I.

INTRODUCTION

A. DISEASE OVERVIEW
a. OBSTRUCTIVE JAUNDICE
Jaundice, (also known as icterus, attributive adjective: icteric) is a yellowish discoloration of the skin, the conjunctival membranes over
thesclerae (whites of the eyes), and other mucous membranes caused by hyperbilirubinemia (increased levels of bilirubin in the blood). This
hyperbilirubinemia subsequently causes increased levels of bilirubin in the extracellular fluids. Typically, the concentration of bilirubin in
theplasma must exceed 1.5 mg/dL ( > 35 micromoles/L), three times the usual value of approximately 0.5 mg/dL, for the coloration to be easily
visible.
Post-hepatic jaundice, also called obstructive jaundice, is caused by an interruption to the drainage of bile in the biliary system.
Causes:
 Gallstone in the Common Bile Duct
 Pancreatic Cancer in the head of pancreas
 Liver flukes in the common bile duct
Symptoms:
 Pale stool
 Dark urine
 Pruritus
Diagnostic Exam:
 Typical Liver Exam:
o minotransferases (ALT, AST)
o alkaline phosphatase (ALP)
o bilirubin (which causes the jaundice)
o protein levels

Treatments:
 Surgical removal of obstruction - generally keyhole (laparascopic) surgery or ERCP
 Cease drugs suspected to be causing liver inflammation - e.g. steroids, sulfonylureas
 Antibiotics
 Liver transplantation

b. VIRAL HEPATITIS
Viral hepatitis is liver inflammation due to a viral infection. It may present in acute (recent infection, relatively rapid onset) or chronic forms. The
most common causes of viral hepatitis are the five unrelated hepatotropic viruses Hepatitis A, Hepatitis B, Hepatitis C, Hepatitis D, and Hepatitis E
• Hepatitis A
Hepatitis A or infectious jaundice is caused by hepatitis A virus (HAV), a picornavirus transmitted by the fecal-oral route often
associated with ingestion of contaminated food. It causes an acute form of hepatitis and does not have a chronic stage. The patient's
immune system makes antibodies against HAV that confer immunity against future infection. People with hepatitis A are advised to rest,
stay hydrated and avoid alcohol. A vaccine is available that will prevent HAV infection for up to 10 years. Hepatitis A can be spread
through personal contact, consumption of raw sea food or drinking contaminated water. This occurs primarily in third world countries.
Strict personal hygiene and the avoidance of raw and unpeeled foods can help prevent an infection. Infected people excrete HAV with
their feces two weeks before and one week after the appearance of jaundice. The time between the infection and the start of the illness
averages 28 days (ranging from 15 to 50 days), and most recover fully within 2 months, although approximately 15% of sufferers may
experience continuous or relapsing symptoms from six months to a year following initial diagnosis.
Symptoms can return over the following 6–9 months and include:
 Fatigue
 Fever
 Abdominal pain
 Nausea
 Diarrhea
 Appetite loss
 Depression
 Jaundice, a yellowing of the skin or whites of the eyes
 Sharp pains in the right-upper quadrant of the abdomen
 Weight loss
 Itching
 Bile is removed from blood stream and excreted in urine giving a dark amber colour
 Feces tend to be light in colour due to lack of bilirubin in bile
• Hepatitis B
Hepatitis B is caused by hepatitis B virus, a hepadnavirus that can cause both acute and chronic hepatitis. Chronic hepatitis develops
in the 15% of adults who are unable to eliminate the virus after an initial infection. Identified methods of transmission include blood
(blood transfusion, now rare), tattoos (both amateur and professionally done), sexually (through sexual intercourse or through contact with
blood or bodily fluids), or via mother to child by breast feeding (minimal evidence of transplacental crossing). However, in about half of
cases the source of infection cannot be determined. Blood contact can occur by sharing syringes in intravenous drug use, shaving
accessories such as razor blades, or touching wounds on infected persons.
Patients with chronic hepatitis B have antibodies against hepatitis B, but these antibodies are not enough to clear the infection of the
affected liver cells. The continued production of virus combined with antibodies is a likely cause of the immune complex disease seen in
these patients. A vaccine is available that will prevent infection from hepatitis B for life. Hepatitis B infections result in 500,000 to
1,200,000 deaths per year worldwide due to the complications of chronic hepatitis, cirrhosis, and hepatocellular carcinoma. Hepatitis B is
endemic in a number of (mainly South-East Asian) countries, making cirrhosis and hepatocellular carcinoma big killers. There are six
treatment options approved by th U.S. Food and Drug Administration (FDA) available for persons with a chronic hepatitis B infection:
alpha-interferon, pegylated interferon adefovir, entecavir, telbivudine and lamivudine. About 65% of persons on treatment achieve a
sustained response.
A few patients may have more severe liver disease (fulminant hepatic failure), and may die as a result of it. The infection may be
entirely asymptomatic and may go unrecognized.

• Hepatitis C
Hepatitis C (originally "non-A non-B hepatitis") is caused by hepatitis C virus (HCV), an RNA virus that is a member of the
Flaviviridae family. HCV can be transmitted through contact with blood (including through sexual contact if the two parties' blood is
 mixed) and can also cross the placenta. Hepatitis C usually leads to chronic hepatitis, culminating in cirrhosis in some people. It usually
remains asymptomatic for decades. Patients with hepatitis C are susceptible to severe hepatitis if they contract either hepatitis A or B, so
all persons with hepatitis C should be immunized against hepatitis A and hepatitis B if they are not already immune, and avoid alcohol.
HCV viral levels can be reduced to undetectable levels by a combination of interferon and the antiviral drug ribavirin. The genotype of the
virus is the primary determinant of the rate of response to this treatment regimen, with genotype 1 being the most resistant.

• Hepatitis D
Occurs in some cases of hepatitis B and only patients with hepatitis B are at risk. The virus requires hepatitis B antigen to replicate. It
is common in IV drug users, hemodialysis patient, and recipient of multiple drug transfusion. Sexual contact is an important mode of
transmission for hepatitis B and D. incubation varies from 21 to 140 days. Symptoms are similar to hepatitis B except that patients are
more likely to have fulminant hepatitis and progress to cirrhosis. Treatment are similar to that of other hepatitis.

• Hepatitis E
Is transmitted by fecal-oral route, principally through contaminated water and poor sanitation. Incubation is between 15 and 65 days.
Onset and symptoms are similar to hepatitis A. hepatitis E is a self-limiting course with abrupt onset. Jaundice is nearly always present;
chronic forms do not develop. Prevention method is through handwashing.

• Hepatitis G
Is a post-transfusion with an incubation period of 14 to 145 days. Antibodies are absent.
c. Cholelithiasis and Cholecystitis
In medicine, gallstones (choleliths) are crystalline bodies formed within the body by accretion or concretion of normal or abnormal bile
components.

Characteristics:
 Size:
o A gallstone's size can vary and may be as small as a sand grain or as large as a golf ball. The gallbladder may develop a single,
often large stone or many smaller ones. They may occur in any part of the biliary system.
 Content:
o Gallstones have different appearance, depending on their contents. On the basis of their contents, gallstones can be subdivided
into the two following types:
 Cholesterol stones are usually green, but are sometimes white or yellow in color. They are made primarily of
cholesterol.
 Pigment stones are small, dark stones made of bilirubin and calcium salts that are found in bile. They contain less than
20% of cholesterol. Risk factors for pigment stones include hemolytic anemia (such as sickle cell anemia and
hereditary spherocytosis), cirrhosis, and biliary tract infections.
 Mixed Stones
o All stones are of mixed content to some extent. Those classified as mixed, however, contain between 30% and 70% of
cholesterol. In most cases the other majority constituent is calcium salts such as calcium carbonate, palmitate phosphate,
and/or bilirubinate. Because of their calcium content, they can often be visualized radiographically.
 Pseudoliths
 o Also known as "Fake stones," they are sludge-like gallbladder secretions that act like a stone.
Risk Factors:
• Gender (more on women than men)
• Use of oral contraceptives
• Age (usually older than 40 y/o)
• Multiparous status
• Obesity
Clinical Manifestation:
 Biliary colic
 Nausea
 Vomiting
 (+) Murphy sign

Cholecystitis is inflammation of the gall bladder.

Cholecystitis is often caused by cholelithiasis (the presence of choleliths, or gallstones, in the gallbladder), with choleliths most
commonly blocking the cystic duct directly. This leads to inspissation (thickening) of bile, bile stasis, and secondary infection by gut
organisms, predominantly E. coli and Bacteroides species.
The gallbladder's wall becomes inflamed. Extreme cases may result in necrosis and rupture. Inflammation often spreads to its outer
covering, thus irritating surrounding structures such as the diaphragm and bowel.
Clinical Manifestations:
 The same as those of cholelithiasis
 fever (usually low grade in uncomplicated cases)
 tender right upper quadrant +/- Murphy's sign
 Ortner's sign - tenderness when hand taps the edge of right costal arch.
 Georgievskiy-Myussi's sign (phrenic nerve sign) - pain when press between edges of sternocleidomastoid muscle.
Diagnostic Exam:
 Abdominal radiograph or ultrasonography
 Percutaneous transhepatic cholangiography
Treatments:
 Medical options
o Cholesterol gallstones can sometimes be dissolved by oral ursodeoxycholic acid, but it may be required that the patient takes
this medication for up to two years. Gallstones may recur however, once the drug is stopped. Obstruction of the common bile
duct with gallstones can sometimes be relieved by endoscopic retrograde sphincterotomy (ERS) following endoscopic
retrograde cholangiopancreatography (ERCP). Gallstones can be broken up using a procedure called lithotripsy (extracorporeal
shock wave lithotripsy). which is a method of concentrating ultrasonic shock waves onto the stones to break them into tiny
pieces. They are then passed safely in the feces. However, this form of treatment is only suitable when there are a small
number of gallstones.
 Surgical options
o Cholecystectomy (gallbladder removal) has a 99% chance of eliminating the recurrence of cholelithiasis. Only symptomatic
patients must be indicated to surgery. The lack of a gall bladder may have no negative consequences in many people.
However, there is a significant portion of the population — between 5 and 40% — who develop a condition called
postcholecystectomy syndrome which may cause gastrointestinal distress and persistent pain in the upper right abdomen. In
addition, as many as 20% of patients develop chronic diarrhea.
o There are two surgical options for cholecystectomy:
 Open cholecystectomy: This procedure is performed via an incision into the abdomen (laparotomy) below the right
lower ribs. Recovery typically consists of 3–5 days of hospitalization, with a return to normal diet a week after release
and normal activity several weeks after release.
 Laparoscopic cholecystectomy: This procedure, introduced in the 1980s, is performed via three to four small puncture
holes for a camera and instruments. Post-operative care typically includes a same-day release or a one night hospital
stay, followed by a few days of home rest and pain medication. Laparoscopic cholecystectomy patients can generally
resume normal diet and light activity a week after release, with some decreased energy level and minor residual pain
continuing for a month or two. Studies have shown that this procedure is as effective as the more invasive open
cholecystectomy, provided the stones are accurately located by cholangiogram prior to the procedure so that they can
all be removed.
B. SPECIFIC OBJECTIVES

After the case presentation, the students will:

1. To Gain knowledge about the disease.
2. To create proper and attainable care plans for a client that has this kind of disease.
3. To provide knowledge to the patient about his/her disease.
4. To construct a good discharge plan for the client.
5. To be able to meet the right needs of the patient.

II. CLINICAL SUMMARY

A. PERSONAL DATA/PROFILE OF THE PATIENT
Patients Name: M.E.L
Age: 53 years old
Sex: Female
Civil Status: Married
Birth Date: September 15, 1957
Address: Makiling Calamba, Laguna
Nationality: Filipino
Religion: Roman Catholic
Diagnosis: OBSTRUCTIVE JAUNDICE T/C VIRAL HEPATITIS, CHOLELITHIASIS,CALCULOUS CHOLECYSTITIS
CHIEF COMPLAINT: Jaundice and Tea-colored Urine
History of Present Illnes:
1 week prior to admission the patient complain of having jaundice and tea-colored urine; with fever of 38.3C; with abdominal pain radiating to the
flank.
History of Past Medical Ilness:
(+)HPN – since the patient is 45 years old
No known other hospitalization
No known food and drug allergy
No known previous hospitalization

Familial History:

FATHER

(+) HPN; (-) DM MOTHER

(+)HPN; (+) DM

M.E.L

OBSTRUCTIVE JAUNDICE T/C

VIRAL HEPATITIS;
CHOLELITHIASIS; CHOLECYSTITIS
 III.PHYSICAL ASSESSMENT
AREA TECHNIQUE NORMS FINDINGS ANALYSIS and INTERPRETATION

SKULL
1. skull, shape and Inspection and Rounded(normocephalic) Normocepahlic symmetrical shape Normal findings states no signs of
symmetry of the skull palpation smooth skull contour, abnormalities
symmetrical
2. Presence of nodules Inspection and Smooth, uniform consistency, Plain & smooth when palpated, there Normal findings states no signs of
masses and depressions palpation absence of nodules/ masses is no nodules/masses upon palpation. abnormalities
3.Facial Features Inspection Symmetrical facial All movements are well procured The face have no movement as abilities
movements
4. Presence of edema and Inspection and Eyes are not protrude & no Eyes are hollowed. But no signs of Insufficient sleep. May possible due to
hollowness in the eye. palpation signs of edema edema. stress.
C.HAIR
1. Evenness of growth Inspection and Evenly distributed, hair thick Evenly distributed. Normal findings states no signs of
thickness, or thinness of palpation abnormalities
hair
2. Texture and oiliness Inspection, Silky, resilient hair Dry hair Dry hair may cause of stress.
over the scalp palpation
3. Presence of infection Inspection and No infection and infestation No signs of lesions on scalp Normal findings states no signs of
and infestation palpation abnormalities
IV.EYES
A. EYEBROWS
Hair distribution, Inspection Hair equally distributed and Clean and evenly distributed Normal findings states no signs of
alignment, skin quality intact skin abnormalities
and movement
B. EYELASHES
Evenness of distribution Inspection Equally distributed, curled, Equally distributed and turned Normal findings states no signs of
and direction of curl slightly outward outward eyelashes abnormalities
C. EYELIDS
Surface characteristics Inspection Lids close, symmetrically, No signs of discharge & discoloration Normal findings states no signs of
and position (in relation
to cornea, ability to blink
and frequency of
blinking)
D.CONJUCTIVA
1. Color, texture and the
presence of lesions in the
bulbar conjunctiva
2. Color, texture and the
presence of lesions in the
palpebral conjunctiva
E.SCLERA
Color and clarity
F.CORNEA
Clarity and texture
G.IRIS
Shape and color
H.PUPILS
1.color, shape and
symmetry of size
2.light reaction and
accommodation
I.VISUAL ACUITY
1. Near vision
K. EXTRAOCULAR
MUSCLES
skin intact, no discharge & , able to close eyes, blinking abnormalities
discoloration normally
Inspection Pinkish or red in color; Yellowish color Indicates jaundice
capillaries sometimes evident
Inspection Pinkish or red in color; shiny, Yellowish color Indicates jaundice
smooth pink/red
Inspection Whitish color; clear; no Sclera is yellow in color Indicates jaundice
yellowish discoloration
Inspection Transparent, shiny and Clear and smooth in texture Normal findings states no signs of
smooth details of iris are abnormalities
available
Inspection transparent Transparent anterior chamber Normal findings states no signs of
abnormalities
Inspection Black in color. Size ranges Pupil size is 3mm, Equal in size of Normal findings states no signs of
from 3-7 mm; Equal in size; both eyes. abnormalities
equally round
Inspection PERRLA Capable of light reaction (constricts Normal findings states no signs of
when there is light) abnormalities
Inspection Able to read newsprint Capable of reading newsprint Normal findings states no signs of
abnormalities
Eye alignment and Inspection Both eyes coordinated, move Moves in unison , has able to follows Normal findings states no signs of
coordination in unison, with parallel object. abnormalities
alignment
L.VISUAL FIELDS
Peripheral visual fields Inspection When looking straight ahead, Can see objects in the periphery Normal findings states no signs of
client can see objects in the abnormalities
periphery
V. EARS
A. AURICLES
1. color, symmetry of size Inspection Color same as facial skin; Same color as facial skin, tip of Normal findings states no signs of
and position symmetrical; auricle aligned auricle aligned at the outer canthus of abnormalities
with outer canthus of eye, the eye
about 10 degrees from vertical
2. Texture, elasticity and palpation Mobile, firm and not tender; Smooth in texture, no tenderness Normal findings states no signs of
areas of tenderness pinna recoils after it is folded abnormalities
C. HEARING ACUITY
TESTS
1. client’s response to Inspection Normal voice tones audible Loss of hearing is absence Normal findings states no signs of
normal voice tones abnormalities
VI. NOSE
1. Any deviations in Inspection Symmetric and straight; no Symmetrically no discharge Normal findings states no signs of
shape, size or color and discharge; uniform color abnormalities
flaring or discharge from
the nares
2. Nasal septum(between Inspection, Nasal septum intact and in Nasal septum intact and in midline Normal findings states no signs of
the nasal chamber) Palpation midline abnormalities
3. Patency of both nasal Inspection Air moves freely as the client Can breathe normally Normal findings states no signs of
cavities breathes through the nares abnormalities
4. tenderness, masses and Palpation Not tender, no lesions No tenderness nor lesions Normal findings states no signs of
displacements of bone abnormalities
and cartilage
VII.SINUSES
Identification of the Inspection Not tender No pain when palpated Normal findings states no signs of
sinuses and for tenderness
VIII. MOUTH
A. LIPS
Symmetry of contour, Inspection,
color and texture palpation
B. BUCCAL MUCOSA
Color, moisture, texture
and the presence of
lesions
C. TEETH
Color, number and
condition and presence of
dentures
D. GUMS
Color and condition
E. TONGUE/FLOOR
OF THE MOUTH
1. Color and texture of the
mouth floor.
2. position, color and
texture, movement and
base of the tounge
3. any nodules, lumps, or
excoriated areas
F. OROPHARYNX and
TONSILS
1. color and texture
2. size, color, and
abnormalities
Uniform pink color; soft, Pale black in color Insufficient supply of vitamins.
moist, smooth texture;
symmetry of contour, ability
to purse lips
Inspection Uniform pink color; smooth, Pink color, smooth Normal findings states no signs of
soft, elastic texture abnormalities
Inspection 32 adult teeth; smooth, white, Patient has dentures Due to loss of teeth.
shiny tooth, intact dentures
Inspection Pink gums Pale color.
Inspection and Pink color, moist, slightly Pink and moist. Tongue moves freely Normal findings states no signs of
palpation rough, raised papillae; no and no pain felt abnormalities
tenderness
Inspection and Pink, smooth, lateral margins Located and positioned in the center. Normal findings states no signs of
palpation Pink and with whitish color at the abnormalities
edge.
Inspection and No palpable nodules, lumps or No tenderness Normal findings states no signs of
palpation excoriated areas abnormalities
Inspection and Pink, smooth posterior wall No swollen or inflamed Normal findings states no signs of
palpation abnormalities
Inspection Not visible, pinkish and No presence of discharge; pinkish Normal findings states no signs of
discharge of the tonsil smooth , no discharge abnormalities
th th
3.gag reflex Inspection Present No damage on 9 or 10 cranial Normal findings states no signs of
nerve abnormalities

Skin Inspection No redness and itch Yellow skin color with minimal itch. Indicates jaundice

Breathing Pattern Inspection and Normal breath sounds, does Patient can breathe normally. She Normal findings states no signs of
Auscultation not uses accessory muscle does not use accessory muscle upon abnormalities
upon breathing breathing.
Heart sounds Inspection, “lub-dub” sounds Normal rhythm Normal findings states no signs of
Auscultation abnormalities

CAROTID ARTERIES
1. Carotid artery palpation Palpation -Symmetric pulse volumes Symmetric pulse volumes Normal findings states no signs of
-full pulsation, trusting quality abnormalities
AXILLAE
1.Axillary, subclavicular, Inspection and No tenderness, masses or no masses and nodules Normal findings states no signs of
and supraclavicular palpation nodules abnormalities
lymph nodes

MUSCLES
1. Muscle size and Inspection Equal size on both sides of the The muscles is proportionate to the Normal findings states no signs of
comparison on the other body body; even in both sides abnormalities
side
2. Fascination and Inspection and No tremor No presence of tremors on the patient Normal findings states no signs of
tremors in the muscles palpation abnormalities
Presence of back pain
3. Muscle tonicity Inspection and Normally firm the muscles of the patient is normally Normal findings states no signs of
palpation firm abnormalities
4. Muscle strength Inspection and Equal strength on each body The muscle strength on the lower Presence of pain at the surgical site.
palpation side extremities is lesser than the upper.
C. JOINTS
1. Joint swelling Inspection and -no swelling There is no presence of swelling on Normal findings states no signs of
 palpation -no tenderness, swelling and the patients joint, no pain abnormalities
nodules
-joints move smoothly
UPPER Inspection, No swelling, no pain or Upper extremities are normal, no Normal findings states no signs of
EXTREMETIES Palpation redness presence of sweeling and pain. abnormalities

Nails Pale color Indicates jaundice/anemia

Abdomen Inspection, Presence of Jackson Pratt and

Palpation, drainage.
Percussion, There is presence of surgical site with
auscultation dry and intake drainage.
Surgical site is on the process of
healing.
There are no signs of tenderness in
the abdomen.
Bowel movement is normal
Liver Palpation no masses, nodularity, and no Tenderness upon palpation
tenderness
 V. DEVELOPMENTAL STAGES

Sigmund Freud’s Psychosexual Development

Genital Stage: Post Puberty
According to Freud to achieve this state you need to have a balance of both love and work. During the final stage of psychosexual development, the
individual develops a strong sexual interest in the opposite sex. Where in earlier stages the focus was solely on individual needs, interest in the welfare of others
grows during this stage. If the other stages have been completed successfully, the individual should now be well-balanced, warm and caring. The goal of this stage is
to establish a balance between the various life areas.
In relation to the patient, she already has a family whom she tries to constantly work hard for them to have a good life. She is a hardworking mother all day
and night as well as a caring mother who always cook for her children, giving guidance for them in times of trouble and also giving the best that she could give to
them.

Erik Erickson
Ego Development Outcome: Generativity vs Stagnation
Generativity is the concern of establishing and guiding the next generation. Socially-valued work and disciplines are expressions of generativity. Simply
having or wanting children does not in and of itself achieve generativity.
During middle age the primary developmental task is one of contributing to society and helping to guide future generations. When a person makes a
contribution during this period, perhaps by raising a family or working toward the betterment of society, a sense of generativity - a sense of productivity and
accomplishment- results. In contrast, a person who is self-centered and unable or unwilling to help society move forward develops a feeling of stagnation - a
dissatisfaction with the relative lack of productivity.
 The patient does most of her time working and earning money for her family. She doesn’t want to put them into harm that’s why she does everything she
could in order to provide them the best possible life they could have. Now that her children had finished college and now working on a decent job, they, in return,
are caring their mother now that she is sick and needs emotional support. The patient felt the sense of gratitude in her family that they return back all the goodness
and caring that their mother has given to them.

Jean Piaget:
Formal operational stage
The formal operational period is the fourth and final of the periods of cognitive development in Piaget's theory. This stage, which follows the Concrete
Operational stage, commences at around 11 years of age (puberty) and continues into adulthood. In this stage, individuals move beyond concrete experiences and
begin to think abstractly, reason logically and draw conclusions from the information available, as well as apply all these processes to hypothetical situations.
The patient, knowing at start that she cannot give enough for her family, she extended her time for work regardless for risking her own health. She has this
parently instinct that she has to work hard in order to give what is enough for her family.

Lawrence Kohlberg:
Post-Conventional Stage
In Stage five (social contract driven), the world is viewed as holding different opinions, rights and values. Such perspectives should be mutually respected as
unique to each person or community. Laws are regarded as social contracts rather than rigid edicts. Those that do not promote the general welfare should be changed
when necessary to meet “the greatest good for the greatest number of people”. This is achieved through majority decision, and inevitable compromise. Democratic
government is ostensibly based on stage five reasoning.
The patient respects the rights of every people she meets. She is also a law-abiding citizen and doesn’t have problems with society. In her family, she
sacrificed time for her family in order to work and make her children finish studying. In return, she is very proud to have such good children who gives all goodness
she has given them and also takes goodness from them.
 VI. NURSING THEORY

Nightingale’s Environmental Theory

Florence Nightingale (1820–1910), considered the founder of educated and scientific nursing and widely known as "The Lady with the Lamp", wrote the
first nursing notes that became the basis of nursing practice and research. The notes, entitled Notes on Nursing: What it is, What is not (1860), listed some of her
theories that have served as foundations of nursing practice in various settings, including the succeeding conceptual frameworks and theories in the field
of nursing. Nightingale is considered the first nursing theorist. One of her theories was the Environmental Theory, which incorporated the restoration of the usual
health status of the nurse's clients into the delivery of health care—it is still practiced today.

Environmental Effects
She stated in her nursing notes that nursing "is an act of utilizing the environment of the patient to assist him in his recovery" (Nightingale 1860/1969),that it
involves the nurse's initiative to configure environmental settings appropriate for the gradual restoration of the patient's health.

Environmental Factors Affecting Health

Defined in her environmental theory are the following factors present in the patient's environment:
• Pure or fresh air
• Pure water
• Sufficient food supplies
• Efficient drainage
• Cleanliness
• Light (especially direct sunlight)
Any deficiency in one or more of these factors could lead to impaired functioning of life processes or diminished health status.
 VII. ANATOMY AND PHYSIOLOGY

LIVER
The liver is a vital organ present in vertebrates and some other animals. It has a wide range of functions, including
detoxification, protein synthesis, and production of biochemicals necessary for digestion. The liver is necessary for
survival; there is currently no way to compensate for the absence of liver function.
This organ plays a major role in metabolism and has a number of functions in the body, including glycogen storage,
decomposition of red blood cells, plasma protein synthesis, hormone production, and detoxification. It lies below
the diaphragm in the thoracic region of the abdomen. It produces bile, an alkaline compound which aids in
digestion, via the emulsification of lipids. The liver's highly specialized tissues regulate a wide variety of high-
volume biochemical reactions, including the synthesis and breakdown of small and complex molecules, many of
which are necessary for normal vital functions.
Medical terms related to the liver often start in hepato- or hepatic from the Greek word for liver, hēpar (ἡπαρ).
Anatomy
The liver is a reddish brown organ with four lobes of unequal size and shape. A human liver normally weighs between 1.4–1.6 kg (3.1–3.5 lb), and is a soft, pinkish-
brown, triangular organ. It is both the largest internal organ (the skin being the largest organ overall) and the largest gland in the human body.
It is located in the right upper quadrant of the abdominal cavity, resting just below the diaphragm. The liver lies to the right of the stomach and overlies the
gallbladder. It is connected to two large blood vessels, one called the hepatic artery and one called the portal vein. The hepatic artery carries blood from the aorta
whereas the portal vein carries blood containing digested nutrients from the small intestine and the descending colon. These blood vessels subdivide into capillaries
which then lead to a lobule. Each lobule is made up of millions of hepatic cells which are the basic metabolic cells.
Blood flow
The liver receives a dual blood supply from the hepatic portal vein and hepatic arteries. Supplying approximately 75% of the liver's blood supply, the hepatic portal
vein carries venous blood drained from the spleen, gastrointestinal tract, and its associated organs. The hepatic arteries supply arterial blood to the liver, accounting
for the remainder of its blood flow. Oxygen is provided from both sources; approximately half of the liver's oxygen demand is met by the hepatic portal vein, and
half is met by the hepatic arteries.
Blood flows through the sinusoids and empties into the central vein of each lobule. The central veins coalesce into hepatic veins, which leave the liver and empty
into the inferior vena cava.

Biliary flow
The biliary tree
The term biliary tree is derived from the arboreal branches of the bile ducts. The bile produced in the liver is collected in bile canaliculi, which merge to
form bile ducts. Within the liver, these ducts are called intrahepatic (within the liver) bile ducts, and once they exit the liver they are considered extrahepatic
(outside the liver). The intrahepatic ducts eventually drain into the right and left hepatic ducts, which merge to form the common hepatic duct. The cystic duct from
the gallbladder joins with the common hepatic duct to form the common bile duct.
Bile can either drain directly into the duodenum via the common bile duct or be temporarily stored in the gallbladder via the cystic duct. The common bile duct and
the pancreatic duct enter the second part of the duodenum together at the ampulla of Vater.
Surface anatomy

Peritoneal ligaments
Apart from a patch where it connects to the diaphragm (the so-called "bare area"), the liver is covered entirely by visceral peritoneum, a thin, double-layered
membrane that reduces friction against other organs. The peritoneum folds back on itself to form the falciform ligament and the right and left triangular ligaments.
These "lits" are in no way related to the true anatomic ligaments in joints, and have essentially no functional importance, but they are easily recognizable surface
landmarks. An exception to this is the falciform ligament, which attaches the liver to the posterior portion of the anterior body wall.

Lobes
Traditional gross anatomy divided the liver into four lobes based on surface features. The falciform ligament is visible on the front (anterior side) of the
liver. This divides the liver into a left anatomical lobe, and a right anatomical lobe.
If the liver is flipped over, to look at it from behind (the visceral surface), there are two additional lobes between the right and left. These are the caudate lobe (the
more superior), and below this the quadrate lobe.
From behind, the lobes are divided up by the ligamentum venosum and ligamentum teres (anything left of these is the left lobe), the transverse fissure (or porta
hepatis) divides the caudate from the quadrate lobe, and the right sagittal fossa, which the inferior vena cava runs over, separates these two lobes from the right lobe.
Each of the lobes is made up of lobules; a vein goes from the centre of each lobule which then joins to the hepatic vein to carry blood out from the liver.
On the surface of the lobules there are ducts, veins and arteries that carry fluids to and from them.
Functional anatomy
The central area where the common bile duct, hepatic portal vein, and hepatic artery proper enter is the hilum or "porta hepatis". The duct, vein, and artery
divide into left and right branches, and the portions of the liver supplied by these branches constitute the functional left and right lobes.
The functional lobes are separated by an imaginary plane joining the gallbladder fossa to the inferior vena cava. The plane separates the liver into the true right and
left lobes. The middle hepatic vein also demarcates the true right and left lobes. The right lobe is further divided into an anterior and posterior segment by the right
hepatic vein. The left lobe is divided into the medial and lateral segments by the left hepatic vein. The fissure for the ligamentum teres also separates the medial and
lateral segments. The medial segment is also called the quadrate lobe. In the widely used Couinaud (or "French") system, the functional lobes are further divided
into a total of eight subsegments based on a transverse plane through the bifurcation of the main portal vein. The caudate lobe is a separate structure which receives
blood flow from both the right- and left-sided vascular branches.

Physiology
The various functions of the liver are carried out by the liver cells or hepatocytes. Currently, there is no artificial organ or device capable of emulating all the
functions of the liver. Some functions can be emulated by liver dialysis, an experimental treatment for liver failure.

Synthesis
Further information: Proteins produced and secreted by the liver
• A large part of amino acid synthesis
• The liver performs several roles in carbohydrate metabolism:
o Gluconeogenesis (the synthesis of glucose from certain amino acids, lactate or glycerol). Note that humans and some other mammals cannot
synthesize glucose from glycerol.
o Glycogenolysis (the breakdown of glycogen into glucose)
 o Glycogenesis (the formation of glycogen from glucose)(muscle tissues can also do this)
• The liver is responsible for the mainstay of protein metabolism, synthesis as well as degradation
• The liver also performs several roles in lipid metabolism:
o Cholesterol synthesis
o Lipogenesis, the production of triglycerides (fats).
• The liver produces coagulation factors I (fibrinogen), II (prothrombin), V, VII, IX, X and XI, as well as protein C, protein S and antithrombin.
• In the first trimester fetus, the liver is the main site of red blood cell production. By the 32nd week of gestation, the bone marrow has almost completely
taken over that task.
• The liver produces and excretes bile (a yellowish liquid) required for emulsifying fats. Some of the bile drains directly into the duodenum, and some is
stored in the gallbladder.
• The liver also produces insulin-like growth factor 1 (IGF-1), a polypeptide protein hormone that plays an important role in childhood growth and continues
to have anabolic effects in adults.
• The liver is a major site of thrombopoietin production. Thrombopoietin is a glycoprotein hormone that regulates the production of platelets by the bone
marrow.

Breakdown
• The breakdown of insulin and other hormones
• The liver breaks down hemoglobin, creating metabolites that are added to bile as pigment (bilirubin and biliverdin).
• The liver breaks down or modifies toxic substances (e.g., methylation) and most medicinal products in a process called drug metabolism. This sometimes
results in toxication, when the metabolite is more toxic than its precursor. Preferably, the toxins are conjugated to avail excretion in bile or urine.
• The liver converts ammonia to urea.
Other functions
• 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 (1-3 years' supply), iron, and copper.
• The liver is responsible for immunological effects- the reticuloendothelial system of the liver contains many immunologically active cells, acting as a 'sieve'
for antigens carried to it via the portal system.
• The liver produces albumin, the major osmolar component of blood serum.
• The liver synthesizes angiotensinogen, a hormone that is responsible for raising the blood pressure when activated by renin, an enzyme that is released when
the kidney senses low blood pressure.

GALLBLADDER
In vertebrates the gallbladder (cholecyst, gall bladder) is a small organ that aids digestion and stores bile produced by the liver.
In humans the loss of the gallbladder is usually easily tolerated.
Human anatomy
The gallbladder is a hollow system that sits just beneath the liver. In adults, the gallbladder measures approximately 8 cm in
length and 4 cm in diameter when fully distended. It is divided into three sections: fundus, body and neck. The neck tapers and
connects to the biliary tree via the cystic duct, which then joins the common hepatic duct to become the common bile duct.
Microscopic anatomy
The different layers of the gallbladder are as follows:
• The gallbladder has a simple columnar epithelial lining characterized by recesses
 Function
The adult human gallbladder stores about 50 millilitres (1.8 imp fl oz; 1.7 US fl oz) of bile, which is released when food containing fat enters the digestive tract,
stimulating the secretion of cholecystokinin (CCK). The bile, produced in the liver, emulsifies fats in partly digested food.
After being stored in the gallbladder, the bile becomes more concentrated than when it left the liver, increasing its potency and intensifying its effect on fats.
In 2009, it was demonstrated that gallbladder removed from a patient expressed several pancreatic hormones including insulin. This was surprising because until
then, it was thought that insulin was only produced in pancreatic β-cells. This study provides evidence that β-like cells do occur outside the human pancreas. The
authors suggest that since gallbladder and pancreas are next door neighbors during embryonic development, there exists tremendous potential in derivation of
endocrine pancreatic progenitor cells from human gallbladders that are available after cholecystectomy.

DIGESTIVE SYSTEM
The human digestive system is a complex series of organs and glands that processes food. In order to use the food we eat, our
body has to break the food down into smaller molecules that it can process; it also has to excrete waste.
Most of the digestive organs (like the stomach and intestines) are tube-like and contain the food as it makes its way through
the body. The digestive system is essentially a long, twisting tube that runs from the mouth to the anus, plus a few other
organs (like the liver and pancreas) that produce or store digestive chemicals.
 The Digestive Process:
The start of the process - the mouth: The digestive process begins in the mouth. Food is partly broken down by the process
of chewing and by the chemical action of salivary enzymes (these enzymes are produced by the salivary glands and break
down starches into smaller molecules).
On the way to the stomach: the esophagus - After being chewed and swallowed, the food enters the esophagus. The esophagus is a long tube that runs from the
mouth to the stomach. It uses rhythmic, wave-like muscle movements (called peristalsis) to force food from the throat into the stomach. This muscle movement
gives us the ability to eat or drink even when we're upside-down.

In the stomach - The stomach is a large, sack-like organ that churns the food and bathes it in a very strong acid (gastric acid). Food in the stomach that is partly
digested and mixed with stomach acids is called chyme.

In the small intestine - After being in the stomach, food enters the duodenum, the first part of the small intestine. It then enters the jejunum and then the ileum (the
final part of the small intestine). In the small intestine, bile (produced in the liver and stored in the gall bladder), pancreatic enzymes, and other digestive enzymes
produced by the inner wall of the small intestine help in the breakdown of food.

In the large intestine - After passing through the small intestine, food passes into the large intestine. In the large intestine, some of the water and electrolytes
(chemicals like sodium) are removed from the food. Many microbes (bacteria like Bacteroides, Lactobacillus acidophilus, Escherichia coli, and Klebsiella) in the
large intestine help in the digestion process. The first part of the large intestine is called the cecum (the appendix is connected to the cecum). Food then travels
upward in the ascending colon. The food travels across the abdomen in the transverse colon, goes back down the other side of the body in the descending colon, and
then through the sigmoid colon.

The end of the process - Solid waste is then stored in the rectum until it is excreted via the anus.
 Digestive System Glossary:
abdomen - the part of the body that contains the digestive organs. In human beings, this is between the diaphragm and the pelvis
alimentary canal - the passage through which food passes, including the mouth, esophagus, stomach, intestines, and anus.
anus - the opening at the end of the digestive system from which feces (waste) exits the body.
appendix - a small sac located on the cecum.
ascending colon - the part of the large intestine that run upwards; it is located after the cecum.
bile - a digestive chemical that is produced in the liver, stored in the gall bladder, and secreted into the small intestine.
cecum - the first part of the large intestine; the appendix is connected to the cecum.
chyme - food in the stomach that is partly digested and mixed with stomach acids. Chyme goes on to the small intestine for further digestion.
descending colon - the part of the large intestine that run downwards after the transverse colon and before the sigmoid colon.
digestive system - (also called the gastrointestinal tract or GI tract) the system of the body that processes food and gets rid of waste.
duodenum - the first part of the small intestine; it is C-shaped and runs from the stomach to the jejunum.
epiglottis - the flap at the back of the tongue that keeps chewed food from going down the windpipe to the lungs. When you swallow, the epiglottis automatically
closes. When you breathe, the epiglottis opens so that air can go in and out of the windpipe.
esophagus - the long tube between the mouth and the stomach. It uses rhythmic muscle movements (called peristalsis) to force food from the throat into the
stomach.
gall bladder - a small, sac-like organ located by the duodenum. It stores and releases bile (a digestive chemical which is produced in the liver) into the small
intestine.
gastrointestinal tract - (also called the GI tract or digestive system) the system of the body that processes food and gets rid of waste.
ileum - the last part of the small intestine before the large intestine begins.
intestines - the part of the alimentary canal located between the stomach and the anus.
jejunum - the long, coiled mid-section of the small intestine; it is between the duodenum and the ileum.
liver - a large organ located above and in front of the stomach. It filters toxins from the blood, and makes bile (which breaks down fats) and some blood proteins.
mouth - the first part of the digestive system, where food enters the body. Chewing and salivary enzymes in the mouth are the beginning of the digestive process
(breaking down the food).
pancreas - an enzyme-producing gland located below the stomach and above the intestines. Enzymes from the pancreas help in the digestion of carbohydrates, fats
and proteins in the small intestine.
peristalsis - rhythmic muscle movements that force food in the esophagus from the throat into the stomach. Peristalsis is involuntary - you cannot control it. It is
also what allows you to eat and drink while upside-down.
rectum - the lower part of the large intestine, where feces are stored before they are excreted.
salivary glands - glands located in the mouth that produce saliva. Saliva contains enzymes that break down carbohydrates (starch) into smaller molecules.
sigmoid colon - the part of the large intestine between the descending colon and the rectum.
stomach - a sack-like, muscular organ that is attached to the esophagus. Both chemical and mechanical digestion takes place in the stomach. When food enters the
stomach, it is churned in a bath of acids and enzymes.
transverse colon - the part of the large intestine that runs horizontally across the abdomen.
 VIII. PATHOPHYSIOLOGY

Pre disposing Factors: Precipitating Factors

-Gender (more on women than -Alcohol abuse
men) -oysters, mussels, shellfish
-Age (usually older than 40 y/o) -Contaminated food
-Multiparous status -Poor hygiene
-Poor sanitation
-Injection drug use

absence of bile constituents (most

spillage into the systemic
importantly, bilirubin, bile salts, and
circulation
lipids) in the intestines

Stools are often pale

because less bilirubin
reaches the intestine

Absence of bile salts can produce malabsorption, leading to steatorrhea

and deficiencies of fat-soluble vitamins (particularly A, K, and D);
vitamin K deficiency can reduce prothrombin levels. In long-standing
cholestasis, concomitant vitamin D and Ca malabsorption can cause
osteoporosis or osteomalacia.
 VIRAL
HEPATITIS
Cholelithiasis

Fatigue
Fever Cholecystitis
Abdominal pain
Nausea
Diarrhea
Appetite loss
Depression Biliary colic
Jaundice, a yellowing of the skin or
Nausea
whites of the eyes
Sharp pains in the right-upper quadrant Vomiting
of the abdomen
(+) Murphy sign
Weight loss
Itching
Bile is removed from blood stream and
excreted in urine giving a dark amber
color
Feces tend to be light in colour due to
lack of bilirubin in bile
 IX. MEDICAL MANAGEMENT

LABORATORY EXAMINATIONS

Chemtech Glucose Hexok

Result Normal Value Interpretation

7.87 mmol/L 3.80-6.00 mmol/L High blood glucose indicates that the body doesn’t have enough insulin. (hyperglycemia)

Tests Normal Value Result Interpretation

BUN Kinetic UV 2.5 – 6.4 mmol/L 2.6 mmol/L Normal
Cholesterol <= 5.2 mmol/L 17.1 mmol/L Elevated cholesterol in the blood is due to abnormalities in the levels of
lipoproteins, the particles that carry cholesterol in the bloodstream.
Creatinine UV 35.4-150.3 mmol/L 5.8 mmol/L Low blood creatinine levels can mean lower muscle mass caused by a disease,
such as muscular dystrophy, or by aging. Low levels can also mean some types
of severe liver disease or a diet very low in protein.
Direct HDL 0.7-2.2 mmol/L 0.2 mmol/L Hypoalphalipoproteinemia (HA) may be caused by familial or primary and
secondary disorders that are associated with low plasma levels of high-density
lipoprotein (HDL) cholesterol.
Triglycerides 0.40-1.80 mmol/L 1.43 mmol/L Normal
LDL 1.7-4.6 mmol/L 16.674 mmol/L High blood cholesterol occurs when there is too much cholesterol in the blood.
Cholesterol level is determined partly by genetic makeup and the saturated fat
and cholesterol in the foods a person eat.

Tests Normal Value Result Interpretation

Sodium 135-148 mmol/L 128.5 mmol/L Low sodium level may caused by water-electrolyte imbalance and blood
conditions
Potassium 3.4-5.3 mmol/L 3.9 mmol/L Normal
Neutrophils 0.51-0.67 0.76 Sudden kidney failure can cause a high neutrophil count. Another cause is a
sudden infection from bacteria. Damage or inflammation of tissues can also lead
to a high neutrophil count.
SGPT 0-49 U/L 94 U/L High SGPT level is caused by Liver inflammation (hepatitis A, B, C, Infectious
mononeuceosis, acute viral fever, ALCOHOL, pancreatic disorder).
Total Bilirubin Up to 17 umol/L 18.3 If conjugated bilirubin is elevated, there may be some kind of blockage of the
Direct Bilirubin Up to 5.1 umol/L 6.4 umol/L
liver or bile ducts, hepatitis, trauma to the liver, cirrhosis, a drug reaction, or
long-term alcohol abuse.
Erythrocyte 4.5-6 4.0 Low
Leukocyte 5.9-10 12.3 A high white blood cell count usually indicates: An increased production of
white blood cells to fight an infection
Hematocrit 0.37-0.37 0.34 A low hematocrit is referred to as being anemic. Some of the more common
reasons are loss of blood (traumatic injury, surgery, bleeding colon cancer),
nutritional deficiency (iron, vitamin B12, folate), bone marrow problems, and
abnormal hematocrit (sickle cell anemia).
Ultrasound of hepatobiliary tree:
The liver is normal in size with homogenous parenchymal echopattern. Its ecogenicity is increased. There is no focal lesion seen. The hepatorenal angle and
inferior edge sharpness are maintained. The right and left intrahepatic ducts and common bile duct (1.7 cm) are dilated. There is a 1.4 x 2.1 cm echogenic focus
in the proximal common bile duct.
The gallbladder is contracted.
There is a 4.1cm shadowing echogenic foci seen with gallbladder fossa exhibiting the wall-echoshaddow complex.
-Mild patty liver
-Intra and extrahepatic biliary tract obstruction secondary to choledocholithiasis
-cholelithiasis

ECG
Vent. 80
PR Int. (ms): 146
P/QRS/T Int.(ms) : 108 131 161
QT/QTc Int.(ms): 358 415
P/QRS/T axis (deg): 40 87 14
RVI/SV5 amp(mv): 0.13 0.14
RV5/SVI Amp.(mV): 0.91 0.17

Open Cholecystectomy with choledoscopy with T-tube chole.

Findings: massive adhesive noted at cholecysto, duodenal and cystic ares with huge stone 1 at the CB fundus and 1 at the proximal (CBC) GBL.
DRUG STUDY

Drug Action Indication Contraindication Side Effects Nursing Management

Simvastatin 20mg Inhibits HMG-CoA > Antilipidemics > Active liver Constipation, > Use drug only after diet and other non-drug
1TAB OD reductase, the disease or dyspepsia, therapies prove ineffective.
enzyme that > In hyperlipidemia: unexplained flatulence, headache
catalyzes the first an adjunct to diet to persistent elevations > Obtain liver function test results at start of
step in the reduce elevated total- of serum therapy and then periodically.
cholesterol C, LDL-C, transaminases.
synthesis pathway, apolipoprotein B & Porphyria. > Instruct patient to take drug with the evening
resulting in a TG in patients w/ meal
decrease in serum primary > Pregnancy &
cholesterol, serum hypercholesterolemia lactation.
LDLs, and either
an increase or no
change in serum
HDLs.
 Drug Action Indication Contraindication Side Effects Nursing Management
Ciprofloxacin Inhibits bacterial > Fluoroquinolones Hypersensitivity to Nausea, diarrhoea, > Obtain specimen for culture and sensitivity
500mg BID DNA synthesis, ciprofloxacin or vomiting, dyspepsia, test before giving first dose
mainly by blocking > UTI other quinolones abdominal pain,
DNA gyrase; flatulence, anorexia, > Monitor I&O
bactericidal dizziness, headache,
tiredness, agitation,
trembling
Drug Action Indication Contraindication Side Effects Nursing Management
Mefenamic acid Aspirin-like drug Relief of pain Ulceration in the Disturbances of the > Assess patients
500mg 1 TAB BID that has including muscular, upper gut such as who develop
analgesic,antipyretic, rheumatic, or lower intestinal indigestion, severe diarrhea
& anti-inflammatory traumatic, tract. Childre diarrhoea, and vomiting
activities dental, post-op & n <14 constipation, nausea, for dehydration
postpartum pain, yr. Pregnancy. vomiting or and electrolyte
headache & in abdominal pain Imbalance.
childn Headache
w/ fever & juvenile Dizziness > Monitor blood
RA. Also for the Drowsiness glucose for loss
relief of primary Skin rashes of glycemic
dysmenorrhea. Visual disturbances control if
diabetic.
 Drug Action Indication Contraindication Side Effects Nursing Management
Nalbuphine 10mg Nalbuphine HCl has Relief of moderate Patients who are Sedation. > Note general
TIV PRN for severe the effect of to hypersensitive Infrequently client condition.
pain lowering severe pain to nalbuphine sweating, GI upsets,
the cardiac work . Pre-op HCl. vertigo, dizziness; > Document
load analgesia, as a dry indications for
and can be used supplement to mouth; headache, therapy, type/
immediately in balanced anesth, allergic reactions. onset of
myocardial surgical anesth, for symptoms &
infarction obstet analgesia anticipated.
(use with caution during labor &
where emesis is relief > Monitor V/S &
involved). of pain following I&O.
Hemodynamic MI.
studies Post-op somatic &
in patients with visceral pain.
severe
arteriosclerotic heart
 Drug Action Indication Contraindication Side Effects Nursing Management
Diphenhydramine Antihistamine that Hay fever, urticaria, Premature & CV & CNS effects
50mg Tcap for reduces allergic vasomotor rhinitis, newborn infants; Blood disorders
pruritus reactions, motion angioneurotic asthma attack; GI disturbances
sickness and vertigo edema, drug lactation Antimuscarinic
(dizziness and loss sensitization, serum effectsAllergic
of balance), and & penicillin reactions
Parkinson's disease reaction, contact
dermatitis, atopic
eczema, other
allergic dermatoses,
pruritus, food
sensitivity,
parkinsonism,
motion sickness
 Drug Action Indication Contraindication Side Effects Nursing Management
Lactulose 30cc OD Inhibits bacterial Constipation, Pt who require a Abdominal >Assess condition before therapy and
HS DNA gyrase thus salmonellosis. low lactose diet. discomfort reassess regularly thereafter to monitor
preventing Treatment of Galactosemia associated with drug’s effectiveness
replication in hepatic deficiency. flatulence and >Monitor pt for any adverse GI reactions,
susceptible bacteria encephalopathy Intestinal intestinal cramps. nausea,vomiting,diarrhea,
obstruction. Nausea, vomiting, >Assess for adverse reactions
diarrhea on >for pt. with hepatic encelopathy: regularly
prolonged use. assess mental condition
>monitor I & O
>monitor for Inc. glucose level in diabetic pts
 Drug Action Indication Contraindication Side Effects Nursing Management
Godex 2 caps BID hepato-protectant acute & chronic Unknown.
hepatitis,
Is a combination of: 1.prevents fat cirrhosis, drug-
Adenine HCl 2.5mg (Vitamin B4) accumulation and protects induced
Carnitine orotate 150mg (antioxidant) cell membrane integrity. hepatitis,
Cyanocobalamin 0.125mg (Vitamin B12) 2. provides efficient general &
Pyridoxine HCl 25mg (Vitamin B6) mitochondrial energy alcoholic
Riboflavin 0.5mg (Vitamin B2) system. intoxication,
Liver extract antitoxic fraction 3. detoxifies acyl groups fatty liver,
12.5mg (liver-protecting substance from and ROS. mitochondrial
the liver of cattle) 4.restores elctron balance dysfunctions.
Biphenyl Dimethyl Dicarboxylate 25mg for greater energy supply.
(used to protect against chronic alcohol 5. increases nucleic acid
toxicity). synthesis and mtDNA
copy number for repair of
mitochondria.

Drug Action Indication Contraindication Side Effects Nursing Management

HNBB 10mg 1
TAB
X. NURSING CARE PLANS
 Assessment Nursing Diagnosis Planning Nursing intervention Rationale Evaluation
Subjective: Ineffective role After conducting Short term: After conducting
performance related to nursing intervention, series of nursing
“nanghihina ako at fatigue as evidenced the patient will: - Interview client - To evaluate factors interventions, the patient
hindi halos makakilos” by decreased level of regarding that may influence was able to adapt to
activities. - Be able to adapt perceptions on client’s view on changes in role
Objective: to changes in inability to self performance as
role perform usual role evidenced by client’s
- Body malaise performance in the family acceptance in changes in
- Facial grimace - Assist client in - To help client deal family role and
- Irritability - Be able to developing with current understanding of current
- Limited ROM verbalize strategies dealing changes in role role obligations.
- Presence of understanding with changes in performance
post-operative to changes of role Goal met.
site at the role obligations. - Encourage client - To develop new
abdomen to use techniques skills and to cope
of role rehearsal with changes

Long term:

- Make information - To provide

available for proactive
client about role opportunities in
expectations dealing with
changes
- Emphasize to - To provide
relatives the reinforcement to
importance of client and facilitate
accepting client in continuation of
a changed role efforts.
 Assessment Nursing Diagnosis Planning Nursing intervention Rationale Evaluation

Subjective: Fatigue related to post After conducting Short term: After conducting
surgical procedure as nursing intervention, - Obtain client’s - To evaluate impact series of nursing
“nanghihina ako at evidenced by patient’s the patient will: description of on client’s daily interventions, the patient
hindi halos makakilos” increased complaints fatigue living was able to decrease
and guarding - Be able to - Encourage client - To increase level of fatigability as evidenced
Objective: behaviors. report improved to do simple activity as tolerated by client’s report of
sense of energy activities if improved level of energy
- Body malaise possible and activity as well as
- Facial grimace - Be able to - Encourage client - To reduce willingness to participate
- Irritability perform ADLs to have adequate fatigability and in continuation of
- Limited ROM at level of own sleep regain energy therapeutic regimen.
- Presence of ability - Encourage client - To conserve body’s
post-operative to use assistive energy Goal met.
site at the devices when
abdomen - Be able to moving
participate in - Encouraged client - To refocus energy
recommended to have and diminish
treatment diversional feeling of anxiety
program. activities that can
accompany fatigue
Long term:
- Refer client to - To improve
rehabilitation stamina and sense
program of well-being
- Discuss therapy - To inform the
regimen client about
continuance of care
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective: Impaired skin integrity Long Term: Independent: Longterm:

“Masakit yung tahi ko at related to altered biliary -After 14 days of nursing 1. connect tubes to 1. to avoid kinking After 14 days of nursing
medyo nangangati ako” drainage after surgical interventions, the patient drainage receptacle and interventions, the patient
as verbalized by the incision will improve biliary secure tubing; elevate improved biliary
patient. drainage as evidenced by above the abdomen drainage as evidenced
brown colored stools. by brown colored stool
Objective: Background Knowledge 2. place patient in low 2. to facilitate drainage >Goal met
-insertion of T-tube for Bile is corrosive to skin. Short Term: semi-fowlers position of bile
biliary drainage If the bile is not properly -After 8 hours of nursing Short term:
-disruption of skin. drain it will leak into the interventions the patient’s 3. change dressing 3. bile is corrosive to the After 8 hours of nursing
-yellow skin subhepatic space and will reported pain and itching frequently skin interventions the
-yellow sclera produce jaundice and will be relieved. patient’s reported pain
-pain scale of 6/10 itching sensation. 4. measure bile collected 4. to monitor for and itching was relieved.
-with facial grimace every 24 hours; complications such as >Goal met
-irritable document amount, color bleeding.
and character of
drainage
5. keep patient’s 5. it prevents skin
fingernails short and excoriation and infection
smooth from scratching

6. provide frequent skin 6. removes waste

care; avoid use of soap products from skin while
and alcohol-based preventing dryness of
lotions skin.

Dependent:
1. administer analgesic 1. pharmacological
and diphenhydramine as management for pain
prescribed and itching
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective: Risk for impaired liver Long Term: Independent: Long Term:
“Naninilaw ako” as function related to viral -After 14 days of nursing 1. educate client on ways 1. to reduce incidence of -After 14 days of
verbalized by the infection as evidenced by interventions, the patient to prevent exposure such HAV infections nursing interventions,
patient. jaundice and marked will be free of signs of as: the patient was free of
elevations in serum liver liver failure as evidenced a. proper community signs of liver failure as
Objective: function test (SGPT: 94 by liver function studies. and home sanitation evidenced by liver
-yellow skin u/L SGOT: ) b. conscientious function studies SGPT:
-yellow sclera Background Knowledge Short Term: individual hygiene SGOT: .
-abdominal pain Hepatitis A virus -After 8 hours of nursing c. importance of hand
-pain scale of 6/10 infection is transmitted interventions the patient hygiene Short Term:
-with facial grimace via the fecal-oral route will verbalized d. avoidance of raw -After 8 hours of nursing
-irritable and leads to hepatic understanding of meat and seafood interventions the patient
injury. The causative individual risk factors that verbalized
agent invades the contribute to possibility of 2. stress the importance 2. to reduce severity of understanding of
mononuclear cells in the liver damage and ways to of avoiding drinking liver damage individual risk factors
liver, replicates, and sets prevent HAV infections. alcohol that contribute to
up an inflammatory possibility of liver
process in the 3. encourage the client to 3. fat interferes with damage and some ways
parenchyma and portal avoid fatty foods normal function of liver to prevent HAV
ducts, causing hepatic cells and can cause infections such as hand
cell necrosis, cellular additional damage to washing and eating
collapse, and liver cells when they cooked meats.
accumulation of necrotic can no longer regenerate
tissue in the lobules and
portal ducts. This results 4. discuss safe use of 4. some medications are
in interference with client’s medications known to cause
bilirubin excretion. regimen hepatoxicity
Cellular regeneration and
mitosis occur Collaborative:
simultaneously with 1. refer to nutritionist, as 1. to promote healing
cellular necrosis, and the indicated, for dietary
liver regenerates within 2 needs including intake of
to 3 months. protein and vitamins
 Assessment Nursing Diagnosis Planning Intervention Rationale Evaluation
Subjective: Anxiety related to Short term: > Assessed > To establish Short term:
“Nahihirapan ako change in health At the end of 3Hrs. of patient’s level of baseline data. At the end of
ngayon sa sakit status, as nursing anxiety. 3Hrs. of nursing
ko”. As verbalized evidence by fear intervention > Placed patient in > To help the intervention
by the patient. of consequence. patient will be comfortable patient have patient was able
Objective: able to reduce position. adequate period to reduce feeling
Vital signs taken anxiety. of rest and sleep. of anxiety.
and recorded: Long term: > Provide non- > To relax & Long term:
BP: mmHg After two weeks pharmacological provide comfort After two weeks
PR: BPM of nursing care, Therapies such to the patient. of nursing care,
RR: CPM patient will be as listening to Radio and patient was able
Temp: able to accept Socialization w/ to accept
changes in health others. /understand his
status. > Provide calm > Can lessen the health status.
activities. anxiety of the
patient.
> Provide health > To give more
teaching about information about
hepatitis disease. his health status.
Assessment Nursing Diagnosis Planning Intervention Rationale Evaluation
Subjective: Nutrition: Short term: -Assessed the clients risk for -to assess causative factors Short term:
Madalas wala akong imbalanced, less At the end of 3hrs. of malnutrition At the end of
ganang kumain dahil than body nursing -Assessed clients Weight daily -To establish baseline 3Hrs. of nursing
ang sama ng panlasa requirements intervention and compare the recent weight parameters intervention
ko as verbalized by the related to patient will be history, measurements. patient was able
patient inadequate diet; able to verbalize -Assisted /encouraged patient -Improved nutrition/diet is to verbalize
inability to understanding of to eat; explain reasons for the vital to recovery. Patient may understanding of
process/digest causative factor types of diet. Consider eat better if family is causative factor
nutrients preferences in food choices. involved and preferred foods
Long term: Encourage patient to eat all are Long term:
Objective: After two weeks meals. included as much as possible. After two weeks
Weight loss (+) of nursing care, -Recommend /provide small, -to avoid of nursing care,
Wt: patient will be frequent meals. Restrict intake of loss of interest in food or patient was able
able to display of caffeine, gas-producing or because of nausea, to accept
normalization of spicy and excessively hot or generalized weakness, /understand his
laboratory values and cold foods. malaise. health status.
be free of sign of -Encourage frequent mouth - Patient is prone to sore
malnutrition care, especially before meals. and/or bleeding gums and
bad taste in mouth, which
contributes to anorexia.
 DISCHARGE PLAN
(DEÑA, DE JESUS, CUERDO)
Medications • Advise client to have a strict compliance to home medications.
Medications should be taken regularly as prescribed by the physician,
making sure that the purpose of medication is fully disclosed by the
health care provider to ensure safety.

• Discuss to client as well as to the relatives the side effects and/or adverse
reactions of the medications prescribed.

Environment and/or Exercise Environment:

• Environment should be kept hazard free and clean so that it may facilitate
continuous recovery of the client.

• Ensure that the environment is conducive for relaxation to promote

optimal healing to patient after hospitalization.
Exercise:
• Encourage client to ambulate as much as possible to increase activity
tolerance
• Advise client to avoid strenuous activities to reduce fatigue
• Instruct client to do simple ROM exercises as tolerated to improve body
movements
Treatment • Begin light exercise immediately such as walking
 • 2. Wash the incision site with mild soap and water
• 3. sitting upright in bed or chair to manage pain
• 4. keep the dressing clean and dry
Health Teachings • Avoid lifting objects exceeding 5 pounds after surgery, usually for 1
week.
• Check incision site daily for signs of infection like redness and pus
formation.
• Allow adhesive strips on the incision site to fall off or put alcohol on it
when removing. Do not pull them off.
• Teach the patient about the proper care of drainage tube
• Emphasize the importance of hand washing, safe water supply and proper
control of sewage disposal.
Out patient •
Diet •