JMJ

Marist Brothers
Notre Dame of Dadiangas University

A Case Study Presented to

The College of Health Science

A CASE STUDY ON CHOLELITHIASIS

In partial fulfillment of the Requirement

In RLE 116 for the Degree of
Bachelor of Science in Nursing

Presented to:
Mr. Joel Penaflorida RN, MAN

Presented by:
Dela Torre, Erica D. SN
Detoyato, Patricia F. SN
Ealdama Gwendee Mae SN.

September 2022
 TABLE OF CONTENTS

Page
Title Page…………………………………………………………………….

Table of Contents……………………………………………………………

I. Introduction 1

A. Introduction…………………………………………………. 1

II. Objectives……………………………………………………….. 4

III. Anatomy and Physiology……………………………………….. 5

IV. Pathophysiology ………………………………………………….. 9

V. Medical and Nursing Management………………………………… 14

Laboratory Findings……………………………………………….. 14

Medical Management & Drug Study………………………………. 17

Nursing Management…………………………………………. … 24

Prognosis……………………………………………………………. 25

VI. Gordon’s Functional Health Pattern ………………………………… 30

Problem List………………………………………………………… 30

Prioritization of Problems…………………………………………… 26

Nursing Care Plans…………………………………………………. 31

Health Teachings………………………………………………… 42

Curriculum vitae 43

References 46
 Chapter I

INTRODUCTION

Cholelithiasis, or gallstones, are hardened deposits of digestive fluid that form

in the gallbladder. The gallbladder is a small, pear-shaped organ that lies beneath the liver

and stores bile made by the liver. Bile is a digestive fluid made of cholesterol, bile salts,

and bilirubin and gets released into the small intestine through the cystic duct and

common bile duct, to aid in fat digestion. Gallstones can range in size and an individual

may develop several small gallstones, one large gallstone, or a combination of different

sized gallstones. In the United States, roughly 6% of men and 9% of women have

cholelithiasis, most of whom are without symptoms.  

The exact cause of cholelithiasis is not entirely clear, and may be a result of

multiple factors. Cholelithiasis most commonly results from a chemical imbalance within

the contents of the gallbladder in which the bile contains too

much cholesterol or bilirubin. The two most common types of gallstones are cholesterol

gallstones and pigment gallstones. 

Cholesterol gallstones are the most common type of gallstone and may develop

when the amount of cholesterol excreted by the liver exceeds what the bile can dissolve,

leading to excess cholesterol depositing into yellow cholesterol stones. Additional risk

factors associated with the development of cholesterol gallstones include high

cholesterol; diabetes; high fat and low fiber diets; obesity; pregnancy;  sedentary living;

rapid weight loss; medications used to lower cholesterol, such as statins; medications that

increase estrogen levels in the body, such as oral contraceptives; being assigned female at

1
birth; being Native American; being over the age of 60; and having a personal or family

history of gallstones.

Pigment gallstones, on the other hand, are dark brown or black pigment stones

that result from an increased load of bilirubin. Bilirubin is a chemical that is produced

when the body breaks down red blood cells and is excreted through the liver. Increased

bilirubin can result from certain conditions, such as liver cirrhosis; biliary

tract infections; cystic fibrosis; blood disorders, such as sickle cell anemia or leukemia;

and gastrointestinal diseases associated with impaired bile reabsorption, such as Crohn

disease. Gallstone disease may also be caused by concentrated bile, which may occur

when the gallbladder is not emptying correctly or frequently enough due to low motility

or contraction, increasing the risk of gallstones. (Syed, 2021)

The critical feature of gallstones is that they are not all symptomatic. Sometimes

they may migrate near the opening of the cystic duct and block the flow of bile. This can

lead to tension in the gallbladder, which results in the classic biliary colicky pain. If the

cystic duct is obstructed for more than a few hours, it can lead to inflammation of the

gallbladder wall (cholecystitis). Sometimes the gallstone may move into the bile duct and

cause obstruction, leading to jaundice and abdominal pain. Patients who have chronic

gallstones may develop progressive fibrosis and loss of motor function of the gallbladder.

The best test to make a diagnosis of gallstones is ultrasound. The treatment of gallstones

depends on symptoms. The standard of care for symptomatic patients is laparoscopic

cholecystectomy. (Jones et. al, 2022)

2
Etiology

There are three main pathways in the formation of gallstones: 

 Cholesterol supersaturation: Normally, bile can dissolve the amount of cholesterol

excreted by the liver. But if the liver produces more cholesterol than bile can

dissolve, the excess cholesterol may precipitate as crystals. Crystals are trapped in

gallbladder mucus, producing gallbladder sludge. With time, the crystals may

grow to form stones and occlude the ducts which ultimately produce the gallstone

disease.

 Excess bilirubin: Bilirubin, a yellow pigment derived from the breakdown of red

blood cells, is secreted into bile by liver cells. Certain hematologic conditions

cause the liver to make too much bilirubin through the processing of breakdown

of hemoglobin. This excess bilirubin may also cause gallstone formation.

 Gallbladder hypomotility or impaired contractility: If the gallbladder does not

empty effectively, bile may become concentrated and form gallstones.

Depending on the etiology, gallstones have different compositions. The three most

common types are cholesterol gallstones, black pigment gallstones, and brown pigment

gallstones. Ninety percent of gallstones are cholesterol gallstones.

Each stone has a unique set of risk factors. Some risk factors for the development

of cholesterol gallstones are obesity, age, female gender, pregnancy, genetics, total

parenteral nutrition, rapid weight loss, and certain medications (oral contraceptives,

clofibrate, and somatostatin analogs).

3
 Approximately 2% of all gallstones are black and brown pigment stones. These

can be found in individuals with high hemoglobin turnover. The pigment consists of

mostly bilirubin. Patients with cirrhosis, ileal diseases, sickle cell anemia, and cystic

fibrosis are at risk of developing black pigment stones. Brown pigments are mainly found

in the Southeast Asian population and are not common in the United States. Risk factors

for brown pigment stones are intraductal stasis and chronic colonization of bile with

bacteria.

Patients with Crohn disease and those with ileum disease (or resection) are not

able to reabsorb bile salts and this increases the risk of gallstones. (Sinton & Shaffer,

2012)

Epidemiology

Cholelithiasis is quite common and can be found in approximately 6% of men and

9% of women. The highest prevalence of cholelithiasis arises in Native American

populations. Gallstones are not as common in Africa or Asia. The epidemic of obesity has

likely magnified the rise of gallstones. Most gallstones are asymptomatic. In the United

States, approximately 14 million women and 6 million men with an age range of 20 to 74

have gallstones. The prevalence increases as a person ages. Obesity increases the

likelihood of gallstones, especially in women, due to increases in the biliary secretion of

cholesterol. On the other hand, patients with drastic weight loss or fasting have a higher

chance of gallstones secondary to biliary stasis. Furthermore, there is also a hormonal

association with gallstones. Estrogen has been shown to result in an increase in bile

cholesterol as well as a decrease in gallbladder contractility. Women of reproductive

age or on estrogen-containing birth control medication have a two-fold increase in

4
gallstone formation compared to males. People with chronic illnesses such as diabetes

also have an increase in gallstone formation and reduced gallbladder wall contractility

due to neuropathy. (Tanaja et. al, 2022)

Diseases of the gallbladder commonly manifest as gallstones and gallbladder

cancer. To identify risk factors in a given population, epidemiological studies must first

define the frequency of disease. Studies employing necropsy surveys or healthcare

databases carry biases by their implicit nature: being postmortem or requiring biliary

symptoms/complications, respectively. Another potential measure of disease burden, the

frequency of cholecystectomy, is a limited marker for the prevalence of gallstones, as the

perceived threshold for surgery and patient access to care differ greatly. Some

epidemiological studies have been confounded by inadequate sample size or selection

bias. Small sample size is open to a beta-II type error: a failure to accurately identify a

true difference (i.e., a false negative result). Selection bias may lead to spurious

differences (i.e., a false positive result). More reliable epidemiological studies now use

transabdominal ultrasound to screen robust numbers in defined asymptomatic

populations. Ultrasonography is an ideal means to quantitate the frequency of gallstone

disease, being a noninvasive and safe imaging technique that accurately can detect the

point prevalence of gallstones in a defined asymptomatic population. (Sinton & Shaffer,

2012)

5
DATA BASE AND HISTORY

Name of Mrs. C Civil Status Married Age 74

Patient
Address General Santos City Nationality Filipino Sex Female
Religion Catholic Date of 08.22.22
Admission
Date of Birth July 2, 1948 Time of 10:30am
Admission
Attending Dr. Tan Consultant Dr. Tan
Physician

T: __36.8__0C PR: _69_ bpm RR: BP:_140/70_mmHg

( ) oral ( ) radial ____24__cpm ( ) site:
( ) rectal ( ) apical ( ) abdominal ______________
Initial Vital ( ) axillary ( / ) regular ( / ) diaphragmatic ( ) position:
Signs ( / ) tympanic ( ) irregular ___________
( ) others,
__________

Height: _____4’6_________ Weight: ___53kg_____________

Chief
2 weeks experiencing abdominal pain
Complaints

In 2 weeks, patient experienced pain in her right upper quadrant; 5/10 pain scale
History of radiating to back aggravated by meals.
Present Illness

History of Past None

Illness

Family Health None

History
Has received
blood in the ( ) Yes If YES, list
past? dates

6
 ( / ) No

Blood
reactions, if
any?

( ) Yes If YES,
Allergies? please
( / ) No specify

Admitting Cholelithiasis
Diagnosis

7
 Chapter II

OBJECTIVES OF THE STUDY

General Objectives:

This study on Cholelithiasis aimed to understand its disease process and provide holistic

awareness regarding its clinical management and comprehensive nursing interventions.

Specific Objectives:

The students had formulated the following objectives to synthesis the study. The student

nurse will be able to:

1. Identify the etiology and epidemiology of the disorder;

2. Describe the structure and function of the gallbladder.

3. Explain the pathophysiology of cholelithiasis through its etiology, precipitating

and predisposing factors, disease process and signs and symptoms.

4. Discuss the medical management necessary to diagnose and treat cholelithiasis

that includes laboratory findings, imaging study, common prescribed drugs, and

other related therapeutic management in order to identify its prognosis;

5. Identify and comprehend the appropriate nursing management;

6. Enumerate and prioritize the identified problems in order to provide a holistic

nursing care plan which includes dependent and independent nursing

interventions.

7. Provide health teaching to both client and family in managing cholelithiasis

whenever they are in the healthcare setting and at home.

8
 Chapter III

ANATOMY AND PHYSIOLOGY

Gallbladder

According to visible body (2022), gallstones develop in the gallbladder and are formally

referred to as cholelithiasis in the medical field. The gallbladder is a little, hollow, pear-

shaped organ beneath the liver on the right side of the belly that stores bile, a fluid

produced by the liver to aid in the breakdown of fat in diet. As with every organ, bile can

malfunction, and when this happens, bile material binds together to produce two different

types of hard, pebble-like particles called gallstones:

 Cholesterol gallstones: This most common type of gallstone often appears

yellow in color and is composed mainly of undissolved cholesterol.

 Pigment gallstones: These dark brown or black stones form when bile contains

too much bilirubin (a brownish yellow substance produced when the liver breaks

down red blood cells).

9
Mechanism

The gallbladder plays an important role in digestion by helping to store and concentrate

bile, a fluid produced by the liver that aids in digestion and absorption of lipids. It is

composed of cholesterol, bilirubin, water, bile salts, phospholipids, and ions.

The bile produced by the liver flows directly into the small intestine during a meal.

Between meals, when there's no fat that needs to be digested, most of the bile flows into

the gallbladder instead, where it is concentrated and stored. The gallbladder usually holds

about 30 to 80 milliliters (about 1 to 2.7 fluid ounces) of fluid. When we eat fatty foods,

the gallbladder contracts and squeezes bile through the bile duct. The bile is mixed into

the semi-digested food in the small intestine.

Bile is mainly made up of water, but also has bile salts, cholesterol, certain fats (lecithin)

and bile pigments in it. The most important bile pigment, bilirubin, is made when red

blood cells are broken down in the liver. Bilirubin is what makes urine yellow and stool

brown.

Bile salts break down larger fat globules in food into small droplets of fat. Smaller fat

droplets are easier for the digestive enzymes from the pancreas to process and break

down. The bile salts also help the cells in the bowel to absorb these fat droplets. (NIH,

2021).

10
 Chapter IV

PATHOPHYSIOLOGY
Predisposing factors; Precipitating factors;
 Gender  High dietary intake of
 Age fats and carbohydrates
 Genetic  Sedentary lifestyle
 Sedentary lifestyle
 Type 2 diabetes mellitus
 dyslipidemia

Gaining weight and higher risk of gallstones

Blockage in pancreatic duct, which can lead to inflammation of pancreas

(pancreatitis)

Gallstones
(Cholelithiasis)

Consist largely of bile supersaturated with cholesterol.

Caused primarily by hypersecretion of cholesterol due to altered hepatic cholesterol

metabolism.

Loss of gallbladder muscular-wall motility and excessive sphincter contraction.

Leads to prolonged bile stasis (delayed gallbladder emptying), along with decreased
reservoir function

11
 Gallstones are hard, pebble-like structures that obstruct the cystic duct. The

formation of gallstones is often preceded by the presence of biliary sludge, a viscous

mixture of glycoproteins, calcium deposits, and cholesterol crystals in the gallbladder or

biliary ducts. In the U.S., most gallstones consist largely of bile supersaturated with

cholesterol. This hypersaturation, which results from the cholesterol concentration being

greater than its solubility percentage, is caused primarily by hypersecretion of cholesterol

due to altered hepatic cholesterol metabolism. A distorted balance between pronucleating

(crystallization-promoting) and antinucleating (crystallization-inhibiting) proteins in the

bile also can accelerate crystallization of cholesterol in the bile. Mucin, a glycoprotein

mixture secreted by biliary epithelial cells, has been documented as a pronucleating

protein. It is the decreased degradation of mucin by lysosomal enzymes that is believed to

promote the formation of cholesterol crystals.

Loss of gallbladder muscular-wall motility and excessive sphincteric contraction

also are involved in gallstone formation. This hypomotility leads to prolonged bile stasis

(delayed gallbladder emptying), along with decreased reservoir function. The lack of bile

flow causes an accumulation of bile and an increased predisposition for stone formation.

Ineffective filling and a higher proportion of hepatic bile diverted from the gallbladder to

the small bile duct can occur as a result of hypomotility. Occasionally, gallstones are

composed of bilirubin, a chemical that is produced as a result of the standard breakdown

of RBCs. Infection of the biliary tract and increased enterohepatic cycling of bilirubin are

12
the suggested causes of bilirubin stone formation. Bilirubin stones, often referred to

as pigment stones, are seen primarily in patients with infections of the biliary tract or

chronic hemolytic diseases (or damaged RBCs). Pigment stones are more frequent in

Asia and Africa.

The pathogenesis of cholecystitis most commonly involves the impaction of

gallstones in the bladder neck, Hartmann’s pouch, or the cystic duct; gallstones are not

always present in cholecystitis, however. Pressure on the gallbladder increases, the organ

becomes enlarged, the walls thicken, the blood supply decreases, and an exudate may

form. Cholecystitis can be either acute or chronic, with repeated episodes of acute

inflammation potentially leading to chronic cholecystitis. The gallbladder can become

infected by various microorganisms, including those that are gas forming. An inflamed

gallbladder can undergo necrosis and gangrene and, if left untreated, may progress to

symptomatic sepsis. Failure to properly treat cholecystitis may result in perforation of the

gallbladder, a rare but life-threatening phenomenon. Cholecystitis also can lead to

gallstone pancreatitis if stones dislodge down to the sphincter of Oddi and are not

cleared, thus blocking the pancreatic duct.

Risk factors

Genetic and environmental factors contribute to gallbladder disease. Female gender,

previous pregnancies, and family history of gallstone disease are highly correlated with

cholelithiasis. Approximately 60% of patients with acute cholecystitis are women;

however, the disease tends to be more severe in men. Estrogen increases cholesterol and

13
its saturation in bile and promotes gallbladder hypomotility.1 Diminished gallbladder

motility is commonly seen during pregnancy.

Other risk factors include a high dietary intake of fats and carbohydrates, a sedentary

lifestyle, type 2 diabetes mellitus, and dyslipidemia (increased triglycerides and low

HDL).  A diet high in fats and carbohydrates predisposes a patient to obesity, which

increases cholesterol synthesis, biliary secretion of cholesterol, and cholesterol

hypersaturation. However, a direct correlation between high dietary intake of fats and

cholelithiasis risk has not been established because previous studies have yielded

controversial results. Acute cholecystitis develops more frequently in symptomatic

cholelithiasis patients with type 2 diabetes mellitus than in symptomatic patients without

it. These patients also are more likely to have complications.

American Indians have the highest prevalence of cholelithiasis, with the disease reaching

epidemic proportions in this population. Gallstone disease is also prevalent in Chilean

and Mexican Hispanics. In addition to ethnicity, age plays a role in gallstone disease.

Patients who develop complicated symptomatic cholelithiasis tend to be older, and the

typical patient with gallstones is in her 40s. (Afamefuna &Allen, 2013)

14
 Chapter V

Medical and Nursing management

Laboratory Findings

 Complete Blood Count

If there is inflammation caused by gallstones, the white blood cell count is usually

elevated (higher). In this situation, the patient will often have a fever.

EXAMINATION RESULT NORMAL RANGE IMPLICATIONS

WHITE BLOOD CELL 11.29 4.0-10.0 HIGH

RED BLOOD CELL 3.89 3.69-5.13 NORMAL

HEMOGLOBIN 11.80 11.7-14.5 NORMAL

HEMATOCRIT 35.20 34.1-44.3 NORMAL

MCV 90.50 81.5-96.7 NORMAL

MCH 30.30 26.5-33.5 NORMAL

RDW 12.60 11.0-16.0 NORMAL

PLATELET COUNT 276.00 150-400 NORMAL

NEUTROPHIL 89 50-70 HIGH

15
 LYMPHOCYTE 7 20-40 LOW

MONOCYTE 4 3-12 NORMAL

EOSINOPHIL 0 1-5 LOW

BASOPHIL 0 0-1 LOW

 Ultrasound

Ultrasound testing uses sound waves to take images of the gallbladder. It is the

gold-standard to look for gallstones because it is simple and non-invasive.

Ultrasound is very good at highlighting gallstones within the gallbladder, as well as

features, such as a thickened gallbladder wall, that point to inflammation of the

gallbladder.

 Computed tomography (CT)

This test uses X-rays to construct detailed images of the abdominal organs. CT

can give additional information on the bile ducts and liver, which may be affected by

gallstones disease.

 Magnetic resonance cholangiopancreatography (MRCP)

This test uses magnetic resonance imaging (MRI) to produce detailed pictures of

the biliary tree (liver, gallbladder and bile ducts). It is of particular use to look at the

bile ducts for signs of stones that have escaped from the gallbladder and are locking

the bile duct which can lead to jaundice.

 Endoscopic retrograde cholangiopancreatography (ERCP)

16
 In this procedure, a tube is placed down the patient’s throat, into the stomach,

then into the small intestine. Dye is injected and the ducts of the gallbladder, liver,

and pancreas can be seen on X-ray. ERCP is now mainly used to treat patients in

whom a gallstone has blocked the bile duct causing pancreatitis (inflammation of the

pancreas), jaundice or cholangitis (infection of the bile).

 Liver function tests (LFTs)

Although these tests are not done specifically for gallstone disease, a simple blood

test looking at the enzyme levels in the liver can show inflammation in the

gallbladder caused by gallstones. Other combinations of liver tests are arranged if

gallstones fall out of the gallbladder and are blocking the bile duct, which can lead to

jaundice (the skin, whites of the eyes and mucous membranes turns yellow).

Medical Management

Brand Name Acifre

Generic Name Omeprazole

Date Ordered 08.25.22

Rationale for the To treat certain conditions where there is too much acid in the

Drug Order stomach.

Classification Antacids, Antireflux Agents & Antiulcerants

Actual Dose/ Refractory esophagitis 40 mg daily

Frequency/ Route

Benign gastric & duodenal ulcers, gastric acid reduction, acid

Indication
reflux disease, acid-related dyspepsia.

17
 Pharmacology: Pharmacodynamics: Omeprazole, a racemic

mixture of two active enantiomers, reduces gastric acid

secretion through a highly targeted mechanism of action. It is a

specific inhibitor of the acid pump in the parietal cell. It is

rapidly acting and provides control through reversible

inhibition of gastric acid secretion with once daily dosing.

Omeprazole is a weak base and is concentrated and converted

to the active form in the highly acidic environment of the

intracellular canaliculi within the parietal cell, where it inhibits

the enzyme H+, K+ - ATPase – the acid pump. This effect on

Mechanism of the final step of the gastric acid formation process is dose-

Action dependent and provides for highly effective inhibition of both

basal acid and secretion and stimulated acid secretion,

irrespective of stimulus.

Pharmacokinetics: Omeprazole is rapidly but variably absorbed

following oral administration. Absorption is not affected by

food. Omeprazole is acid-labile and pharmacokinetics may vary

between the various formulations developed to improved oral

bioavailability. The absorption of omeprazole also appears to

be dose-dependent; increasing the dosage above 40mg has been

reported to increase the plasma concentrations in a non-linear

fashion because of saturable first-pass hepatic metabolism.

18
Contraindication Hypersensitive to omeprazole

 Headache

 Nausea

Side Effects  Vomiting

 Stomach pain

 Constipation

 Flatulence

Reported headache, diarrhea and skin rashes; severe enough to

require discontinuation of treatment; other effects include

Adverse Reactions pruritus, dizziness, fatigue, constipation, nausea and vomiting,

flatulence, abdominal pain, arthralgia, and myalgia, urticaria

and dry mouth; Increase the risk of gastrointestinal infections

because of their acid and suppressive effects.

Nursing  Lab tests: Monitor urinalysis for hematuria and

Considerations/ proteinuria. Periodic liver function tests with prolonged

Responsibilities use.

 Report any changes in urinary elimination such as pain

or discomfort associated with urination, or blood in

urine.

 Report severe diarrhea; drug may need to discontinued

 Advise patient to avoid alcohol and foods that may

cause an increase GI irritation. Instruct patient to report

19
 bothersome or prolonged side effects, including skin

problems (itching, rash) or GI effects (nausea, diarrhea,

vomiting, constipation, heartburn, flatulence, abdominal

pain).

Brand Name Cefurex

Generic Name Cefuroxime

Date Ordered 08.25.22

Rationale for the To treat certain infections caused by bacteria

Drug Order

Classification Cephalosporin

Actual Dose/ 200mg 1cap BID x 10 days

Frequency/ Route

Infections caused by susceptible organisms eg, bone & joint

Indication infections, skin & skin structure infections; surgical infection

prophylaxis

Mechanism of Cefurex inhibits bacterial cell wall synthesis following

Action attachment to penicillin binding proteins (PBPs). This results in

the interruption of cell wall (peptidoglycan) biosynthesis, which

leads to bacterial cell lysis and death.

Pharmacodynamics/Pharmacokinetics: For cephalosporins, the

most important pharmacokinetic-pharmacodynamic index

20
 correlating with in vivo efficacy has been shown to be the

percentage of the dosing interval that the unbound

concentration remains above the minimum inhibitory

concentration (MIC) of Cefurex for individual target species

Contraindication  Hypersensitivity to cephalosporins

 Rash

 Vomiting
Side Effects
 Increased liver enzymes

 Nausea

 Diarrhea

 Diarrhea; decreased Hb/hematocrit, eosinophilia,

Adverse Reactions
nausea/vomiting, vaginitis, transient rise in hepatic

transaminases, thrombophlebitis.

Nursing Assessment:

Considerations/  History: Hepatic and renal impairment, lactation,

Responsibilities pregnancy

 Physical: Skin status, renal function tests, culture of

affected area, sensitivity tests

Interventions

 Culture infection, and arrange for sensitivity tests before

and during therapy if expected response is not seen.

 Give oral drug with food to decrease GI upset and

21
 enhance absorption.

 Give oral drug to children who can swallow tablets;

crushing the drug results in a bitter, unpleasant taste.

 Have vitamin K available in case hypoprothrombinemia

occurs.

 Discontinue if hypersensitivity reaction occurs.

Health Education

Oral drug

 Take full course of therapy even if you are feeling

better.

 This drug is specific for this infection and should

not be used to self-treat other problems.

 Swallow tablets whole; do not crush them. Take the

drug with food.

 You may experience these side effects: Stomach

upset or diarrhea.

 Report severe diarrhea with blood, pus, or mucus;

rash; difficulty breathing; unusual tiredness,

fatigue; unusual bleeding or bruising; unusual

itching or irritation.

Parenteral drug

 Avoid alcohol while taking this drug and for 3 days

after because severe reactions often occur.

22
  You may experience these side effects: Stomach

upset or diarrhea.

 Report severe diarrhea, difficulty breathing,

unusual tiredness or fatigue, pain at injection site.

Brand Name Arcoxia

Generic Name Etericoxib

Date Ordered 08.25.22

Rationale for the Help to reduce the pain and swelling in the joints and muscle

Drug Order

Classification Nonsteroidal Anti-Inflammatory Drugs (NSAIDs)

Actual Dose/ Acute pain & post-op gynecological pain 90 mg or 120 mg once a

Frequency/ Route day

Indication Relief of acute pain. Moderate to severe acute post-op pain.

Mechanism of Pharmacology: exhibits anti-inflammatory, analgesic, and

Action antipyretic activities in animal models. Arcoxia is a potent, orally

active, highly selective cyclooxygenase-2 inhibitor within and

above the clinical dose range. Arcoxia produced dose-dependent

inhibition of COX-2 without inhibition of COX-1 doses up to 150

mg daily. Arcoxia did not inhibit gastric prostaglandin synthesis

as compared to placebo. Platelet Function: Multiple doses of

23
 Arcoxia up to 150 mg administered daily up to nine days had no

effect on bleeding time relative to placebo.

 Hypersensitivity to any component of this product

 Congestive heart failure (NYHA II-IV)

 Establish ischemic heart disease, peripheral arterial disease

Contraindication and/or cerebrovascular disease

 Patients with hypertension whose blood pressure has not

been adequately controlled

 Pregnancy

 Nausea/vomiting
Side Effects
 Heartburn, pain in the stomach

 Diarrhea

 Swelling of the legs, ankles or feet

Adverse Reactions  High blood pressure

 Dizziness

 Headache

Elderly

Nursing No dose adjustment is necessary for elderly patients. As with

Considerations/ other medicines, caution should be exercised in elderly patients.

Responsibilities
Method of administration

ARCOXIA is for oral use. Take the tablets once a day.

24
 ARCOXIA can be taken with or without food.

If you take more ARCOXIA than you should

You should never take more tablets than the doctor recommends.

If you do take too many ARCOXIA tablets, you should seek

medical attention immediately.

If you forget to take ARCOXIA

It is important to take ARCOXIA as your doctor has prescribed. If

you miss a dose, just resume your usual schedule the following

day. Do not take a double dose to make up for the forgotten tablet.

Brand Name Paracetamol

Generic Name Algesia

Date Ordered 08.25.22

Rationale for the Used for the treatment of short-term acute pain

Drug Order

Classification Analgesic and Antipyretic drug

Actual Dose/ 325mg film-coated tab: 1-2tab(s) 4-6 hourly as needed.

Frequency/ Route

Paracetamol is a mild analgesic and antipyretic, and is

Indication
recommended for the treatment of most painful.

Mechanism of Tramadol is a centrally acting opioid analgesic that binds to

micro-opiate receptors in the CNS, leading to inhibited

25
 ascending pain pathways and altered pain perception and

response. It is also inhibiting the reuptake of norepinephrine

and enhances the release of serotonin.

Action Paracetamol is a para-aminophenol derivative with analgesic,

antipyretic and weak anti-inflammatory activity. The exact

mechanism of its analgesic action is still unknown, but it is

believed to be by activating the describing serotonergic

inhibitory pathways in the CNS.

Hypersensitivity to tramadol or paracetamol.

Contraindication
Significant respiratory depression, acute or severe bronchial

asthma

 Skin rash

Side Effects  Wheezing

 Tightness in the chest

 Trouble breathing

An allergic reaction, which can cause a rash and swelling

Adverse Reactions  Flushing, low blood pressure and a fast heartbeat—this can

sometimes happen when paracetamol is given in hospital

into vein in your arm.

 Check that the patient is not taking any other medication

Nursing
containing paracetamol.
Considerations/

Responsibilities
 For children who may refuse medicine off a spoon try

26
 using a medicine syringe to squirt liquid slowly into the

side of the child’s mouth or use soluble paracetamol

mixed with a drink.

 Some children may be happy to take one paracetamol

product but dislike the taste of another.

 There are no known harmful effects when used during

pregnancy.

 Small amounts may pass into breast milk. However,

there are no known harmful effects when used by

breastfeeding mothers.

 Alcohol increases the risk of liver damage that can

occur if an overdose of paracetamol is taken. The

hazards of paracetamol overdose are greater in

persistent heavy drinkers and in people with alcoholic

liver disease.

Evaluate therapeutic response.

Cholecystectomy

27
A gallbladder surgery or cholecystectomy is a procedure that removes your gallbladder

and its contents. The gallbladder stores bile, a digestive fluid produced in your liver by

removing your gallbladder. Cholecystectomy is a surgery to remove your gallbladder,

which makes bile, and also stores excess fat. In most cases, doctor will perform a

laparoscopic cholecystectomy by inserting a tiny video camera and special surgical tools

through four small incisions to see inside your abdomen and remove the gallbladder.

Nursing Management

Pre-operative

1. Advice for NPO the night before the surgery.

2. Assess the history, physical exam, and blood work.

3. For required surgery, explain all preoperative and postoperative procedures and

treatments to the patient and his family. Rationale: to avoid unexpected

complications during surgical procedures, it's important that the patient follow

pre-operative instructions.

Post-operative

1. Monitor the vital signs of the patient before transferring to the recovery room.

2. Monitor the incision of the patient and wound dressing.

3. Check if there are any bleeding, swelling, and redness in the incision site

4. Educate the patient on how to take care of the incision.

5. Instruct the patient to rest much as possible for at least two weeks and should

avoid driving during this time. Always rest lying down

28
6. Educate the patient to avoid standing for more than a few minutes at a time in the

early post-operative period. You can increase standing time as your recovery

progresses

7. Instruct the patient to avoid heavy lifting and stretching

8. Educate the patient to avoid constipation, drink plenty of fluids and eat fresh fruits

and vegetables. You may be advised to take stool softeners for the first few days

9. With the patient and doctor, plan a pain control regimen. Rationale: Pain

interferes with many daily activities, and one of the goals of acute pain

management is to reduce the effect of pain on patient function and quality of life.

10. Encourage the patient to express his concerns about the disorder. Rationale: by

encouraging them to make comparisons, nurses can help patients discover

solutions to their problems

11. Assess the patient’s pain status and his response to the pain-control regimen.

Rationale: Detect and describe pain to help in the diagnostic process and cause of

the pain to help determine.

12. Provide time to listen to concerns and fears of patient and SO. Discuss patient’s

perceptions of self-related to anticipated changes and her specific lifestyle.

Rationale: Listening conveys interest and concern. Give opportunities to correct

common misconceptions like women may fear the loss of femininity and

sexuality, weight gain, and menopausal body changes.

13. Assess the emotional stress the patient is experiencing. Identify the meaning of

loss for patient and SO. Encourage patient to vent feelings appropriately.

Rationale: Nurses need to be aware of what this operation means to the patient to

29
 avoid inadvertent casualness or over solicitude. She may fear the loss of ability to

fulfill her reproductive role and may experience grief.

14. Discuss prescribed medications to the patient.

Prognosis

The client has a good prognosis as he is able to follow his treatment/therapy and is

performing activities of daily living independently.

Criteria Poor Fair Good Justification

The rate is fair since it major

Duration of operation and be in hospital for up to

Condition 5 days after surgery, and it takes

about 6 to 8 weeks to fully recover.

Recovery times can also vary

depends of healing with proper

treatment, it could be lessened or

cured.

The rate is poor because the client

Onset of Condition sought for a delayed medical

assistance after she experience pain

in her abdominal.

30
 Rated as good because the patient

Risk Factors had surgery and is currently

recovering and healing with proper

care.

The rate was fair because many

Age women have a cholelithiasis. It's

more common for women aged 20 to

60.

Willingness to take Rated as good because the client was

the medication/ willing to comply with the entire

Compliance with course of treatment.

Therapeutic Regimen

The rate was good because her

family support her.

Family Support

Total Criteria:

Poor = 1; Fair = 2; TOTAL = 3

Good = 3 Scale interpretation

Poor (1 x 0 = 0) Poor = 0 – 1.6

Fair (2 x 3 = 6) Fair = 1.7 – 3.3

31
Good (3 x 3 = 9) Good = 3.4 – 5

Score: 15/5 = 3

Implication: Patient has a good prognosis because the patient had surgery and is

currently recovering and healing with proper care and it takes weeks to fully recover

depends in treatment. Has enough emotional and financial assistance form her family.

32
33
 GORDON’S FUNCTIONAL HEALTH PATTERN

Functional Health Cue Cluster Inference Diagnostic Statement Priority Rationale

Pattern
1. Health Perception N/A
& Management

2. Nutrition / Subjective cues: Imbalance Nutrition: Imbalanced Nutrition: High 2 This is considered as a
Metabolism “gamay lang akung less than body less than body high 2 for the reason
gina kaon, kay requirements requirements related to that she is unable to eat
ginasuka gihapon vomiting when eating properly because of
nako.” as evidenced by her stomach ache.
Patient verbalized
Objective Cues: “gamay lang akung
Restless gina kaon, kay
Body malaise ginasuka gihapon
Rapid breathing nako.”

3. Elimination N/A
Pattern

4. Activity / Exercise N/A

34
5. Sleep / Rest N/A

6. Cognitive / Subjective cues: Pain Abdominal pain HIGH 1 This is considered high
Perceptual “Sakit ang akong tiyan related to post 1 priority nursing
maam.” operative as evidenced problem for the reason
by high pain scale of that pain in his
7/10 stomach can result a
Objective cues: complications if not
 Pain scale of 7/10 treated immediately.
 Incision in the right
upper quadrant
 Patient is oriented
in time, place and
date, Impaired skin Integrity Impaired skin Integrity HIGH 3 This is considered high
 Positive facial related to surgical 3 priority for the
grimace incision as manifested reason that this is only
by Incision in the right temporary wound and
upper quadrant it can heal within 3
weeks.

7. Self – Perception / N/A

Self - Concept

35
8. Role / Relationship N/A

9. Sexuality / N/A
Reproductive

10. Coping – Stress N/A

Tolerance

11. Value Belief N/A

PROBLEM IDENTIFICATION

Problem (PES) Date Identified Time Date Resolved

Abdominal pain related to post operative as 08.30.22 11pm 9/1/22

evidenced by high pain scale of 7/10

36
Imbalanced Nutrition: less than body 08.30.22 11pm 9/1/22
requirements related to vomiting when eating
as evidenced by Patient verbalized “gamay
lang akung gina kaon, kay ginasuka gihapon
nako.”

Impaired skin Integrity related to surgical 08.30.22 11pm 9/1/22

incision as manifested by Incision in the right
upper quadrant

PRIORITIZATION OF PROBLEMS
Nursing Diagnosis Prioritization Rationale

Abdominal pain related to post operative as evidenced by high HIGH 1 This is considered high 1 priority nursing problem for the
pain scale of 7/10 reason that pain in his head can result a complications if not
treated immediately.

Imbalanced Nutrition: less than body requirements related to HIGH 2 This is considered as a high 2 for the reason that she is unable
vomiting when eating as evidenced by Patient verbalized to eat properly because of her stomach ache.
“gamay lang akung gina kaon, kay ginasuka gihapon nako.”

Impaired skin Integrity related to surgical incision as HIGH 3 This is considered high 3 priority for the reason that this is only
manifested by Incision in the right upper quadrant temporary wound and it can heal within 3 weeks.

NURSING CARE PLAN

Name of Patient Mrs. Cor Rm/Bed No. 204 B Age 74 Chief Complaints Abdominal pain

Address GSC Admission Date 08.25.22 Sex F Diagnosis Cholelithiasis

ASSESSMENT HEALTH NURSING DESIRED OUTCOME INTERVENTION EVALUATION

37
 PATTERN DIAGNOSIS
Subjective cues: Cognitive / Note: Use P- After 8 hours of effective Independent: GOAL MET
“Sakit ang akong Perceptual E-S format nursing Intervention, the
tiyan maam.” patient will be able to  Assess patient’s level of understanding. After 8 hours of effective nursing
Abdominal express relief from Rationale: Facilitates planning of preoperative Intervention The patient was able
pain related discomfort or control of teaching program, identifies content needs. to express relief from discomfort
to post their condition or control of their condition
operative as  Apply cold compress to the affected area
evidenced by Rationale: this is to relieve the pain
high pain
scale of 7/10  Review specific pathology and
anticipated surgical procedure. Verify
that appropriate consent has been signed.
Rationale: Provides knowledge base from
which patient can make informed therapy
Background choices and consent for procedure, and
Objective Cues Knowledge presents opportunity to clarify
 Pain scale of misconceptions.
7/10 Pain is a  Encourage the patient to disclose any
 Incision in the signal in your discomfort or pain he/she may be
right upper nervous experiencing.
quadrant system that Rationale: Instead of asking for painkillers or
 Patient is something analgesics, the patient may strive to tolerate
oriented in may be his/her discomfort. Encouraging the patient to
time, place wrong. It is report their pain could aid in the provision of
and date, an unpleasant treatment.
 Positive facial feeling, such
grimace as a prick,  Assist the patient in managing his/her
tingle, sting, pain by providing comfort therapy such
burn, or ache. as:
Pain may be -Distraction techniques (e.g., deep
sharp or dull. breathing exercises, guided imagery)

38
It may come -Hot and cold application
and go, or it -Music therapy
may be -Positioning
constant. You -Back massage/back rubs
may feel pain
in one area of Rationale: Non-pharmacologic interventions,
your body, particularly comfort measures, promote a
such as sense of well-being. It also helps to redirect
your back, ab the patient’s thoughts and improves his/her
domen, chest,  ability to cope with stress.  
pelvis, or you  Discuss individual postoperative pain
may feel pain management plan. Identify misconceptions
all over. patient may have and provide appropriate
Pain can be information.
helpful in Rationale: Increases likelihood of successful
diagnosing a pain management. Some patients may expect
problem. If to be pain-free or fear becoming addicted to
you never felt narcotic agents.
pain, you  Provide opportunity to practice coughing,
might deep-breathing, and muscular exercises.
seriously hurt Rationale: Enhances learning and continuation
yourself of activity postoperatively.
without  Assess for abdominal distension. Monitor
knowing it, or the patient’s vital signs (e.g., fluctuations
you might not in blood pressure and body temperature).
realize you Rationale: Abnormal variations in the
have a patient’s vital signs could point to an
medical impending obstruction of the digestive tract,
problem that swelling/edema, inflammation, and scarring.
needs
treatment.

39
ASSESSMENT HEALTH NURSING DESIRED OUTCOME INTERVENTION EVALUATION
PATTERN DIAGNOSIS
Subjective cues: Nutrition/ Note: Use P- After 8 hour of effective Independent: GOAL MET
“gamay lang Metabolism E-S format nursing intervention the   Provide nutritional supplements as After 8 hour of effective nursing
akung gina kaon, patient will be able to eat appropriate or ordered. intervention the patient is be able
kay ginasuka Imbalanced normally and less of Nutritional supplements may be prescribed to eat normally and less of
gihapon nako.” Nutrition: vomiting. as necessary by the MD or dietician. The vomiting noted.
less than RN should ensure the patient is receiving
body and taking these supplements to further
requirements strengthen the body.
related to  Educate the patient on the body’s
vomiting nutritional needs.
when eating This will allow the patient to gain
as evidenced knowledge in the area of how to
by Patient independently care for oneself upon
verbalized discharge.
“gamay lang  Provide the patient with resources
akung gina regarding nutrition.
kaon, kay The patient will be able to take these
ginasuka resources home upon discharge and will
gihapon further help in the patient being
nako.” independent in their care.
 If underweight, provide patient with
additional snacks in between meals.
Patients may not be able to meet all the
body’s requirements during regular meal
times. Providing snacks in between meals
Background can be another way to meet the body’s
Objective Cues Knowledge extra nutritional needs.
40
  Provide good oral hygiene. Good oral
Restless Imbalanced hygiene can increase an individual’s
Body malaise nutrition appetite. The oral mucosa is also a vital
Rapid breathing refers to part of salvia production which will further
either aid in the digestion of food.
nutrition that
is more than Dependent:
or less than  Administer antiemetics as needed before
the body’s meals.
requirements Other underlying medical conditions may
and metabolic cause nausea limiting the patient’s intake
needs. It can of food. Providing appropriate antiemetics
occur with will allow for patient’s appetite to
any potentially increase and tolerate intake
individual. better.
Listed below
is a brief list Collaboration:
of potential  Discuss with MD the potential need for
causes that referral to a dietitian.
may result in Rationale: Utilizing appropriate resources
an individual is a vital part of being a nurse. The dietitian
experiencing will be able to appropriately assess the
an imbalance patient and individualize the patient’s plan
in their of care regarding nutrition.
nutrition
status.

ASSESSMENT HEALTH NURSING DESIRED OUTCOME INTERVENTION EVALUATION

PATTERN DIAGNOSI
41
 S
Subjective cues: Cognitive / Note: Use P- After 3 weeks of effective Independent: GOAL MET
Perceptual E-S format nursing intervention the  Complete skin assessment After 8 hour of effective
patient wound will be Rationale: A thorough head-to-toe skin nursing intervention the patient
Impaired able to heal assessment should be performed on wound is heal.
skin admission, transfer between units, and once
Integrity per shift to monitor and/or prevent skin
related to breakdown.
surgical
incision as  Assess skin turgor, sensation, and
manifested circulation.
by Incision Rationale: Poor skin turgor, decreased
in the right sensations (nerve damage), and poor
upper circulation (lack of blood flow assessed via
quadrant palpation of pulse sites as well as observed
by purplish or ruddy discoloration of lower
legs) increase the risk of tissue damage
Background
Objective Cues Knowledge  Monitor ambulation status and bed
 Pain scale of mobility.
7/10 The skin is Rationale: Patients who cannot walk or
 Incision in the body’s cannot shift their weight in a chair or bed
the right outermost are at a higher risk for skin breakdown.
upper defense Patients who may have adequate mobility
quadrant system that but are under the use of restraints are also at
 Patient is keeps risk.
oriented in pathogens
time, place from  Proper documentation of wounds
and date, entering and Rationale: Observed wound and skin
 Positive causing breakdown requires accurate
facial illness. documentation in order to monitor the
42
grimace When the healing and effectiveness of interventions.
skin is Wounds must be staged correctly including
compromise length, width, and depth with detailed
d due to cuts, descriptions of drainage, peri-wound area,
abrasions, odor, and any tunneling or undermining. A
ulcers, photograph should be taken for baseline
incisions, comparison.
and wounds,
it allows  Perform wound care per guidelines and
bacteria to orders.
enter causing Rationale: Wound care differs depending
infections. It on the type of skin breakdown, location on
is important the body, and size of the wound. Inadequate
that nurses or incorrect wound care delays healing and
understand increases the risk for infection.
how to
assess,  Keep the skin clean and dry.
prevent, Rationale: Consider incontinence or
treat, and increased perspiration. Along with a
educate turning schedule, patients should be
patients on assessed for any bodily secretions. Bed
impaired linens, clothing, and any use of adult
skin diapers must be kept dry as urine, feces,
integrity.  and sweat are irritating to the skin.

43
44
Prognosis

After any surgery or procedure, the patients will experience some sort of post-surgical pain. Post-surgery pain

should be temporary lasting about 2 to 5 days and is managed using pain medications, anti-inflammatory drugs and/or local

anesthetics. For minor surgical procedures, pain is anticipated to last from 1-2 days. Chronic post-surgical pain can last for 2

months or longer, and if left untreated, can potentially lead to long-term disabilities and a reduced quality of life.

Health teaching:

For Patient:

1. Teach the patient to apply God or hot compress in the area of pain

2. Teach the patient in doing deep breathing

3. Instruct Patient about Eating foods that are bland and soft for the first day or so 

4. After surgery it is important to have a bowel movement within a day or two. If you do not, you may take over the counter

laxatives to encourage your bowels to move.

5. Tell patient DO NOT use a hot tub, ocean or pool for 6 weeks.

6. Tell patient to AVOID sports or strenuous activities 4 to 6 weeks as your surgeon gives you clearance during your post-

operative visits. This is to avoid any unnecessary complications (bleeding, bruising, swelling).

7. Patient may return to work when he feel able and are cleared to do so by your surgeon.

8. Feel free to call upon us at any time. We want you to be as comfortable as possible during your healing period.

9. Limit lifting, pulling or pushing for 10 days.

10. If you experience any generalized itching, rash, wheezing or tightness in the throat, stop taking all medications and call the

office immediately, as this may be a sign of a drug allergy.

For Family:

1. Family of the patient should know the diet of the patient

2. Educate the family of how to clean the wound and it should be dry always

3. Ask your family and friends to help with chores and errands.

4. Avoid lifting anything over 10 pounds for 4 to 6 weeks. You can ask your family to do it for you temporarily

5. Tell the patient family to drive for you until your healthcare provider says it’s OK.

Community:

1. Follow any diet instructions given by your healthcare provider. You may need to start with liquids and then slowly add solid

foods back into your diet. 

2. If you have constipation, your healthcare provider may tell you to add more fiber to your diet. You may also be told to use a

laxative or stool softener. These can often be bought over the counter.

3. Drink plenty of fluids.

4. You may be prescribed pain medicine. Do not wait until your pain becomes severe before taking the medicine. It may not

work as well if you wait too long to take it between doses.

5. Most surgeons prescribe stool softeners along with opioid prescriptions. Take these as prescribed. 

45
6. You may be prescribed antibiotics to help treat or prevent infection. Be sure to take all of the antibiotics even if you start to

feel better.

CURRICULUM VITAE

46
DETOYATO, PATRICIA F.

Bachelor of Science in Nursing – Level III

PERSONAL INFORMATION

Birthdate: November 23, 2000

Birthplace: General Santos City

Home Address: Golden Village Prk Mellinnium GSC

Age: 20 Sex: Female

Civil Status: Single Religion: Roman Catholic

Father: Manuel C. Detoyato Jr.

Mother: Arlene F. Detoyato

ACADEMIC BACKGROUND

Tertiary Notre Dame of Dadiangas University

Marist Ave, General Santos City 9500 Bachelor of Sciences in

Nursing 2019-Present

Secondary GSC SPED Integrated School

Mabuhay, General Santos City

Elementary Seventh Day Adventist Elementary School

Atis Street, General Santos City

AFFILIATIONS POSITION INCLUSIVE YEARS

Philippine Nursing Student Member 2019-Present

Association (PNSA)

First Aiders Club Member 2019-Present

College of Health and Science Member 2019-Present

CURRICULUM VITAE

47
EALDAMA, GWENDEE MAE A.

Bachelor of Science in Nursing – Level III

PERSONAL INFORMATION

Birthdate: May 26, 2001

Birthplace: General Santos City

Home Address: Emiliana Village, Calumpang GSC

Age: 21 Sex: Female

Civil Status: Single Religion: Roman Catholic

Father: Mario M. Ealdama

Mother: Normita A. Ealdama

ACADEMIC BACKGROUND

Tertiary Notre Dame of Dadiangas University

Marist Ave, General Santos City 9500

Bachelor of Sciences in Nursing 2019-Present

Secondary General Santos City National High School, General Santos City

Elementary Romana C. Acharaon Elementary School, General Santos City

AFFILIATIONS POSITION INCLUSIVE YEARS

Philippine Nursing Student Member 2019-Present

Association (PNSA)

First Aiders Club Member 2019-Present

College of Health and Science Member 2019-Present

CURRICULUM VITAE

48
DELA TORRE ERICA D.

Bachelor of Science in Nursing – Level III

PERSONAL INFORMATION

Birthdate: April 5, 2000

Birthplace: General Santos City

Home Address: Poblacion Maasim Sarangani Province

Age: 22 Sex: Female

Civil Status: Single Religion: BASOPI

Father:

Mother:

ACADEMIC BACKGROUND

Tertiary Notre Dame of Dadiangas University

Marist Ave, General Santos City 9500

Bachelor of Sciences in Nursing 2019-Present

Secondary

Elementary

AFFILIATIONS POSITION INCLUSIVE YEARS

Philippine Nursing Student Member 2019-Present

Association (PNSA)

First Aiders Club Member 2019-Present

College of Health and Science Member 2019-Present

49
50