of
ischemia, infection, or bile stasis. Sometimes an infecting organism can be identified (eg,
Salmonella species or cytomegalovirus in immunodeficient patients). In young children, acute
acalculous cholecystitis tends to follow a febrile illness without an identifiable infecting
organism.

Risk factors
Acute Calculous Cholecystitis
 Sex - Although 60% of acute cholecystitis patients are women, the proportion of
people with gallstones who develop cholecystitis is higher in men. 80% of cases of
acalculous cholecystitis are in male patients of age 50 and older.
Being female
 Pregnancy
 Hormone therapy (woman who takes estrogen replacement therapy or birth control
pills.)
 Older age
 Being Native American or Hispanic
 Obesity
 Losing or gaining weight rapidly
 Diet high in fat and cholesterol
 Diabetes
 Family history of gallstones
 Sickle cell disease, where red blood cells are broken down forming excess bilirubin and
forming pigmented stones also increases the incidence of gallstones.
 Hyperparathyroidism, excessive calcium can cause calcium stones
 Neoplasms or stricture, occlusion of the common bile duct can also lead to stasis of
the bile flow causing gallstone formation.

Acute Acalculous Cholecystitis

 Critical illness (eg, major surgery, burns, sepsis, or trauma)
 Prolonged fasting or total parenteral nutrition, both of which predispose to bile stasis
 Shock
 Immune deficiency
 Vasculitis (eg, systemic lupus erythematosus [SLE], polyarteritis nodosa)

Signs and Symptoms

The main symptom is pain in the upper right side or upper middle of your belly that usually
lasts at least 30 minutes. You may feel:

 Sharp, cramping, or dull pain

 Steady pain
 Pain that spreads to your back or below your right shoulder blade

Other symptoms that may occur include:

 Clay-colored stools- bilirubin
 Yellowing of skin and whites of the eyes (jaundice)-bilirubin

It is important to know, one can have pain due to temporary obstruction by gallstones,
and that is called biliary colic. The pain of cholecystitis is similar in quality and location to
biliary colic but lasts longer (ie, > 6 hours) and is more severe. Nausea and vomiting are
common, as is right subcostal tenderness. Within a few hours, the Murphy sign (deep
inspiration exacerbates the pain during palpation of the right upper quadrant and halts
inspiration) develops along with involuntary guarding of upper abdominal muscles on the
right side. Fever, usually low grade, is common.

In older patients, the first or only symptoms may be systemic and nonspecific (eg,
anorexia, vomiting, malaise, weakness, fever). Sometimes fever does not develop.

Acute cholecystitis begins to subside in 2 to 3 days and resolves within 1 week in 85%
of patients even without treatment.

Complications
 Empyema (pus in the gallbladder)
 Gangrene- Regardless of the cause of the blockage, the gallbladder wall edema will
eventually cause wall ischemia and become gangrenous. The gangrenous gallbladder
can become infected by gas-forming organisms, causing acute emphysematous
cholecystitis; all of these conditions can quickly become life-threatening, and rupture
has a high rate of mortality.
 Injury to the bile ducts draining the liver (may occur after gallbladder surgery)
 Pancreatitis
 Perforation
 Peritonitis (inflammation of the lining of the abdomen)
 PHYSICAL ASSESSMENT

Name: __GG ______________________________ Age: __49__ Sex: _Male__ Civil Status: _Married_ Address: _123 Fidel Rada St., Brgy. 1, Lucban,
Quezon_

Place of Birth: _December 15, 1972_ Religion: _Roman Catholic_ Occupation: __High School Teacher__ Nationality: Filipino
Admitting Diagnosis Diagnosis: _Acute Cholecystitis_

GENERAL APPEARANCE

Ø seen with facial grimace; guarding behavior on RUQ of abdomen; restless; sweats excessively; is conscious and coherent; oriented to time and place

VITAL SIGNS

Height: 5’8 Weight: 205 lbs. Temperature: 37.7°C

Pulse Rate: 72 bpm Respiration Rate: 18breaths/pm Blood Pressure: 150/82mmHg

HEALTH HISTORY

Reason for Seeking Health Ø reported acute pain in his abdomen and back, having sudden sharp pain in those areas and cramping
Care

Past Health History Ø has hypertension and gout

Ø undergone appendectomy on 2020

Ø reported having no any prior episodes of pain in his abdomen and his posterior right side
Family Health History Ø father has emphysema

Ø mother has osteoporosis

Lifestyle and Health Practices Ø stated he quit smoking two years ago, denies the use of recreational smoke and drinks occasionally, specifically two beers on
weekends

Ø takes telmisartan and furosemide as maintenance medication

24-hour Dietary Record Ø stated that he ate lechon, sisig, pansit, and lumpia yesterday and forgot to take his maintenance medication for his hypertension

PHYSICAL ASSESSMENT

Skin Inspected with flushed skin with excessive sweating, no scars nor lesions; palpated skin warm to touch,

Abdomen Palpated RUQ is tender to touch, with warm temperature

Musculoskeletal Inspected with redness, swelling; palpated metatarsophalangeal joint of first toe on R foot as tender to touch; unable to dorsiflex and extend both feet
 NURSING CARE PLAN

ACUTE PAIN
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
Subjective: Acute pain related to the After 4 hrs. of nursing Establish rapport To promote nurse-patient After 4 hours of nursing
-“sobrang sakit ng tyan ko inflammatory process intervention, the pain will relationship intervention, the patient
ang hirap secondary to acute lessen according to verbalized “Medyo
gumalaw…tsaka likod cholecystitis as evidenced patient’s verbalization and Monitor pain and note its Assists in differentiating kumikirot pa rin ang tiyan
ko” as verbalized by the by tender abdomen upon pain scale of 4/10. location, severity (0–10 cause of pain, and ko, pero hindi na katulad
patient palpation scale), and character provides information nung kanina.”
-Patient rated pain as 9/10 (steady, intermittent, about disease progression
from the pain scale colicky). and resolution, rated pain as 5/10
development of
Objective: complications, and Vital Signs:
- seen with facial grimace effectiveness of T - 37.1°C
- with guarding behavior interventions. BP – 120/80mmHg
on the abdomen
- inspected redness and
swelling, with tenderness Assist in comfortable To alleviate pain with
on metatarsophalangeal position, such as semi- comfort
joint of the right foot fowler’s position.

Vital Signs: Provide a quiet room by Lessening the stimuli

T – 37.7°C limiting patient visits. could also lessen the
BP – 150/82mmHg stressors for the patient
and promotes rest
Reduces irritation and
inflammation
Use soft or cotton linens;
cool or moist compresses
as indicated. To promote comfort and
reduce pain
Teach and demonstrate
use of relaxation
techniques, such as deep
breathing exercises. Allows patient to vent out
and alleviate anxiety
Allow to verbalize feelings
of pain. To provide immediate
care and intervention as
Educate about worsening needed.
symptoms of
inflammation and notify
the physician. Ibuprofen has a
mechanism of action that
Administer pain prevents cyclooxygenase
medications, such as to lessen inflammation
ibuprofen, as ordered. response.

Severe pain not relieved

by routine measures may
Note response to indicate developing
medication, and report to complications or need for
physician if pain is not further intervention.
being relieved.
 DECREASED CARDIAC OUTPUT
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
Subjective: Decreased cardiac output After 8hrs of nursing Establish rapport To promote nurse-patient “magaan-gaan na
“medyo naliliyo ako secondary to intervention, the patient relationship plkiramdam ko salamat”
kanina … dibdib ko pati hypertension as will demonstrate as verbalized
adequate cardiac output Assess and monitor pulse Compensatory
parang naninikip” as evidenced by increased
blood pressure as evidenced by blood rate and blood pressure tachycardia is a common
verbalized pressure of 130/80mmHg response for patients with Vital Signs:
and PR of 90 bpm. significantly low blood BP – 130/80mmHg
Objective: pressure to reduce cardiac PR – 99 bpm
- guarding behavior on output
chest
Auscultate heart and The new onset of a gallop
- cold, clammy skin
breath sounds rhythm, tachycardia, and
- poor capillary refill fine crackles in lung bases
can indicate the onset of
Vital Signs: heart failure
BP – 150/82mmHg
PR – 72 bpm Monitor vital signs, Cold, clammy, and pale
especially temperature. skin is secondary to low
Note skin color, cardiac output and
temperature, and oxygen desaturation
moisture

Monitor chest pain. Note Chest pain or chest

for location, intensity and discomfort generally
cahracteristics suggests myocardial
ischemia or inadequate
blood supply to the heart

Monitor urine output

 Reduced cardiac output
results in reduced
perfusion of the kidneys,
with a resulting decrease
in urine output
Instruct client to limit
fluids and sodium as Fluid restriction decreases
ordered the extracellular fluid
volume and reduces
demands on the heart

Closely monitor fluid

intake and output, In patients with decreased
including IV lines cardiac output, poorly
functioning ventricles
may not tolerate
increased fluid volumes
Assist to lie down in a
semi-fowler’s position These actions can
whenever chest pain is increase oxygen delivery
present to the coronary arteries
and improve patient
prognosis
Administer medications
as prescribed, noting side Medications such as
effects and toxicity diuretics and vasodilators
greatly helps lower blood
pressure
Remind the patient to
avoid straining when When defecating, that
defecating results in the Valsalva
maneuver, straining can
lead to dysrhythmia
Explain the importance of
smoking cessation and Educating the patient on
avoidance of alcohol the effects of smoking can
intake help them understand the
health risks involve in
smoking
Educate regarding diet,
such as adhering to low- Health education have
fat diet sticking to foods been shown to reduce
long-term mortality
rich in omega-3 (sardines
and avocado), eliminating
trans fat and other food
rich in saturated fat.
 KNOWLEDGE DEFICIT
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
Subjective: Knowledge deficit After 4hrs of nursing Establish rapport To promote nurse-patient After 4 hrs of nursing
“di ko pa rin gaano related to insufficient intervention, the patient relationship intervention, “maayos-
naiintindihan yung information as evidenced will verbalize ayos naman ang aking
kondisyon ko, masyado by patient’s verbalization understanding of Assess ability to learn or Cognitive impairments pakiramdam,
akong napapaisip” as condition, disease process, perform desired health- must be recognized so an nakakapwesto na ako ng
verbalized and treatment related care appropriate teaching plan maayos” as verbalized
can be outlined
Objective:
- restless Assess motivation and Patients must see a need
willingness of patient to or purpose for learning
learn

Determine priority of Knowing what to

learning needs within the prioritize will help prevent
overall care plan wasting valuable time

Consider the patient’s Every individual has his or

learning style, especially if her learning style
the patient has learned
and retained new
information in the past

Determine the patient’s Self-efficacy refers to a

self-efficacy to learn and person’s confidence in his
apply new knowledge or her own ability to
perform a behavior
 The patient brings to the
Assess barriers to learning learning situation a
unique personality, or
cultural norms

Ensuring physical comfort

Render physical comfort allows the patient to
for the patient concentrate on what is
being discussed

A calm environment
Grant a calm and peaceful allows the patient to
environment without concentrate and focus
interruption more completely

Goal setting allows the

Include the patient in learner to know what will
creating the teaching plan, be discussed and expected
beginning with
establishing objectives and
goals
This technique aids the
learner make adjustments
Help patient in integrating in daily life
information into daily life
Patients are better able to
ask questions when they
have basic information
Provide clear, thorough,
and understandable Learning requires energy,
explanations so shorter, well-paced
sessions reduce fatigue
Pace the instruction and and allow the patient to
keep sessions short absorb more completely

Patients are expected to

read and understand
labels on medicine
containers
Identify patient’s
understanding of common Questions facilitate open
medical terminology communication between
patient and health care
Encourage to ask professionals
questions
Documentation allows
additional teaching to be
based on what the learner
Note progress of teaching has completed
and learning.

DRUG NAME MECHANISM OF
ACTION
Generic Name: It is an antibiotic that is
ceftriaxone works by exerting a
Brand Name: bactericidal action
Rocephin through inhibition of
the bacterial wall
Drug Class: synthesis. This action is
Third-generation done when the beta-
cephalosporins lactam moiety of
ceftriaxone binds to the
carboxypeptidase,
endopeptidase, and
transpeptidase of the
bacterial cytoplasmic
membrane.
DRUG STUDY
INDICATION CONTRAINDICATION SIDE EFFECTS NURSING RESPONSIBILITY
This drug is  Hypersensitivity to  Seizures Preparation:
intended to use antibiotics  Pseudomembrano  Verify correct IV concentration and rate of
for the presence us Colitis infusion based on doctor’s order.
of infection  Diarrhea  Check labels; if discoloration occurs, discard.
(used in  Cholelithiasis  Clean stopper of vial with cotton with alcohol.
combination  Sludging in the  Clean injection port of PNSS with wipes or
with gallbladder cotton balls with alcohol.
metronidazole)  Rashes  Withdraw 20mL of PNSS from the bag and
inject into vial of Ceftriaxone; swirl around
 Urticarial
with until medications is fully dissolved.
 Bleeding
 Inject prepared dose directly to center of port.
 Esoniophilia
 Hemolytic anemia  Withdraw needle and discard.
 Leukopenia  Remove giving set from packaging and close
 Thrombocytosis roller clamp. Insert IV set and prime the line.
 Pain at IV site Assessment:
 Allergic reactions  Determine if there is history of hypersensitivity
reactions to cephalosporins.
 Check IV injection sites for signs of redness,
swelling, and pain.
 Monitor for signs of allergic reactions and
anaphylaxis and even skin reactions.
 Monitor S&S.
 Watch out for seizures. Notify physician
immediately if patient develops seizure.
Administering Medication:
 Wash hands and put on sterile gloves.
 Clean connector on IV line with cotton balls
and allow to dry.
 Flush IV line with 10 mL of PNSS.
  Connect IV tubing set securely to extension set
and administer over 30 minutes. Disconnect
when finished.
Patient Education:
 Advice the patient to report any discomfort felt
after administration of medication.
 Report any signs of bleeding.
 Report loose stools.
Generic Name: A type of antibiotic that Used for treating  Hypersensitivity to  Dizziness Preparation of Medication:
metronidazole diffuses into the actual infections imidazoles  Headache  Verify correct IV concentration and rate of
Brand Name: organism-causing caused by  Bloody dyscrasias  Stomach upset infusion for administration.
Flagyl disease, by inhibition of susceptible  Active CNS  Nausea  Reconstitute with 4.4mL of PNSS.
protein synthesis, anaerobic disease  Vomiting  Dilute IV solution.
Drug Class: interacting with the bacteria in  Used in caution  Loss of Appetite  Neutralize with approximately 5 mEq of
Nitroimidazole DNA and causes a loss intraabdominal with coexistent sodium bicarbonate.
 Diarrhea
antibiotic of helical DNA infections – candidiasis, Assessment:
structure and breakage hence, presence  Constipation
alcoholism, and  Metallic taste on  Assess for hypersensitivity reactions to
of strands – causing cell of infection due liver diseases imidazoles.
death in organisms. to cholecystitis. mouth
 Assess use of corticosteroid therapy.
 Assess dizziness that might affect gait, balance,
and other functional activities.
 Be alert for confusion, agitation, headache and
other mental alterations.
 Monitor IV injection site for pain, swelling, and
irritation.
 Discontinue therapy if symptoms of CNS
toxicity appear.
 Advice to chew ice chips.
 Advice to increase fluid intake, such as juice, as
tolerated.
 Monitor CBC, noting WBC counts before,
during and after therapy.
 Monitor culture test, as indicated.
Administration of Medication:
 Infuse through IV over 20-60 minutes.
 Patient Education:
 Adhere closely to established regimen and
schedule.
 Avoid drinking alcohol during therapy.
 Urine may appear dark or reddish brown.
 Report symptoms of candida overgrowth.
Generic Name: Inhibits Intended to  Hypersensitivity to  Dyspepsia Assessment:
ibuprofen cyclooxygenase (which decrease pain ibuprofen and  Nausea  Assess for hypersensitivity reactions to
Brand Name: is the enzyme felt on abdomen other NSAIDs  Loss of appetite ibuprofen and other NSAIDs.
Advil responsible for making and posterior  History of  Stomach pain  Assess history for perforation and ulceration.
prostaglandins) to right side of the perforation and  Diarrhea  Assess pain scale, by rating 1-10 before and
Drug Class: inhibit inflammatory body related to ulceration related  Dizziness after medication.
Non-steroidal response infection to NSAID therapy  Monitor baseline for CBC, especially Hgb.
 Fatigue
Antiinflammatory  Severe Cardiac  Headache  Monitor Metabolic Panel, as ordered by
Drug Failure  Nervousness physician, and note renal and hepatic function.
 Asthma  Skin rashes and  Monitor for GI distress and S&S of GI
 Active itching bleeding.
Gastrointestinal  Fluid retention Administration:
Bleeding  Always give on an empty stomach, 1 hr before
 Peptic Ulceration or 2 hours before meals.
Patient Education:
 Notify physician immediately for passage of
dark stools, “coffee ground” emesis, or other
GI distress.
 Limit activities until response to drug is known.
 Do not self-medicate with ibuprofen.
 Avoid alcohol
 Avoid other NSAIDs unless otherwise advised.
Generic Name: Works by binding with Prescribed when  Hypersensitivity to  Asthenia Assessment:
oxycodone stereo-specific receptors ibuprofen is not oxycodone  Constipation  Assess hypersensitivity to oxycodone.
Brand Name: in various sites of CNS working with  Respiratory  Dizziness  Assess closely for symptoms of respiratory
that alters both pain depression  Dry mouth depression.
perception of pain and  Bronchial asthma  Headache  Monitor respiratory rate and oxygen saturation.
Drug Class: emotional response to  Hypercarbia  Nausea
Opiate analgesics pain; precise
 Pruritus
 mechanism of action  Known or  Somnolence  Be alert for excessive sedation or mood changes
not clear; as told to suspected ileus  Sweating and behavior. Notify physician if patient is
have same actions as  In caution with  Vomiting unconscious.
morphine alcoholism, renal  Bradycardia  Advice to take ice chips for nausea.
or hepatic disease,  Hypotension  Advice to limit movements as necessary.
viral infections,  Palpitations  Provide precautionary and safety measures,
addison’s disease;  Diaphoresis such as bedside rails if ever dizziness occurs.
cardiac  Photosensitivity  Monitor hepatic function and CBC as ordered
arrhythmias; by physician.
 Rash
chronic ulcerative Patient Education:
 Anorexia
colitis; history of  Avoid altering dosage.
drug abuse or  Abdominal Pain
 Diarrhea  Avoid hazardous activities.
dependency;  Avoid drinking alcoholic beverages.
gallbladder  Glossitis
disease; acute
abdominal
conditions; head
injury; intracranial
lesions;
hypothyroidism;
prostatic
hypertrophy;
respiratory
disease; urethral
stricture; older
adult or debilitated
patients; peptic
ulcer or
coagulation
abnormalities
Generic Name: Reduces the production Used to decrease  Hypersensitivity to  Drowsiness Assessment:
allopurinol of uric acid in the body production of allopurinol  Headache  Monitor for therapeutic effectiveness which is
Brand Name: stopping the uric acid related  Idiopathic  Vertigo indicated by normal serum and urinary uric
Zyloprim biochemical reactions to gout. Uric hemochromatosis  Nausea acid levels usually by 1–3 wk (aim of therapy is
that precedes its acid is produced  Used in caution  Vomiting to lower serum uric acid level gradually to
Drug Class: formation. It is made by xanthine, with impaired  Diarrhea about 6 mg/dL), gradual decrease in size of
Xanthine Oxidase possible when converted from hepatic or renal  Abdominal tophi, absence of new tophaceous deposits
Inhibitors allopurinol is hypoxanthine function Discomfort (after approximately 6 mo), with consequent
metabolized to its enzyme.  History of peptic  Malaise relief of joint pain and increased joint mobility.
active metabolite ulcer  Thrombocytopeni  Monitor for S&S of an acute gouty attack
(oxypurinol) in the  Lower GI tract a which is most likely to occur during first 6 wk
liver, which is the disease  Urticaria of therapy.
inhibitor of xanthine  Bone marrow  Renal  Lab tests: Monitor serum uric acid levels q1–
oxidase. depression insufficiency 2wk to check adequacy of dosage. Perform
baseline CBC, liver and kidney function tests
before therapy is initiated and then monthly,
particularly during first few months. Check
urinary pH at regular intervals.
 Monitor patients with renal disorders more
often; they tend to have a higher incidence of
renal stones and drug toxicity problems.
 Report onset of rash or fever immediately to
physician; withdraw drug. Life-threatening
toxicity syndrome can occur 2–4 wk after
initiation of therapy (more common with
impaired renal function) and is generally
accompanied by malaise, fever, and aching, a
diffuse erythematous, desquamating rash,
hepatic dysfunction, eosinophilia, and
worsening of renal function.
Patient Education:
 Monitor for therapeutic effectiveness which is
indicated by normal serum and urinary uric
acid levels usually by 1–3 wk (aim of therapy is
to lower serum uric acid level gradually to
about 6 mg/dL), gradual decrease in size of
tophi, absence of new tophaceous deposits
(after approximately 6 mo), with consequent
relief of joint pain and increased joint mobility.
 Monitor for S&S of an acute gouty attack
which is most likely to occur during first 6 wk
of therapy.
 Lab tests: Monitor serum uric acid levels q1–
2wk to check adequacy of dosage. Perform
baseline CBC, liver and kidney function tests
before therapy is initiated and then monthly,
particularly during first few months. Check
urinary pH at regular intervals.
 Monitor patients with renal disorders more
often; they tend to have a higher incidence of
renal stones and drug toxicity problems.
 Report onset of rash or fever immediately to
physician; withdraw drug. Life-threatening
toxicity syndrome can occur 2–4 wk after
initiation of therapy (more common with
impaired renal function) and is generally
accompanied by malaise, fever, and aching, a
diffuse erythematous, desquamating rash,
hepatic dysfunction, eosinophilia, and
worsening of renal function.
 LABORATORY ANALYSIS
A. Computer Tomography Scan
IMAGE INTERPRETATION/RESULTS
- Positive for Acute Cholecystitis
- With pericholecystic fat strand, thickened
gallbladder
- Large calculus on neck of gallbladder
NURSING CONSIDERATIONS
Before the procedure:
1. Explain to the client the procedure to be done,
what to expect, and how long the procedure
would take.
2. Obtain the informed consent.
3. Assess for history of allergies to iodinated dye or
shellfish.
4. Instruct to remove all metal objects, such as
jewelries, dentures, and eyeglasses, that may
interfere with image results
5. Instruct patient not to eat or drink for 8 hours. If
wanted to drink, sip of water is the only option.
6. Instruct to wear comfortable, loose clothing or
the gown provided as per hospital; guidelines.
7. Tell the patient that a mild pain will be felt due
to the needle puncture and flushed sensation
from IV contrast medium.
After the procedure:
1. Instruct the patient to resume usual diet as
tolerated, unless ordered.
2. Encourage increase fluid intake to promote
excretion of dye.
B. Endoscopic Ultrasound
IMAGE INTEPRETATION/RESULTS
- Positive of gallstones
- Seen gallbladder wall thickening
NURSING CONSIDERATIONS
Before the procedure:
1. Explain procedure to the client.
2. Obtain informed consent.
3. Assess for any allergies to medications.
4. Advice to stop usage of anticoagulants, if ever.
5. Remind to be NPO for 8 hours prior EUS.
6. If sees the need for ingesting liquid, remind that
it should only be clear liquids for 24-48 hours
before the test.
7. Instruct to empty bladder prior to procedure.
8. Instruct to remove all metallic objects, such as
jewelries.
During the procedure:
1. Assist the patient in positioning.
2. Administer medications as ordered.
3. Encourage patient to take slow, deep breaths
After the procedure:
1. Monitor for signs of perforation.
2. Monitor the patient’s vital signs.
3. Instruct to resume a normal diet, fluids, and
activity as advised by healthcare provider.
4. Monitor for rectal bleeding.
5. Encourage increase in fluid intake.
6. Provide privacy to patient while resting after the
procedure.
 C. Complete Blood Count
TEST RESULT NORMAL RANGE INTERPRETATION NURSING CONSIDERATIONS
Hgb 16g/dL Male: 13.2-17.3g/dL NORMAL Before the procedure:
Female: 11.7- 1. Explain to the client the procedure to be done and its
15.5g/dL purpose
Hct 44% Male: 43-49% NORMAL 2. Assess for history of hematologic and clotting disorders
Female: 38-44% 3. Encourage to avoid stress as possible.
White Blood Cell 14x103mm/3 4.5-11.0x103/mm3 ABOVE AVERAGE 4. Explain that fasting is not necessary.
Count After the procedure:
 Neutrophils 8% 0-6% ABOVE ABERAGE 1. Apply manual pressure and dressings over puncture site.
 Lymphocytes 60% 40-80% NORMAL 2. Monitor puncture site for signs of infection.
 Monocytes 44% 15-45% NORMAL 3. Monitor vital signs, such as temperature.
 Eosinophils 4. Monitor complete blood count, especially WBC count.
350cells/mcL <500cells/mcL NORMAL
5. Screen all visitors for communicable diseases.
 Basophils 250cells/mcL 0-300cells/mcL NORMAL
6. Encourage fluid intake, as tolerated.
MCV 85 fl 85-95 fl NORMAL
7. Maintain aseptic technique during nursing procedures,
MCH 28 pg/cell 28-32 pg/cell NORMAL such as proper handwashing.
MCHC 34 g/dL 33-35 g/dL NORMAL 8. Educate client and SO regarding respiratory hygiene,
RDW 11.7 11.6-14.8 NORMAL such as wearing of mask.
PLT 451x109/L 150-450x109/L ABOVE AVERAGE 9. Educate regarding the importance of proper nutrition,
and adequate rest.
10. Administer medications, such as antibiotics, as ordered.
 D. Urinalysis
TEST RESULT NORMAL RANGE INTERPRETATION NURSING CONSIDERATIONS
Color Orange Clear MAY INDICATE Before the procedure:
HIGH BILIRUBIN 1. Explain the client the procedure to be done.
LEVELS 2. Provide the client the specimen cup.
Protein 18 mg/dL Less than 20 mg/dL NORMAL 3. Educate the client to catch the midstream of the urine.
pH level 5.0 5.0-9.0 NORMAL 4. Provide privacy to the client and allow to void in the
Glucose Negative Negative NORMAL container.
Ketones Negative Negative NORMAL After the procedure:
Hemoglobin Negative Negative NORMAL 1. Label the specimen container with the proper patient
Bilirubin identifying information and send to lab immediately.
Positive Negative INDICATION OF
2. Perform proper handwashing.
HIGH BILIRUBIN
3. Document.
LEVELS
Patient Education:
Urobilinogen 1mg/dL Up to 1 mg/dL NORMAL
1. Encourage client to increase fluid intake at least 1-2
RBC 4/hpf Less than 5/hpf NORMAL L/day, unless contraindicated.
WBC 4/hpf Less than 5/hpf NORMAL 2. Advise to consume more fruits and vegetables, such as
Renal cells 34 g/dL None seen NORMAL cranberries, citrus fruits to lower bilirubin levels in
Bacteria Positive None seen MAY INDICATE urine.
INFECTION 3. Educate about low-protein diet and increasing
Urea 716 mmol 428.4-714 mmol HIGH URIC ACID antioxidant intakes.
4. Educate on adhering to prescription of medication,
especially NSAIDs.
5. Advise to avoid intake of purine-rich foods, including
meat, seafood, asparagus, spinach, peas, and
cauliflower; sodium-rich, and phosphorus.
6. Administer medication for lowering uric acid, such as
allopurinol, as ordered.
7. Monitor culture tests, as ordered by physician.