HOLY ANGEL UNIVERSITY COLLEGE OF NURSING AND ALLIED MEDICAL SCIENCES A.Y.

2013-2014

A CASE STUDY

CHOLECYSTITIS
SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS IN NURSING CARE MANAGEMENT 104 RELATED LEARNING EXPERIENCE (NCM104-RLE)

SUBMITTED TO: Elvira Chan R.N.,M.A.N Clinical Instructor

SUBMITTED BY: N-401 / GROUP I Calma, Louieliza Nucum, Patricia Camille Vergara, Xzeegnah Xuxa Yuson, Ramon Gabriel

February 2014

I.

INTRODUCTION

A. DESCRIPTION OF THE DISEASE Cholecystitis is an inflammation of the gallbladder wall and nearby abdominal lining. Cholecystitis is usually caused by a gallstone in the cystic duct, the duct that connects the gallbladder to the hepatic duct. The presence of gallstones in the gallbladder is called cholelithiasis. Cholelithiasis is the pathologic state of stones or calculi within the gallbladder lumen. A common digestive disorder worldwide, in Asia, pigmented stones predominate, although recent studies have shown an increase in cholesterol stones in the Far East. Gallstones are crystalline structures formed by concretion (hardening) or accretion (adherence of particles, accumulation) of normal or abnormal bile constituents. According to various theories, there are four possible explanations for stone formation. First, bile may

undergo a change in composition. Second, gallbladder stasis may lead to bile stasis. Third, infection may predispose a person to stone formation. Fourth, genetics and demography can affect stone formation. Risk factors associated with development of gallstones include heredity, Obesity, rapid weight loss, through diet or surgery, age over 60, Native American or Mexican American racial makeup, female gender-gallbladder disease is more common in women than in men. Women with high estrogen levels, as a result of pregnancy, hormone replacement therapy, or the use of birth control pills, are at particularly high risk for gallstone formation, Diet-Very low calorie diets, prolonged fasting, and low-fiber/high-cholesterol/high-starch diets all may contribute to gallstone formation. Sometimes, persons with gallbladder disease have few or no symptoms. Others, however, will eventually develop one or more of the following symptoms; (1) Frequent bouts of indigestion, especially after eating fatty or greasy foods, or certain vegetables such as cabbage, radishes, or pickles, (2) Nausea and bloating (3) Attacks of sharp pains in the upper right part of the abdomen. This pain occurs when a gallstone causes a blockage that prevents the gallbladder from emptying (usually by obstructing the cystic duct). (4) Jaundice (yellowing of the skin) may occur if a gallstone becomes stuck in the common bile duct, which leads into the intestine

blocking the flow of bile from both the gallbladder and the liver. This is a serious complication and usually requires immediate treatment. B. RECENT TRENDS IN THE TREATMENT OF THE DISEASE Most patients in the 21st century with AC undergo LC with a low conversion rate and low morbidity. In the general population with acute cholecystitis, LC results in lower morbidity and mortality rates than OC even in the setting of open conversion. (Csikesz N, Ricciardi R, Tseng JF, Shah SA., 2008) C. STATISTICS (LOCAL AND INTERNATIONAL) D. OBJECTIVES After accomplishing this case study, the student nurses will be able to: Cognitive explain the disease condition interpret physical assessment data discuss the anatomy and physiology of the major systems involved in the disease explain the pathophysiology of Cholecystitis based on the clients condition identify the predisposing and precipitating factors of cholecystitis discuss the signs and symptoms of the disease present the laboratory and diagnostic procedures in detecting the disease interpret the laboratory and diagnostic results done to the patient make a drug study regarding the pharmacological treatment of cholecystitis identify actual and potential problems on clients condition prioritize the problems identified with the need of the patient formulate nursing care plans related to prioritized problems identified

 provide health teachings on how to prevent or control cholecystitis Psychomotor perform physical assessment cephalocaudally render appropriate independent nursing interventions for the management of the symptoms of the disease process carry-out applicable doctors order such as medication administration collaborate with the health care team towards patients recuperation and improvement implement nursing care plans with utmost care Affective establish rapport to build trust and comfort to the patient listen to patients view of the diagnosis of cholecystitis let the patient express all her concerns with regards to her condition provide emotional support to the patient in dealing with her situation apply non-pharmacologic measures such as the therapeutic use of touch, backrub, massage, etc., motivate the patient to improve diet and lifestyle to prevent the aggravation of the condition encourage the participation of the significant others in providing care to the patient II. NURSING HISTORY A. PERSONAL DATA A. DEMOGRAPHIC DATA

The client in this study is named as Maria and she is a 38 year old female born on November 1, 1975, married and has three children. As for her educational background, she is a college undergraduate. Maria is currently residing in Pampanga, a natural born Filipino citizen and was baptized as a Roman Catholic. Kapampangan is their main dialect at home but she also knows Filipino and English language. She is currently a government employee at a certain city hall and her work focuses on the job orders. B. SOCIO- ECONOMIC AND CULTURAL FACTORS Maria worked as a domestic helper in Hong kong for 5 years from 2000 until 2005 before she worked as a government employee. She and her husband are the economic sources of their family and their monthly income ranges from pHp20,000 25,000. Their usual health belief is that when she has illness, she consults directly to a clinician but when her children get fever, cough or colds, she consults first in an albularyo and then, to a clinician when the said illness continues for 3 days. C. ENVIRONMENTAL FACTORS Maria is currently living at Pampanga and their type of family is an extended type since they are living with her husbands parents. Their house is privately owned and a concrete type and is near to a school and lots of sari-sari store. D. LIFESTYLE As said before, Maria is currently employed and usually her work starts at 8:00am and ends at 5:00pm. She works from Monday to Friday and for these days, she usually wakes up at 6:00am and then prepare for breakfast and for work. After work, she attends the needs of her children and at evening prepares for dinner. After, she sleeps at 8:00pm but sometimes exceeded at 11:00pm. She does not engage herself to drinking or smoking. Her usual diet is high in fat but she also eats fruits and vegetables. She is fond of eating chicharon, sisig, lechon kawali and junk foods together with soda. E. PAST MEDICAL HISTORY

As she recalls, her mother told her that she completed her immunizations and she still did not experience childhood illnesses like mumps, chicken pox and measles. As she grow up and gave birth to her children, she was hospitalized because she undergone Caesarian Section. When experiencing illness like flu she takes medication like paracetamol and if it stays for three days she consults a clinician immediately. F. HISTORY OF PRESENT ILLNESS According to Maria, symptoms started way back 2002, rarely she experiences severe abdominal pain after eating fatty and bulk foods then it is relieved after vomiting, she didnt had check-up because it happens rare only until 2011, abdominal pain happens very often and decided to have a check-up and undergone an ultrasound in May and found out that she has stones in the gallbladder (cholelithiasis). Surgery was offered to her but decided not to go for a surgery first because she was busy at work. Until the 23rd of January 2014, since she knew that there is a medical mission and her co-workers and the head pushed her to go for a surgery, she confide to go to a hospital somewhere in Angeles City and was admitted with the diagnosis of cholelithiasis and undergo emergency cholecystectomy on January 24, 2014 at 12:27pm. G. FAMILY HISTORY OF ILLNESS Maria is the eldest of the 3 siblings and she is the only one who acquired the said disease. Her grandfather at father side died of heart failure while her grandmother is currently experiencing kidney problem. Her grandfather on mother side died of colon cancer and her grandmother is currently having a cataract. Shown below is the family diagram of Maria:

III. PHYSICAL ASSESSMENT *January 27, 2014* a. General Survey Maria is received in a semi-fowlers position; conscious and coherent; with an ongoing IVF of D5NM 1L x 8o @ 350 cc level infusing well on left hand. She appears untidy and is wearing blue shirt with blood stain and a pajamas. She is participative and answers question appropriately Vital signs: BP- 110/70mmHg PR- 80bpm RR- 20cpm T- 36.7oC Pain scale- 8/10 Assessing the skin, hair and scalp Brown in color; uniform in skin color upon inspection Smooth and warm to touch Good skin turgor No rashes, edema, sores and/or bruising seen upon inspection Hair is dark brown in color and dry Hair is evenly distributed on scalp, eyebrows and eyelashes Flakes in the scalp seen

Assessing the head and neck Skull is normocephalic and symmetrical No nodules or masses palpated in the skull and neck

Assessing eyes, ears, nose and sinuses Eyebrows are symmetrically aligned and have equal movement Eyelashes are equally distributed and slightly curled outward Eyelids close symmetrically and involuntarily blinks Palpebral conjunctiva is pale pink in color

The cornea is transparent, shiny and smooth Pupils are dark brown in color; equal in size; round and with smooth border Pupils constricts when illuminated and dilates when non illuminated; constricts when looking at near objects and dilates when looking at far objects (+PERRLA) Auricles are smooth and mobile as pinna recoils after it is folded and ears are not tender upon palpation Both ear canals are not clean upon inspection Nostrils are symmetric and nose bridge is straight; absence of nasal discharges and flaring upon inspection Nose is non-tender, absence of masses, and displacements of bone and cartilage upon inspection Air freely moves as he breathes through the nares upon occlusion of other nare Nasal septum is intact and in the midline Facial sinuses are non-tender upon palpation No discharges seen upon inspection

Assessing the mouth and oropharynx Lips are uniform, pale in color Inner lips and buccal mucosa are slightly pale Tongue is in the central position She was able to move his tongue upward, downward and side to side Uvula is positioned at the midline of soft palate upon inspection Cavities and plaques seen

Assessing the thorax and lungs Normal thoracic and lumbar curvature Do not use accessory muscles during breathing Thorax expands symmetrically when breathing No abnormal lung sound

Assessing the heart and central vessels Normal heart rhythm

Pulses are easily palpabale

Assessing the abdomen Abdominal skin is unblemished and uniform in color Abdominal movements caused by respirations are symmetrical Bowel sounds heard during auscultation Presence of surgical lesion on right upper quadrant Dressing is dry, intact with some blood stains Pain on the incision site with a pain scale of 8/10

Assessing the upper and lower extremities ROM was performed in all extremities without pain and equal muscle strength Nails are long and dirty Nail beds are pinkish Capillary refill time of 1-2 seconds

IV. DIAGNOSTIC AND LABORATORY PROCEDURES Diagnostic/ Laboratory Procedures Hematology Indications or Date Ordered Results Purpose Date Results Released Reveal the general condition of many body systems and can aid in the diagnosis of many disorders. January 13, 2014 Hemoglobin = 127 Normal Values (units used in the hospital) 120-160 g/L Analysis and Interpretation of Results There is adequate amount of red blood cells that carries oxygen which indicates sufficient amount of oxygen in blood.

There is sufficient volume of red blood cells;

Hematocrit = 0.38 RBC = 4.44

0.37-0.47 L/L 4.2-5.4 x1012/L There is a normal amount of immune cells which indicates that the body has no infection.

White blood cell = 8.2 Segmenters = 0.62 Lymphocytes = 0.3

5-10 x109/L

Platelet count = 426 150400x109/L

There is adequate amount of platelets which indicates adequacy of clotting factor, has no risk for bleeding.

Nursing Responsibilities: Before:

Verify doctors order. Verify the patient. Instruct the SO about the schedule of the test since the patient is an infant and is still not mentally capable. Explain the procedure and its purpose to the SO Obtain a history of the SO's complaints, including a list of known allergens, especially allergies or sensitivities to latex. Note any recent procedures that can interfere with test results. Obtain a list of the patient's current medications, including herbs, nutritional supplements, and nutraceuticals. Review the procedure with the SO. Inform the SO that specimen collection takes approximately 5 to 10 min. Explain that there may be some discomfort during the venipuncture. There are no food, fluid, or medication restrictions unless by medical direction.

During: If the patient has a history of allergic reaction to latex, avoid the use of equipment containing latex. Instruct the SO to cooperate fully and to follow directions.

After: Apply pressure or a pressure dressing on the punctured site to prevent bleeding. A report of the results will be sent to the requesting HCP, who will discuss the results with the patients SO. Depending on the results of this procedure, additional testing may be performed to evaluate or monitor progression of the disease process and determine the need for a change in therapy. Evaluate test results in relation to the patient's symptoms and other tests performed. Record all procedures done.

Diagnostic/ Laboratory Procedures

Indications or Purpose

Date Ordered Date Results Released January 13, 2014

Results

Normal Values (units used in the hospital)

Analysis and Interpretation of Results

Clinical Microscopy : Urinalysis

Test urine glucose, infection of urinary tract, and to identify presence of blood cells, protein or micro organisms in the urine.

Color = Yellow

Urine color is still normal which may indicate the body is well hydrated.

Transparency = hazy

This is normal if it happens every once in while. However, if hazy urine becomes a constant problem, it could mean that mucus, phosphates, bacteria, pus, or fats are spilling into your urine.

Urine is normally concentrated and balanced water in the body.

Specific Gravity

Presence of 45/hpf pus cells

= 1.030

is still normal.

Moderate pithelial cells seen in the urine is still normal.

Pus Cells = 45/HPF

Urine is normally slightly acidic because of metabolic activity.

Epithelial Cells = moderate

Negative glucose is a normal result; kidney functions well.

pH = 6.3

Negative albumin is a normal result; kidney functions well

Glucose = Negative

Albumin = negative

Nursing Responsibilities: Explain the procedure and purpose to the SO prior to the procedure and assist with specimen collection, if needed. Stress to the SO that the midstream when urinating will be the specimen to be collected. Ensure that the specimen is labeled properly and that specimen is taken to the laboratory in a timely manner.

Diagnostic/ Laboratory Procedures

Indications or Purpose

Results Date Ordered Date Results Released

Normal Values (units used in the hospital)

Analysis and Interpretation of Results

Blood Chemistry

This test January 18, measures the 2014 amount of potassium and sodium in the blood wherein it detects whether nutrients are into the cell and waste products out of the cell.

FBS = 106

74-106 mg/dl

Normal amount of blood glucose

BUN = 10

7-17 mg/dl

Normal amount of blood urea nitrogen indicates that the kidneys are functioning properly.

Creatinine = 0.6

0.7-1.2 mg/dl

Slightly decreased in blood creatinine is not significant meaning the kidneys are functioning well and no other severe diseases. But low levels may indicate severe liver disease or a diet very low in protein.

Normal amount of sodium indicates a balance amount of liquid and sodium in the

blood.

Sodium = 138.9 137-145 mg/dl

Normal amount of potassium indicates normal rhythm of heart beats.

Potassium = 4 3.5-5.1 mg/dl

Nursing Responsibilities: Before: Verify doctors order. Verify the patient. Instruct the SO about the schedule of the test since the patient is an infant and is still not mentally capable. Explain the procedure and its purpose to the SO

Obtain a history of the SO's complaints, including a list of known allergens, especially allergies or sensitivities to latex. Note any recent procedures that can interfere with test results. Obtain a list of the patient's current medications, including herbs, nutritional supplements, and nutraceuticals. Review the procedure with the SO. Inform the SO that specimen collection takes approximately 5 to 10 min. Explain that there may be some discomfort during the venipuncture. There are no food, fluid, or medication restrictions unless by medical direction.

During: If the patient has a history of allergic reaction to latex, avoid the use of equipment containing latex. Instruct the SO to cooperate fully and to follow directions.

After: Apply pressure or a pressure dressing on the punctured site to prevent bleeding. A report of the results will be sent to the requesting HCP, who will discuss the results with the patients SO. Depending on the results of this procedure, additional testing may be performed to evaluate or monitor progression of the disease process and determine the need for a change in therapy. Evaluate test results in relation to the patient's symptoms and other tests performed. Record all procedures done.

Diagnostic/ Laboratory Procedures

Indications or Purpose

Date Ordered Date Results Released January 9, 2014

Results

Normal Values (units used in the hospital)

Analysis and Interpretation of Results

Hepatobiliary ultrasound

It is the least invasive radiologic

Gallstones

Evidence of stones in the

modality for imaging the liver and biliary tract and is indicated for the evaluation of biliary colic, cholecystitis, hepatomegaly, and ascites.

gall bladder

Fatty change (Grade 1) or diffuse parenchymal disease, liver

Grade 1 is slight (mild) increase in liver echogenicity but normally visualized intrahepatic vessels.

Normal biliary tree

Normal biliary tree indicates no obstruction linked to some diseases.

Nursing Responsibilities: Before: Verify doctors order. Verify the patient. Ensure that consent is understood and signed by the SO of the patient since the patient is still an infant and is not capable of doing so. Instruct the SO about the schedule of the test. Explain the procedure and its purpose to the SO Explain the procedure to the SO, indicating that she can watch the procedure and ask questions about the images on the screen. If appropriate, point out landmarks on the screen. If indicated, ensure that the womans bladder is full by forcing fluids and instructing her not to void. If she is NPO, a Foley catheter may be inserted into the bladder and sterile water instilled. The catheter is then clamped to prevent the water from leaving the bladder. The full bladder lifts the pelvic organs higher into the abdomen and improves visualization.

Inform the patients SO on what to expect like the abdomen will be coated with ultrasonic transducing gel. The gel provides a better image when the scanner is applied to the abdomen.

After: A report of the results will be sent to the requesting HCP, who will discuss the results with the patient. Depending on the results of this procedure, additional testing may be performed to evaluate or monitor progression of the disease process and determine the need for a change in therapy. Evaluate test results in relation to the patient's symptoms and other tests performed. Record all procedures done.

V. THE PATIENT AND HIS ILLNESS

V. THE PATIENT AND HIS ILLNESS MEDICAL MANAGEMENT IVFS Medical Management General Description Indication/Purpos e Date Ordered, Performed, Changed DO: January 24, 2014 Clients Response to Treatment The client has good hydration status. Before: Check the doctors order Explain the procedure to the patient, its importance and its benefits. Prepare all the materials needed Check for the label of the IVF Check for the patency of the line Clean site for insertion Check the patency of the IV tubing Check IV level During: Always check if it the infusion site is intact and in place Assess for the redness and signs of inflammation on the IV site Assess vital signs Be sure that IV line is free from any kinks and bubbles Check for the infusion rate Inspect for level of IV always Monitor client for fluid overload Nursing Responsibilities

DLRS 1L x 8 Hours

Classificatio n: Hypertonic Solution

The Dextrose 5% in Lactated Ringers Solution (D5LRS) is useful for daily maintenance of body fluids and nutrition, and for rehydration. Dextrose 5% in Normosol M Solution (D5NM) is a hypertonic solution that is nonpyrogenic and is a nutrient

Treatment for persons needing extra calories who cannot tolerate fluid overload.

DS: January 24, 2014

Treatment of shock.

D5NM 1L X 8 hours

Classificatio n: Hypertonic

For parenteral maintenance of routine daily fluid and electrolyte requirements with minimal carbohydrate calories from

DO: January 25, 2014

DO: January 25, 2014

DS: January 25, DS: January 2014 25, 2014

Solution

replenisher.

dextrose.

Magnesium in the formula may help to prevent iatrogenic magnesium deficiency in patients receiving prolonged parenteral therapy.

Provide a splint to prevent injury of the vein Regulate the flow rate as ordered After: Check for doctors order for discontinuation of the IV solution Label IVF on the date and time started and on the infusion rate Monitor for the patency and regulation of the IV Monitor hydration status of patient and document Assess patients response to the treatment Monitor for evidenced of local IV complication such as pain, swelling and tenderness Record all procedures done Document response

DRUGS

Generic Name, Brand Name

General Action

Indication/Purpose

Date Ordered, Started, Changed/ Discontinu ed

Clients Response to Medication

Nursing Responsibilities

Generic Name:

Cefuroxime is a semisynthetic Cefuroxime cephalosporin antibiotic, chemically similar to penicillin. Brand Name: Cephalosporins stop or slow the growth of Zinaceft bacterial cells by preventing bacteria from forming the cell wall that 1gm slow IV (-) surrounds each cell. ANST, then 750mg q 8 hours x 2 doses

used for treating urinary tract infections, skin infections, and gonorrhea

DO: January 24, 2014 DS: January 24, 2014

The client

If you have ever had an allergic reaction to a medicine. It is particularly important that you tell your doctor if you have had a bad reaction to a penicillin or cephalosporin antibiotic

Cefuroxime is effective against susceptible bacteria causing infections of the middle ear (otitis media), tonsillitis, throat infections, laryngitis, bronchitis, and pneumonia.

If you have any problems with the way your kidneys work.

If you are pregnant, trying for a baby or breast-feeding. (Although cefuroxime is not known to be harmful to babies, it is still important that you tell your doctor if you are expecting or breastfeeding a baby.)

If you are taking or using any other medicines. This includes any medicines you are taking which are available to buy without a prescription, such as herbal and complementary medicines.

Generic Name: Ketorolac

Brand Name Toradol

30 mg IV q 8 hours x 4 doses

Ketorolac works by blocking the action of a substance in the body called cyclo-oxygenase (COX). Cyclo-oxygenase is involved in producing prostaglandins, in response to injury or certain diseases, such as arthritis. These prostaglandins cause pain, swelling and inflammation. Ketorolac blocks the production of these prostaglandins and so is effective at relieving pain and inflammation.

Short-term relief of moderate to severe pain following surgery.

DO: The client pain January 24, scale 2014 decreased from 8/10 to 2/10 DS: January 24, 2014

Always begin with parenteral therapy; oral administration indicated only as continuation of IV/IM dosing, if necessary Duration of therapy should not exceed 5 days Dosage beyond maximum or labeled doses will not provide better efficacy but will increase risk of serious adverse events Decrease daily dose in patients >65 years, <50 kg, or with moderately elevated serum creatinine

Generic Name: tramadol

Centrally acting opiate receptor agonist that inhibits the uptake of norepinephrine and

Management of moderate to moderately severe pain

DO: The client pain January 24, scale 2014 decreased from 8/10 to 2/10 DS:

Assess for level of pain relief and administer prn dose as needed but not to exceed the recommended total daily dose.

serotonin, suggesting both opioid and nonopioid mechanisms of pain relief. May produce opioid-like effects, but causes less respiratory depression than morphine.

January 24, 2014

Monitor vital signs and assess for orthostatic hypotension or signs of CNS depression.

Discontinue drug and notify physician if S&S of hypersensitivity occur.

Assess bowel and bladder function; report urinary frequency or retention.

Use seizure precautions for patients who have a history of seizures or who are concurrently using drugs that lower the seizure threshold.

Monitor ambulation and take appropriate safety precautions.

Control environment (temperature, lighting) if sweating or CNS effects occur.

DIET Type of Diet General action Indication/Purposes Date Ordered, Date Started, Changed DO: january 26, 2014 DS: january 26, 2014 Clients response Nursing responsibilities

Soft Diet

Type of diet where in the clients food are softened by cooking, mashing, chopping which are easy to chew and swallow

Type of diet where in the clients food are softened by cooking, mashing, chopping which are easy to chew and swallow

The client ingested regular meals in a day.

Prior: Check order for specific diet.

During: Ensure correct identification of patient.

After: Evaluate the response of the client from diet.

ACTIVITY Type of exercise General action Indication/Purposes Date Ordered, Date Started, Changed DO: january 25, 2014 DS: january 25, 2014 Clients response Nursing responsibilities

Ambulation

a technique of postoperative care in which a patient gets out of bed and engages in light activity (as sitting, standing, or walking) as soon as possible after an operation

a technique of postoperative care in which a patient gets out of bed and engages in light activity (as sitting, standing, or walking) as soon as possible after an operation

The client can stand and walk go to restroom

Prior: Check order for specific diet.

During: Ensure correct identification of patient.

After: Evaluate the response of the client from diet.

2. SURGICAL MANAGEMENT

A. DESCRIPTION OF THE PRESCRIBED SURGICAL TREATMENT Cholecystectomy is the surgical removal of the gallbladder, an organ located just under the liver on the upper right quadrant of the abdomen. The gallbladder stores and concentrates bile, a substance produced by the liver and used to break down fat for digestion. B. INDICATIONS Indications for cholecystectomy include inflammation of the gall bladder (cholecystitis), biliary colic, risk factors for gall bladder cancer, and pancreatitis caused by gall stones. Cholecystectomy is the recommended treatment the first time a person is admitted to hospital for cholecystitis. Cholecystitis may be acute or chronic, and may or may not involve the presence of gall stones. Risk factors for gall bladder cancer include a "porcelain gallbladder," or calcium deposits in the wall of the gall bladder, and an abnormal pancreatic duct. Cholecystectomy can prevent the relapse of pancreatitis that is caused by gall stones that block the common bile duct.

C. REQUIRED INSTRUMENTS, DEVICES, SUPPLIES, AND FACILITIES

Suction Machine

Electrosurgical Unit

Mayo Table

Mosquito

Kelly

Right Angle

Richardson

Army Navy

Russian Forceps

Adson

Thumb Forceps

Tissue Forceps

Needle Holder

Surgical Blade

Allis

Babcock

Kocher

Towel Clips

Straight Scissors

Metzenbaum Scissors

Senn Mueller Retractor

Kidney Basin

Blade Handle / Holder

Malleable

Deaver

D. PREOPERATIVE TASKS AND RESPONSIBILITIES OF THE NURSE Assess the patients understanding of the procedure. Provide explanation, clarification, and emotional support as needed. Reassure that the anesthesia will eliminate any pain during surgery and that medication will be administered postoperatively to minimize discomfort. The patient who understands about the procedure to be performed and what to expect after surgery will be less anxious. Cleanse the abdominal area.

Administer preoperative medications as ordered. Check the chart to ensure that the consent form has been signed.

Scrub Nurse Reads the schedule, noting the type of case, estimated length and type of anesthesia to be used. Review basic anatomy, physiology and operative technique if not thoroughly familiar with the type of case to be performed. Check all types of instruments to be needed and discuss these with the surgeon to obtain idea of preference which are not written in his own preference card and for visiting surgeons. Discusses any question she has about the nature of the case with the surgeon. Makes available all types of sutures in each surgeons preference card that will be used in the case.

Circulating Nurse The circulating nurse will function as an overseer of the room during the procedure to maintain sterility. He/She assists the entire team and the patient. He/She also sends for the patient at the appropriate time. He/She receives, greets and identifies the patient upon admission and checks for the completeness of the chart. Upon admission to the operating room, she will assist the patient in moving safely to the operating room table.

E. INTRAOPERATIVE TASKS AND RESPONSIBILITIES OF THE NURSE Always keep concept of sterility in mind and in practice. All items are counted initially by the circulating and the scrub nurse together (aloud) as the scrub nurse touches each item. The number (count) of type of each item is immediately recorded by the circulating nurse. Counts are taken before beginning the procedure, before wound closure begins, and when skin closure is initiated.

Pay attention to the surgeon, anticipating every instrument about to be asked. Incorrect closure counts must be repeated immediately. If the count remains incorrect, the circulating nurse alerts the surgeon who will inspect the patient's wound for the missing item. If the item is not located, hospital policy must be followed (usually to include x-ray examination), and an incident report must be filed.

Scrub Nurse Aids the surgeon in gowning and gloving. He/She also aids in draping the patient. Intraoperative, the scrub will set up sterile supplies and instruments assist the surgeon as needed throughout the surgery like pulling the retractors manageable in order to visualize the part to be manipulated. He/she will also be responsible for draping the patient and the field. Instruments, sutures and sponges are handed to the surgeon in an efficient manner. As a scrub nurse, it is also his/her responsibility to keep operative tidy during the operation. As much as possible, the scrub nurse must wipe blood from instruments and keep close watch on needles, instruments and sponges so that none will be misplaced or lost during the operation. The instrument nurse and the suture nurse will keep an accurate account of needles and instruments. Makes sure that supplies are sterile and if in doubt, they should be discarded immediately. An important nursing responsibility is to count the instruments at all times. The scrub nurse and the circulating nurse should establish an accurate count on the things that are present before, during and after the operation. Observe the skin incision from the viewpoint of how much bleeding is occurring so as to anticipate the need for hemostatic clamps and ligatures to control bleeding. Observe the progress of dissection to be able to anticipate the need for special instruments, sponges and free suture ends. Thus maintaining the orderliness and neatness of the field, this is the major factor in safe and efficient surgery. Anticipate special problems so as to advise the circulating nurse accordingly for the possible need for special instruments and equipments.

Circulating Nurse He/She is also the one who assist the anesthesiologist, when requested, stays with the patient during the induction of anesthesia.

Being a circulating nurse, included in the unsterile team, she will also tie the scrubbed members gowns and checks operating room lights on at appropriate time and adjusts when needed. After positioning the patient, the circulating nurse will prepare the operative site using an antiseptic in a circular motion from inner to outer part. A dependent nursing function like inserting a Foley catheter is also done if ordered by the surgeon. The circulating nurse and the scrub nurse do the sponge count. As an overseer, it is her responsibility to provide foot stools of needed by the surgical team and watches the forehead for perspiration. Intraoperatively, she will fill out required operative records completely and legibly. He/she remains in the room as much as possible to be constantly available. Watches progress of the surgery, anticipates needs and reacts quickly to emergency. He/she is also responsible for using equipment and supplies economically and conservatively like the use of the suction machine, the need for extra cherry, abdominal packs, OS (gauze) and sterile water. Working on a sterile field, the circulating nurse should watch out for the sterility at all times and remind those who break any technique.

F. POSTOPERATIVE TASKS AND RESPONSIBILITIES OF THE NURSE Scrub Nurse: At the termination or conclusion of the procedure, the scrub nurse will clean the instruments and supplies used during the operation so that the instruments will ready for sterilization. Accountable for any loss of such instruments, wash and return the instruments properly.

Circulating Nurse: At the conclusion or termination of the operation, the circulating nurse also directs cleaning of the room and preparation for the next operation. Gathers supplies for case and opens sterile supplies for the scrub nurse.

He/She is also responsible for sending all tissues or specimen removed from the patient to the laboratory with proper label and necessary request for the kind of laboratory work to be done as soon as the case is terminated.

Postoperative Care Monitor vital signs every 4 hours, auscultate lungs every shift and measure intake and output. These data are important indicators of hemodynamic status and complications. Assess for complications. Encourage turning, coughing, deep breathing, and early ambulation. Encourage fluid intake. Instruct to restrict physical activity for 4 to 6 weeks. Heavy lifting, stair climbing, douching, tampons, and sexual intercourse should be avoided. The woman should shower, avoiding tub baths, until bleeding has ceased. Infection and hemorrhage are the greatest postoperative risks; restricting activities helps reduce these risks. Explain to the patient that she may feel tired for several days after surgery and needs to rest periodically. Explain that appetite may be depressed and bowel elimination may be sluggish. These are after effects of general anesthesia, handling of the bowel during surgery, and loss of muscle tone in the bowel while empty.

Problem #1: Acute Pain Cues Subjective: masakit ya meopera ku. Nursing Diagnosis Acute pain related to nerve irritation as evidenced by surgical lesion and a pain scale of 8/10 Scientific Explanation Acute pain is an unpleasant sensory and emotional experience arising from actual or potential tissue damage or described in terms of such damage; sudden or slow onset of any intensity from mild to severe with an anticipated or predictable end and a duration less than 6 months. Planning After 1-2 hours of intervention, patient will verbalize a decrease of pain from 8/10 to 3/10 in pain scale. Intervention Rationale Evaluation After 1-2 hours of intervention, patient verbalized a decrease of pain from 8/10 to 3/10 in pain scale.

>Keep client >To decrease comfortably on oxygen bed. consumption.

Objective: >surgical lesion >facial grimaces during mobility >pain scale of 8/10

>Encourage >To reduce deep breathing tension exercise. >Decrease >To promote stimuli; provide adequate rest. quiet environment. >Provide comfort measures; repositioning the client. >To promote nonpharmacological management

>encourage the >to lessen anxiety use of relaxation technique >Administer >As per doctors analgesic, as order. needed. .

Problem #2: Risk for Infection Cues Subjective: Nursing Diagnosis Risk for infection related to post operative incision Scientific Explanation Wounds involving injury to soft tissue can vary from minor tears to severe crushing injuries. The decision to suture a wound depends on the nature of the wound the time since the injury was sustained the degree of contamination. Planning After 8 hours of nursing intervention, the patient will be able to: Identify the risk factors that are present Have partial understanding about infection control Be free from any signs and symptoms of related to infection Intervention >Note risk factors for occurrence of infection in the incision >Observed for localized sign of infection at insertion sites of invasive lines, surgical incisions or wounds. >Make health teachings especially in identification of environmental risk factors that could add up on infection. >Administer antibiotics as ordered by the physician Rationale To help the patient identify the present risk factors that may add up to the infection To evaluate if the character, presence and condition of the present infection To help the client modify/change/avoid some of the environmental factors present which could reduce the incidence of infection. Antibiotics will help kill and stop the proliferation and growth of the bacteria which could cause infection.. Evaluation After 8 hours of nursing intervention, the patient was able to meet the goals with an evidence of the absence of the signs and symptoms related to infection.

Objective: >surgical lesion

Problem #3: Impaired Skin Integrity Cues Subjective: Nursing Diagnosis Impaired skin Integrity related to removal of gallstone in the gallbladder AEB presence of surgical incision Scientific Explanation Surgical intervention: cholecystectomy- incision to the RUQ to remove the disease tissue- surgical involves cutting/penetration skin surface/ injury trauma on the skin is inflicted because of the injury there in vasodilation hurriedly send nutrients in the body via bloodstream/ Planning AFTER 3 HOUR of NPI, the patient will be able to verbalized and complied to heath teaching given Intervention >Monitor site of skin impairment at least once a day for color changes, redness, swelling, warmth, pain, or other signs of infection. Rationale >systemic infection can identify impeding problem early Evaluation AFTER 3 HOUR of NPI, the patient will be able to verbalized and complied to heath teaching given

Objective: Presence of surgical incision

>Avoid harsh cleansing agents, hot water, extreme friction >Monitor client's or force, or skin care practices, cleansing too noting type of frequently soap or other cleansing agents used, temperature >Instruct and of water, and assist client and frequency of skin caregivers to cleansing remove or control impediments to > Instruct and wound healing assist client and (e.g., caregivers to remove or control management of underlying impediments to disease, wound healing (e.g., management improved approach to client of underlying disease, improved positioning, approach to client improved

positioning, improved nutrition).

nutrition).

> Teach skin and wound assessment and ways to monitor for signs and symptoms of infection, complications, and healing.

>Early assessment and intervention help prevent serious problems from developing.