Bulacan State University

City of Malolos, Bulacan

College of Nursing

A CASE STUDY OF A 64 YEAR OLD MALE WITH CHOLECYSTOLITHIASIS/ CYSTITIS

CHOLEDOCHOLELITHIASIS WITH BILIARY ECTACIA

SUBMITTED BY:

CARATING, MANILEN

DE JESUS, HERNILY ANGELICA

DE JESUS, MARIA THERESA

GAN, LOVELY SHANE

LOPEZ, LARISSE

MARCIAL, DHANILIE

MORELOS, JENNIFER

REYES, ANNA MARIE

PAYONGAYONG, ACEY BRYLLE

SORIANO, JERICO

BSN4A- GROUP # 4

I. INTRODUCTION

This is a case study of a 64 year old male client who were rushed at Lubao Clinic at Lubao, Pampanga complaining of severe pain on the right upper

quadrant of the abdomen. After performing abdominal ultrasound, the result shows that he has Cholecystolithiasis/cystitis and choledocholelithiasis with

secondary biliary ectacia. He was then diagnosed with cholecystocholedocholithiasis and was referred by Dr. G to Dr. PB of Bulacan Medical Center. He was

admitted at Bulacan Medical Center last August 27, 2010 at 12:32 p.m. and was scheduled for cholecystectomy with billiary exploration.

Cholecystocholedocholithiasis is presence of gallstone in both gallbladder and common bile duct, in turn leading to bile obstruction and gallbladder

irritation. Gallstones are crystalline bodies formed within the body by accretion (increase by natural growth) or concretion (formation of stone-like substance) of

normal or abnormal bile components, it can occur anywhere within the biliary tree, including the gallbladder and common bile duct. The bile is a fluid produced

by the liver that aids in digestion of lipids and neutralizing of partly digested foods, it is stored in the gallbladder and upon eating it is discharged to the duodenum

(the first part of the small intestine) by passing to a duct called common bile duct. The gallbladder is an organ which aids in the digestive process. Its function is to

store and concentrate bile. The common bile duct is a tube-like structure that is formed by the union of the common hepatic duct and the cystic duct. Its primary

function is conduction of concentrated bile from the gallbladder to the duodenum. Cholecystectomy is a surgical removal of gallbladder. Fortunately, the

gallbladder is an organ that people can live without. Despite of the importance of gallbladder in the digestion of fat, many people are unaware of it. That is why

they often neglect to take care of their gallbladder. And biliary exploration is done to search for any gallstone present in the biliary tree.

Cholecystocholedocholithiasis can affect both men and women but it is more prevalent in women at the age of 40 years old. People who have a history of

gallstones are at increased risk for having this kind of disease. In the international level, gallstones are prevalence among people of Scandinavian descent, Pima

Indians, and Hispanic populations, whereas gallstones are less common among individuals from sub-Saharan Africa and Asia. It affected 20.5 million people (1988-

1994) with a mortality record of 1,077 deaths in 2002. Hospitalizations total up to 636,000 in the same year and over 500,000 have undergone cholecystectomies.

In the Philippines alone, an extrapolated prevalence of 5,073,040 people are affected by the disease last 2007. (http://digestive.niddk.nih.gov/statistics)

No unanimous consensus has been achieved regarding the ideal management of cholecystocholedocholithiasis. The treatment of gallbladder and common

bile duct stones may be achieved currently according to a two-step-protocol (endoscopic sphincterotomy associated with laparoscopic cholecystectomy) or by a

one-step laparoscopic procedure, including exploration of the common bile duct and cholecystectomy. Endoscopic sphincterotomy is reported to have

considerable morbidity/mortality and common bile duct stone recurrence rates, whereas laparoscopic common bile duct clearance is a demanding procedure,

which to date has not spread beyond specialized environments. (http://pubget.com/paper/19466493#)

Significance of the study

We, the student nurses have chosen this case as we see it fit for the peri-operative concept as the patient has had undergone cholecystectomy with billiary

exploration and cholechoduodenostomy. Moreover, despite the Cholecystocholedocholithiasis’ low incidence, we would like to give credit and to know more of

the nature and function of the gallbladder. Much often this small organ is not given importance. Thus we are in a pursuit for knowledge to be able to impart it to

others. Furthermore, this case is quite interesting since it does not always affect only females and elderly. It can affect everyone. It can be alarming since many

people are confused and unaware of the symptoms presented.

As teen-agers living in a fast-phased world and governed by schedules, we too are predisposed to lifestyle modification – especially diet and food

preferences which can contribute to the disease. With this study, we hope to apply our learning in taking care not only of our patients but also of ourselves.

As nursing students and future nurses, we would want to understand and appreciate more on what is happening to a patient with

Cholecystocholedocholithiasis. Consequently, we are interested on what will be the necessary management that will be given. Through this, we are hoping that

we will be able to find the right plan of care and sound interventions, not forgetting the patient’s rights as a person. All in all, these will help us to become efficient

nurses and better persons later on.

OBJECTIVES

General Objective:

Our first main goal is to gain knowledge through the completion of the case study and to impart this learning to Mr. BM and to those directly and indirectly

involve with the completion of this case. In psychomotor aspect, our goal is to apply all what we have learned during the process of completing this case study to

improve nursing care that will meet Mr. BM’s need for the improvement of his general welfare. With the knowledge gained and through the application of this

knowledge, another goal is that we will be able to empathize with the current situation of the patient and to gain some values like the value of patience and

calmness which is important for us to have in order to become better nurses in the future.

Specific Objectives:

Conduct a thorough physical assessment and to interpret the assessment in order to give the care the patient need.

Research and understand the disease process of the patient’s illness and also the possible causes and the symptoms the patient experienced that may

suggest the current condition of the patient.

Integrate knowledge of nursing care in post Cholecystectomy with biliary exploration client to formulate a quality nursing care plan.

Implement appropriate nursing intervention to satisfy the patient’s needs.

Use critical thinking to evaluate the effectiveness of the nursing intervention given in meeting the needs of the patient.

PATIENT’S PROFILE

BIOGRAPHIC DATA

NAME: Mr. BMAGE: 64 years oldSEX: MaleBDAY: October 28, 1945ADDRESS: Sta. Cruz Lubao, PampangaSTATUS: MarriedPosition in the family: Head of the familyNationality: FilipinoReligion: Roman CatholicCare Financing: Philhealth and SSSDate of Admission: August 27, 2010 Time of Admission: 12:32 PMFinal Diagnosis: Cholecystocholedocholithiasis

II. NURSING HEALTH HISTORY

A. CHIEF COMPLAINT

A.1 Chief complaint on admissionThe patient verbalized that he experienced pain in the right upper quadrant prior to admission.“Sobrang sakit sa itaas na kanang bahagi ng aking tiyan” as verbalized by the client.

A.2 During the interactionThe patient verbalized that he doesn’t feel any pain during actual assessment.“Wala na akong nararamdaman na sakit sa tahi ko” as verbalized by the client.

B. HISTORY OF PRESENT ILLNESS

One month prior to admission (August, 2009), Mr. BM experienced tolerable pain in the right upper quadrant of his abdomen with a tolerable pain of

6/10.. He does not seek medical attention yet and he does not take any medication. By august 22, 2010, he experienced intolerable pain of 10/10. He was worried

about his condition so he seeks medical attention, Mr. BM consult a doctor at Lubao, Clinic, and he undergone abdominal ultrasound. The result shows

Cholecystolithiasis/cystitic choledocholelithiasis with secondary biliary ectacia and he was diagnosing of having cholecystocholedocholithiasis. He was reffered to

Dr. PB of Bulacan Medical Center by Dr. G of Lubao Clinic and some medications were prescribed to him such as omeprazole20 mg capsule, ciprofloxacin 500mg

tab and tramadol 50 mg tab. Three days prior to admission (August 24, 2010), he noticed a yellowish discoloration on his skin, dark urine and clay-colored stool.

By August 25, 2010, he exhibited nausea and vomiting resulting in a decrease in appetite but still he was not able to consult Dr. PB. He also had a fever (38.4 ˚C)

on that day.Until August 27, 2010, he went to Bulacan Medical Center to consult Dr. PB to present the referral slip of Dr. G. Laboratory exam were done such as;

hematology, CBC, Createnine, PT and PTT. He received IVF of D5Lr 1L regulated at 30gtts/min. He was scheduled for cholecystectomy with billiary exploration and

cholechoduodenostomy.

C. PAST HISTORY

According to the patient, this is not the first time he has been hospitalized. A year ago, he undergone prostatectomy at Manila Doctors Hospital facilitated by Dr. Gatchalian. As far as the client concerned, He does not have any allergies to any kind of medication or food. He has a history of smoking cigarettes and drinking alcohol beverages but he stopped 22 years ago. The patient also stated that he can’t remember the immunizations he received.

D. FAMILY HISTORY OF ILLNESS

The patient has a familial disorder of hypertension, diabetes mellitus, cardiovascular accident, lung cancer, rheumatoid arthritis, liver cancer and asthma. The patient stated that his grandmother on maternal side and his grandfather on paternal side died due to natural death. His grandfather on maternal side died due to DM complications. While his grandmother died due to lung cancer. A2 died due to pulmonary tuberculosis, A3 died due to lung cancer while patient’s mother died due to cardiovascular accident. A5 has diabetes mellitus while A6 and A7 both have rheumatoid arthritis. On the paternal side, B1 and B2 as well as patient’s father died due to lung cancer. B5 died due to cardiovascular accident. And B8 died due to complication of hypertension (heart attack). He has 8 siblings, the eldest(C1) died due to meningitis. C2, C5, C7 and C9 are hypertensive. Patient (C3) has DM, asthma and hypertension, C4 died due to cardiovascular accident, C6 died due to liver cancer and C8 has rheumatoid arthritis.

GENOGRAM

MATERNAL SIDE PATERNAL SIDE

FUNCTIONAL HEALTH PRIOR DURING

FEMALE

MALE

PATIENT

DECEASED

HYPERTENSION

CARDIOVASCULAR ACCIDENT

DIABETES MELLITUS

LUNG CANCER

RHEUMATOID ARTHRITIS

UNKNOWN

ASTHMA

LIVER CANCER

A1/89 A2/88 A3/86 A4/85 A5/80 A6/78 A7/76 B1/95 B2/92B3/89 B4/85 B5/82

B6/77 B7/72 B8/75

C3/64C2/67C1/71 C4/62 C5/59 C6/57 C7/54 C8/50 C9/48

PATTERNI. Health Perception and Health Management Pattern

Prior to admission, the patient stated that being a healthy person is being free from diseases. And to keep himself healthy, he eats balanced and nutritious foods and regular exercise as well.

During admission, the patient stated that its hard for him to follow some of the doctor’s order in terms of the foods that are not allow for him to eat.

II. Nutritional and Metabolic Pattern

Prior to admission, the patient’s usual food preferences are vegetables, fish and seafood. The client’s fluid intake was around 1000-1500mL of water per day. His skin is dry but does not have any lesions or other skin problems.

AUGUST 24, 2010

BREAKFAST 1 cup of rice ½ milk fish (pangat) 150mL of water

LUNCH 1 cup of rice 1 cup of milk fish (sinigang) 360 mL of water 1 pc of regular banana

DINNER 1 cup of rice 1 fried of gigi fish 175mL of water

During admission, the usual foods that the patient eats are the foods offered by the hospital. After the surgery her daily fluid intake is 600-700mL of water.

AUGUST 27, 2010

BREAKFAST 120mL of hot coffee 2 pcs of pandesal(regular) 1 pc of fried egg

LUNCH 1 cup of rice ½ fried milk fish 1 small bowl of chopseuy 360mL of water

DINNER 1 cup of rice 1 fried of fish(galunggong) 1 small bowl of milk fish (sinigang)

AUGUST 25, 2010

BREAKFAST 1 cup of rice 2pcs boiled eggplant 2pcs of fish (sardines) 240mL of water

LUNCH 1 cup of rice 1 pc of fried tilapia 300mL of water

DINNER 1 cup of rice 1pc gigi fish (pangat) 150mL 1pc of regular banana

AUGUST 26,2010

BREAKFAST 120mL of hot coffee. 4pcs of hot pandesal(regular)

LUNCH

240mL of water

AUGUST 28, 2010

BREAKFAST 1 cup of rice 1 pc of boiled egg 150 mL of water

LUNCH 1 cup of rice 1 small cup of pakbet 240mL of water

DINNER 1 cup of rice 1 small fried chicken 150mL of water

AUGUST 29, 2010

BREAKFAST 2pcs of pandesal (regular) 120mL of water

1 cup of rice 4 pcs of crabs 3 pcs of big shrimp 280mL of water

DINNER 1 cup of rice 2 pcs of banana (regular)

LUNCH 1 cup of rice 1 small cup of pakbet 200 mL of water

DINNER 1 cup of rice 1 small fried chicken 120 mL of water

III. Elimination Pattern Prior to admission, the patient defecates once a day. The stool was pale in color, firm, acolic stool (3 days prior). The patient said that defecation is not hard for him. The patient urinates 9 times a day depending on how much his fluid intake was. According to him, he noticed a dark-colored urine 3days before admission.

Color Frequency Consistenc

y

Odor difficul

ty

Stool Clay-

colored/

gray

1x/day Formed foul None

Urine Dark-

colored

9x/ day Clear aromatic none

During admission, the patient defecated once a day, and the stool was brown in color, and firm. The patient urinates 7 times a day because of the infused intravenous fluid and oral fluid intake. He does not perspire excessively and no body odor problems.

Color Frequen

cy

Consiste

ncy

Odor Difficulty

Stool Clay-

colored

1x/day Formed Foul none

Urine Dark-

colored

7x/day clear Aromatic None

vomit None vomit None

IV. Activity Exercise Pattern

0 – Full self care.

1 – use of equipment

2 – assistance from other person

3- assistance from other person and devices

4- dependent

Prior to hospitalization, the patient had sufficient energy to do his entire task and still he can manage their farm independently.

During hospitalization, the patient didn’t have enough energy to do his task. His only form of exercise was early ambulation and some active and passive range of motion.

Activity Level

Feeding 0

Bathing 0

Bed mobility 0

Dressing 0

Grooming 0

Toileting 0

Activity Level

Feeding 0

Bathing 2

Bed mobility 0

Dressing 2

Grooming 2

Toileting 2

V. Sleep Rest Pattern Prior to hospitalization, he had 8 hours of continuous sleep a day; she slept at 9PM and wake as early as 5AM. He took naps in the afternoon at least 30-1hour.

During hospitalization, he has only 6 hours of sleep and it’s not continuous like before due to surrounding. He usually sleeps at 10 PM and awakens at 4AM.

VI. Cognitive Perceptual Pattern

Prior to hospitalization, the client stated that he had no hearing difficulty and his memory were still intact because he can still remember the information being asked to him.

Prior to hospitalization, the client stated that he had no hearing difficulty and his memory were still intact because he can still remember the information being asked to him

VII. Self –Perception and Self-Concept Pattern

Prior to hospitalization, the patient described himself as a good person and approachable.

The patient described himself as a good person but during the occurrence of the disease he easily get irritated and he feels moody most of the time.

VIII. Role Relationship Pattern

The patient is the head of the family; they both played the role in decision making. They belong to the nuclear type of family.

The patient is the head of the family; they both played the role in decision making. They belong to the nuclear type of family.

XI. Sexuality-Reproductive Pattern

According to the patient, they can’t practice sexual intercourse due to their age.

They can’t participate on sexual activity due to their age. The patient also stated that they used to take care of their grandsons and daughters and just enjoying their remaining time.

X. Coping Stress Tolerance Pattern

According to the patient he feels tense every time he feels dizzy. Her wife was the most helpful person in taking things over. He is taking his home medication to cope with it most of the time. But if some stress triggered his feelings the patient went to farm to get some fresh air and to feel relax. Her husband was the most helpful person in taking things over.

The patient stated that he doesn’t feel any tension during this time because he feel safe and secured coz they can easily contact a doctor if there’s any problem encounter.

XI. Value-Belief Pattern The client believed that all things that happening to their family have purpose from GOD, to made them a better and stronger individual. Faith in GOD is the thing that made them hold to problems even if it was very difficult to handle.

The client believed that all things that happening to their family have purpose from GOD, to made them a better and stronger individual. Faith in GOD is the thing that made them hold to problems even if it was very difficult to handle.

III. GROWTH AND DEVELOPMENT

THEORY STAGES NORMAL FINDINGS ACTUAL FINDINGS RESOLUTION

Freud’s psychosexual theory

Genital phase(13 years and older)

At this point, learned to desire members of the opposite sex and to fulfill instincts to procreate and thus ensure the survival of the human species.

He is married and has 3 children.Mr. BM and his wife were remains sweet to each other.

Positive (+) the development of relationship and also have his own family.

Erikson’s Psychosocial theory

Stage 8 – Ego Integrity vs. Despair

Feeling of self acceptance, sense of dignity, worth and importance.

Mr. BM has a sense of self worthiness, meaningless and hopeless with self satisfaction in activities.

Positive (+) Mr. BM has a feeling of self satisfaction and worthiness.

Kohlberg’s Moral Development theory

.Post conventional Stage

Stage 6 – Universal ethical principle orientation.

Higher Law and conscience orientation. Orientation to internal discussion of conscience but without clear rationale or universal principle.“I must follow rules because my conscience tells me”.

Mr BM understands the different roles of the society, and can distinguish what is right or wrong based on internalized rules on conscience rather than social law. According to him, she will follow the entire doctor’s order that will help to make his condition better. He also

Positive (+). Mr. BM follows rules according to his knowledge and willingness.

said that he does things if he knows that it is good for him and according to his willingness.

Fowlers spiritual development theory

Conjunctive faith Here there must also be a new reclaiming and reworking of one's past. There must be an opening to the voices of one's "deeper self." Importantly, this involves a critical recognition of one's social unconscious-the myths, ideal images and prejudices built deeply into the self-system by virtue of one's nurture within a particular social class, religious tradition, ethnic group or the like.

Mr. BM said that even if he does not always go to church regularly, it is still a must for him to pray and thank God for his graces and ask guidance for his current condition.

Positive (+). He integrates other perspectives about faith into own definition of truth.

Piaget’s cognitive development

Formal operations(12 - adulthood)

Able to see relationships and to reason in the abstract.

Mr. BM said that he thinks logically for the possible solution and learn to think and reason in abstract terms.

Positive (+). Mr. BM can think reasonably.

IV. ANATOMY AND PHYSIOLOGY

LIVER

Largest organ in the body

Lies under the diaphragm; occupies most of the right hypochondrium and part of the epigastrium.

Weighing 1.5 kgs.

LIVER LOBES AND LOBULES

The liver has two lobes, separated by the falciform ligament

Left lobe- about one sixth of the liver

Right lobe- about five sixth of the liver.

BILE DUCTS

Right hepatic duct- drains bile from the right functional lobe of the liver

Left hepatic duct- drains bile from the left functional lobe of the liver

Common hepatic duct-is the duct formed by the convergence of the right hepatic duct and the left hepatic duct ; Length: Usually 6–8 cm. Approximate width: 6 mm in

adults; merges with cystic duct to form common bile duct, which opens into the duodenum.

Cystic duct- is the short duct that joins the gall bladder to the common bile duct.

Common bile duct- formed by the union of the common hepatic duct and the cystic duct (from the gall bladder).

FUNCTIONS OF THE LIVER

The liver stores a multitude of substances, including glucose (in the form of glycogen), vitamin A (1–2 years' supply), vitamin D (1–4 months' supply),

vitamin B12, iron, and copper.

Glucose metabolism- after meal, glucose is taken up from the portal venous blood by the liver and converted into glycogen (glycogenesis), which is stored

in the hepatocytes. Glycogen is converted back to glucose (glycogenolysis) and release as needed into the blood stream to maintain normal level of the

blood glucose

Ammonia conversion- use of amino acid from protein for glucogenesis result in the formation of ammonia as a by product. Liver converts ammonia to

urea.

Protein metabolism- liver synthesizes almost all of the plasmas protein including albumin, alpha and betaglobulins, blood clotting factor plasma

lipoproteins.

Fat metabolism- fatty acid can be broken down for production of energy and production of ketone bodies.

Bile formation- bile is formed by the hepatocytes

- Composed of water, electrolytes such as sodium, potassium, calcium, bicarbonate, lecithin, fatty acids, cholesterol, bile salts

- Collected and stored in the gallbladder and emptied in the intestine when needed for digestion.

BILE

Bile is the greenish-yellow fluid (consisting of waste products, cholesterol, and bile salts) that is secreted by the liver cells to perform two primary functions,

including the following:

to carry away waste

to break down fats during digestion

Bile salt is the actual component which helps break down and absorb fats. Bile, which is excreted from the body in the form of feces, bile gives feces its dark

brown color.

TRANSPORT OF BILE

1. When the liver cells secrete bile, it is collected by a system of ducts that flow from the liver through the right and left hepatic ducts.

2. These ducts ultimately drain into the common hepatic duct.

3. The common hepatic duct then joins with the cystic duct from the gallbladder to form the common bile duct, which runs from the liver to the duodenum

(the first section of the small intestine).

4. However, not all bile runs directly into the duodenum. About 50 percent of the bile produced by the liver is first stored in the gallbladder, a pear-shaped

organ located directly below the liver.

5. Then, when food is eaten, the gallbladder contracts and releases stored bile into the duodenum to help break down the fats.

GALLBLADDER

The gallbladder is a small organ whose function in the body is to store bile and aid in the digestive process.

A hallow pear- shaped sac from 7- 10 cm (3-4 inches) long and 3 cm broad. It consists of a fundus, body and a neck.

Fundus - the lower free and the expanded end of the Gall bladder.

Body - the body of the gall bladder is the portion that is lying between that of the fundus and also the neck. The direction of the body is upwards,

backwards, and to the left.

Neck-it is the “S” shaped curve present above the body, and extends up to the cystic duct. Direction is upwards, forwards and then takes a turn and

becomes downwards and backwards.

It can hold 30 to 50 ml of bile.

It lies on the undersurface of the liver’s right lobe and attached there by areolar connective tissue.

The cystic duct connect the gallbladder to the common hepatic duct to form common bile duct.

FUNCTION OF THE GALLBLADDER

Stores bile that enters it by way of the hepatic and cystic duct. During this time the gallbladder concentrates bile five folds to ten folds. Then later when digestion

occurs in the stomach and in the intestines, the gallbladder contracts, ejecting the concentrated bile into the duodenum. Jaundice, a yellow discoloration of the

skin and the mucosa, results when obstruction of bile flow into the duodenum occurs. Bile is thereby denied its normal exit from the body in the feces. Instead, it

absorbed in the blood, and an excess of bile pigments with a yellow hue enters the blood and is deposited in the tissues.

The gallbladder stores bile, which is released when food containing fat enters the digestive tract, stimulating the secretion of cholecystokinin (CCK). The bile,

which is produced in the liver, emulsifies fats and neutralizes acids in partly digested foods.

V. PATHOPHYSIOLOGY

Predisposing Factors Precipitating Factors

Advancing age (age 40 and above)

Diet (high cholesterol/fat)Biliary infection (bacteria)

Decreased gallbladder motility

Release of inadequate amount of bile to break

down/digest fats

Significant increase of cholesterol in the circulating

blood

Liver excrete relatively high proportion of cholesterol in

the bile

Liver excrete conjugated bilirubin into bile along with

bile salts and cholesterol

Invasion of bacteria

Bacteria hydrolyze conjugated bilirubin

Increase in unconjugated bilirubin

Liver excrete relatively high proportion of cholesterol in

the bile

Bile is supersaturated with cholesterol

Formation of solid Crystals that is insoluble

Crystals fuse together to form stones

Bile is supersaturated with cholesterol

Formation of solid Crystals

Crystals must come together and fuse to form stones

Unconjugated Bilirubin tends to form insoluble precipitates with bile salts and cholesterol

Formation of stones

Stones in bile ducts (choledolithiasis) and gallbladder (cholelithiasis)

Mild to moderate pain/biliary colic in the right part of the abdomen – due to functional spasm

of the cystic duct; irritation of the viscera

(August, 2009)

Obstruction of the bile ducts

Jaundice – due to obstruction of bile flow

(August 24, 2010)

Clay-colored stool – may result from problems in the biliary system; due to absence of bile in

the duodenum; warning signal that’s something wrong with digestion

(August 24, 2010)

Dark-colored urine

(August 24, 2010)

Continues irritation of the gallbladder

Inflammation of the gallbladder

CHOLECYSTOCHOLEDOCHOLITHIASIS

Fever – due to elevated WBC because of bacteria invasion in the injured gallbladder

(August 25, 2010)

Nausea and vomiting – may accompany a gallbladder attack

(August 25, 2010)

Severe Pain/biliary colic – due to inflammatory process

(August 22, 2010)

Decrease in appetite

(August 25, 2010)

Cholecystocholedocholithiasis - presence of gallstone in both gallbladder and common bile duct, in turn leading to bile obstruction and gallbladder inflammation.

Signs and Symptoms

Rationale

Biliary Colic The most common symptom is in pain the right upper part of the abdomen or epigastrium. This can cause an attack of abdominal pain,

called biliary colic, which: develops quickly, is severe, lasts about one to three hours before fading gradually, isn't helped by over-the-

counter and isn't helped by passing wind. The pain may radiate to the back, right scapula or shoulder. The pain often begins suddenly

following a meal. The pain of biliary colic is caused by the functional spasm of the cystic duct when obstructed by stones, whereas pain in

acute cholecystitis is caused by inflammation of the gallbladder wall.

Fever Gallstones sometimes get trapped in the neck of the gallbladder and can cause persistent pain that lasts more than several hours and is accompanied by

fever, also due to the irritation and inflammation of the gallbladder wall.

Fever occurs in about one third of people with acute cholecystitis. The fever tends to rise gradually to above 100.4° F (38° C) and may be accompanied

by chills

Loss of appetite The pain often begins suddenly following a large or rich meal. People tend not to eat, especially fatty or oily foods, in order not to experience that pain.

Fat absorption is also impaired for the lack of bile salts, As a result, rapid loss of weight and anorexia can occur.

Jaundice Due to obstruction of the bile flow

Clay-colored stool may result from problems in the biliary system; due to absence of bile in the duodenum; warning signal that’s something wrong with digestion

Precipitating Factors

Factors Rationale

Diet (high cholesterol, high fats) Increased intake of cholesterol and saturated fats has all been postulated to cause cholesterol gallstones.

If there is an increased production of cholesterol, bile is bring supersaturated with cholesterol, that leads in formation of crystals/stones.

Biliary Infection (bacterial) Brown pigment stones are frequently found in the intrahepatic bile ducts and are always associated with infection by colonic organisms usually

E.coli, or parasitic infestation (Ascaris lumbricoides, or other helminthes). Intraductal stones developing after cholecystectomy are invariable

associated with bile stasis, biliary tree infection, and/or retained suture material.

Predisposing Factor

Factor Rationale

Advancing Age The incidence increases with age. Less than 5-6% of the population under age 60 has stones, in contrast to 25-30% of those over 80. It usually

affects people with age of over 40 but it is more prevalent after 60 years of age. It is primarily due to decreased gallbladder motility of older

person that may result in releasing of inadequate amount of bile to help digest fats.

VI. DIAGNOSTIC AND LABORATORY RESULTS

Diagnostic Laboratory Procedures

Date Indication or Purpose

Result Normal values

Analysis and interpretation of the results

Nursing Responsibilities

Ordered Result in

prior during After

HEMATOLOGY August 27, 2010

August 27, 2010

A white blood cell count is a determination of number of WBC or leukocytes/unit volume in a sample of venous blood. The test is used to detect infection or inflammation and also used to help monitor the body’s response to various

WBC 5.6 x109/L

3.5- 10.0 x109/L

NORMAL -Check if

there’s a

doctor’s

order for

CBC

-Explain

the

procedure

to the

patient

-Use standard

precaution

and sterile

technique

when getting

specimen

>apply

pressure on

the

venipuncture

site after

withdrawing

specimen

-Label the

specimen

container with

name, age,

date and time

the specimen

was

obtained,room

no., the doctor

who ordered

the specimen.

-Send the specimen to the laboratory

treatments and to monitor bone marrow function, and to determine the need for further tests, such as differential count.

immediately

Red blood cells, which are made in the bone marrow, carry oxygen from the lungs to the cells of organs in the body and transport carbon dioxide from those cells back to the lungs.

RBC 4.17

x1012/L

3.80- 5.80 x1012/L

Within normal range

When the values of the RBC count and hemoglobin decrease below the established reference range, the patient is said to be anemic. When the values increase above this range, the patient is said to be polycythemic.

Hemoglobin is an important component of red blood cells that carries oxygen and carbon dioxide to and from

HGB 119 g/L 110-165 g/L

Within normal range

tissues. The hemoglobin determination test is used to screen for diseases associated with anemia and in determining acid-base balance. The oxygen carrying capacity of the blood is also determined by the Hemoglobin concentration

Measures the percentage of RBC in a blood volume. The test is performed to help diagnose blood

HCT 0.352 LL/L

.350-.500 LL/L

Within normal range

disorders, such as polycythemia, anemia or abnormal dehydration, blood transfusion decisions for severe symptomatic anemias, and the effectiveness of those transfusions.

The smallest formed elements in blood that promote blood clotting after an injury. The test is performed to determine if blood clots normally,

PLT 302

150 –

310

X109/L

Within normal range

evaluate platelet production, and to diagnose and monitor a severe increase or decrease in platelet count

A small white blood cell (leukocyte) that plays a large role in defending the body against disease. Evaluate bacterial and viral infection, immune disease, leukemia, and ulcerative colitis

Lymphocytes 21.6 17.0-48.0

Within normal range

PT AND PTT August 28,2010

August 28,2010

Prothrombin time

13.99 sec

10-14 sec

Within normal range

Activity 95% 70-100% Within normal range

INR 1.20 1.14 Within normal range

Partial thromboplastin Time

35-45 sec

38.7 Within normal range

Abdominal ultrasound

To visualize abdominal structures by using non-invasive diagnostic technique in which high-frequency sound waves are passed into internal body structures.

IMPRESSION

> Cholecystolithiais/cystitis

>Choledocholithiases with secondary biliary

ectacia

>> Explain

the purpose

and the

procedure

of the test.

> Instruct

him not to

eat solid

food for 12

hours prior

to exam to

allow

greatest

dilation of

the

>> Explain

the following:

>patient will

be ask to lie

on the

examination

couch next to

ultrasound

machine

>the area to

be scanned

will be

exposed and a

clear water-

>> Patient can

expect to

resume

her/his normal

activities

immediately.

>inform patient regarding the result

gallbladder

>Inform patient that ultrasound is a noninvasive procedure.

soluble gel

will be

applied to the

skin for the

transmission

of sound

waves into

the patient’s

body

>a scan probe

will then be

placed in

contact with

patient’s body

and move

over the skin

to examine

the tissues

below.

>the parient

will

experience no

pain during

the procedure

>Ultrasound scans take approximately 30 min. to complete.

VII. PATIENT AND HIS CARE

MEDICAL MANAGEMENT

TREATMENT

DATE ORDERED/ DATE

PERFORMED

GENERAL DESCRIPTION INDICATIONS/ PURPOSES CLIENTS RESPONSE TO THE

TREATMENT

IVF(PNSS 1L)

Date ordered:August 30, 2010

Date discontinue:September 2, 2010

Non-pyrogenic intravenous fluid, ideal for the initial correction of extracellular fluid

Used as a means of route for medications

Ideal for patient needs fluid replcement

The client is well hydrated

NURSING RESPONSIBILITIES FOR IV THERAPY

PRIOR DURING AFTER

1. Explain the procedure to the client.

2. Review physician’s order for IV infusion (type of solution,

1. Assess the client’s response to the IV, rate of IV flow, how much has infused, how much fluid remains to be infused, and condition of the IV insertion site.

1. Check for physician’s order for discontinuing IV infusion therapy

2. Assessed for venipuncture site (if there is bleeding, inflammation,

amount to be administered, rate of flow of infusion, if there are medicine to be added / time to be completed)

2. Inspect for IV tubing patency3. Assess IV site for fluid infiltration, phlebitis,

bleeding.4. In changing the IV container, obtain the correct

solution container, flow rate, amount of solution.5. Use aseptic technique when changing IV solution

container, apply new IV tag.

phlebitis) for amount of fluid infused

3. Document relevant information, type solution used, date and time of discontinuing the infusion.

MEDICAL MANAGEMENT TREATMENT DATE ORDERED/ DATE

PERFORMED

GENERAL DESCRIPTION INDICATIONS/ PURPOSES CLIENTS RESPONSE TO THE

TREATMENT

IVF

5% Dextrose in Lactated Ringer’s Solution

Date ordered:August 29, 2010

Date shifted:August 30, 2010

-hypertonic solution that contains some form of carbohydrate and varying amount of electrolytes

- Treatment for persons needing extra calories who cannot tolerate fluid overload.- Treatment of shock.-For rehydration-To increase the blood volume

Client exhibits natural fluid and electrolyte balance.Client does not experience any dehydration

NURSING RESPONSIBILITIES

PRIOR DURING AFTER

1. Explain the procedure to the client.2. Review physician’s order for IV infusion

(type of solution, amount to be administered, rate of flow of infusion, if there are medicine to be added / time to be completed)

1. Assess the client’s response to the IV, rate of IV flow, how much has infused, how much fluid remains to be infused, and condition of the IV insertion site.

2. Inspect for IV tubing patency3. Assess IV site for fluid infiltration, phlebitis, bleeding.4. In changing the IV container, obtain the correct

solution container, flow rate, amount of solution

1. Check for physician’s order for discontinuing IV infusion therapy

2. Assessed for venipuncture site (if there is bleeding, inflammation, phlebitis) for amount of fluid infused

3. Document relevant information, type solution used, date and time of

5. Use aseptic technique when changing IV solution container, apply new IV tag.

discontinuing the infusion

MEDICAL MANAGEMENT

TREATMENT

DATE ORDERED/ DATE

PERFORMED

GENERAL DESCRIPTION INDICATIONS/ PURPOSES CLIENTS RESPONSE TO THE

TREATMENT

Oxygen therapy (3-6L/min) facial mask

Date ordered:August 30,2010

Date discontinued:August 30,2010

-Administration of oxygen at a concentration greater than that found in the environmental atmosphere.

-Facial mask is used to provide moderate oxygen support and higher concentration of oxygen and humidity

-post anesthesia recovery

-to increase amount of oxygen in the blood ,reduces the extra work of the heart, and decreases shortness of breath

-To maintain adequate ventilation.

No response from the patient because he is sedated.

NURSING RESPONSIBILITIES

PRIOR DURING AFTER

1. Check for the doctor’s order including the flow rate of O2 and what kind of O2 therapy would be used.

2. Assess patient’s vital signs.3. Explain the procedure to the patient.4. Fill the humidifier with plain NSS.5. Check the oxygen tank, humidifier, and flow

1. Assess for kinks and obstructions in the tube.2. Secure the tubing, comfortably and the device used.3. Always check the humidifier. It should be always filled

with water.4. Observe for moisture in the mask to prevent aspiration.5. Observe for pressure necrosis.6. Take note for any presence of irritation at the nares.

1. Check for client’s response to the therapy.

2. Do after care on all the materials.3. Check for skin irritations.

rate meter if they are working properly.6. Place a no smoking sign at the head of the bed.

Medical Management Treatment

Date Ordered/Performed

General Descriptions Indication/purposes Client Response

Catheterization

Foley Catheter (3 way FC)

Date ordered:August 31,2010

August 31,2010

Urinary catheterization, or "cathing" for short, a plastic tube known as a urinary catheter is inserted into a patient's bladder via their urethra. Retained by means of a balloon at the tip which is inflated with sterile water. The balloons typically come in two different sizes: 5 cc and 30 cc. which are commonly made in silicone rubber or natural rubber.

Catheterization allows the patient's urine to drain freely from the bladder for collection, or to inject liquids used for treatment or diagnosis of bladder condition.Providing relief for persons with an initial episode of acute urinary retention, allowing their bladder to regain its normal muscle tone

Bladder distension is relieved.

NURSING RESPONSIBILITIES

PRIOR DURING AFTER

1. Verify the doctor’s orders for the type of catheter to be used.

2. Explain procedure to the client. 3. Asses the time the client last voided, the

client’s age, developmental stage and sex.

1. Monitor for indication of obstruction, infection, or complications before the catheter is changed.

2. Monitor and record the output. 3. Perform catheter care.

1. Checked for the doctor’s orders for removal of catheter.

2. Reassess the patient to determine the response to catheterization.

3. Document the time, date the catheter is removed.

4. Document significant findings.

NURSING RESPONSIBILITIESPRIOR DURING AFTER

Medical Management Treatment

Date Ordered/Performed General Descriptions Indication/purposes Client Response

Penrose Drain

Date ordered:August 31,2010

Date Discontinue:---

Is consists of a soft rubber tube placed in a wound area, to prevent the build up of fluids. Promoting drainage of blood, pus and other fluids helps reduce the risk of infection and keeps the patient more comfortable.

- Prevent the area from accumulating fluid, such as blood, which could serve as a medium for bacteria to grow in.- Removes fluid from a wound area.

1. Review the physicians order for the drain2. Explain the procedure to the client3. Place the bed at an appropriate and

comfortable working height

1. Position the patient to a comfortable position

2. Assist the physician while doing the procedure

3. A large safety pin is placed on the tube outside the wound to maintain its position.

1. Place a dressing over the Penrose drain to contain drainage.

2. Secure a large safety pin on the tube outside the wound

3. Always check the dressing if it is damp4. Clean the area around the drain and incision. Apply

a new dressing change or gauze after this.5. Assess the wound area by checking for signs of

infection and drainage. Record the amount, color, consistency, and odor of any drainage. Make sure the drain is patent or free of any blockage.

DRUG STUDY

Name of drug

Date ordered, taken/given

Date changed/ D/C

Route of administration

, dosage, frequency

General action, Classification,

Mechanism of Action

Indications/

Purpose

Client response to the

medication, actual side

effects

Nursing Responsibilities

Generic Name:

cefuroxime

Brand Name:

Date ordered:

August 29,2010

9:50am

August 30, 2010

12:30pm

Date given:

August 30, 2010

Date changed:

September 2, 2010

1.5g (vial) TIV

750mg TIV q8

500mg tab TID

Classification: second-generation cephalosporin

General action: treating or preventing bacterial infections by stopping the growth of bacteria

Mechanism of action:

Inhibits cell-wall synthesis, promoting osmotic instability; usually bactericidal

Reduce incidence of certain post-

operative infection undergoing

surgical procedures

Prior:

-verify physician’s order

-check expiration date

-check for hypersensitivity to cefuroxime or other cephalosporin

-assess condition of the patient

-explain possible side effect

-check for any discoloration of the drug

-check the IV site (for inflammation, redness or swelling)

During:

-administer as prescribed

-administer over 3 to 5 minutes

-do not take a double dose to

make up for a missed one

After :

-monitor for adverse effect

-report loose stools or diarrhea promptly

-document administration of the drug

Name of drug Date ordered, taken/given

Route of administration,

General action, Classification,

Indications/ Client response to the medication,

Nursing Responsibilities

Date changed/ D/C

dosage, frequency

Mechanism of Action Purpose actual side effects

Generic Name:

Ketorolac

Brand Name:

Toradol

Date ordered:

August 30,2010

Date given:

August 30, 2010

30 mg TIV Classification:

NSAID

General action:

Analgesic, relieve pain

Mechanism of action:

Anti-inflammatory and analgesic activity; inhibits prostaglandins and leukotriene synthesis

Short-term management of

pain (up to 5 days) of moderately

severe acute pain. It is most open

used after surgery.

Pain was relieved

No actual side effects

Prior:

- Assess patient for contraindication.- Assess for baseline data.

- Tell patient that he may experience side effects brought upon by the drug.

During:

-provide comfort measures

-administer the drug slowly

After:

- Provide comfort measures if headache occurs.

-Instruct to report intolerable side effects for prompt intervention

- Instruct to report signs of bleeding such as black tarry stool, weakness and dizziness upon standing.

Name of drug Date ordered, Route of General action, Indications/ Client response to Nursing Responsibilities

taken/given

Date changed/ D/C

administration, dosage,

frequency

Classification, Mechanism of Action Purpose

the medication, actual side effects

Generic Name:

Buspirone HCl

Brand Name:

Buspar

Date ordered:

August 30,2010

Date given:

August 30, 2010

Classification:

Anxiolytic

General action:

Mechanism of action:

Mechanism of action not known; lacks antiseizure, sedative, or muscle relaxant properties; binds serotonin receptors, but the clinical significance is unclear

Management of short term relief of

symptoms of anxiety.

Prior:

- Assess for contraindication.- Assess for baseline data.

- Tell patient that he may experience side effects

During:

- Monitor for occurrence of adverse effects

After:

-Monitor vital signs carefully, drug depresses the pulmonary and cardiac system.

-Monitor for side effects.

- Oral care if vomiting occurs.

Name of drug Date ordered, Route of General action, Indications/ Client response to Nursing Responsibilities

taken/given

Date changed/ D/C

administration, dosage,

frequency

Classification, Mechanism of Action Purpose

the medication, actual side effects

Generic Name:

Potassium chloride

Brand Name:

Kalium durules

Date ordered:

August 28,2010

Date given:

August 28, 2010

Discontinue:

August 29, 2010

2 tab BID Classification:

Potassium salt

General action:

maintains potassium levels

Mechanism of action:

Replaces potassium and maintains potassium levels

Indicated to prevent

hypokalemia

Prior:

- Do not open foil-wrapped powders and tablets before use.

- Do not self prescribe laxatives. Chronic laxative use has been associated with diarrhea-induced K+ loss

- Do not use salt substitute unless specifically ordered by Dr.

- Avoid licorice, large amounts cause both hypokalemia and Na+ retention

During

- Instruct patient to avoid salt substitutes or low-salt milk or food unless approved by health care professional.

After

- Notify Dr. of persistent vomiting

because losses of K+ can occur

- A missed dose should be taken as soon as remembered within 2 hr; if not, return to regular dose schedule.

- Instruct patient to report dark, tarry, or bloody stools; weakness; unusual fatigue; or tingling of extremities.

Name of drug Date ordered, taken/given

Route of administration

General action, Classification,

Indications/ Client response to

Nursing Responsibilities

Date changed/ D/C

, dosage, frequency

Mechanism of Action Purpose

the medication, actual side

effects

Generic Name:

Vitamin K

Brand Name:

Aqua-Mephyton

Date ordered:

August 28,2010

Date given:

August 28, 2010

10mg 1 amp IM q8

Classification:

Fat soluble vitamin

General action:

Plays an important role in blood clotting

Mechanism of action:

Vitamin K is essential for the hepatic synthesis of factors II, VII, IX, and X, all of which are essential for blood clotting. Vitamin K deficiency causes an increase in bleeding tendency, demonstrated by ecchymoses, epistaxis, hematuria, GI bleeding.

Prevention of bleeding, Vitamin K malabsoption, hypo-prothrombinemia

Prior:

- Assess for contraindication.- assess for baseline data.

- Tell patient that he may experience side effects brought about by the drug and to report intolerable ones so as prompt interventions be done.

During:

- do not to take with other supplements

After:

- monitor for bleeding,pulse and BP-Instruct patient to report adverse effect that he may experience.

-Instruct patient to report symptoms of bleeding: bruising, nosebleeds, bleack tarry stools, hematuria.

Name of drug Date ordered, taken/given

Route of administration

General action, Classification,

Indications/ Client response to the medication,

Nursing Responsibilities

Date changed/ D/C

, dosage, frequency

Mechanism of Action Purpose actual side effects

Generic Name:

losartan

Brand Name:

Cozaar

Date ordered:

August 29,2010

Date given:

August 29, 2010

50mg tab STAT Classification:

Antihypertensive

General action:

Reduce blood pressure level

Mechanism of action:

Selectively blocks the binding of angiotensin II to specific tissue receptors found in the vascular smooth muscle and adrenal gland; this action blocks the vasoconstriction effect of the renin-angiotensin system as well as the release of aldosterone leading to decreased blood pressure.

Treatment of hypertension, alone or in combination with other antihypertensive agents

Prior:

- Assess patient’s blood pressure before starting therapy and regularly and pulse rate.

- Assess for hydration status: mucous membranes and skin turgor

- Ensure that patient is not pregnant before beginning therapy, suggest using barrier birth control while using losartan.

- Obtain baseline liver and renal function before therapy and regularly assess kidney function BUN and creatinine.

During:

- Take drug without regard to meals. Do not stop taking this drug without consulting your health care provider.

After:

- Tell patient to avoid sodium substitutes because it may contain potassium which can cause

hyperkalemia

-Teach patient to avoid sunlight or wear sunscreen because photosensitivity may occur.

- Monitor patient closely in any situation that may lead to a decrease in blood pressure.

- Report fever, chills, dizziness, pregnancy.

Name of drug Date ordered, taken/given

Route of administration,

dosage,

General action, Classification, Mechanism of

Indications/

Purpose

Client response to the medication,

Nursing Responsibilities

Date changed/ D/C

frequency Action actual side effects

Generic Name:

metoprolol

Brand Name:

Neobloc

Date ordered:

August 27,2010

Date given:

August 27 2010

50mg tab PO BID Classification:

Anti-hypertensive drug, Beta-blocker

General action:

Reduce blood pressure level

Mechanism of action:

A selective beta blocker that selectively blocks beta 1 receptors, decreases cardiac output, peripheral resistance and cardiac oxygen consumption and depresses rennin secretion.

Hypertension and chronic angina pectoris

Prior:-Monitor V/S for baseline data.-Assess for asthma,emphysema, depression,circulation problems, liver or kidney disorders; may preclude drug therapy.During:-Take with food.-Do not crush or chew; swallow tablets whole.-Take at same time each day; do not stop suddenly.After:-Do not discontinue the drug abruptly.-Avoid activities that require mental alertness until drugs effect realized.-Continue with diet, regular exercise and weight loss in the overall plan to control BP

Name of drug Date ordered, taken/given

Route of administration

General action, Classification,

Indications/ Client response to the medication,

Nursing Responsibilities

Date changed/ D/C

, dosage, frequency

Mechanism of Action Purpose actual side effects

Generic Name:

clonidine

Brand Name:

Catapres

Date ordered:

August 29,2010

75mg tab SL

PRN >160/100 mmHg

Classification:

Antihypertensive

General action:

Reduce blood pressure level

Mechanism of action:

Stimulates CNS alpha2-adrenergic receptors, inhibits sympathetic cardioaccelerator and vasoconstrictor centers, and decreases sympathetic outflow from the CNS.

Hypertension, used alone or as part of combination therapy

Not taken Prior:

- Assessment hypersensitivity to clonidine or severe coronary insufficiency, recent MI, cerebrovascular disease.

-Note evidence of alcohol, drug or nicotine addiction.

Monitor V/S especially the BP.

During:

- Take this drug exactly as prescribed. Do not miss doses.

-If taken PO, take last dose of the day at bedtime to ensure overnight control of BP.

After:

-Do not engage in activities that require mental alertness such as operating machinery and driving.

-Do not discontinue the drug abruptly.

-Record weight daily, in the morning.

- Report urinary retention, changes in vision, blanching of fingers, rash.

Name of drug Date ordered, taken/given

Route of administration

, dosage,

General action, Classification,

Mechanism of Action

Indications/

Purpose

Client response to the medication,

Nursing Responsibilities

Date changed/ D/C

frequency actual side effects

Generic Name:

Paracetamol

Brand Name:

Acetaminophen

Date ordered:

August 31,2010

300mg IV q 4

>37.5 C

Classification:

non-opioid analgesic

General action:

produce analgesia by blocking pain impulses

Mechanism of action: inhibits synthesis of prostaglandin that may serve as mediators of pain primarily in the CNS or other substances that sensitize pain receptors to stimulation

For fever and mild pain

Not taken Prior administration:

-Verify physician’s order

-check for the expiration date

-check hypersensitivity to the drug

-explain for possible side effect

-assess the type, location and intensity of pain

PO-assess for vomiting

During administration:

-administer as prescribed

IV-slowly administer at least over 3-5 minutes

PO-take with food

-take with full glass of water

After administration:

-assess for pain relief

-monitor and report for side effects

-document administration of the drug

Name of drug Date ordered, Route of General action, Indications/ Client response to Nursing Responsibilities

taken/given

Date changed/ D/C

administration, dosage,

frequency

Classification, Mechanism of Action

Purposethe medication,

actual side effects

Generic Name:

celecoxib

Brand Name:

celebrex

Date ordered:

September 2,2010

Date given:

September 2,2010

200mg cap BID Classification:

Nonsteroidal

Anti- inflammatory

Drug

General Action

Pain Reliever

Mechanism of Action

-Inhibits prostaglandin

synthesis, primarily by

inhibiting cyclo-

oxygenase-2 thus

decreasing

inflammation.

Indication:

-Acute and long-

term treatment of

signs and

symptoms of

rheumatoid

arthritis and

osteoarthritis

-Management of

acute pain

-Treatment of

primary

dysmenorrhea

PRIOR

Determine any GI bleed/ulcer history, sulfonamide allergy, aspirin and other NSAID-induced asthma, urticaria, allergic type reaction

Monitor sign and symptoms Assess for liver or renal

dysfunction; reduce dose

DURING

Take with foods; decreases stomach upset

AFTER

Monitor CBC and electrolytes Determine any G.I bleed

Name of drug

Date ordered, taken/given

Date changed/ D/C

Route of administration,

dosage, frequency

General action, Classification,

Mechanism of Action

Indications/

Purpose

Client response to the medication,

actual side effectsNursing Responsibilities

Generic Name:

Simvastatin

Brand Name:

Zocor

80mg 1/2 tab OP OD Classification:

Anti-hyperlipedimia

General action:

Catalyzes the early rate- limiting step in the synthesis of cholesterol.

Mechanism of action:

Inhibit an enzyme, 3-hydroxy-3-methylglutaryl- coenzyme A (HMG-CoA) reductase, which is responsible for catalyzing an early step in the synthesis of cholesterol.

An adjunct to diet when the response to a diet restricted

in saturated fat and cholesterol and

other nonpharmacologic

measures alone has been inadequate. In patients with coronary heart

disease (CHD) or at high risk of CHD.

Prior:

-Obtain base line data of the patient.

-Instructed patient that this medication should be used in conjunction with diet restrictions (fat, cholesterol, carbohydrates, and alcohol), exercise, and cessation of smoking.

During:

- Instruct patient to take medication as directed and not to skip doses or double up on missed doses.

- Advise patient to avoid drinking more that 1 qt/day of grapefruit

juice during therapy.

After:

- Instruct patient to notify health care professional if unexplained muscle pain, tenderness, or weakness occurs.

- Advise patient to wear sunscreen and protective clothing to prevent photosensitivity reactions (rare).

-Emphasize the importance of follow-up exams to determine effectiveness of the drugs.

Name of drug Date ordered, Route of General action, Indications/ Client response to Nursing

taken/given

Date changed/ D/C

administration, dosage, frequency

Classification, Mechanism of Action Purpose

the medication, actual side effects

Responsibilities

Generic Name:

captopril

Brand Name:

Capoten

Date ordered:

August 30,2010

Date given:

August 30, 2010

Classification:Angiotensin-converting enzyme (ACE) inhibitorAntihypertensive

General action: Reduce level of blood pressure

Mechanism of action:Blocks ACE from converting angiotensin I to angiotensin II, a powerful vasoconstrictor, leading to decreased blood pressure, decreased aldosterone secretion, a small increase in serum potassium levels, and sodium and fluid loss; increased prostaglandin synthesis also may be involved in the antihypertensive action.

Treatment of hypertension alone or in combination with thiazide-type diuretics

Prior:-assess history of allergy to drug-inform the patient for possible side effects

During:-Administer 1 hour before meal-monitor patient closely for drop in BP

Post:- mark patient's chart with notice that captopril is being taken-instruct to consult health care provider if light-headedness or dizziness occurs,

Name of drug

Date ordered, taken/given

Date changed/ D/C

Route of administration,

dosage, frequency

General action, Classification,

Mechanism of Action

Indications/

Purpose

Client response to the

medication, actual side

effects

Nursing Responsibilities

Generic Name:

Metformin

Brand Name:

Fortamet, Glucophage,

Glumetza, Riomet

Date ordered:

August 27,2010

Date given:

August 27 2010

80mg tab OD Classification:

Antidiabetic, oral;

Biguanide

General Action:

Antidiabetic

Mechanism of Action:

Decreases hepatic glucose production, decreases intestinal absorption of glucose, and increases peripheral uptake and utilization of glucose.

-Improve glycemic control in clients with type 2 diabetes.

- Extended-Release form used to treat type 2 diabetes as initial therapy.

Prior - Check doctors order for latest dosage, frequency & route.- assess for history of allergy to drug- Inform the patient about the possible side effects that he/she can feel upon administration of drug

During-avoid using alcohol while taking these drug-instruct to swallow extended-release tablets whole-do not crush,cut or chew

After-monitor urine or serum glucose levels frequently to determine effectiveness of drug-instruct to do not discontinue drug without the doctors order.

DIET

Type of diet

Date Started

Date ChangeGeneral

DescriptionIndication/Purposes

Specific foods/fluids

taken

Client Respons

e

Nursing Responsibilities

Prior During Post

NPO(Nothing Per Orem)

An instruction meaning to withhold oral foods and fluidsbut for patients who will undergo surgery the physician will allow before intake of medication

This diet is usually ordered for preparation prior to surgery specially who will undergo general anesthesia to prevent aspiration pneumonia

none Feels very hungry and thirsty

-asses the level of understanding of the patient-Explain the importance of following strictly NPO diet in terms that the client can understand and then evaluate

-Strictly monitor clients behavior in following NPO diet

-Educate the client of what kind of food he can eat after NPO diet

General Liquid Diet

Diet that allows intake of fluid or liquid forms of food only

Before DAT diet is instructed the physician first ordered general liquid diet to train

-Asses the level of understanding of the patient-Explain the importance of following strictly General Fluid diet

-Strictly monitor clients behavior in following General

-Educate the client of what kind of food he can eat after General Liquid diet

the normal digestion and to bring back the normal digestion process

in terms that the client can understand and then evaluate-Emphasize what kind of foods the client can eat during this diet.

Liquid diet

DAT(diet as tolerated)

(until discharge)

It is a diet that allows the patient to eat all types/kinds of foods as long as the client can tolerate it

Instructed following a general liquid diet for better source of good nutrition

-Asses the level of understanding of the patient-Explain that immediate shifting of foods from NPO to General Fluids to DAT without undergoing soft diet can result to constipation thats why we need to emphasize eating first soft foods before eating any solid foods

-Strictly monitor clients behavior in following DAT diet

-Educate the client of what kind of food he can now eat that he can tolerate

ACTIVITY AND EXERCISE

TYPE OF EXERCISES DATE STARTED GENERAL DESCRIPTION INDICATION AND PURPOSE

CLIENT RESPONSE TO EXERCISE

NURSING RESPONSIBILITY

ACTIVE ROMAn exercise accomplished by the patient without assistance. Activities include turning from side to side and from back to abdomen and moving up and down on bed.

-Helps keep joint and muscle as healthy as possible-Increases muscle strength

PRIOR:- Ensure that the patient understand the reason for doing the exercise- Assist client to sit on bed

DURING:- Assist patient while doing the exercise if necessary.- Check if there is difficulty in breathing- Check if he feels any pain while doing the exercise

AFTER:- Check if he feels any pain after the exercise- Monitor the V/S of the patient to check if there is changes

TYPE OF EXERCISES DATE STARTED GENERAL DESCRIPTION INDICATION AND PURPOSE

CLIENT RESPONSE TO EXERCISE

NURSING RESPONSIBILITY

AMBULATIONA type of exercise that requires the patient to move by feet

Act of travelling by foot

Walk from place to place

aids in good circulation

facilitate voiding

stimulate peristalsis

prevent thromboembolism

The patient tolerated the exercise but he felt little bit tired

PRIOR:-Assess patients ability to tolerance the procedure-Assess the patient if she needs assistance performing the procedure-Explain the procedure to the client

DURING:-Assess the client if needed-Encourage client to ambulate independently if she is able, but walk beside the client-Be alert for signs of activity intolerance

AFTER-Assess vital signs-Document significant findings

VIII. SURGICAL MANAGEMENT

Open Cholecystectomy with Biliary ExplorationCholedochoduodenostomy

Type of operation

Definition:

A cholecystectomy is the surgical removal of the gallbladderA choledochoduodenostomy is the surgigal creation of a passage uniting the common bile duct and the duodenum.

Discussion:Cholecystectomy may be performed to treat chronic or acut cholecystitis, with or without cholelithiasis, or to resect a malignancy.

Choledochoduodenostomy may be performed for a biliary bypass operation are benign biliary strictures and malignant obstruction of the biliary system caused by pancreatic or biliary ductal carcinomas.Indicated mainly in patients with recurrent stones, giant stones, or concominant common bile stricture and stones.

Note:Cholecystectomy, perfomed laparospically, is the preferred treatment for symptomatic gallstones unless the patient is extremely obese, there are excessive adhesions, or ductal or vascular anomalies exist. If unexpected pathology is encountered, if acute inflammation distorts normal tissue planes, or if there is excessive bleeding or surgical injury, the laparoscopic procedure is promptly converted to “open” cholecystectomy.

Choledochoduodenostomy is also useful for preventing cholangitis caused by recurrent stones in patients with chronic disease, such as chronic heart failure, chronic respiratory failure, and diabetes.Main indication for biliary obstruction either benign or malignant.

Type of AnesthesiaSpinal Anesthesia Block- is induced by injecting small amounts of local anaesthetic into the cerebro-spinal fluid (CSF). The injection is usually made in the lumbar spine below the level at which the spinal cord ends (L2). Spinal anaesthesia is easy to perform and has the potential to provide excellent operating conditions for surgery below the umbilicus.

Instrumentation/ Device Number Size Comments

Laparoscopic cartHigh-intensity halogen light source(150–300 watts)High-flow electronic insufflator(minimum flow rate of 106 L/min)Laparoscopic camera boxVideocassette digital video and still imagerecorder (optional)Digital still image capture system (optional)

Laparoscope 1 3.5-10mm

Available in 0° and angled views; we prefer to use a 30°5 mm diameter laparoscope

Atraumatic grasping forceps 2-4 2-10mm Selection of graspers should allow surgeon choiceappropriate to thickness and consistency of gallbladderwall; insulation is unnecessary

Large-tooth grasping forceps 1 10mm Used to extract gallbladder at end of procedure

Curved dissector 1 2-5mm Should have a rotatable shaft; insulation is required

Scissors 2-3 2-5mm One curved and one straight scissors with rotating shaftand insulation; additional microscissors may be helpfulfor incising cystic duct

Clip appliers 1-2 5-10mm Either disposable multiple clip applier or 2 manuallyloaded reusable single clip appliers for small andmedium-to-large clips; 5 and 10 mm diameter

Dissecting electrocautery hook or spatula 1 5mm Available in various shapes according to surgeon’spreference; instrument should have channel for suctionand irrigation controlled by trumpet valve(s); insulationrequired

High-frequency electrical cord 1 Cord should be designed with appropriate connectorsfor electrosurgical unit and instruments being used

Suction-irrigation probe 1 5-10mm Probe should have trumpet valve controls for suctionand irrigation; may be used with pump forhydrodissection

10-to-5 mm reducers 2 Allow use of 5 mm instruments in 10 mm trocarwithout loss of pneumoperitoneum; these are oftenunncessary with newer disposable trocars and may bebuilt into some reusable trocars

5-to-3 mm reducer 1 Allows use of 2–3 mm instruments and ligating loopsin 5 mm trocars

Ligating loops

Endoscopic needle holders 1-2 5mm

Cholangiogram clamp with catheter 1 5mm Allow passage of catheter and clamping of catheterin cystic duct

Veress needle 1 Used if initial trocar is inserted by percutaneoustechnique

Allis or Babcock forceps 1-2 5mm Allow atraumatic grasping of bowel or gallbladder

Long spinal needle 1 14gauge Useful for aspirating gallbladder percutaneously incases of acute cholecystitis or hydrops

Retrieval bag 1 Useful for preventing spillage of bile or stones inremoval of infl amed or friable gallbladder; facilitatesretrieval of spilled stones

A cholecystectomy with choledochoduodenostomy was performed with patient under Spinal Anesthesia Block in supine position, a right subcostal incision was made; the adhesion was released, and the area of the hepatoduodenal ligament was dissected. The cholecystectomy was performed in the usual manner.

A right subcostal incision is usually performed.The duodenum is widely mobilized by generous Kocher maneuver, so that it can be approximated to the common bile duct without tension. A 2.0- 2.5 cm longitudinal incision is made in the distal common bile duct as close as possible to the area of stenosis or obstruction in

patients with benign disease. In patients with a stricture, the bile duct is divided and the stricture excised. The duodenum and duct are joined by a posterior or row of interrupted 3-0 silk sutures. The duodenum is opened longitudinally for a distance of 2.0- 2.5cm and a second row of interrupted 3-0 or 4-0 chromic catgut. Sutures is placed to approximate the ductal and duodenal mucosa. A T-tube is used in patients with thin walled ducts or difficult anastomosies. A final row of interrupted 3-0 silk sutures completes the anterior row of anastomosies.

Procedure

Preparation of the Patient:

Antiembolitic hose may be put on the legs, as requested. The patient is supine; both arms may be extended on padded

armboards. A pillow may be placed under the sacrum and/ or under the knees to avoid straining back muscles. Pad all bony

prominences and areas vulnerable to skin and neurovascular pressure of trauma. A nasogastric tube may be inserted by the

anesthesia provider. A foley catheter is not routinely placed. An electrosurgical dispersive pad is applied.

Skin Preparation:

Begin at the intended site of incision, either right subcostal (most frequently used), right paramedian, or medline,

extending from the axilla to the pubic symphysis and down to the table on the sides.

Draping:

4 folded towels and a laparotomy sheet

Procedure:The incision is right subcostal, right paramedian, or midline. The abdominal cavity is entered in the usual manner. The gallbladder is grasped (generally with a Pean clamp). The cystic duct, cystic artery, and common bile duct are exposed. The surgeon must be aware of anomalies of these structures. The cystic artery is clamped (using two right-angle clamps) and ligated with a suture passed on a long instrument or by clips (e.g., Hemoclips), as is the cystic duct. The gallbladder is mobilized by incising the overlying peritoneum and after local dissection is removed. The underlying liver bed may be reperitonealized. A drain (e.g., Jackson-Pratt ™) may be employed exiting a stab wound and secured to the skin with a stitch. The wound is closed in layers. The skin is closed with interrupted stitches, tapes, or skin staples.

NURSING RESPONSIBILITY

Preoperative All care that is given and observations made regarding the patient (e.g., condition of skin preoperatively) must

be documented in the operative record for continuity of care and for medicolegal reasons. The nurse conveys to the patient that he will act as the patient’s advocate by speaking for him while the patient

is in surgery. Assess health factors that affects the patient preoperatively: nutritional status, drug or alcohol use,

cardiovascular status, hepatic and renal function, endocrine function, immune function, previous medication use, psychosocial factors, as well as the spiritual and cultural beliefs.

When the circulator reviews patient allergies with the patient, he ascertains that the patient has no history of allergy to radiopaque dye.

Inform the patient of the scheduled date and time of the surgery and where to report Instruct what to bring (insurance card, list of meds & allergies) Check the chart for patient’s sensitivities and allergies e.g. allergy to iodine. Document allergies noted

preprocedure and document alternative used. Instruct what to leave at home such as jewelry, watch, medications and contact lenses Instruct what to wear ( loose fitting, comfortable clothes and flat shoes) Remind the patient not to eat or drink if directed The patient may have fear and anxiety regarding the surgical procedure and the unfamiliar environment. Explain

nursing procedures before performing them and the sequence of perioperative events. Assess and document patient’s anxiety level and level of knowledge regarding the intended procedure. Clarify

misconceptions by answering the patient’s questions in a knowledgeable manner and refer questions to the surgeon as necessary.

Decrease fear Teach deep-breathing, coughing or incentive spirometer Provide emotional support to the patient regarding feelings of altered body image by providing the patient an

opportunity to express her feelings. Respect cultural, spiritual and religious beliefs

Intraoperative It is imperative that the patient be positioned over the correct area on the table to ensure accurate visualization of the biliary tract.

A protective facial shield is suggested for those scrubbed to avoid inadvertent splashing of contaminated fluids onto mucous membranes and eyes.

All medications, dyes, etc., on the opening field must be labeled. Scrub person should use a marking pen on labels to identify all solutions. All medication containers should be kept in the room until the completion of the procedure.

Instruments used on the gallbladder are isolated in a basin (considered contaminated) Prevent musculoskeletal injuries to team members by employing ergodynamic measures when positioning the

patient. Take appropriate measures to maintain patient’s body temperature e.g., offer warm blanket or raise room

temperature as necessary. Keep the patient adequately covered to maintain patient’s privacy, expose only the immediate area involved for

the procedure. Strictly follow the principles of surgical asepsis Keep surgical conscience Count all instruments and sharps with circulating nurse before and after the procedure Know the name and use of the instrument Never pile the instruments on top of each other Know the name and use of the instrument and handle the instrument individually Hand the surgeon the correct instrument Pass the instrument firmly and decisively Be careful in handling of sharp instruments at all times The scrub person sets up the instruments on the back table for the surgeon. Scrub person needs to have a right angle clamp (Mixter) available throughout the dissection of the biliary tree. Usually a stab wound is made in the cystic duct using a #11 blade. The incision is extended with Pott’s scissors. Have T-tubes available following common duct exploration One syringe is filled with saline, and a second syringe is filled with radiopaque dye diluted to half strength

(labeled accordingly) Scrub person takes care to make certain that the saline or dye catheters are devoid of air bubbles (which can be

confused for calculi) Use a small basin to accept the specimen Aerobic and anaerobic cultures may be taken of the bile or gallbladder bed.

Postoperative

The circulator accompanies the anesthesia provider and the patient to the PACU; he/she gives the PACU perioperative practioner a detailed intraoperative patient report regarding the course of events as they apply to the individual.

Assess the patient: appraise air exchanges status & note skin color; verify & identify operative status & surgeon performed; assess neurological status (LOC)

PACU nurse observes the patient’s breathing, monitors blood pressure and vital signs, and documents all pertinent information.

PACU nurse assumes the role as the patient’s advocate.. Report for abnormalities especially for signs and symptoms of shock Perform safety checks – good body alignment, side rails and maintain patent airway and cardiovascular

stability Relieve pain and anxiety

Client Response

Pre operative: Patient complaint of pain on right upper quadrant Feeling of fear to the procedure.

Intra Operative: Patient is sedated

Post operative: Patient finds it hard to sleep because of pain felt on the incision site Client appears weak

Skin color improvement from jaundice to slight jaundice as of August 24, 2009IX. NURSING CARE PLAN

ASSESSMENT NURSING DIAGNOSIS

BACKGROUNDKNOWLEGDE

PLANNING NURSING INTERVENTION

RATIONALE EXPECTED OUTCOME

Subjective: Elevated body Exogenous pyrogen Short term goal: Independent: Short term goal:

“Nilalamig ako”as verbalized by the client.

Objective: cold clammy

skin hot flsh warm to touch v/s as follows:

T- 38.3*CPR- 77 bpm

RR- 22 cpm

temperature related to Infection.

(expose to foreign microorganism)

Bacterial invasion

Release of substances

(activation of TNF, interleukins and

interferons)

Hypothalamus signals increase in heat production

Fever

After 30 minutes of nursing intervention the patient temperature will decrease from 39.2 oC to 37.5 oC.

Long term goal:After 1-2 days of nursing intervention the patient vital sign will be on normal range especially the temperature.

Provide tepid sponge bath

Encourage to wear hypothermic clothing

Promote bed rest

Promote inatake of caloric rich food and rich in vitamin C

Dependent: Administer

medication as ordered by the physician

To decrease body temperature through evaporation

To provide comfort

To regain loss energy due to illness process

To adapt on the increasing metabolism of the client during fever. Vitamin C boosts immune system and resistance to infection.

To decrease body temperature

Source:

The patient temperature was decrease from 39.2 oC to 37.5 oC.

Long term goal:After 1-2 days of nursing intervention the patient vital sign was on normal range especially the temperature.

Mattson Porth, Essentials of Pathophysiology Concepts of Altered Health Status, Lippincott Williams and Wilkins 2007

Nurses pocket guide

Diagnoses, prioritize intervention and rationale, 11th Edition.

ASSESSMENT DIAGNOSIS SCIENTIFIC BACKGROUND PLANNING INTERVENTION RATIONALE EVALUATION

Subjective:“nangangati yung tahi ko”, as verbalized by the client.

Objective Moist intact

Impaired skin integrity related to inadequate primary defences (surgical incision)

Surgical incision on the right upper quadrant and epigastric area of the

abdomen

Trauma to the skin

Short term:After 3 hours of nursing intervention the patient will verbalize understanding of condition and

Place in a comfortable position

Monitor and record vital signs

To prevent back aches or muscle aches

To note any significant changes that may be brought about

Short term:Goal met, patient was verbalized an understanding of the condition and causative factor.

Long term:

dressing at the right lower quadrant.

Feeling of itchiness

Destruction of skin surface

Thus, impairing the integrity of the skin

Source:http://www.nlm.nih.gov/medlineplus/ency/article/002930.htm

causative factor.

Long term:After 2 days of nursing intervention the patient displays progressive improvement in wound healing.

Practiced aseptic technique for cleaning, dressing, medicating wound

Emphasize importance of proper nutrition and fluid intake

Encourage adequate period of rest and sleep

Promote early ambulation

by the disease Reduce risk for

infection

To maintain general good health and skin turgor

To limit metabolic demands, remain energy available for healing and meet comfort needs

Promote circulation and prevent excessive tissue pressure.

Source:Nurses pocket guideDiagnoses,

Goal met, patient displays progressive improvement in wound healing.

prioritize intervention and rationale, 11th Edition.

ASSESSMENT DIAGNOSIS SCIENTIFIC BACKGROUND

PLANNING INTERVENTION RATIONALE EVALUATION

Subjective: Ø

Objective

Risk for infection related to inadequate primary defences (surgical incision).

Surgical Incision

Traumatized tissue on the injured site

Short term:After 2 hours of nursing intervention the patient will verbalize understanding to

Independent: Monitor Vital

signs. Note onset of fever, chills and diaphoresis.

Practice hand

Suggestive of presence of infection or developing sepsis.

Short term:Goal met, patient was verbalized an understanding to prevent or reduce risk of infection.

Presence of an incision site on right lower quadrant.

s/p cholecystectomy with biliary exploration.

Increasing risk of infection

May result to further complication if not

prevented

Mattson Porth, Essentials of Pathophysiology Concepts of Altered Health Status, Lippincott Williams and Wilkins 2007

prevent or reduce risk of infection.

Long term:After 2 days of nursing intervention the patient will be able to demonstrate techniques to promote timely wound healing without any complication.

washing and aseptic wound care.

Inspect incision and dressing.

Dependent: Administer

medications as prescribed (antibiotics).

Cleanse incision site with povidone iodine.

Instruct not to wet incision site.

Emphasise importance of adequate nutritional and fluid intake.

Encourage

Reduce risk of spread of bacteria or prevent cross contamination.

Provide early detection of developing infectious process.

Prevent invasion of bacteria or microorganism at site and eventually prevents possible infection.

Disinfect site and prevent multiplication of microorganism which may cause infection.

Microorganism thrives at damp areas and makes it conducive for replication.

Maintain general good health and

Long term:Goal met, patient was able to demonstrate techniques to promote timely wound healing without any complication.

ambulation as tolerated.

skin turgor.

To enhanced good circulation.

Source:Nurses pocket guideDiagnoses, prioritize intervention and rationale, 11th Edition.

ASSESSMENT DIAGNOSIS SCIENTIFIC BACKGROUND

PLANNING INTERVENTION RATIONALE EVALUATION

Subjective:“hindi ko nga alam kung paano ako nagkaron ng bato sa apdo e” as verbalized by the client.

Deficient Knowledge related to unfamiliarity with information resources.

Lack in information resources

Feeling of

After 4 hours of nursing intervention the patient will verbalize understanding of

Determine ability or readiness and barriers to learning.

Identify support

Individual may not be physically, emotionally or mentally capable.

Goal met, patient was verbalized an understanding of condition or disease process or treatment.

Objective Unawareness

unawareness

Deficient Knowledge

condition or disease process or treatment.

persons or SO requiring information.

Note personal factors such as age, cultural influences, religion, and level of education.

Provide positive reinforcement.

Provide mutual goal setting and learning contracts.

Provide written information or guidelines and self learning modules.

Begin with information already know and move to what does not know.

May need to help SO to learn.

To facilitate learning.

Can encourage continuation of effort.

Clarifies expectation of teacher and learner.

Reinforces learning process, allows to proceed at own pace.

Can allows interest and limits sense of being overwhelm.

ASSESSMENT DIAGNOSIS SCIENTIFIC BACKGROUND

PLANNING INTERVENTION RATIONALE EVALUATION

Subjective:“pauwi na ako, meron na lang akung iinuming gamut sa amin,” as verbalized by the client.

Readiness for enhance therapeutic regimen management

Verbalization of willingness to follow home health maintenance

Short term After 4hours of nursing intervention the patient will assume responsibility for managing

Verify client’s knowledge/understanding of therapeutic regimen

Identify steps necessary to reach desired goal

Provides opportunity to assure accuracy and completeness of knowledge base for future learning

Understanding the process enhances

Short term Goal met, patient was assumed responsibility for managing treatment regimen.

Long term Goal met, patient was

Objective

Willingness to follow

Assumes responsibility in maintaining health

Readiness for enhance therapeutic regimen management

treatment regimen.

Long term After 2 days of nursing intervention the patient will remain free of preventable complications/progression of illness.

Accepts clients evaluation of own strengths/ limitations while working together to improve abilities.

Acknowledge individuals efforts/ capabilities to reinforce movement toward attainment of desired outcomes.

Assist in implementing strategies for monitoring progress/ responses to therapeutic regimen.

commitment and the likehood of achieving the goals.

Promotes sense of self-esteem and confidence to continue efforts

Provides positive reinforcement encouraging continued progress toward desired goals

Problem proactive problem solving

remain free of preventable complications/progression of illness.

X. HEALTH TEACHINGS

HEALTH TEACHING RATIONALE1. Encourage to decrease intake of foods high in fat/ cholesterol.

2. Explain the importance of ambulation.

After cholecystectomy, the liver still produce bile but in a slow tickle process, therefore if the diet is high in fat, the malabsorption of fat occurs because the minimal production of bile cannot handle the normal absorption process

To promote good circulation.

3. Explain to the patient the importance of deep breathing exercises/ divertional activities.

4. Explain to the patient the importance of splinting.

5. Explain to the patient not to touch the incision site with bare hands.

6. Explain to the patient the importance of eating small frequent meals (preferably 4-6 meals) rather that to eat 3 times a day.

7. Explain the importance of proper hygiene

8. Explain to the patient the importance of maintaining a clean and well ventilated environment.

Deep breathing exercises/ divertional activities help to reduce pain. Splinting reduces the pressure in the abdomen thus reducing the pain.

To prevent infection

Since cholecystectomy is done, the liver will compensate by excreting slow and low level of bile that can cause the malabsorption of fat.

Prevent the spread of microorganism/ cross contamination

To reduce the risk of infection and to promote patient’s comfort.

XI. DISCHARGE PLANNING

MEDICINES:

Instructed to continue home medication Give relevant information about the drugs, their side effects and their adverse effects Teach the following to the client with regards to proper administration of the prescribed medication

-right patient -right assessment-right drug -right documentation

-right time -right to educate-right dose -right to evaluate-right route -right to refuse

ENVIRONMENT AND EXERCISE

Encourage to establish a clean and well ventilated environment Avoid strenuous exercise that cause tension on the affected area and further deprivation Daily activities should be spaced to provide rest periods between times of exercise

TREATMENT

Advise to continue to take the prescribed home medication until end of the regimen or unless specified by the physician Instruct him to visit physician to follow-up check-up

HEALTH TEACHING

Explain to patient what to expect afterwards. As the anesthetic wears off, there is likely to be some pain. The anesthetist will prescribe pain killers. Suffering from pain san slow down recovery, so it’s important to discuss any pain with the doctors or nurses

Instruct caring for the stitches, hygiene and bathing and will arrange an outpatient appointment for the stitches to be removed. Instruct patient to comply with the home medications that would be given by his physician. Encourage the patient to do the recommended light exercises such as walking. Avoid doing strenuous activities which could low down his recovery Encourage him to comply with the dietary modifications; limit the intake of saturated fat to prevent the occurrence of serious post-cholecystectomy side

effects Explain to the patient to refer for unusualities immediately

OUT PATIENT CARE

Instruct to visit the physician for follow-up check-up If any of the following symptoms are noted he should contact his doctor

-if the wound become more painful, red, inflamed or swollen

-if the abdomen swells

-if the pain is not relived by the prescribed painkillers

-if a fever develops these could be a sign of an infection that may need to e treated with antibiotics

DIET

Should limit the intake of foods high in fat Should eat smaller amount of foods during a single meal. Advised to eat around 5 to 6 smaller meals a day instead of 2 to 3 usual meals

SPIRITUAL/SAFETY

Encourage going to church and asking for guidance, encourage praying Avoid strenuous activity.

XII. CONCLUSION

Generally, we, the student nurse’s 3 days exposure and duty at Bulacan Medical Center have been a memorable experience to us. The exposure had been an

avenue for further development and enhancement of our skills and capabilities in rendering care and promoting holistic wellness to our clients. It reminded us again

that nursing profession entails a deep sense of responsibility and challenging tasks.

After 3 days of exposure at BMC Medical Ward, we the student nurse has identified and understood the causative factors of cholecystitis, its signs and

symptoms, clinical manifestations, diagnostic studies, medical, pharmacological and nursing interventions through obtaining cues and health history in conjunction

to the disease process. We underwent extensive research in order to comprehensively understand our patient’s condition. Upon learning his case, it challenged and

motivated us to work hard to provide the appropriate and effective nursing intervention and care.

Moreover, cholecystitis is the most common problem resulting from gallbladder stones. It occurs when a stone blocks the cystic duct, which carries bile from

the gallbladder. Predisposing factors can include heredity, age, sex and race. With the presented factors that cannot already be modified, one has to take action

towards preventing the disease to happen. The only one who can help yourself is you alone. With the proper knowledge about the nature of the disease as well as its

preventive measures along with responsibility and sense of will, one can surely direct himself away from the complications.

“No matter how the disease has already reached an alarming incidence rate or not, it is a duty of every human person to take care of his own body, not just for the

sake of other people that depend on him, but most especially for himself ~ a primary obligation that he must fulfill.”

XIII. BIBLIOGRAPHY

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