ENDORSEMENT: You are on duty in the medical ward at 7- 3 shift to a male patient

Endorsing a male client, 52 y/o

 With an IVF of 0.45% Normal Saline Solution 1 liter x KVO @ 750cc level.
 With an O2 at 2LPM via NC
 Monitor I & O
 Monitor vital signs q 1⁰
 V/S as follows: T – 36.7 °C PR – 62 BPM RR– 24 BP – 140/90mmHg
SP02- 90%

Patient’s Profile:
Name: Patient : Isaiah Pablico
Age: 52
Sex: Male
Civil status: Married
Address: OB 158 Tawang, La Trinidad, Benguet
Occupation: Farmer
Nationality: Filipino
Religion: Born Again
Date and time of Admission: November 21, 2021 7:00 pm
Ward & Bed no. Surgical ward, Bed 7
Admitting Diagnosis: Cholecystitis
Chief complaints: Abdominal Pain
Final diagnosis: Chronic Calculous Cholecystitis

HISTORY OF PRESENT ILLNESS:

 A day prior to admission, patient suffer from abdominal pain at the right upper quadrant
radiating to his upper back with vomiting episodes after eating a heavy meal.

PAST MEDICAL AND SURGICAL HISTORY:

 Three years prior to admission, patient was suffering from right upper quadrant pain. Sought
consultation and was given pain reliever. Patient has a history of 3X caesarean sections. No
known allergies

FAMILY HISTORY:
 Patient’s family health history has no known illnesses that contribute to present condition.

SOCIAL, ENVIRONMENTAL AND HEALTH HISTORY

ACTIVITY 1: Underline using a red pen the pertinent positive and negative data or
findings that you think are relevant in the formulation of your nursing diagnoses

PHYSICAL EXAMINATION & REVIEW OF SYSTEMS

Focused assessment on the organs/system affected and state pertinent findings appropriately
(+/-)

General Survey Awake and lying on bed with ongoing IVF of .45% PNSS 1L regulated
at KVO, at 750cc level. The patient had a catheter and his urine
output was monitored. She has an ectomorph body type, with a
height of 5’2” and a weight of 52 kilograms. Patient needed
assistance when changing positions and doing activities. She wore a
neat gown, with minimal body odor. Patient was oriented to the
current time and date and was aware that she was staying at the
Surgery Ward.

Skin Patient's skin was dry, flaky and warm to touch. There was an incision
present horizontally below the costal margin due to the
cholecystectomy. No areas of increased vascularity, ecchymosis or
bleeding. No lesions and rashes noted. Nails were clean and trimmed,
with smooth texture, whitish in color and intact tissues surrounding
the nails. Hair was black in color, oily, straight and fairly distributed.
Capillary refill was 2-3 seconds. Reduced/decreased skin turgor.

Head, Eyes, Ears, Nose, Head was normocephalic and asymmetrical without deformities,
Throat masses, or tenderness upon palpation. Presence of dandruff was
observed during inspection. Patient was able to distinguish different
colors, and was able to follow the 6 cardinal gazes. Pupils were
equally round and reactive to light. Ears were symmetrical and in line
with the outer canthus of the eyes, with minimal amount of cerumen.
Patient was able to hear and understand spoken Ilocano and Tagalog
without difficulty. Nose was symmetrical in shape with the septum
located midline and with no noted discharges. The patient was able to
distinguish the scent of ethyl alcohol and perfume. Semi-dry buccal
mucosa; tissue was smooth and moist w/o lesions. Tonsils were
bilaterally present and not inflamed. Uvula was located midline.

Neck Patient was able to move neck in different directions without

complaining of pain. Carotid pulses were symmetrical with strong
palpable pulses.

Breast Skin color was similar to the rest of the body. Nipples were
symmetrical and darker in color. No evidence of masses, dimpling, or
retraction.

Respiratory The chest wall is intact with no tenderness and masses. There’s a full
and symmetric expansion and the thumbs separate 2-3 cm during
deep inspiration when assessing for the respiratory excursion. The
client manifested quiet, rhythmic and effortless respirations.
Cardiovascular Patient had a normal heart rate with regular rhythm, and no murmurs
were noted. Apical pulse was auscultated. Patient has increased blood
pressure because of pain.

Gastrointestinal Incision was present horizontally below costal margin. Tenderness in

the right upper quadrant and epigastrium was noted upon palpation.
Sparse bowel sounds were heard in three quadrants except right
upper quadrant.

Urinary No pain during urination, no foul odor. Patient has an intact catheter
with a urine output of about 500 ml every 8 hours.

Genital Sexual development was appropriate for gender and age.

Peripheral / Vascular Able to feel pain when using a sharp object. Capillary refill was 2-3
seconds. Patient has normal HR, normal temperature.

Musculoskeletal Upper extremities: Symmetrical hands and arms, no edema or lesions

and no tenderness. Absence of muscle wasting. Full active ROM and
muscle strength of 4/5.

Lower extremities: legs are symmetrical.

Neurologic Able to discriminate between sharp and dull sensation when touched
with needle and cotton. Patient was well able to do the fine motor test
for both lower and upper extremities.

Hematologic Patient’s complete blood count indicates normal range of the blood
components except for the neutrophil, has 74% which is out of the
normal range, may indicate stress or an impending infection.

Endocrine No abnormal breath sounds/odor. No cardiac murmurs. Normal skin

color. Patient had nausea and vomiting prior to surgery, minimal
nausea (post op) and decrease in appetite.

Psychiatric Oriented to a person, place, date or time. Able to concentrate as

evidence by answering the questions appropriately.
ACTIVITY 2: Recalling the concepts of health assessment, anatomy and physiology,
you have to identify at least FIVE pertinent PE findings that shows abnormality. Read
your books or notes for you to elaborate on the cause of your patient’s clinical signs
and symptoms. In your own words, explain the condition by summarizing what you
have read or understood, this is highly encouraged. You must also supply the
textbooks or materials that you have utilized as references.
PERTINENT ABNORMAL EXPLANATION
PE/ROS

INCREASED BLOOD Upon assessment, there is an increased blood pressure because

PRESSURE: 140/90 patient is experiencing pain from the surgical incision rated as
7/10.

NAUSEA AND VOMITING Patient is experiencing vomiting and nausea because the
gallbladder which produces enzymes that breaks down fat isn’t
present anymore, even before operation patient experiences
nausea and vomiting because of the formation of gallstones.

DECREASED SKIN TURGOR There is decreased skin turgor in our patient due to continuous
nausea and vomiting, there isn’t enough fluid and electrolytes
in the body which causes our skin to have delayed skin turgor.

PAIN AND TENDERNESS IN There is pain in the RUQ due to inflammation of the gallbladder.
RUQ

DRY, FLAKY SKIN The patient has dry, flaky skin because the patient hasn’t been
able to take a bath, and declines tepid sponge bath.

Reference/s:

Medical-Surgical Nursing, AUTHOR: Black, Hawks, EDITION: 8th (2008), CONDITION:

Volumes I & II:

https://nurseslabs.com/cholecystitis/

DIAGNOSTIC STUDIES:

ACTIVITY 3: Using a reference book (specify), you have to fill in the values that are
asked. Indicate the appropriate rationale for the diagnostic test done, its purpose, the
abnormality and/or nursing intervention needed.

Laboratory Reference/norm Result Interpretation What have caused

test & al values the abnormality/
Pertinent Purpose/NI
Laboratory
Result
1.CBC

A CBC may Neutrophils Result: it can mean you have an Neutrophils contribu
be ordered infection or are under a lot te to tissue injury by
Normal Range: 74%-
when a of stress. It can also be a amplifying the
High
person has 50-70% symptom of more serious inflammatory
any number conditions. Neutropenia, or response and direct
of signs and a release of toxic
symptoms low neutrophil count, can la effectors.
that may be st for a few weeks or
related to it can be chronic.
disorders
that affect
blood

2.URINALYSI SERUM
S ELECTROLYTES:

A urinalysis Sodium
Result: If your sodium blood levels Patient was
is done in
Normal Range: are too high or too low, it dehydrated.
order to 158.0
may mean that you have a
analyze 135-145 mmol/L
problem with your kidneys,
urine, mmol/L (high)
dehydration, or another
because
medical condition.
toxins and
excess fluids

Chloride Result: An increased level of blood

chloride (called
Normal Range: 118.5 hyperchloremia) usually
mmo/L indicates dehydration, but
98-108 mmol/L
(high) can also occur with other Indicates
problems that cause high Dehydration.
blood sodium, such as
Cushing syndrome or
kidney disease.

Result: Extremely high blood sugar

can lead to a potentially
Glucose
9.29 deadly condition in which
Normal Range: mmo/L your body can’t process Patient had mild
(high) sugar. urine may become dehydration.
2.8-4.2 mmol/L
dark and you could get
severely dehydrated.

High uric acid levels in the

body can cause crystals of
 Result: uric acid to form, leading to
Uric acid
gout. Some food and
387.80 Possible dietary
Normal Range: drinks that are high in
mmo/L intake.
purines can increase the
0.15–0.41 (high)
level of uric acid.
mmol/L

People who have very high

Result: triglyceride levels may
Triglycerides develop inflammation of
210 the pancreas (pancreatitis), Patient experiences
Normal Range: mmoL which can cause sudden, nausea, had
(high) severe abdominal (belly)
1.7 mmo/L vomiting episodes
pain, loss of appetite, and has a decreased
nausea and vomiting, and appetite.
fever. If you have high
triglycerides, you may also
have high cholesterol.

Result:
HDL People who have low HDL
1.24 cholesterol will have
Normal Range: mmo/L Absence of
greater risk of developing
Above 1.5 (low) heart disease than people Gallbladder.
mmo/L with high HDL levels.

3.Liver Serum bilirubin Result: LIVER

Function and amylase DISEASE/OBSTRUCTION
Elevated
Tests
NORMAL/ .
OBSTRUCTION.
ELEVATED

Serum liver Slight elevation; alkaline

OBSTRUCTION.
enzymes—AST; phosphatase and 5-
Result:
ALT; ALP; LDH: nucleotidase are markedly
Slightly elevated in biliary
Elevated obstruction.
NORMAL/ .

ELEVATED
4.Prothrombi NORMAL: RESULT: Reduced when obstruction OBSTRUCTION.
n Time Test to the flow of bile into the
11 to 13.5 8.23
intestine decreases
seconds. seconds
absorption of vitamin K.

MEDICAL/SURGICAL DIAGNOSIS:

ACTIVITY 4: Read about your patient’s diagnosis using your textbook (MedSurg/
specify). Focus on the description of the disease, the etiology or cause, what are the
signs and symptoms and why do they occur, what are the recommended interventions
and nursing interventions. Digest the information that you have obtained. Take time to
process and analyze them. Once you are ready, in 500 words or briefly answer the
following questions.

Signs & Symptoms Signs & symptoms

(book)
Description of the Etiology (patient)
Disease

CHRONIC CALCULOUS Chronic cholecystitis severe abdominal Right upper

mostly occurs in the pains that may feel quadrant pain.
CHOLECYSTITIS
setting of sharp or dull
Nausea.
cholelithiasis. The
abdominal cramping
proposed etiology is Vomiting.
and bloating
recurrent episodes of
acute cholecystitis or pain that spreads to
chronic irritation from your back or below
gallstones invoking your right shoulder
an inflammatory blade
response in the
gallbladder wall. fever
Sometimes the term chills
is used to describe
abdominal pain nausea
resulting from vomiting
dysfunction in the
emptying of the loose, light-colored
gallbladder. This stools
overlaps with
jaundice, which is
Sphincter of Oddi
when your skin and
 dysfunction and is the whites of your
best referred to as eyes turn yellow
biliary or gallbladder
itching
dyskinesia.

Reference: Medical-Surgical Nursing, AUTHOR: Black, Hawks, EDITION:

8th (2008), CONDITION: Volumes I & II:

https://nurseslabs.com/cholecystitis/

https://www.healthline.com/health/chronic-cholecystitis#symptoms

PRESCRIBED THERAPEUTIC (MEDICAL/SURGICAL) MANAGEMENT, AND HEALTH

PROMOTION PROGRAMS:

Activity 5: After reading your textbook or notes on pharmacology and/or med-surgical

books, answer what are asked on the following table.

MECHANISM OF
DRUG NAME
ACTION
GENERIC NAME: It binds to 1 or more of
CEFAZOLIN the penicillin-binding
proteins (PBPs) which
BRAND NAME: inhibits the final
CEFAVEX transpeptidation step of
peptidoglycan synthesis
CLASSIFICATION: in bacterial cell wall, thus
CEPHALOSPORINS inhibiting biosynthesis
and arresting cell wall
PHARMACOLOGIC assembly resulting in
: bacterial cell death.
FIRST GENERATION Pharmacokinetics:
CEPHALOSPHORINS Absorption: Poorly
absorbed from GI tract.
Time to peak plasma
THERAPEUTIC
concentration: 1 hr. (IM).
EFFECT: Distribution: Diffuses
NURSING
ADVERSE EFFECT RESPONSIBILITIE
S
Diarrhea, oral Before:
candidiasis, Dx:
vomiting, nausea, ● Assessed for any
stomach cramps,
history allergy of the
anorexia;
eosinophilia, medication.
itching, drug fever, ● Reviewed patient’s
skin rash, Stevens- chart for physician’s
Johnson syndrome; order.
neutropenia, ● Assessed patient
leucopenia, for history of
thrombocytopenia,
hypersensitivity to
thrombocythemia;
transient elevation penicillin and other
in SGOT, SGPT and drugs
alkaline Tx:
phosphatase levels;
● Recorded patient’s
hepatitis; increased
initial vital signs.
BUN and creatinine
Works by stopping into bone, ascitic, pleural
the growth of and synovial fluids; CSF
bacteria (small amount). Crosses
the placenta and enters
breast milk. Plasma
DOSAGE: protein-binding: Approx.
1 G Q 12 HS 85%.
Metabolism: Minimally
ROUTE: hepatic.
IV Excretion: Via urine (80-
100% as unchanged
drug). Plasma half-life:
Approx. 1.8 hr.
References:
Jones & Bartlett Learning
, 2011, Nurse’s Drug
Handbook 10th Edition
levels, renal failure; ● Assured for the
phlebitis, right medication’s
induration; genital route.
and anal pruritus
● Ensured that there
(e.g. vulvar
pruritus, genital are no
moniliasis, gastrointestinal
vaginitis). complaints, such as
Potentially Fatal: nausea, vomiting and
Anaphylaxis, skin rash.
pseudomembranou Edx:
s colitis. ● Advised patient to
take medication
● Explained that
Cefazolin can
enhance
anticoagulant effect.
● Instructed to avoid
alcohol or other
central nervous
system depressants
while taking it.
During:
Dx:
●Assessed any signs
of intestinal
obstruction, such as
abnormal bowel
sounds, diarrhea,
nausea, and vomiting
before administering
metoclopramide,
notify physician if
you detect them.
● Asked patient’s
name for the
verification of right
patient.
● Clarified the
importance and the
purpose of the
medication.
Tx:
●Assisted patient in
taking medication.
● Ensured that
patient took the
medication
● Administered 1 g of
cefazolin every 12
hours.
Edx:
● Advised patient to
take medication with
a glass of water.
● Instructed to take
medication with an
upright position.
● Encouraged not to
engage in potentially
hazardous activities.

After:
Dx:
● Assessed for any
sign of allergic
reaction after
administering
medication.
● Checked for any
gastrointestinal
complaints 1 hour
after giving
medication.
● Monitored for
adverse effects to
the patient.
Tx:
● Compared vital
signs to the initial
vital signs.
● Documented in
patient’s chart that
the medication was
given.
● Evaluated the
therapeutic effect of
the medicine.
Edx:
● Advised patient to
immediately report
involuntary
 movements of face,
eyes, tongue, or
hands, including lip
smacking, chewing,
puckering of mouth,
frowning, scowling,
sticking out tongue,
blinking, moving
eyes or shaking arms
and legs
● Urged patient to
avoid alcohol and
CNS depressants
while taking
cefazolin.
● Educated that
stopping cefazolin
may cause
withdrawal
symptoms that
include dizziness,
nervousness, and
headache.

GENERIC NAME: It is a pyrrolizine CNS: Cerebral BEFORE

KETOROLAC carboxylic acid derivative, hemorrhage, Dx:
is an NSAID that seizures stroke ● Assessed patient
BRAND NAME: reversibly inhibits CV: Edema, fluid for any allergy of the
KETODOL cyclooxygenase-1 and -2 retention, medication
(COX-1 and -2) enzymes, hypertension ● Monitored for initial
CLASSIFICATION: resulting in decreased EENT: Stomatitis vital signs.
Nonsteroidal Anti- formation of ENDO: ● Reviewed if there is
Inflammatory Drugs prostaglandin precursors. Hyperglycemia any history of renal
(NSAIDs) It has antipyretic, anti- GI: Abdominal impairment.
inflammatory and pain, nausea, Tx:
PHARMACOLOGIC analgesic properties. vomiting, jaundice ● Explained that
NAME: Onset: Analgesic: 30-60 GU: Renal failure, patient should eat
acetic acid minutes (oral); approx. renal retention something prior to
derivatives and 30 minutes (IV/IM); HEME: taking medication.
related substances within 20 minutes Agranulocytis, ● Provided cues
of non-steroidal (nasal). anemia, regarding the
anti-inflammatory Duration: Analgesic: 4-6 leukopenia, therapeutic effect of
and antirheumatic hours. pancytopenia the drug.
products. Pharmacokinetics: RESP: ● Assured that
Absorption: Well Bronchospasm, Ketorolac should be
THERAPEUTIC absorbed from the pneumonia, infused via side drip.
EFFECT: gastrointestinal tract respiratory Edx:
Ketorolac exhibits after oral administration; depression ● Instructed to eat
analgesic, anti- rapidly and completely SKIN: Diaphoresis, something prior to
inflammatory, and absorbed following IM pruritus, rash, taking medication.
antipyretic activity. administration. sepsis ● Explained some
Bioavailability: 100% adverse effects of the
DOSAGE: (Oral, IM); approx. 60% medication.
30MG Q8HS X 1 (nasal). Time to peak ● Educated about the
AMP plasma concentration: importance of taking
Approx. 45 minutes medication.
ROUTE: (oral); 1-3 minutes (IV);
IV 30-60 minutes (IM). DURING:
Distribution: Poor Dx:
penetration into the ● Asked patient for
cerebrospinal fluid, history of peripheral
crosses placenta and edema, heart failure
present in breastmilk or hypertension.
(small amounts). Volume ● Checked the right
of distribution: Approx. name, dosage and
13 L. Plasma protein expiration date of the
binding: 99%. medication.
Metabolism: Metabolized ● Verified patients
in the liver via glucuronic name for the right
acid conjugation and patient.
hydroxylation. Tx:
Excretion: Via urine ● Administered
(approx. 92%; approx. ketorolac via IV
60% as unchanged Route.
drug), feces (approx. ● Administered
6%). Elimination half-life: ketorolac to the
Approx. 5 hours (S- patient every 4 hours
enantiomer: approx. 2.5 to relieve severe
hours, R-enantiomer: 5 pain.
hours). ● Administered 4
doses of ketorolac
Reference: after every 4 hours.
MIMS Philippines. (2020). Edx:
Ketorolac. ● Instructed to report
immediately if any
adverse reaction
occurred.
● Advised patient to
watched out for any
signs of GI bleeding,
including abdominal
pain.
● Urged patient to
avoid alcohol while
taking ketorolac.

AFTER:
Dx:
● Assessed for any
adverse reaction
 after administering
medication.
● Assessed patient’s
skin routinely for
rash or other
evidence of
hypersensitivity
reactions.
● Assessed patient
pain scale an hour
after giving
medication.
Tx:
● Assured that there
are no any abnormal
changes in the
patient’s vital signs.
● Ensured that the
patient’s pain was
manageable an hour
after drug
administration.
● Provided comfort
measures and safety
precautions to the
patient.
Edx:
● Instructed patient
to verbalize if any
unusual feelings
happen.
● Cautioned patient
to avoid hazardous
activities.
● Advised patient not
to use other NSAIDS
while taking this
drug.
GENERIC NAME: Omeprazole is a ●CNS: Fever BEFORE:
OMEPRAZOLE substituted benzimidazole ●CV: Chest pain, DX:
gastric antisecretory hypertension ● Monitor bowel
BRAND NAME: agent and is also known ●EENT: stomatitis function.
LOSEC as proton pump inhibitor ●GU: Interstitial ●Checked serum
(PPI). It blocks the final nephritis magnesium prior to
CLASSIFICATION: step in gastric acid ●HEME: and periodically
PROTON PUMP secretion by specific Eosinophilia during therapy.
INHIBITOR inhibition of adenosine ●RESP: Cough, ● Assessed patient
triphosphatase (ATPase) ●MS: Back pain for epigastric or
PHARMACOLOGIC enzyme system present ●SKIN: Rash abdominal pain and
: on the secretory surface frank or occult blood
BENZAMIDE of the gastric parietal in the stool, emesis,
cell. Both basal and or gastric aspirate.
THERAPEUTIC stimulated acid are TX:
EFFECT: inhibited.
Diminished Onset: Antisecretory:
accumulation of Approx. 1 hour.
acid in the gastric Duration: Up to 72
lumen with lessened hours.
gastroesophageal Pharmacokinetics:
reflux. Absorption: Rapid but
variably absorbed from
DOSAGE: the gastrointestinal tract.
40 MG OD Bioavailability: Approx
30-40%. Time to peak
ROUTE: plasma concentration:
IV 0.5-3.5 hours.
Distribution: Enters
breast milk. Plasma
protein binding: Approx
95%.
Metabolism: Metabolize
d in the liver primarily by
CYP2C19 isoenzyme to
hydroxyl-omeprazole;
and lesser extent by
CYP3A4 to omeprazole
sulfone.
Excretion: Mainly via
urine (approx 77% as
metabolites, small
amount as unchanged
drug); faeces (small
amount). Elimination
half-life: 0.5-3 hour.
References:
MIMS Philippines. (2020).
Omeprazole.
● Assured giving
medication before
meals.
●Administered
medication on the
right time as per
physician’s order.
●Ensured that the
medication was
taken before meals.
EDX:
●Instructed to
observe for unusual
side effects.
● Advise patient to
notify prescriber
immediately about
abdominal pain or
diarrhea.
●Encouraged patient
to avoid products
that might increase
gastric secretions.
DURING:
DX:
●Assessed for any
allergy to the
medication.
●Monitored patient’s
vital signs.
● Checked CBC with
differential
periodically during
therapy.
TX:
●Administered on
empty stomach, as
least 1hr before a
meal.
●Ensured suspend
feeding for 3hr
before and 1hr after
administration.
●Assured that the
medication
suspended in 20 mL
of water.
EDX:
●Instructed to inform
healthcare provider if
persistent headache
or if fever develop.
●Advised to report
severe diarrhea;
drug may need to be
discontinued.
● Encouraged to
notify prescriber
immediately about
abdominal pain.

AFTER:
DX:
●Observed for any
changes in urinary
elimination such as
pain or discomfort
associated with
urination, or blood in
urine.
●Checked for
abdominal pain or
diarrhea.
●Assessed for
persistent fever or
headache.
TX:
● Discussed that
drug may cause
occasional
drowsiness or
dizziness.
●Provided
information about
taking medication.
●Emphasized the
importance of
completing therapy.
EDX:
●Instructed to
comply with the drug
therapy.
●Advised patient to
avoid alcohol,
products containing
aspirin or NSAIDs,
and foods that may
cause an increase in
GI irritation.
●Educated patient to
notify healthcare
professional of all Rx
or OTC medications,
vitamins, or herbal
products being
 taken.
GENERIC NAME: Tramadol inhibits Resp depression, BEFORE:
TRAMADOL reuptake of seizure, dizziness, ●DX:
norepinephrine, serotonin headache, ●Checked physicians
BRAND NAME: and enhances serotonin somnolence, order.
DOLOTRAL release. It alters weakness, CNS ●Assessed for allergy
perception and response stimulation (e.g. to the medication.
CLASSIFICATION: to pain by binding to mu- anxiety, euphoria, ●Monitor initial vital
Analgesics opiate receptors in the hallucinations), signs prior to giving
CNS. asthenia, sweating, medication.
PHARMACOLOGIC Onset: Approx. 1 hr. confusion, TX:
: Duration: 9 hr. coordination ●Provided cues on
Opioids. Pharmacokinetics: disturbance, the importance of
Absorption: Readily paresthesia, medication.
THERAPEUTIC absorbed from the GI hypoesthesia, ● Assured to give
EFFECT: tract. Bioavailability: amnesia, cognitive I.V. drug by slow
Alters perception Approx. 70-75% (oral); dysfunction, infusion over 1 hour.
and response to 100% (IM). depression, ● Ensured to
pain Distribution: Widely dysphoria, administer the drug
distributed. Crosses the constipation, via IV.
DOSAGE: placenta and enters nausea, vomiting, EDX:
50 MG 1 AMP Q6 HS breast milk. dyspepsia, ● Instructed to eat
PRN Metabolism: Extensive diarrhea, abdominal something prior to
hepatic first-pass pain, anorexia, taking medication.
ROUTE: metabolism. Converted flatulence, wt loss, ● Explained some
IV to O-desmethyltramadol gastroenteritis, adverse effects of the
(active) via N- and O- pruritus, rash, medication.
demethylation by CYP3A4 dermatitis, ● Educated about the
and CYP2D6 isoenzymes urticaria, importance of taking
and also via bronchospasm, medication.
glucuronidation or angioedema,
sulfation. anaphylaxis, DURING:
Excretion: Via urine (as allergic reaction, DX:
metabolites). Elimination Stevens-Johnson ●Monitor patient with
half-life: Approx. 6 hr. syndrome, toxic severe liver disease
epidermal because slowed
Reference: necrolysis, metabolism may
MIMS Philippines. (2020). vasodilation, cause drug to
Tramadol. orthostatic accumulate in body
hypotension, and increase the risk
syncope, of adverse effects.
tachycardia, ●Checked for the
flushing, chest right patient.
pain, palpitations, ●Verified for the right
MI, HTN, peripheral dose and route.
ischemia, TX:
menopausal ● Ensured to
symptoms, dysuria, discontinue primary
menstrual disorder, I.V. infusion during
micturition tramadol infusion.
difficulty, ●Administered
hematuria. tramadol every 6
hours as needed
● Assured correct IV
concentration and
rate of infusion for
administration
EDX:
● Instructed to notify
prescriber if no
improvement occurs
within a few days of
taking medication.
● Advised to avoid
hazardous activities
until drug’s CNS
effects are known.
●Encouraged to
notify health care
professional promptly
if rash occurs.

AFTER:
DX:
●Monitor CBC and
culture and
sensitivity tests if
therapy lasts longer
than 10 days or if
second course of
treatment is needed.
● Observed
especially for
seizures and
peripheral
neuropathy.
● Checked on lithium
for elevated lithium
levels.
TX:
●Discussed that drug
may cause dizziness
or light-headedness.
●Emphasized the
importance of drug
compliance.
●Provided
information about
therapeutic effects of
drugs.
EDX:
●Cautioned patient to
avoid alcohol during
therapy and for at
least 3 days
afterward.
 ●Urged to complete
the entire course of
therapy.
●Instructed to notify
healthcare provider if
severe side effects
are observed.

IVF Amount Infusion Purpose Nursing responsibilities

rate

1.PNSS
-Isotonic 1L 0.45% Fluid of choice for resuscitation Ensured undamaged container
Intravenous @KVO Normal efforts. Used to replace fluid and clear solution prior to
Solution Saline loss from hemorrhage, severe administration.
Solution vomiting or diarrhea, heavy - Monitored patient frequently
- Non-
1 liter x drainage from GI suction, for:
pyrogenic
KVO fistulas or wounds. a. signs of infiltration/ sluggish
solution for
Use to treat shock, mild flow.
fluid and
hyponatremia, metabolic b. signs of phlebitis / infection.
electrolyte
acidosis, c. Dwell time of IVF and when to
replenishment
hypercalcemia. replace.
d. Condition of dressing.

- Checked the level of the IVF.

- Checked and regulated the
drop rate.
- Changed the IVF solution
when needed.
Caution in cardiac or renal
disease.
- May cause fluid volume
overload.

Diagnostic Description Purpose Nursing Responsibilities

Procedure
Before Chest X-ray
1.CHEST X- A chest X-ray is a It is used to evaluate the
RAY fast and painless lungs, heart and chest wall The following are the nursing
imaging test that and may be used to help interventions prior to chest x-ray:
uses certain diagnose shortness of
Remove all metallic
electromagnetic breath, persistent cough,
objects. Items such as jewelry,
waves to create fever, chest pain or injury. It
pictures of the is used to determine any pins, buttons etc can hinder the
structures in and complication to the patient’s visualization of the chest.
around your chest. body such as broken bones, No preparation is
X-rays are a type of tumors and presence of
required. Fasting or medication
radiation called foreign bodies. It is also use
restriction is not needed unless
electromagnetic to determine the progress of
directed by the health care
waves. X-ray her medical and surgical
 imaging creates management. Application of provider.
pictures of the radiation to produce a film
inside of your body. or picture of a part of the Ensure the patient is not
The images show body can show the structure pregnant or suspected to be
the parts of your of the vertebrae and the pregnant. X-rays are usually not
body in different outline of the joints. X-rays recommended for pregnant
shades of black and of the spine are obtained to women unless the benefit
white. Chest search for other potential outweighs the risk of damage to
radiography is the causes of pain, i.e. tumors, the mother and fetus.
first investigation infections, fractures, etc.
performed to Xrays, however, are not very Assess the patient’s ability to
assess lungs reliable in diagnosing hold his or her breath. Holding
because it is tumors. one’s breath after inhaling
simple, enables the lungs and heart to be
inexpensive, rapid, This is to rule out seen more clearly in the x-ray.
and noninvasive; respiratory causes of
however, it is much referred pain. Provide appropriate
less sensitive than clothing. Patients are instructed
chest CT in to remove clothing from the waist
detecting a small up and put on an X-ray gown to
pneumothorax, wear during the procedure.
blebs, and bullae
Instruct patient to cooperate
during the procedure. The patient
is asked to remain still because
any movement will affect the
clarity of the image.

After Chest X-ray

The nurse should note of the

following nursing interventions
after chest x-ray:
2. CT SCAN
No special care. Note that no
special care is required following
the procedure

Provide comfort. If the test is

facilitated at the bedside,
reposition the patient properly.

Computed CT scan of the liver and

tomography (CT) biliary tract provides an in- Before the procedure
scan, also known depth information about the
as computerized liver, gallbladder, bile ducts, The following are the nursing
axial tomography interventions before computed
and other related structures.
(CAT), or CT tomography:
scanning
computerized  Informed
tomography is a Consent. Obtain an
painless, non- informed consent
 invasive diagnostic properly signed.
imaging procedure
 Look for
that produces allergies. Assess for
cross-sectional any history of allergies
images of several to iodinated dye or
types of tissue not shellfish if contrast
clearly seen on a media is to be used.
traditional X-ray.
 Get health
history. Ask the patient
about any recent
illnesses or other
medical conditions and
current medications
being taken. The
specific type of CT scan
determines the need for
an oral or I.V. contrast
medium
 Check for NPO
status. Instruct the
patient to not to eat or
drink for a period
amount of time
especially if a contrast
material will be used.
 Get dressed
up. Instruct the patient
to wear comfortable,
loose-fitting clothing
during the exam.
 Provide information
about the contrast
medium. Tell the
patient that a mild
transient pain from the
needle puncture and a
flushed sensation from
an I.V. contrast medium
will be experienced.
 Instruct the patient
3.BILIARY
to remain still. During
ULTRASOUND
the examination, tell the
patient to remain still
and to immediately
report symptoms of
itching, difficulty
breathing or swallowing,
nausea, vomiting,
dizziness, and
headache.
 Reveals calculi, with  Inform about the
gallbladder and/or bile duct duration of the
distension (frequently the procedure. Inform the
initial diagnostic procedure). patient that the
procedure takes from
4.CHOLE- five (5) minutes to one
CYSTOGRAM To visualize and (1) hour depending on
assess the cystic the type of CT scan and
and common bile his ability to relax and
ducts of the remain still.
gallbladder toward
diagnosing
obstructions, After the procedure
stones,
The nurse should be aware of
inflammation, and
these post-procedure nursing
tumor.
interventions after computed
Cholecystography reveals tomography (CT) scan:
stones in the biliary system.
 Diet as usual. Instruct
the patient to resume
the usual diet and
activities unless
otherwise ordered.
A cholecystogram is
an x-ray  Encourage the patient
procedure used to increase fluid
to help evaluate intake (if a contrast is
the gallbladder. For given). This is so to
the procedure, a promote excretion of
the dye.
special diet is
There are no activity restrictions
consumed prior to
unless by medical direction.
the test and
Instruct the patient to restrict
contrast tablets are
food and fluids for 4 to 6 hr prior
also swallowed to
to the procedure. Explain that
help visualize the
fasting for more than 24 hr
gallbladder on x-
before the procedure or receiving
ray.
total parenteral nutrition may
produce a false-positive result.
Instruct the patient, as ordered,
to discontinue use of opiate-
based or morphine-based drugs 2
to 6 hr before the procedure. No
other radionuclide scans or
procedures using barium contrast
medium should be scheduled
within 24 to 48 hr before this
procedure. Protocols may vary
among facilities.
 PREPARATION OF THE PATIENT

Explain the procedure to the

patient to relieve tension and
worries

Stop medications which contain

iodine compounds and bismuth
three days prior to the test

Check whether the patient is

allergic to iodine or sea food
before giving the dye

Record the patient’s weight to

calculate the dose of the dye

The patient is given a low-fat

evening meal to avoid gallbladder
contraction. Thereafter, no food
and water should be given to the
patient until the X-ray
examinations are complete

The bowel is cleansed with saline

enema

The emergency drugs and

resuscitation equipment should
be kept ready to resuscitate the
patient

AFTER CARE

Observe the patient for allergic

reactions. Check the vital signs of
the patient

Accompany the patient

throughout the procedure

Make the patient comfortable

ACTIVITY 6: Applying the nursing process, integrate all the significant findings
obtained in the analysis of the case and formulate a nursing care plan for your patient.
Use the given table/format presented.
 DATA GOALS/EXPECT ACTION/NURSI RATIONALE RESPONSE/EVALUAT
ED OUTCOMES NG ION
INTERVENTION
S
SUBJECTI STG: DX: After 8hrs of nursing
VE Within 8 hrs., Assess for the Using charts or interventions, patient
FINDINGS patient uses location of the drawings of the was able to have a pain
: pharmacological pain by asking to body can both scale rated as 5/10 and
“NASAKI and point to the site help the patient was seen interacting
T DYAY nonpharmacologi that is and the nurse in more with his watcher,
SUGAT cal pain-relief discomforting. determining no grimace, and plays
KO” strategies. As specific pain on his phone during
evidenced by; locations. free time.
patient seen GOAL MET.
OBJECTIV interacting more Determine the In taking a pain
E with watcher client’s history, provide After 72 hrs., of
FINDINGS and/or family perception of an opportunity nursing interventions,
: members, pain. for the client to patient manifests
PAIN patient watching express in their normal VS such as a BP
SCALE: movies and/or own words how of 120/80, a PR of 80
7/10 playing with they view the and an O2 sat of 88%.
BP:140/9 phone. pain and the GOAL MET.
0 situation to gain
GUARDIN LTG: an
G Within 72 hrs., understanding of
BEHAVIO patient displays what the pain
R improved well- Assess the means to the
GRIMACE being such as patient’s client.
baseline levels willingness or
for pulse, BP, ability to explore Some patients
NURSING respirations, and a range of may be hesitant
DX: POST relaxed muscle techniques aimed to try the
OPERATI tone or body at controlling effectiveness of
VE ACUTE posture. As pain. nonpharmacolog
PAIN manifested by ical methods
normal vital and may be
signs. E.g. BP: willing to try
120/80, PR: 80- traditional
100 TX: pharmacological
Provide measures methods.
to relieve pain
before it
becomes severe. It is preferable
to provide an
analgesic before
the onset of pain
or before it
becomes severe
Provide when a larger
nonpharmacologi dose may be
c pain required.
management.
 Nonpharmacolog
ic methods in
pain
management
may include
Provide physical,
pharmacologic cognitive-
pain behavioral
management as strategies, and
ordered. lifestyle pain
management.

Pain
EDX: management
using
Evaluate the pharmacologic
patient’s methods
response to pain involves the use
and management of opioids
strategies. (narcotics),
nonopioids
(NSAIDs), and
coanalgesic
drugs.
Evaluate what
the pain suggests
to the patient.
It is essential to
assist patients
to express as
factually as
possible (i.e.,
without the
effect of mood,
Evaluate the emotion, or
effectiveness of anxiety) the
analgesics as effect of pain
ordered and relief measures.
observe for any
signs and The meaning of
symptoms of side pain will directly
effects. determine the
patient’s
response. Some
patients,
especially the
dying, may
consider that the
“act of suffering”
meets a spiritual
need.
 The
effectiveness of
pain medications
must be
evaluated
individually by
the patient since
they are
absorbed and
metabolized
differently.

Activity 7: As a future nurse you should be able to work with your co-nurses and other
health care professionals and form a team sharing knowledge and resources to solve
or provide patient care.
 After administering the nursing and medical interventions, you assessed that patient X HAS
DIFFICULTY TURNING FROM SIDE TO SIDE. As a nursing student what are you going to do
next? (limit you answers in 3-5 sentences only.)

As a student nurse the best intervention I could do is to Present a safe environment: bed rails
up, bed in a down position, important items close by and the following; to establish measures to
prevent skin breakdown and thrombophlebitis from prolonged immobility, if the patient is
unwilling to move especially that the surgical incision is on the right side. These measurements
or interventions could be to Clean, dry, and moisturize skin as necessary. If possible, if the
patient can tolerate to encourage his to still execute active and passive ROM. This is all to
prevent pressure ulcers.

ACTIVITY 9:
Incorporating all the data that had been presented to you and your readings, create in
a diagram form the pathophysiology of the patient’s disease/condition. Incorporate
the risk factors present in your patient based on his/her history, the signs and
symptoms presented by your patient as shown on his/her PE and ROS, the lab results
provided by the various diagnostic exams. Group all cues together showing how you
were able to arrive to a certain nursing diagnosis/es.
Lastly, include the various medications and or procedures. Do not forget to include the
arrows to show connections and/or relationships among the various concepts.

Study the given sample below for you to understand.

BE CREATIVE BUT KEEP IT SIMPLE

 RISK FACTORS PRE-OPERATION

50 Y/O, FEMALE NAUSEA/VOMITING

Multiple Pregnancies
Recurrent RUQ pain
FLUID VOLUME DEFICIT

OMEPRAZOLE
SIGNS AND SYMPTOMS
NAUSEA/VOMITING
ABDOMINAL PAIN

DIAGNOSTICS
CBC
URINALYSIS
LIVER FUNCTION TESTS
PROTHROMBIN TIME TEST
CHEST X-RAY
CT SCAN
BILIARY ULTRASOUND
CHOLECYSTOGRAM

INCREASED CHOLESTEROL SYNTHESIS IN LIVER

GALLSTONE FORMATION

INFLAMMATION CHANGES IN GALL BLADDER

SUDDEN PAIN IN RUQ

 SURGICAL INCISION

RISK FOR INFECTION

IMPAIRED PHYSICAL
MOBILITY CEFAZOLE

POSTOPERATIVE
ACUTE PAIN

IMPAIRED SKIN
INTEGRITY

KETOROLAC
TRAMADOL

COMMUNICATION
Activity 10: Your shift is about to end, using ISBAR (a patient safety communication
structure that aids simplified, effective, structured and anticipated communication
between healthcare personnel). Fill in your end of shift report to help guide the
incoming student nurse.
Identify yourself: your name: RABANG, GEROME ISAIAH P. C. role: student nurse
ward/area: SURGERY WARD
Situation: What is your patient’s name, age & gender, current situation/status (stable but
in danger of deterioration, unstable), concern or your observations, what needs to
monitor/observe (ex; abnormal VS, labs, active clinical signs/symptoms)
Patients name is I. Pablico, a 52 y/o male, a post op patient, undergone
cholecystectomy, stable VS, watch out for signs of infection, patient is reluctant to
clean, and put sterile dressing. Watch out for signs of pressure ulcers, patient has
difficulty to move from side to side.
Background: Give the relevant details such as presenting problems and clinical history that
will help the incoming staff interpret the situation easily; may also include meds / procedures
already administered.
Patient has difficulty turning side to side.
Patient is reluctant to clean and do sterile dressing. Removes dressing as it is uncomfortable.

Assessment: What is your assessment? (Base it on your observation on your

patient during your shift what is his/her current condition, risks & needs).
After 72 hrs. of nursing interventions, patient is now on stable vital signs, let her finish her
medications even if feeling well, watch out for signs of pressure ulcer and take note of the
sterile dressing, patient keeps on removing it. Execute active and passive ROM, encourage
her to ambulate if tolerated.
Recommendation: What do you recommend being done to correct the situation? Be clear
about what you are requesting. (e.g transfer/review/treatment? When should it happen?
Always reiterate health teaching especially executing passive and active ROM, Ambulation as
well. Check dressing q1, watch out for Laboratory diagnostics especially CBC to keep track of
normal wbc count.
13 AREAS OF ASSESSMENT

1. Psychosocial and Psychological Status

Patient X is a 52-yr. old, male and married. He lives with his family and is residing at OB
158Tawang, La Trinidad, Benguet. The patient and his family are Born again. He spends his time
at the crop fields. During his freetime he chooses to sleep, if not watches television Mental and
Emotional Status

Patient X is oriented to time and date. Active and alert, knows the reason why he was
hospitalized. Able to recall and has remote memory. He is able to respond all directions given to
his and is able to maintain eye to eye contact. No social concerns and no medicine taken to alter
his emotional response.

2. Environmental status

Family owns a 2-storey house which is located near the main road.

3. Visual Status

Eyelashes are evenly distributed. Eyebrows are present bilaterally and symmetrical w/o lesions
or scaling. Can raise both eyelids symmetrically. Conjunctivas are pink and moist, no swelling,
lesions, exudates and foreign bodies present. Sclera is white in color with some small superficial
vessels. Iris is round, flat and evenly colored. Pupils constrict during near vision and dilate with
distant vision. Both eyes move smoothly and symmetrically in each of the 6 fields of gaze.

A. Auditory

Ears are symmetrical in shape. Pinna is positioned centrally in proportion to the head and
matches the flesh color of the rest of the skin. No pain and tenderness palpated. No redness,
swelling, lesions, foreign bodies and drainage in the ear canal. Able to correctly repeat the
whispered word.

B. Olfactory
Nose is symmetrically in midline of the face, straight. With whitish discharges, no flaring. Nasal
mucosa is pinkish with swelling. Septum is at the midline w/o perforation, lesions or bleeding.
Both nostrils are patent. Sinuses are inflamed.

C. Gustatory

Lips are pale, dry and chapped. Buccal mucosa is pinkish in color; tissue is smooth and moist
w/o lesions. Presence of dental carries in some teeth. No swelling or bleeding in the gums. The
tongue is in the midline without lesions or atrophy. Uvula hangs freely in the midline. Tonsils are
not inflamed and no discharges. Elicits gag reflex.

D. Tactile

Able to discriminate sharp dull, light and firm touch, able to perceive heat, cold, pain in
proportion to stimulus. Able to differentiate common objects by touch by doing necessary
procedure.

4. Motor Status

Can bend his arms and legs with pain on abdominal area, RUQ. With minimal redness. No signs
of deformities. No swelling or inflammation.

5. Thermoregulatory Status

DATE TIME TEMPERATURE ANALYSIS

February 8 8 am 38.5 Febrile
2pm 37.3 Normal
February 9 8am 38.7 Febrile
2pm 37.1 normal
February 10 8am 36.7 Normal
2pm 38.6 Febrile

7.Respiratory Status

Patient X is on oxygen cannula with an order of 2L/min., doesn’t use accessory muscle when
breathing. Upon auscultation no decreased breath sounds

RESPIRATOR O2
DATE TIME ANALYSIS
Y RATE SATURATION
February
8am 20 cpm 90% NORMAL
8,2021
2pm 19 cpm 92% NORMAL
February
8am 21 cpm 90% NORMAL
9,2021
2pm 18 cpm 95% NORMAL
February
8am 20 cpm 96% NORMAL
10,2021
2pm 19 cpm 94% NORMAL

8. Circulatory Status

Jugular vein is not distended. No visible pulsations except at the point of maximal impulse.
regular heart rate and rhythm. No heart murmur noted.
DATE TIME CIRCULATORY Analysis
RATE
September 26, 8am 70 bpm NORMAL
2019
2pm 78bpm NORMAL
September 27, 8am 80 bpm NORMAL
2019
2pm 78 bpm NORMAL
September 28, 8am 85bpm NORMAL
2019
2pm 90bpm NORMAL

9. Nutritional Status

Due to hospitalization, patient started to develop loss of appetite and is seen eating unnecessary
foods such as foods rich in msg. which is not appropriate for her condition.

10.Elimination Status

The patient eliminates once a day. The stool is described as brownish and semi solid. He drinks
water to aid her elimination. He urinates 4-6 times during our shift. His urine is amber in color.

11.Sleep, rest and Comfort Status

The patient claims that he normally sleeps 8-10 hours in a day. Her sleep was now only 5-6
hours during Hospitalization. He said he is not also comfortable with sleeping because of the pain
he feels on his incision site.

12.Fluids and Electrolytes Status

The patient usually drinks 4-5 glasses of water only daily and urinates regularly. He has an
ongoing IVF of PLNS x1L regulated at KVO. The patient denies the feeling of thirst.

13.Integumentary Status

Fingernails have convex curvature and angle of nail plate is normal. Smooth texture, pinkish in
color and intact tissues surrounding the nails. Capillary refill is within 3-4 seconds. Hair is black
in color, oily, straight and fairly distributed. Skin is dry, Flaky and warm to touch. He has fair
complexion. No areas of increased vascularity, ecchymosis or bleeding. No lesions and rashes
noted.