Case study: Cholelithiasis

In Partial Fulfillment of the Requirements for the Subject

Care of Mother and Child at Risk or with Problem (Acute & Chronic) RLE

Submitted by:
Angel, KlienJean S.
Borromeo, Janette H.
Dorigo, Danilo Jr. R.
Faustino, Avegail D.
Guillermo, Kristine Faith V.
Gumaru, Kristine Ariane L.
Manuel, Mizylore P.
Rasquero, Faye Ingrid I.
Turaray, Lady Rose A.
Yap, Krizeth Cherel C.

Bachelor of Science in Nursing

March 2023

Maria Rebecca Corazon A. Manipon, MAN, RN

CLINICAL INSTRUCTOR
General Objectives
This case study is meant to assist us as nursing students in broadening our knowledge and
providing the best nursing care possible for a patient with cholelithiasis.
This study aims to improve nursing interventions that could help the patient understand their
needs, increase awareness of everyone who may have this sort of disease, and implement suitable
nursing care for patients with cholelithiasis.
Specific objectives
This study specifically aims to:
1. Familiarize the nursing students with the background of what cholelithiasis is all about.
2. Recognize the predisposing and precipitating factor that may increase development of
cholelithiasis.
3. Explain and illustrate the pathophysiology of cholelithiasis.

Overview

· Cholelithiasis or Gallstones are hardened deposits of digestive fluid that form in the
gallbladder.

· Commonly results from a chemical imbalance within the contents of the gallbladder in
which the bile contains excessive cholesterol or bilirubin.

· In the United States, roughly 6% of men and 9% of women have cholelithiasis, most of
whom are without symptoms.

· There are two common types of Cholelithiasis or Gallstone this are:

-Cholesterol Gallstones

-Pigment Gallstones

Epidemiology:

· Prevalence varies between 5 and 25% of the population

· Higher prevalence in Western Countries, women and elderly

· Remain asymptomatic in the majority of patient

· About 10% of the patient develop symptoms within 5 years and 20% of patient within
20 years

Symptoms:

Gallstone may cause no sign and symptoms. If a gallstone lodges in a duct and causes a
blockage, the resulting sign and symptoms may include:

· Severe, rapidly intensifying pain in the upper right portion of the abdomen and
in the center portion of the abdomen, just below in the breastbone

· Clay-Colored stool

· Bloating

· Indigestion
 · Belching (Burp)

· Back pain between shoulder blades and right Shoulder

· Nausea or vomiting

Risk Factor:

Cholesterol Stone

Increased Biliary cholesterol

· Obesity

· Increased Dietary cholesterol

· Diabetes

· Hyperlipidemias

· Female Sex hormones

· Familial

Decreased bile acids

· Female sex hormones

· Primary Biliary Cirrhosis

· Mutation of CYP7A1 gene (Cholesterols7-alpha Hydroxylase/cytochrome P450

7A1)

Gallbladder Stasis

· Pregnancy

· Neurogenic or hormonal

Pigment Stones

-Black Stones

Increased production of unconjugated bilirubin

· Chronic hemolysis: Thalassemia, sickle cell anemia, hereditary spherocytosis,

microagiopathic hemolytic anemia

· Crohn disease

· Unknown

-Brown Stone
Bile stasis associated with biliary infection

· E. Coli infection

· Clonorchis sinensis and roundworm infestation

Complications:

Complication of gallstone may include:

· Acute Cholelithiasis

· Chronic Cholelithiasis

· Choledocholithiasis

· Acute Cholangitis

· Obstructive jaundice

· Pancreatitis

Treatment:

· Medication

· Extracorporeal wave lithotripsy (ESPWL)

· Endoscopic retrograde cholangiopancreatography (ERCP)

Surgery

· Laparoscopic cholecystectomy

· Open Cholecystectomy

Prevention:

· Exercise regularly

· Eat healthy food

· Maintain healthy body weight

I. DEMOGRAPHIC DATA
Client: Darna
Sex: Female
Age: 66
Birthdate: January 2, 1957
Civil status: Married
Nationality: Filipino
Religion: Born Again Christian
Address: P4 Banuar, Cabarroguis, Quirino
Educational background: Highschool graduate
Occupation: Housewife
Date and time admitted: February 18, 2023 | 10:21 am
Chief Complaints: Epigastiric pain
Admitting diagnosis: Peptic Ulcer Disease to consider Urolithiasis
Final Diagnosis: Cholelithiasis

II. MEDICAL HISTORY

Past Medical History
Whenever the patient is experiencing common illnesses such as fever, she takes 500 mg of
paracetamol. Patient X stated that she never experienced any allergic reaction with food and
medicines.The patient has not undergone any previous surgery.The patient also stated that she
has never encountered any injuries or accidents. Patient also has complete immunization and has
never had chicken pox.
Patient was previously admitted to QPMC for 5 days due to acute gastroenteritis with signs of
moderate dehydration last February 20, 2020. Patient was also recently admitted to
Madchiw-Dulnuan Medical Center due to hypertension and kidney stones in which she was
given medications such as Clopidogrel, Isosorbide Monotitrate, Atorvastin, Amoxicillin,
Citicoline, Rowatinex, Rowachol, and Trimetazidine.

Present medical history

6 hours prior to admission, patient X experienced severe epigastric pain which radiated to the left
lower quadrant with a pain level of 8 according to her. She was then admitted at Quirino
Provincial Medical Center on February 18, 2023 at 10 am. Upon admission, the patient was
nauseous and the pain was persistent, there was also no vomiting and no difficulty in urination,
however, the patient is positive for hypertension with a blood pressure of 150/90 mmHg. The
admitting diagnosis was peptic ulcer disease to consider urolithiasis and the final diagnosis was
cholelithiasis.
Family history
Psychological history
The patient is not diagnosed with any psychological disorder.
Social history
The patient is a nonsmoker and nonalcoholic drinker.

III. PHYSICAL ASSESSMENT

Vital Signs
Date: February 22, 2023
Time: 11am
Blood pressure: 140/90 mmHg
Pulse rate: 70 bpm
Respiratory rate: 19 cpm
Temperature: 36°C
Oxygen saturation: 98% at room air
Measurements:
Height: 144cm
Weight: 60kg
BMI: 28.9-overweight
A. General Survey
The patient was hospitable to the student nurses as they comprehensively questioned the
patient and then conducted a physical examination. The patient is a female, age 66. The patient
has a BMI of 28.9, which lies in the overweight range for someone her height (144 cm) and
weight (60 kg), the patient also has an endomorph body type. The patient maintained good
composure during the interview and was able to respond appropriately to the questions. In
addition, it was noted that the patient kept her eyes fixed on the student nurse and was extremely
cooperative, responding to inquiries in a direct and audible manner. There were no issues with
the student nurses' ability to converse with the patient. Additionally, the patient cooperated with
instructions, actively listened during the physical evaluation, and offered the student nurses the
freedom to complete the physical assessment. The patient showed adequate memory since she
was able to recollect key events in her medical background. The patient answered all of the
questions honestly and consistently throughout the session. The interview and physical
examination went smoothly and the student nurses ensured to leave the patient in good shape
afterward.
B. Physical Examination

Date and time of assessment: February 22, 2023 (11am)

Area Assessed Technique Normal Findings Actual Findings Interpretation

Skin- color Inspection and Inspection reveals The skin color NORMAL
variation, skin palpation evenly colored of the patient is
integrity, skin tones without light brown and
texture, unusual presence of
discolorations, the
temperature, moles are seen.
skin is intact, has
edema, odor
a good skin turgor,
smooth texture,
even, and without Her skin is
lesions. The skin’s
warm to touch, NORMAL
temperature is
skin turgor is
within normal
poor as a sign of
limit. The skin
aging
does not show
signs of edema.
No presence of
any foul odor. However, there
is a presence of ABNORMAL
edema at the (due to
dorsum part of excessive fluid
her hand intake)
 Hair- color, Inspection and Natural hair Hair color is NORMAL
general Palpation color that may black and is
condition of be smooth, firm finely
the scalp, and somewhat distributed.
amount and elastic, the scalp However, white
distribution of is clean and dry- hairs is present
hair in scalp, free from as a sign of
body, and dandruff. aging
axillary Varying amounts
of terminal hair
cover the scalp,
No dandruff NORMAL
axillary, body,
present in the
and pubic areas
scalp
according to
normal gender
distribution.
Presence of hair NORMAL
in axillary, body
and pubic area

Nails- Inspection and Nails are well Nail plates is NORMAL

grooming, Palpation groomed, no pink in color
cleanliness, visible dirt can
color, be seen in the
markings, underside of the
No clubbing of
shape of nails, distal. Pink tones NORMAL
the nails
texture, and should be seen
capillary refill and longitudinal
ridging should
be noted. The texture of
Clubbing should the nail bed is
not be observed, NORMAL
smooth and
and nail are capillary refill is
smooth with the within 1 second
nail plate
attached firmly
to the nail bed.
Pink tone returns
within 3 seconds
after pressure is
applied.
Head- face and Inspection and Face shows The patient’s NORMAL
skull Palpation symmetrical head is round
facial and is
movement, normocephalic
palpebral fissure
length is equal,
and symmetric
There is no sign
nasolabial folds. NORMAL
of drooping in
The skull is
her face and
rounded, has a
cranial nerve
normal shape
VII is intact
(normocephalic)
and symmetrical.
There are also no
presence of mass No masses or NORMAL
and nodules nodules felt on
her head upon
palpation, her
cheeks are warm
and soft to touch
 Eyes and Inspection and Hair is evenly Eyelashes are NORMAL
vision- Palpation distributed in the equally
eyebrows, brow area with distributed
eyelashes, the skin intact,
eyeballs, and brow arches
eyelids, bulbar are also
Her pupils
conjuctiva, symmetrical.
appeared to be
palpebral Eyeballs are NORMAL
in black color
conjuctiva, similar in size
sclera and are equally
round. Eyelids
are intact with PERRLA
no discharges (Pupils Equally NORMAL
and no Round Respond
discoloration, to Light
lids close Accomodation)
symmetrically
and blinks
involuntarily.
The bulbar Her eyes can
conjunctiva follow moving NORMAL
appears object
transparent with
capillaries
slightly visible Can identify
while the what word is NORMAL
palpebral being shown
conjunctiva near or far
appears smooth,
shiny and
pinkish . The
sclera is white
with no
discoloration.
 Ear and Inspection and Ears are equal in Her hearing NORMAL
hearing- Palpation size bilaterally, ability is good.
auricles, the Auricles are
external ear symmetrical and
canal, hearing have the same
Ear size is
acuity test, and color with his NORMAL
symmetrical to
watch tick test facial skin. The
her face and
auricles are
skin color to
aligned with the
face is even.
outer canthus of
the eye. When
palpating for the
texture, the Auricles are NORMAL
auricles are firm and mobile
mobile, firm and upon palpation
not tender. The
pinna recoils
when folded.
During the No abnormal NORMAL
assessment of drainage
the Watch tick
test, the client
was able to hear Pinna recoils
ticking in both when folded NORMAL
ears.

Pt can hear NORMAL

watch ticks test
 Nose and Inspection The nose Presence of NORMAL
sinuses- appeared ciliary hair. Size
external nose, symmetric, and shape of the
nasal cavity straight and nose is normal
uniform in color.
There is no
presence of
No tenderness
discharge or NORMAL
felt by the
flaring. When
patient. Nose
lightly palpated,
patency is
there were no
normal when the
tenderness and
patient breathes
lesions. There
which means
are also no
there is no
blockages,
blockage,
masses, and
discharge,
discharges on the
masses upon
nasal cavity.
inspection and
palpation.

NORMAL
No tenderness
on sinuses
 Mouth and Inspection The lips of the Number of ABNORMAL
oropharynx- client are remaining teeth (due to teeth
teeth, tongue, uniformly pink; is 14, 7 on the loss)
floor of the moist, upper and 7 on
mouth, tongue symmetric and the lower gum.
movement and have a smooth
uvula. texture. The
client was able
to purse his lips
when asked to There is a ABNORMAL
whistle. presence cavity (due to cavity)

Teeth and Gums:

There are no
discoloration of Tongue and NORMAL
the enamels, no gums are pink in
retraction of color
gums, pinkish in
color of gums

The buccal Tongue of the

mucosa of the client is aligned NORMAL
client appeared at the center,
as uniformly pink in color,
pink; moist, soft, moist and
glistening and slightly rough
with elastic
texture.

The tongue of The smooth

the client is palates are light
pink and smooth NORMAL
centrally
positioned. It is while the hard
pink in color, palate has a
moist and more irregular
slightly rough. texture.
There is a
The uvula of the
presence of thin
client is NORMAL
whitish coating.
positioned in the
The smooth midline of the
palates are light soft palate.
pink and smooth
while the hard
palate has a
more irregular
texture.

The uvula of the

client is
positioned in the
 midline of the
soft palate.

Neck Inspection and Positioned at the Presence of NORMAL

Palpation midline without moles are seen,
tenderness and neck flexion is
flexes easily. No good
masses palpated.

No masses or
tenderness.
Trachea is in the NORMAL
midline.
Thyroid is not
palpable.
Carotid pulses
are full and
equal

Head Inspection Coordinated, Head movement NORMAL

movement smooth is good, no
movement with discomfort felt
no discomfort, by the patient
head laterally
flexes, head
laterally rotates
and
hyperextends.

Lungs and Inspection, Chest expansion Presence of NORMAL

Chest Palpation, and is symmetric. moles are seen,
Auscultation The chest wall is skin color is
intact with no light brown
tenderness and
masses. No masses or
Manifestation of nodules felt and
quiet, rhythmic, warm to touch, NORMAL
and effortless no tenderness
respiration. when palpated

Breath sounds
are normal. No
crackles, stridor, NORMAL
wheezes, and
friction rub
heard.
 Abdomen Inspection, The abdomen of Skin color is NORMAL
Auscultation, the client has an light brown
Percussion, and unblemished
Palpation skin, uniform in
color, and has
Gurgle sound of
symmetric NORMAL
bowel
contour. No
movement is
abnormal bowel
heard, not loud
movements
sounds. No
abnormal
percussion No tenderness
sounds. No felt by the NORMAL
tenderness felt. patient, no
palpated mass

Extremities- Inspection and The extremities Her upper limbs NORMAL

muscles, and Palpation are symmetrical are symmetrical
joints in size and and so with her
length. The lower limbs.
muscles do not
have tremors.
Muscles also
However, there
demonstrate
is presence of
firm, smooth,
edema in the ABNORMAL
and coordinated
upper and lower (due to
movements.
limbs with a pitting-edema)
Joints move
pitting of 2-3
smoothly and no
seconds in the
evidence of
upper limb and
swelling. Upon
1-2 seconds in
palpation, no
the lower limbs.
tenderness can
be felt.

Her ability to
flex her NORMAL
extremities are
good.

However, the
patient ABNORMAL
verbalized that (due to pain)
there is a
presence of pain
in her shoulder
blaze
IV. 11 GORDON’S FUNCTIONAL HEALTH PATTERN
Pre-condition
Condition

I.HEALTH According to the patient, she After admission, the patient

PERCEPTION-HEALTH prioritizes her work and family realizes that her health is
MANAGEMENT PATTERN more than her health. She did important. She said that she
not have cough or colds. The will not bring back her vices
patient received her vaccine and she will follow the
(Johnson’s) against covid-19 doctor’s suggestions or order
last 2022. She was not able to to improve her health.
receive her booster due to her
condition. The patient said that
she started drinking liquor at
the age of 35, she stopped in
the year 2016. She also
smoked cigarettes and started
at the age of 17, she consumes
10 sticks per day. She stopped
smoking cigarettes in the year
2022.

II. NUTRITIONAL – The patient said that she eats 3
METABOLIC PATTERN meals per day. In her diet, she
includes meat, vegetables,
rice, milk, coffee, and water.
Her meals include oily or fried
meat and salty food. She also
eats fruits but not daily. She
drinks 1-2 cup/s of coffee.
According to the patient she
takes Vitamin C and Iron. The
patient does not have
difficulties in chewing and
swallowing.
According to the patient, she
eats 3 meals per day. She said
that she excluded oily or fried
meats in her diet, she
increased her vegetable intake,
she drinks milk and 2 cups of
coffee daily. The patient said
that she does not have
difficulties in chewing and
swallowing. She still takes
Vitamin C.

III. ELIMINATION PATTERN The patient said that she According to the patient, she
defecates every other day or did not defecate for 6 days.
after 3 days. The color of her Her urine is yellowish in color
stool is either yellow or black. and has no strong foul odor.
Her stool is not so firm, but She said that she does not
not too hard. She does not experience difficulties while
experience pain during and urinating.
after defecation. During the
months of September, October,
and November last year; the
patient said that her urine has a
foul smell, with bubbles, and
brownish and yellowish in
color.
IV. AACTIVITY – The patient said that she does
EXERCISE PATTERN the household chores (floor
sweeping, gardening, and
cooking). Her children and
their partners help her in doing
the household chores
whenever they are not busy.
According to the patient, she
takes a bath 1x per day but it
depends on the weather.
Whenever the weather is too
hot, she takes a bath more than
1x. She walks 500 meters
every other day, which serves
as her exercise. The patient
can feed, bath, and groom
herself.
V. SLEEP – REST PATTERN The patient said that she
experiences interrupted sleep.
She sleeps at 9:00 pm and will
wake up at 11:00 pm or 12:00
am. After a few hours she will
sleep again and will wake up
after 2 hours. She naps in the
afternoon.
VI. COGNITIVE The patient can follow and
PERCEPTUAL PATTERN understand directions, retain
information, make decisions,
and solve problems. The
patient wears eye glasses due
to her poor vision. She speaks
Tagalog, Ifugao, English, and
Ilocano.
VII. SELF PERCEPTION – The patient is confident with
SELF CONCEPT her physical appearance. She
doesn’t want to change any
parts in her body because she
is satisfied with what she has.
VIII. ROLE – The patient said that she has a
RELATIONSHIP PATTERN good relationship with her
family. 3 of her children and
their own family lives with
them. She takes care of her
grandchildren when their
parents are busy. She does not
work anymore because her
children give her money.
The patient said that she can
only walk in a limited space
and she does some stretching
that serves as her exercise. She
also chats with the other
patients near her in the room.
The patient can feed herself. In
grooming and bathing, she is
being assisted by her daughter
in law.
The patient said that she still
experiences interrupted sleep.
She can only sleep for 3-4
hours and will wake up after.
She will wait again until she
falls asleep and wake up again
after a few hours of sleep. She
does not nap in the afternoon.
The patient is responsive while
having a conversation, can
follow and understand
information.
The patient said that she can
get easily irritated. She feels
good with her looks. She feels
loved and valued because of
her family’s support.
The patient said that her
children and her husband cook
food for her. She has a good
relationship with her whole
family.
IX. COPING STRESS According to the patient, when
PATTERN she feels stress, she talks with
her neighbors to redirect her
mind from thinking about her
problem. She also talks with
her children about her problem
or when something is
bothering her. Taking care of
her grandchildren also relieves
her stress. She relaxes herself
by inhaling and exhaling.
The patient said that she chats
with the other patients to
relieve stress. She also talks
with her daughter in law who
is with her in the room. She
said that she always prays
whenever she has problems.

X. SEXUALITY – The patient said that she had The patient no longer performs
REPRODUCTIVE PATTERN her menopause when she was intimate activities. She and her
48-years-old. She had her husband do not sleep in the
menarche when she was 12 same bed.
years old. She had no
problems concerning her
reproductive system. She
delivered all of her children in
Normal delivery. G8 T7 P0 A1
L6. She said that she and her
husband stopped having coitus
3 years ago.

XI. VALUE – BELIEF The patient is religious and
PATTERN spiritual. Her religion is born
again. She joins in Bible study,
goes to their place of worship,
and prays. She does not
believe in superstitious beliefs.
The patient prays every
morning and evening. She said
that there are prayers that were
granted already but there are
also prayers that were not and
are still on its way.
V. ANATOMY AND PHYSIOLOGY

2 distinct sources that supply blood to the liver

1.Oxygenated blood flows in from the hepatic artery

2.Nutrient-rich blood flows in from the hepatic portal vein

Functions

- All the blood leaving the stomach and intestines passes through the liver. The liver processes
this blood and breaks down, balances, and creates the Nutrients and also metabolizes drugs
into forms that are easier to use for the rest of the body or that are nontoxic.

-Production of bile, which helps carry away waste and break down fats in the small intestine
during digestion

-Production of cholesterol and special proteins to help carry fats through the body

-When the liver has broken down harmful substances, its by-products are excreted into the bile or
blood. Bile by-products enter the intestine and leave the body in the form of feces.Blood
byproducts are filtered out by the kidneys, and leave the body in the form of urine.

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.

Histology

Cholelithiasis produces diverse histopathology changes in gallbladder mucosa, namely in

cholesterolosis When a patient with cholelithiasis becomes symptomatic, therapeutic intervention
is necessary.

VI. PATHOPHYSIOLOGY
VII. COURSE IN THE WARD

DATE / TIME PROGRESS NOTES DOCTOR’S ORDERS INTERPRETATION

Feb 18, 2023 Admit patient to ward Ø Need for further

treatment
10:21 am

Ø For legal basis

Secure consent purposes

Plain LR 1L x 12 hours Ø Used as a source of

electrolytes,
calories, and water
for hydration

Ø To maintain
DIET: Diet as tolerated nutritional status.
Aspiration
Aspiration precaution
precautions that
foods or fluids get
into airway

Ø To monitor for the

Vital signs monitoring evry 4 improvement and
hours abnormalities of the
patient vital sign

Side drip: 0tramadol 200mg in

Ø To help relieve
500mL D5 water to run for 30
moderate to
hours
moderately severe
pain

Laboratory:

Urinalyis Ø To detect and manage

a wide range of
 disorders such as
UTI, kidney dse and
Diabetes. Also
checkings for
appearance,
concentration, and
content of urine

Ø To measure of how
Creatinine well your kidneys
are performing their
job of filtering
waste your blood

Ø Waste product that

your kidneys
remove from your
Blood urea nitrogen
blood

Ø Waste product found

in blood. Its created
Uric acid
when body breaks
down chemical
called Purines

Ø To exam and evaluate

the kidney, ureters,
urinary bladder
Kub utz

Ø To treat a wide
variety of bacterial
infection (UTI)

Ø To treat certain
Ceftriaxone 1 gm iv q 8 ANST stomach and
esophagus
problems
 Omeprazle 40 mg + 90mL D5w
side drip x 30 mins q 12 hours
Ø To treat stomach and
esophageal
problems, it is
commonly used to
treat and prevent
nausea and
vomiting.
Continue mgt

Metoclopromide 10 mg iv q
Feb 19, 2023 6hours PRN

12 am Ø is a noninvasive
procedure used to
assess the organs
and structures
within the
abdomen.

Facilitate whole abdomen utz

Feb 19, 2023

(+) epigastric pain Ø is a simple, common,

safe blood test that
(+) bloated can diagnose
prediabetes,
diabetes and
gestational diabetes
Fbs

Ø is a blood test that

can measure the
amount of
cholesterol and
triglycerides in your
blood.

Lipid profile

Ø is a representation of
the heart's electrical
activity recorded
from electrodes on
the body surface.
 12 L ecg

Ø Medicine that
increases the
movements or
contractions of the
stomach and bowel

Cont. Meds

Domperidone 10 mg 1tab TID

Ø For further
management

Ø is used to treat
certain stomach and
esophagus
problems (such as
acid reflux, ulcers)

Feb 20, 2023 Refer to general surgeon

regarding hepatic cyst left
11pm
Omeprazole 40mg iv
(+) epigastric pain radiating to
the left quadrant

Feb 21, 2023 Elective surgery

3:30pm Ff up at OPD

Feb 22, 2023 May go home

7:45 am Continue meds

Follow up at opd
VIII. LABORATORY RESULTS
Patient Name: X Date:Saturday/ Feb 18, 2023(1:01pm)
Date of Birth: January 2, 1957 Gender: Female

Patient Name: X Date:Saturday/ Feb 18, 2023(1:00pm)

Date of Birth: January 2, 1957 Gender: Female
Patient Name: X Date:Saturday/ Feb 18, 2023(5:42pm)
Date of Birth: January 2, 1957 Gender: Female
IX. DRUG STUDY

Generic name, Dosage, Mechanism of Indication Contraindication Adverse Effect Nursing Responsibility
Brand name, Route, and Action
and Drug Frequency
classification

Generic name: 200 mg, Unknown. Moderate Contraindicated CNS: dizziness, headache, drowsiness, •Monitor the patient for any
IV, STAT Thought to to in pts who are lethargy. adverse reactions.
Tramadol bind to opioid moderately hypersensitive
hydrochloride receptors and severe to drug and its CV: vasodilation, chest pain •Assess the pt’s level of pain
inhibit chronic components. 30 minutes after admission of
reuptake of pain GI: constipation, nausea, vomiting drug
norepinephrine
Brand name: and serotonin. GU: UTI, urine retention
Tramal

Drug
classification:
Analgesic
Generic name: 40 mg, IV, Inhibits proton Short-term Contraindicated CNS: asthenia, dizziness, headache •Administer drug 30-60
q12 pump activity treatment in pts who are minutes before meals
Omeprazole by binding to of active hypersensitive GI: abdominal pain, constipation,
hydrogen-pota benign to drug and its diarrhea, flatulence, nausea, vomiting, •Monitor pt for adverse
ssium gastric components. acid regurgitation reactions
adenosine ulcer
Brand name: triphosphate, Muscoskeletal: back pain, weakness
Prosec located at
secretory Respiratory: cough, URI
surface of
Skin: rash
Drug gastric parietal
classification: cells to
Antiulcer suppress
gastric acid
secretion
Generic name: 10 mg, IV, Stimulates Nausea Contraindicated CNS: anxiety, drowsiness, dystonic •Monitor bowel sounds
Metoclopramide q6 PRN motility of and in pts who are reactions, fatigue, lassitude,
upper GI tract, Vomiting hypersensitive restlessness, seizures, suicidal ideation, •Monitor pt for fever, CNS
increases to drug and its akathisia, confusion, depression, symptoms, irregular pulse,
lower components. extrapyramidal symptoms, fever, cardiac arrythmias, or
Brand esophageal hallucinations, headache, insomnia, abnormal BP, which may
name:Metvex sphincter tone, tardive dyskinesia, NMS indicate NMS.
and blocks
dopamine CV: bradycardia, supraventricular •Monitor pt for dizziness,
receptors at the tachycardia, hypotension, fluid headache, or nervousness.
Drug retention, transient HTN, HF
chemoreceptor
classification:
zone
GI: bowel disorders, diarrhea, nausea
GI Stimulant
GU: incontinence, urinary frequency,
erectile dysfunction

Hematologic: agranulocytosis,
neutropenia,

Skin: rash, urticaria

Other: loss of libido, prolactin

secretion, gynecomastia, amenorrhea
Generic name: 10g, PO, Antiemetic: Short-term Contraindicated CNS: dizziness, disorientation, fainting •Advise pt to take this
TID The antiemetic treatment in pts who are medication by mouth as
Domperidone properties of of nausea hypersensitive CV: arrythmia prescribed usually 30 minutes
domperidone & to drug and its before meals and at bedtime.
are related to vomiting components.
its dopamine of various •Advise pt to obtain medical
Brand name: receptor etiologies. attention if fainting, dizziness,
Motilium blocking irregular heartbeat or pulse, or
activity at both other unusual symptoms occur.
the
chemoreceptor •Monitor pt for persistence of
Drug nausea and vomiting to
classification: trigger zone
and at the evaluate the effectiveness of
gastric level. It the drug.
Antiemetics
has strong
affinities for •Monitor for signs of
the D2 and D3 abdominal discomfort such as
dopamine epigastric pain or abdominal
receptors, fullness.
which are
found in the
chemoreceptor
trigger zone,
located just
outside the
blood brain
barrier, which -
among others -
regulates
 nausea and
vomiting

Generic name: 1 g, IV, q8 Inhibits Urinary Contraindicated GI: pseudomembranous colitis, diarrhea
cell-wall Tract in pts who are
Ceftriaxone synthesis, Infection hypersensitive Hematologic: eosiniphilia,
sodium promoting to drug and its thrombocytosis, leukopenia
osmotic components.
instability; Skin: pain, induration, tenderness at
usually injection site, rash
Brand name: bactericidal
Forgram Other: hypersensitivity reactions, serum
sickness, anaphylaxis

Classification:
Antibiotics
X. NURSING CARE PLAN

Assessment Diagnosis Planning Intervention Rationale Evaluation

Subjective: Acute pain in shoulder Within the shift, the Independent Within the shift, the
blades related to disease patient will be able to intervention: patient reported
Pt-”Isang linggo nang process (cholelithiasis) report decreased pain decreased pain with a
sumasakit ‘tong balikat as evidenced by patient from 4/10 to 1/10 to no level of 1/10 as she
ko” verbalizing pain level of pain at all. To initiate the verbalized, “Thank you
4/10 •Established rapport nurse-patient interaction sa pagmasahe sa akin, at
with patient and to gain the patient’s sa mga tips ninyo, hindi
trust na gaanong masakit at
Objective: hindi ko na siya gaanong
nararamdaman.”
Pain level of 4/10

0- No pain

1- 3 Mild pain

4 Moderate

5-6 Moderately strong •Performed

pain nonpharmacologic
treatment such as
8-10 Severe pain
1. Therapeutic touch, To alleviate pain by
massaged to the site of reducing muscle tension
pain

Redirects attention from

2. Encouraged the pain to the said
diversional activites such activity
as watching movies,
listening to favorite
music, or playing mobile
games.
To promote emotional
comfort and may
3. Advised SO to initiate enhance coping abilities.
therapeutic
communication with the
patient.
To inform the HCP for
better pain management

•Advised the patient to

seek medical care
provider’s attention if
pain develops further.

To avoid straining the

muscles which are in
 •Instructed the patient to pain
avoid strenuous
activities which may
develop the pain

Assessment Diagnosis Planning Intervention Rationale Evaluation

Subjective: Readiness for enhanced Within the shift of Independent Within the shift of
comfort related to relief nursing intervention the nursing intervention the
Mabuting mabuti na client will be able to - interact with the client -the nurse could be the client will be able to
yung pakiramdam ko as verbalize the sense of in a therapeutic manner most important comfort verbalized the sense of
verbalized by the patient comfort or contentment intervention for meetings comfort or contentment
and demonstrate the client needs and demonstrated
behaviors of optimal behaviors of optimal
level of ease level of ease
Objective: demonstrate
behavior of willingness
to go back at home and
health management prior
to surgery
-establish realistic -this enhances a
activity goals with client commitment to
promoting optimal
outcomes
-provide information -to enhances acquisition
about condition, health of information and gives
risk factors example client choices for
articles accessing and applying
information

-promote overall health

measures example - to reducing differences
nutrition, adequate fluid in current health status
intake and improves
XI. DISCHARGE PLAN

Medication:

1. Encouraged the patient to take the medications at home with the proper dose, time, frequency
and the route.

2. Encouraged the patient to comply with the medications to prevent further complications.

Environment:

1. Instructed the patient to settle in a peaceful surrounding to prevent an irritable mood and for
relaxation.

Exercise:

1. Encouraged the patient to do at least 10 minutes of light slow walking a day in the morning as
a form of exercise.

Health Teaching:

1. Instructed the patient to limit or avoid drinking alcohol and don’t smoke.

2. Instructed the patient to not forget to eat small amounts of food frequently.

3. Advised SO to provide emotional support to the patient and to monitor her lifestyle.

Outpatient Follow Up:

1. Encouraged the patient to visit the doctor at the given time

2. Encouraged the patient to call the physician, for an ambulance, or tell family members or
friends to take the patient to the hospital if severe pain is felt.

Diet:

1. Instructed the patient to avoid eating spicy or acidic food that may cause gastric irritation.

2. Instructed the patient to not drink carbonated drinks, alcohol, soda, coffee and tea.

3. Advised the patient to eat a variety of foods as recommended by the physician to get a
balanced intake of the nutrients.

4. Advised the patient to reduce the amount of fat intake.

Spiritual:

1. Encouraged to continue to seek God’s guidance and enlightenment.

2. Emphasized the importance of prayers in healing.

3. Encouraged to ask for divine assistance in everything

4. Encouraged to continue to have a positive outlook in life.