Cholecystitis Case Pres

COLLEGE OF NURSING
Silliman University
Dumaguete City
A Case Study on Cholecystitis
Submitted to: Asst. Prof. Maria Ellaine Adarna

Submitted by: Laurenciana, Antonio III C.
Case Description
Case Description:
This case presentation focuses on Cholecystitis. The anatomy and physiology of the gallbladder will be reviewed to enhance understanding of the case.
Pharmacologic interventions as well as the rationale for each medication will also be mentioned. Nursing care plans and functional health pattern specifically for
this case will also be presented.
Central Objective:
At the end of the case presentation, the learners will augment their knowledge, strengthen their learned skills, and project qualities intended for the care of the
patient with cholecystitis.
Specific Objectives:
At the end of the case presentation, the learners will:
Correctly recall the parts and functions of gallbladder

Explain correctly using 2-3 sentences their understanding of the concepts of cholecystitis
Correctly trace the pathophysiology of cholecystitis
Critically analyze the nursing care plans for the client with cholecystitis
Give at least three medications given to the client
Adequately explain the correlation between the mode of actions of the medications given to the client and his condition
Enumerate correctly nursing interventions essential for the client with cholecystitis
Vision
As a leading Christian Institution committed to total human development for the well-being
of society and environment.
Mission
o Infuse into the academic learning the Christian faith anchored on the gospel of Jesus
Christ; provide an environment where Christian fellowship and relationship can be
nurtured and promoted.
o Provide opportunities for growth and excellence in every dimension of the University life
in order to strengthen character, competence and faith.
o Instill in all members of the university community an enlightened social consciousness
and a deep sense of justice and compassion.
o Promote unity among peoples and contribute to national development.
LETTER OF PERMISSION
Silliman University, College of Nursing
Dumaguete City, Negros Oriental
Philippines
July 7, 2016
Asst. Prof. Maria Ellaine Adarna
Clinical Instructor, Surgery Rotation
Silliman University College of Nursing
Dear Maam:
Greetings!
I, Antonio C. Laurenciana III, a senior student currently rotated in the Surgery Rotation, at Silliman University Medical Center would like
to apply for a case study regarding the condition of my patient.
My patient is Ms. M.L.Y., a 43-year old client who was admitted last June 11, 2016 due to the presence of right upper quadrant pain and
vomiting. She was diagnosed with Cholecystitis. She was under my care last June 29, 2016.
I am grateful to have been assigned to this very interesting and challenging case because not only did I get the opportunity to augment
our knowledge with regarding this condition but also it enhanced the application of my skills and knowledge and attitude. Furthermore,
presenting this case to the class will be a good benefit for everyone. I assure you that the confidentiality of my patients case will be
maintained.
Hoping for your kind consideration.
Thank you very much!
Respectfully yours,
Antonio C. Laurenciana III
TABLE OF CONTENTS
CASE DESCRIPTION............................................................................................................................................. 1
INTRODUCTION................................................................................................................................................... 7
DEMOGRAPHIC DATA........................................................................................................................................... 8
DEFINITION OF COMPLETE DIAGNOSIS................................................................................................................ 10
PSYCHOSOCIAL PROFILE.................................................................................................................................... 11
PHYSICAL ASSESSMENT..................................................................................................................................... 20
ANATOMY AND PHYSIOLOGY.............................................................................................................................. 28
ETIOLOGY AND SYMPTOMATOLOGY..................................................................................................................... 32
PATHOPHYSIOLOGY........................................................................................................................................... 38
DIAGNOSTIC EXAM............................................................................................................................................ 40
DRUG STUDY..................................................................................................................................................... 46
PROCEDURAL REPORT........................................................................................................................................ 60
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NURSING CARE PLAN......................................................................................................................................... 66

NURSING CARE PLAN............................................................................................................................................ 67
FUNCTIONAL HEALTH PATTERN........................................................................................................................... 82
RELATED READING............................................................................................................................................. 88
REFERENCES..................................................................................................................................................... 90
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INTRODUCTION
One of the body organs that we can live without is the gallbladder. However, does this mean it is of no use to the body? The gallbladder is a
pear-shaped organ situated underneath the liver. Its function is to store bile and release it as needed for digestion. Bile emulsifies the fats in food,
breaking them to small fragments so they can be further digested and absorbed in the small intestine. If the gallbladder is not working as it should,
the digestion of fats can be seriously impaired.
One of the common gallbladder diseases is cholecystitis. Cholecystitis is a condition wherein gallstones obstruct the gallbladder outlet leading
to poor drainage of bile. Trapped bile can irritate and inflame the walls of the bladder, thus leading to inflammation. It affects women more often than
men and is more likely to occur at the age of 20-50 or over 60. Asians are also more prone to develop pigment stones. Moreover, people who are
obese and those who had had low fat diet are at an increased risk for developing cholelithiasis. In the United States, it is estimated that 6.3 million
men and 14.2 million women aged 20 to74 had gallbladder disease (Everhart, Khare, Hill, Maurer, 1999). In the Philippines, an extrapolated
prevalence of 5, 073, 040 people are affected by the disease (http://digestive.niddk.nih.gov/statistics). Gallstones that do not cause symptoms do not
require treatment. However, if gallstones cause, disruptive, recurring episodes of pain, surgical removal of the gallbladder is recommended.
Recently, I had a patient who was diagnosed with symptomatic cholecystitis and underwent open cholecystectomy. I chose this case for I find
the condition very interesting and very challenging to work with. I am hoping that through this case study, I will be more knowledgeable and aware
about such gallbladder disorder and the surgical procedure done for the said disease. I am also interested to know the proper and necessary nursing
management that will be given to a patient affected by the disease. Moreover, Iwould also like to impart their learning to their families and their
community regarding the prevention and care if ever such condition will arise in the scenario.
As a nursing student, I am hoping that this study will help me and my colleagues become more efficient and better nurses in the future. The
student nurses also hope to apply their learning in taking care not only of their patients but of themselves as well.
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DEMOGRAPHIC DATA
Name: M.L.Y. Civil Status: Single
Educational Attainment: College Graduate
Address: San Jose St. Dumaguete City, Negros Oriental

Room and Bed Number: NEM 7
Sex: Female
Religion: Jesus Christ of Latter Day Saints
Doctor(s)-in-charge: Dr. JCC
Occupation: Secretary
Natioality: Filipino
Age: 43 y/o
Date and Time of Admission: June 11, 2016 0216H
Chief complaint(s): Pain @ RUQ, vomiting

Diagnosis: Cholecystits
History of Present Illness:
3 years ago, was hospitalized in NOPH for the same reason but was only given medications to relieve pain and no further actions were taken as
claimed.
12 hours PTA, patient had onset of pain and vomiting with food particles associated with RUQ pain, it is continuous and non radiating.
General impression:
Received on bed, awake, alert, and verbally responsive with wound dressing @ RUQ of abdomen, dry and without signs of infection on
surrounding site. Vital Signs : BP- 100/80 mmHg T- 36.2C P-71 bpm strong and regular R- 19 cpm without use of accessory muscles.
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DEFINITION OF COMPLETE DIAGNOSIS

Complete Diagnosis: Cholecystitis
Cholecystitis
Cholecystitis is the inflammation of the gallbladder. In more than 90% of the cases, gallstones are present.
Source: White, L. Foundations of Nursing: Caring for the Whole Person, p. 832.
Inflammation of the gallbladder is called cholecystitis (chole = bile +cyst = bladder + itis = inflammation)
Inflammation of the bladder which may be either acute or chronic.
In an acute cholecystitis, the blood flow to the gallbladder may become
compromised which in turn will cause problems with the filling and emptying of the gallbladder. A stone may block the cystic duct which will
result in bile becoming trapped within the bladder due to inflammation around the stone within the duct. Chronic cholecystitis occurs when
there have been recurrent episodes of blockage of cystic duct.
PSYCHOSOCIAL PROFILE
According to Taylor, Lillis, LeMone and Lynn (2008), growth and development are orderly and sequential as well as continuous and complex.
All humans experience the same growth patterns and developmental levels, but, because these patterns and levels are individualized, a wide
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variation in biologic and behavioral changes is considered normal. Within each developmental level, certain milestones can be identified; for
example, the time the infant rolls over, crawls, walks, or says his or her first words. Although growth and development occur in individual ways for
different people, certain generalizations can be made about the nature of human development for everyone.
Robert Havighursts Developmental Task Theory
Robert Havighurst believed that living and growing are based on learning, and that a person must continuously learn to adjust to changing societal
conditions. He described learned behaviors as developmental tasks that occur at certain periods in life. Successful achievement leads to happiness
and success in late tasks, whereas unsuccessful achievement leads to unhappiness, societal disapproval, and difficulty in later tasks. The
developmental tasks arise from maturation, personal motives, and values that determine occupational and family choices, and civic responsibility.
(Taylor, et al. 2008)
Stage
Description
Middle
In the middle years, men and women reach the peak of their
Age(30-50)
influence upon society, and at the same time the society makes
Result
Justification
its maximum demands upon them for social and civic

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responsibility. It is the period of life to which they have looked

forward during their adolescence and early adulthood. And the
time passes so quickly during these full and active middle years
that most people arrive at the end of middle age and the
beginning of later maturity with surprise and a sense of having
finished the journey while they were still preparing to commence
it.
Selecting a mate
Learning to live with a partner
Starting family
Rearing children
Achieved
The patient got pregnant last 1998. She and the father
or her child works together with her husband in taking
care of and rearing their child by providing especially
financially. She verbalized that she and the father of
her child have a very good relationship as friends and
as providers for their child.
The patient is a secretary to her aunt who is an

Attorney at Law, she is the one managing the house,
Managing home
Getting started in occupation
by cleaning, washing clothes, doing other household

chores. She is the one managing the house to have a
Achieved
peaceful and organized home. She is also responsible

for budgeting their money needed to sustain them in
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their everyday living.
The patient is doing her responsibilities as a Filipino

citizen by following laws in our country such as not
throwing garbage anywhere, and following traffic rules.
She is also a registered voter. Patient verbalized that
she partook last May 2016 elections. She also pays
Taking on civic responsibility
Achieved
taxes (property tax and cedula) as part of her

responsibility as a citizen.
Erik Eriksons Psychosocial Development Theory

Erikson emphasized developmental change throughout the human life span. In Eriksons theory, eight stages of development unfold as we go
through the life span. Each stage consists of a crisis that must be faced. According to Erikson, this crisis is not a catastrophe but a turning point of
increased vulnerability and enhanced potential. The more an individual resolves the crises successfully, the healthier development will be. It is
patterned to the Psychosexual Development of Sigmund Freud but more concentrated on what task and conflict should a person be able to manage
in a certain age group. That is termed psychosocial development. He described eight stage of development:
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1. Infancy
2. Early childhood
3. Late childhood
4. School age
5. Adolescence
6. Young adulthood
7. Adulthood
8. Maturity
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9. Each stage signals a task that must be accomplished. The resolution of the task can be complete, partial, or unsuccessful.
10.
11. Stage
12. Description
13. Result
14. Justification
15. Middle
21.
29.
33.
22. The significant task is to perpetuate culture and
30.
34.
31.Working
35. As a mother of, she is the one who
towards
inculcates values in the family whom
achievin
she acquired from her parents. She
g goal
makes sure that her son will be
Adulthood:
25-65 years
16.
transmit values of the culture through the family

(taming the kids) and working to establish a stable
environment. Strength comes through care of others
17. Ego
Developmen
t
Outcome:
Generativity
vs.
Self
absorption
and production of something that contributes to the

betterment of society, which Erikson calls generativity,
so when a person is in this stage, she often fear
inactivity and meaninglessness.
23. As the children leave home, or the persons
or
relationships or goals changes, she may be faced with
Stagnation
major life changesthe mid-life crisisand struggle

with finding new meanings and purposes. If a person
18.
19. Basic
Strengths:
Production
and Care
doesn't get through this stage successfully, she can

becomes self-absorbed and stagnate.
32.
raised with good attitude and as

good Filipino Citizens.
36. As of now, her son is dependent and
still with them, she still doesnt know
what her feelings will be when his
son
will
leave
home
someday.
Today, she is busy taking care of her

child
as
those
are
the
responsibilities of a mother.
24. Significant relationships are within the workplace, the
community and the family.
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20.
25. Creativity, productivity, concern for others or selfindulgence,
self-concern,
lack
of
interests
and
commitments
26.
27. Kozier and Erbs, Fundamentals of Nursing, Chap. 20,
page 352
28. http://www.learningplaceonline.com/stages/organize/E
rikson.htm
37.
38.
39.
40.
41.
42.
43.
44.
45.
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46.
47. Lawrence Kohlbergs Levels of Moral Development
48.
Lawrence Kohlberg outlined the different planes of moral adequacy, based on his continued interest in how children would react to
varying moral dilemmas. Kohlberg stated that ethical behavior was based on moral reasoning, which in turn could be broken down into six specific
developmental stages. The stages are progressive, in that it is highly improbable for someone to regress backwards. Once a person acquires the
functionalities of higher stages of moral development, it will be difficult for him to lose these abilities and revert to lower levels of growth. Every stage
follows another, making it difficult for a person to jump forward and virtually skip an entire stage.
49.
50. The levels and stages are as follows:
51. Level 1: Preconventional
52. Stage1: Punishment/obedience
53. Stage2: Instrumental/relativist
54.
55. Level 2: Conventional
56. Stage3: Approval Seeking
57. Stage4: Law and order
58.
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59. Level 3: Postconventional

60. Stage5: Social Contract
61. Stage6: Universal-ethical
62.
63. Stage
64. Description
65. Resu
66. Justification
lt
67.Postconve
ntiona
74.
79.
75. At
stage
social
contract and utilitarian
orientation,
Level
correct
behavior is defined in
68.Stage
terms of societys law.
5:
Laws can be changed,
Social
however,
Contr
societys needs,
act
maintaining respect for
to
meet
while
self and others.
69.
70.
80.Achie
77. Stage
6,
universal
89. She sees that most of the laws are correct and
ved
worth to be followed. She said that she follows

the rules of the country and the city she lives in.
81.
She doesnt want nuisance in the society because
82.
she believes that to be able to live in a serene

place, people must maintain and establish
83.
84.
85.
86.
76.
88.
respect with themselves and then to others.

90.
91.
92.
87.Worki
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71.
ethical
principle
orientation,
93. She knows about universal laws, specifically
towar
about justice. She is concerning about justice,
the persons concern for
ds
malooy gyud ko sa mga tao nga dili matagaan
equality for all human
achie
ug hustisya, labaw na ng mga pobre , as
6:
beings,
guided
by
ving
verbalized by the patient.
Unive
personal
values
and
goal
rsal-
standards regardless of
ethica
those set by society or
laws. Justice might be
72.
73. Stage
represents
ng
internalized at an even
higher level than society.
Few adults ever reach
this
stage
of
development.
78. (Taylor et. al, 2008)
94.
95.
96.
97.
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98. PHYSICAL ASSESSMENT

99.
Patients Name: M.L.Y
100.
Age: 43 yrs. old
101.
Sex: Female
102.
Admitting Diagnosis: Cholelithiasis
103.
Final Diagnosis: Cholecystitis
104.
Chief Complaint: right upper quadrant pain, vomiting
105.
Date of Assessment: June 29, 2016
106.
Time of Assessment: 1:00 pm
107.
Location of Assessment: NEM 7
108.
Vital Signs upon physical assessment:
109.
110.
111.
112.
113.
1. Temperatur
2. 36.2 C
e:
3. Pulse Rate:
4. 71 bpm
5. Respiratory
6. 19 cpm
Rate:
7. Blood
Pressure:
8. 100/80 mmHg
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I.
General Survey
114.
The patient was received lying on bed, awake, alert, and verbally responsive with wound dressing @ RUQ of abdomen, dry and
without signs of infection on surrounding site. Patient complains of pain on the incision site and rated this pain as 6 out of 10 in the pain scale. She is
oriented to time (verbalized it was late in the afternoon), person (identified watcher correctly), place (verbalized shes in the hospital) and reason for
admission (stated that she was admitted due to right upper quadrant abdominal pain and vomiting). Patient is not in respiratory distress.
115.
Patient appears appropriate for her stated age. She stands 5 feet and 2 inches tall and weighs 57 kg. Her body mass index (BMI) is
22.9 which is normal. She has an endomorphic body type. Patient is in fair grooming as evidenced by unsoiled gown she is wearing, well-kept hair
and clean linens and pillows. Nails were short and clean.
116.
Through the course of the physical assessment, it was observed that the patient is cooperative and has an accommodating attitude
towards the student. The patient is calm. Patients speech was audible, comprehensible and in moderate pace.
117.
II.
Skin
118.
Skin is fair in color, intact and with hairs, except in the palms, soles and dorsa of the distal phalanges. Skin is dry and slightly warm
upon palpation. It returns quickly to its normal state when picked up between two fingers and released. Skin texture is soft and fine while extensor
surfaces such as the elbows have coarser skin. The palms and the soles are calloused. No skin breaks present aside from the incision sites on her
abdomen. No edema present.
119.
III.
Hairs and Nails
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120.
Upon inspection, hair was noted to be black. It is thick, oily, straight, long and well-kept. Hair is also evenly distributed as evidenced by
absence of bald spots. Dandruff or flaking was not present. Other infestations, such as lice, were not noted. The color of scalp is lighter than the color
of skin.
121.
Nails on both hands and feet are short and clean. Nail polish was removed. Client has a capillary refill time of 2 seconds. No clubbing of
the nailbeds noted.

122.
IV.
Head
123.
Patients head is round and normocephalic in configuration with smooth skull contour. There were no palpated masses, nodules,
deformities or fractures. Facial features are symmetric as evidenced by palpebral fissures being equal in size and symmetric nasolabial folds. Facial
movements are symmetrical and patient is able to perform different kinds of expression effortlessly and without any obstructions. Patient can move
her head up and down and side to side. No lesions noted on the face.
124.
V.
Eyes
125.
Hairs of eyebrows are thick and evenly distributed. Eyebrows are symmetrically aligned and theres equal movement as
evidenced by the patients ability to elevate and lower the eyebrows. No edema, lesions, puffiness or tenderness noted upon inspection and palpation
of the periorbital area. Eyelashes are equally distributed and curled slightly outward. Eyelids surface is intact with no discharges and no discoloration
but with noted eye bags on the lower surface. No lid lag noted. Blink reflex is present. Palpebral fissure is equal in both eyes. Bulbar conjunctiva is
pale pink. Cornea is transparent and without cloudiness. Sclera is anicteric. Eyeballs are symmetrical with no bulging observed. Pupils were black in
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color, equally round, and reactive to light and accommodation. Pupils quickly constrict when a penlight is shone towards the pupil from a lateral
position. Iris is dark brown in color.
126.
Client has central and peripheral vision. She can see things on the side of her eye, like the adjacent bed, even when looking
straight ahead. Moreover, pupils constrict when looking at near objects and dilate when looking at far objects. During ocular testing, patient was
asked to follow the examiners finger in the six cardinal fields of gaze. There was smooth, parallel movement of eyes in all direction. Both eyes move
in unison. No nystagmus noted. To test her visual acuity, she was asked to read the newspaper placed about 1 feet away from her. She was able
to correctly read the names without any difficulty. Patient verbalized she doesnt use any corrective aids. She also did not report any vision difficulty
or eye pain.
127.
VI.
Ears
128.
The color of the patients ears is the same as her facial skin. The skin behind the ear in the crevice is smooth and without breaks.
The left and right pinna are symmetrical and aligned with the inner canthus of the eye. Pinna recoils after it is folded. Auricle is nontender upon
palpation. Mastoid process is smooth and hard and no tenderness or swelling noted. External canals have minimal cerumen. No sanguinous
discharges noted on the meatus. Patient was able to hear a soft whisper equally in both ears. She can also hear normal voice tones as evidenced by
prompt responses to questions asked.
129.
VII.
Nose
130.
It was noted that the nostrils were symmetrical and the nasal septum is midline. There were no observed discharges draining
from the clients nose. Hair is noted on the nares. Nares are patent since patient is able to breathe normally on both nostrils without difficulty when
one nose is closed with digital compression and patient inhaled with mouth closed. No lesions on the external nose structure were seen. There was
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no tenderness over the maxillary and frontal sinuses upon palpation of the cheeks and supraorbital ridges. Clients gross smell was functional as she
could identify the scent of alcohol.
131.
132.
133.
VIII.
Mouth
134.
Mouth is proportional and symmetrical. Lips are cracked, dry, pink in color and with no masses or congenital defect. Buccal
mucosa was uniform pale pink in color and moist. The patients gum was, moist, firm and pinkish in color. No gum retraction or bleeding was noted.
Teeth are of complete set. There are no spaces in between teeth. Dental carries are evident in lower right and left molar. Teeth are yellow in color.
Patient has no dentures. Tongue is pink, moist, slightly rough and has thin whitish color on the surface. It is also in central position and moves freely.
The base of tongue is smooth with prominent veins. No tenderness, lesions or any unusualness noted. Soft palate is light pink in color. On the other
hand, hard palate is much lighter and more irregular in texture. Uvula is positioned in midline of soft palate and rises when the patient says ah.
Tonsils are not inflamed. No ulcerations and exudates present. Patient has no difficulty of masticating and swallowing. Patient has no speech
disorders.
135.
IX.
Neck
136.
Neck is symmetrical with no masses or unusual swelling upon palpation. No jugular vein distention noted. Pulsation at carotid
arteries is strong and regular in rhythm. Range of motion is normal and no pain elicited upon flexion, extension, and rotation of head. Thyroid is not
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enlarged upon palpation with no nodules, masses or irregularities upon palpation. Thyroid also rises when patient was asked to swallow. Trachea is
symmetrical and in midline without deviation. No lymph adenopathies appreciated. No torticollis present.
137.
138.
X.
Breast
139.
Breast is conical, symmetrical and skin color is lighter than exposed areas. No lesions, redness, or edema and texture is even. No
dimpling or retraction. Nipples are in midline and everted pointing in the same direction. Areola and nipples are dark brown in color and has no
discharges, crusting and masses.
140.
XI.
Chest/Lungs
141.
Chest skin integrity is good and intact. Patient has symmetrical chest wall movement. Point of maximal impulse is at 5 th intercostal
space left midclavicular line. Apical pulse is 71bpm. Patient has distinct heart sounds, with S1 louder than S2; negative for murmurs. There were no
noted deformities in the clients thoracic area. There are no bulges or retraction of the intercostal spaces.
142.
Clients respiratory rate is 19 cycles per minute. Patient did not complain of chest pain or chest tightness. Guarding of the chest noted
upon respiration due to the proximity of the incision site to the diaphragm. Patient is not in respiratory distress. Coughing episodes were also not
observed. Vesicular breath sounds are soft and low pitched. Her breathing is deep, regular and slow with a long inspiratory phase and a short
expiratory phase. With no adventitious sounds, lungs are clear to auscultation and no crackles, wheezes or rubs. It was observed that vocal fremitus
is present both at the back and front of the chest when the patient says ninety-nine.
143.
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XII.
Abdomen
144.
Abdomen is round. Color of skin in abdomen is slightly lighter than the rest of the body. Patient complains of pain on the surgical
site and verbalized, Nagangulngol tong gioperhan. Pwede makapangayo ug tambal para sa sakit? Patient reported a pain scale of 6 out of
10. Aortic pulsations are not visible. Umbilicus is midline and inverted. Symmetrical movement of abdomen upon respiration was noted. Upon
auscultation of the abdomen, it was noted that patient has normal bowel soundshigh-pitched and occurred 16 times per minute. Abdomen is
soft and there is no point tenderness. Patient was on Low Fat Diet as ordered.
145.
XIII.
Back and Extremities

146.
Peripheral pulse of the patient was symmetrical and regular in rhythm; radial pulse is 71 bpm. Patient has normal capillary refill
of 2 seconds. The nails were pinkish in color without cyanosis and clubbing. Patient is able to ambulate freely. She was able to sit up on bed and
perform range of motion on both upper and lower extremities. However, it was noted that patient has guarded and slow movement for she feels pain
on her abdomen. Clients grasping ability was moderately strong on both hands. No edema or cyanosis was noted on both upper and lower
extremities. There is no swelling, tenderness or nodules palpated on each joint. The shoulders, arms, elbows and forearms are free of nodules,
swelling, deformities and atrophy.
147.
The skin at the back of the patient is uniform in color. Symmetrical chest expansion with respirations noted. No spinal tenderness
noted. There are no skin breaks present. The back is also symmetrical with the spinal cord aligning from the neck down to the buttocks. There were
no deformities or abnormalities on the bone such as scoliosis, osteoporosis and alike to be noted.
148.
XIV.
Genito-urinary
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149.
Pubic hair is present, thick in each strand, curly and equally distributed on the mons pubis. No vaginal bleeding or any other
unusual discharges noted. Patient voids freely. She has no difficulty urinating and did not report dysuria. She verbalized her urine is amber in color.
150.
XV.
Neurological
151.
Patient was received lying on bed, awake, conscious, coherent and afebrile. Reflexes are normal and symmetrical bilaterally in both
extremities. Patient is oriented to person, place and time. She is also alert and attentive.
152.
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153.
ANATOMY AND PHYSIOLOGY
154.
155.
156.
GALLBLADDER
The gallbladder is a hollow organ 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. Its function is to store and release bile, a fluid made by
the liver.
Page | 28
157.
Page | 29
158.
159.
CYSTIC DUCT
The cystic duct is the short duct that joins the gall bladder to the common bile duct. The cystic duct varies from 2 to 3 cm in length and
terminates in the gallbladder. Throughout its length, the cystic duct is lined by a spiral mucosal elevation, called the valvula spiralis (valve of Heister)
which is a series of crescentic folds of mucous membrane in the upper part of the cystic duct, arranged in a somewhat spiral manner. Its length is
variable and usually ranges from 2 to 4 cm. The cystic duct is usually 2-3 mm wide. It can dilate in the presence of pathology (stones or passed
stones).
160.
The duct and spiral folds contain muscle fibers responsive to pharmacologic, hormonal, and neural stimuli. There is, however, no
convincing evidence of a discrete muscular sphincter within the duct. Although the cystic duct is unlikely to play a major role in gallbladder filling and
emptying, it appears to function as more than a passive conduit. Coordinated, graded muscular activity in the cystic duct in response to hormonal and
neural stimuli may facilitate gallbladder emptying. The principal function of the internal spiral folds that are found in man may be to preserve patency
of this narrow, tortuous tube rather than to regulate bile flow.
161.
162.
BILE
163.
The main components of bile include contains water, cholesterol, fats, bile salts, proteins, and bilirubin.
164.
Bile, is produced by hepatocytes in the liver and and then flows into the common hepatic duct, which joins with the cystic duct from the
gallbladder to form the common bile duct. The common bile duct in turn joins with the pancreatic duct to empty into the duodenum. If the sphincter of
Oddi, a muscular valve that controls the flow of digestive juices (bile and pancreatic juice) through the ampulla of Vater into the second part of the
duodenum, is closed, bile is prevented from draining into the intestine and instead flows into the gallbladder, where it is stored and concentrated to up
to five times its original potency between meals. This concentration occurs through the absorption of water and small electrolytes, while retaining all
the original organic molecules.
Page | 30
165.
When food is released by the stomach into the duodenum in the form of chyme, the duodenum releases cholecystokinin, which causes
the gallbladder to release the concentrated bile to complete digestion.

166.
Bile helps to emulsify the fats in the food. Besides its digestive function, bile serves also as the route of excretion for bilirubin, a
byproduct of red blood cells recycled by the liver.

167.
The alkaline bile also has the function of neutralizing any excess stomach acid before it enters the ileum, the final section of the small
intestine. Bile salts also act as bactericides, destroying many of the microbes that may be present in the food.
168.
In the absence of bile, fats become indigestible and are instead excreted in feces, a condition called steatorrhea.
169.
Page | 31
170.
171.
ETIOLOGY AND SYMPTOMATOLOGY
Etiology
172.
P
redispo
sing
Factors
176.
173.
Prese
nt/
Ab
se
nt
174.
180.
177.
183.
181.
EN
179.
Women between 20 and 60 years of age are twice as likely to
Justification
186.
187.
The patient is female.
develop gallstones as men.
PRES
178.
175.
182.
emale
Rationale
184.
Estrogen increases cholesterol levels in bile and decrease

gallbladder movement, both of which can lead to gallstones.
185.
188.
190.
189.
193.
iabetes
191.
mellitu
ABSE
192.
NT
People with diabetes generally have high levels of fatty acids
called triglycerides. These fatty acids increase the risk of gallstones
195.
196.
The patient is not

diabetic.
194.
Page | 32
197.
201.
198.
203.
A
ge
199.
204.
202.
20-50;
Many of the bodys systems and protective mechanisms
206.
207.
The patient is 43 years
become less efficient with age. Body systems and processes become
PRES
old.
sluggish.
EN
205.
over
age 60)
200.
208.
212.
209.
214.
thnicity
210.
Native
Americ
an,
Mexica
n
215.
Native Americans have a genetic predisposition to secrete high
213.
PRES
218.
219.
The patient is Filipino.
levels of cholesterol in bile. In fact, they have the highest rate of
She is predisposed to having
gallstones in the United States. A majority of Native American men
pigment stones.
EN
have gallstones by age 60. Mexican American men and women of all
ages also have high rates of gallstones.

216.
Asians are more genetically predisposed to having pigment

stones as compared to those living in the Western countries
217.
Americ
an)
Page | 33
211.
Asian)
220.
221.
222.
223.
224.
225.
226.
P
recipit
ating
Factor
s
227.
Presen
t/
Abs
ent
228.
Rationale
229.
Justification
Page | 34
230.
231.
P
regna
ncy
232.
233.
ABSEN
T
234.
235.
Excess estrogen from pregnancy, hormone replacement
therapy, or birth control pills appears to increase cholesterol levels in
bile and decrease gallbladder movement, both of which can lead to
gallstones.
237.
238.
The patient is not

pregnant.
236.
239.
240.
241.
R
apid
weight
loss
244.
242.
ABSEN
T
248.
249.
O
besity
250.
251.
252.
253.
260.
262.
261.
F
asting
243.
254.
ABSEN
T
As the body metabolizes fat during rapid weight loss, it causes

the liver to secrete extra cholesterol into bile, which can cause
gallstones.
246.
247.
No rapid weight loss was

noted by the patient.
245.
255.
256.
The most likely reason is that obesity tends to reduce the
amount of bile salts in bile, resulting in more cholesterol. Obesity also
decreases gallbladder emptying.
258.
259.
The patient is not obese.
269.
268.
The patient doesnt fast.
257.
265.
266.
263.
ABSEN
T
Fasting decreases gallbladder movement, causing the bile to

become overconcentrated with cholesterol, which can lead to
gallstones.
Page | 35
270.
271.
H
ormon
e
replac
ement
therap
y, or
birth
contro
l pills
264.
267.
272.
274.
273.
ABSEN
T
275.
Excess estrogen from pregnancy, hormone replacement
therapy, or birth control pills appears to increase cholesterol levels in
bile and decrease gallbladder movement, both of which can lead to
gallstones.
278.
277.
The patient has not been
on birth control pills.
276.
279.
280.
281.
282.
283.
284.
285.
286.
Page | 36
287.
288.
289.
Symptomatology
290.
Signs
and
Symptoms
291.
Presen
t/
292.
Absent
293.
Rationale
294.
Justification
Page | 37
295.
296.
299.
301.
Right
upper
quadrant
pain
302.
304.
Obstruction of ducts connected to the gallbladder
300.
will
cause
inflammation
produced
by
increased
PRESE
intraluminal pressure and distension of the gallbladder.
305.
The patient came into DMSF
complaining of RUQ pain.
NT
303.
297.
(may
radiate to
right
scapula,
shoulder, or
interscapula
r area)
298.
biliar
y colic
306.
307.
308.
310.
Fever
(low grade)
311.
313.
Fever is a nonspecific response that is mediated
309.
by endogenous pyrogens released from host cells in
ABSEN
response to infectious or non-infections disorders. It may
314.
The patient was not febrile.
be brought about by prostaglandins released during

inflammation.
Page | 38
312.
315.
316.
317.
319.
Nause
a and
vomiting
320.
322.
Nausea and vomiting sometimes occur with biliary
323.
The patient was admitted
318.
colic. The inflammation of the gallbladder causes pain
due to pain accompanied with
PRESE
and spasms of the abdominal muscles which may make
projectile vomiting
NT
one feel nauseated.
324.
321.
325.
326.
327.
329.
Mildly
elevated
serum
bilirubin
330.
332.
Biliary obstruction causes suppression of bile flow,
328.
and regurgitation of conjugated bilirubin into the
ABSEN
bloodstream.
333.
The patients bilirubin was
not increased.
331.
334.
335.
Page | 39
336.
337.
338.
339.
340.
341.
PATHOPHYSIOLOGY
Precipitating
Factors:
Birth control
Predisposing Factors:
pills
Low Fat Diet
Pregnancy
Rapid weight
loss
Female
Age 43
Ethnicity
Diabetes Mellitus
Bile stagnates in the

gallbladder
342.
343.
344.
345.
Pigment solute
precipitate as solid
crystals
346.
Crystals clump
together and form
stones
347.
Gallstones
348.
349.
350.
351.
352.
353.
Gallbladder contracts
after intake of fat to
release bile
Upon contraction, a stone is moved
and becomes impacted on the
cystic duct
CHOLELITHIASIS
Page | 40
Lumen is obstructed
by stones
354.
Bile stasis
355.
356.
357.
358.
Chemical reaction inside

gallbladder triggers the release
of inflammatory enzymes
359.
360.
(Prostaglandins)
361.
362.
Fluids leak into

gallbladder
363.
364.
Inflammation of the
gallbladder
Edema
365.
366.
Increased
intraluminal
pressure and
distention of the
Constriction of
blood vessels
Surgery, proper
diet (low fat,
high fiber),
Good
compliance
If treated to
Biliary
Colic
(RUQ
Murphys Sign
CHOLECYSTITIS
Continued
Spread
of bile and
Continued
lack
ofPerforation
blood supply
Gangrene
and
Necrosis
ofgallbladder
to
increase
in
indigenous
intraluminal into
microorganisms
Rupture of
pressure
of
If cavity
not
peritoneal
gallbladder
Sepsi
s
Death
Page | 41
367.
368.
DIAGNOSTIC EXAM
CBC a determination of red and white blood cells per cubic millimeter of blood. It helps health professional check any symptoms such
as weakness, fatigue, or bruising. It also helps diagnose conditions such as anemia, infection and other disorders
369.
6/19/16
370.
Test
376.
Hemoglo
bin
371.
Nor
m
a
l
V
a
l
u
e
s
377.
372.
Res
u
lt
373.
Re
m
a
r
k
378.
379.
12-
11.4
Nor
374.
380.
Rationale
Hemoglobin carries oxygen to and removes
375.
Interpretation
381.
Within normal range
387.
Within normal range
carbon dioxide from red blood cells. It measures total

amount of hemoglobin in the blood
m
382.
%
383.
384.
385.
386.
Hematocrit measures the percentage of red blood
Page | 42
Hematocr
it
37-
37.0
Nor
388.
%
389.
390.
l
391.
RBC
4.2-
4.45
Nor
/c
/c
cells in the total blood volume
392.
Measures the number o RBCs per cubic
393.
Within normal range
399.
Elevated levels may
millimeter of the whole blood.
u
m
394.
m
395.
396.
397.
WBC
4500
1260
High
infections tuberculosis,
pneumonia, meningitis,
tonsillitis, appendicitis,
colitis, etc.
398.
Determines the number of circulating WBCs per
cubic millimeter of the whole blood.
be caused by acute
0
c
Page | 43
u
m
400.
Neutrophi
l
406.
Lymphoc
ytes
m
401.
402.
403.
55-
74
Nor
407.
408.
l
409.
20-
21
Nor
404.
Phagocytes engulfing bacteria and cellular debris.
405.
Within normal levels.
411.
Within normal range
419.
Within normal range
It prevents or limits bacterial infections.
410.
Cells present in the blood and lymphatic tissue
that provide the main means of immunity for the body.
There are three types of lymphocytes: the natural killer
(NK), thymus-derived lymphocytes (T cells), and bone
marrow-derived lymphocytes (B cells). NK cells are

found in the blood, red bone marrow, lymph nodes and
spleen and are able to destroy many kinds of infected
body cells and tumor cells. The T cells and B cells are
412.
Monocyte
s
413.
414.
415.
1-6
Nor
involved in specific immune responses.

418.
This type of granular leukocyte functions in the
ingestion of bacteria and other foreign particles
m
a
l
416.
Page | 44
420.
Eosinoph
421.
422.
417.
423.
1-4
Nor
il
424.
Functions in allergic responses and in resisting
425.
Within normal range
431.
Within normal range
infections. Eosinophils mount on attack against parasitic
invaders by attacking to their bodies and discharging
toxic molecules from their cytoplasmic granules.
426.
427.
428.
l
429.
Platelet
150.
292
Nor
millimeter and are important in triggering the sequence
/c
of events that leads to the formation of blood clots.
430.
A test that direct count of platelets in whole blood.
Platelets number from 100,000-500,000 per cubic
.
0
T
/c
u
m
m
432.
433.
Page | 45
434.
435.
Urinalysis - Urinalysis is a physical, microscopic, or chemical examination of the urine. It is done to detect urinary tract infection. It also
measures the level of ketones, sugar, protein, blood components and many other substances
436.
6/12/16
437. TEST
441. Glucos
438.
RESU
LT
442.
439.
NORMA
L
443.
Negat
<50mg/d
445. Protein
ive
446.
447.
Negat
<30mg/d
Negat
<1mg/dL
453. Urobilin
ive
454.
455.
ogen
Norm
<2mg/dL
457. pH
al
458.
459.
CLINICAL SIGNIFICANCE
Glucose is the type of sugar found in blood. Normally there is very little or no glucose in
urine. When the blood sugar level is very high, as in uncontrolled diabetes. Glucose can also be
448.
451.
444.
ive
450.
449. Bilirubin
440.
found in urine when the kidneys are damaged or diseased.

Protein is normally not found in the urine. Fever, hard exercise, pregnancy, and some
diseases, especially kidney disease, may cause protein to be in the urine.
4.5-8
452.
This is a substance formed by the breakdown of red blood cells. If it is present, it often
means the liver is damaged or that the flow of bile from the gallbladder is blocked.
456.
This is a substance formed by the breakdown of bilirubin. Urobilinogen in urine can be a

sign of liver disease (cirrhosis, hepatitis) that the flow of bile from the gallbladder is blocked.
460.
Urine pH is used to classify urine as either a dilute acid or base solution. The lower the pH,
the greater the acidity of a solution; the higher the pH, the greater the alkalinity. The glomerular
filtrate of blood is usually acidified by the kidneys from a pH of approximately 7.4 to a pH of about
461. Blood
462.
463.
6 in the urine
464.
Red blood cells in the urine may be caused by kidney or bladder injury, kidney stones, a
Page | 46
Negat
ive
<5-
urinary tract infection (UTI), inflammation of the kidneys (glomerulonephritis), a kidney or bladder
10R
tumor, or systemic lupus erythematosus (SLE).
BC/
mL
465. Ketone
466.
Negat
ive
467.
468.
<5
Ketones in the urine may mean a very serious condition, diabetic ketoacidosis, is present.
A diet low in sugars and starches (carbohydrates), starvation, or severe vomiting may also cause
mg/d
ketones to be in the urine.
L
469. Nitrite
470.
471.
Negat
Negative
473. Leukoc
ive
474.
475.
ytes
25
<25WB
478.
C/mL
479.
480.
Urine is normally clear. Bacteria, blood, sperm, crystals, or mucus can make urine look
481. Specific
Clear
482.
Clear
483.
484.
cloudy.
This checks the amount of substances in the urine. It also shows how well the kidneys
gravity
1.010
1.010-
477. Clarity
472.
Bacteria that cause a urinary tract infection (UTI) make an enzyme that changes urinary
nitrates to nitrites. Nitrites in urine show a UTI is present.
476.
Leukocyte esterase shows leukocytes in the urine. WBCs in the urine may mean a UTI is
present.
balance the amount of water in urine. The higher the specific gravity, the more solid material is in
1.03
the urine.
0
485. Color
486.
487.
489.
Many things affect urine color, including fluid balance, diet, medicines, and diseases. How
Yello
Pale to
dark or light the color is tells you how much water is in it. Vitamin B supplements can turn urine
dark
bright yellow. Some medicines, blackberries, beets, rhubarb, or blood in the urine can turn urine
yello
red-brown.
Page | 47
w
488.
490.
491.
Blood Chemistry - A number of tests performed on blood serum (liquid portion of the blood). It determines certain enzymes that may
be present (including lactic dehydrogenase [LDH], certain kinase [CK], aspartate aminotransferase [AST], and alanine aminotransferas [ALT]),
serum glucose, hormones such as thyroid hormone and other substances such as cholesterol and triglycerides. These tests provide valuable
diagnostic cues.
492.
6/19/16
9. TEST
10. R
ES
14. Total
Bilirubin
11. REFERE
NCE
12. REM
13. RATIONALE
ARK
UL
494.
495.
15. 8.
16. 2.0
21.0
17. Norm
al
18. It occurs when bilirubin production exceeds the
liver's excretory capacity. This may occur

because (1) too much bilirubin is being
produced, (2) hepatocytes are injured and
cannot metabolize or excrete bilirubin, or (3) the
biliary tract is obstructed blocking the flow of
conjugated bilirubin into the intestine
19. Direct
493.
20. 0.
21. 0.0 3.4
Bilirubin
24. Inderct
25. 7.
26. 2.0
Bilirubin
17.0
22. Norm
al
27. Norm
al
496.
497.
498.
499.
500.
23. Increases in conjugated bilirubin are highly
specific for disease of the liver or bile ducts

28. Increase in unconjugated bilirubin may be
caused by hepatic disease, cholestasis, and

hemolysis
501.
Page | 48
502.
503.
504.
505.
506.
507.
Medical sonography (ultrasonography) is an ultrasound-based diagnostic medical imaging technique used to visualize muscles,
tendons, and many internal organs, to capture their size, structure and any pathological lesions with real time tomographic images. Ultrasound
has been used by sonographers to image the human body for at least 50 years and has become one of the most widely used diagnostic tools
in modern medicine.
508.
509.
6/17/16
510.
Impression:
Chronic Cholecystitis with cholelithiasis
511.
Ultrasonically normal liver, intrahepatic ducts,

pancreas, spleen, aorta, paraaortic areas, kidneys
and urinary bladder
512.
Page | 49
513.
DRUG STUDY
514.
515.
Gener
ic Name:
517.
Class
ification:
519.
Order
ed Dose:
521.
Mode
Of Action:
516.
Lanzoprazole
518.
Proton pump inhibitor
520.
Lanzoprazole 30 mg IV every 12 h
523.
Indica
tions:
524.
To reduce risk of NSAID-related ulcer
525.
Contr
aindications
:
526.
Hypersensitivity to the drug and its components
522.
Inhibits proton pump and binds to hydrogen or potassium adenosine triphosphatase thus decreasing gastric acid
formation
Ampicillin, esters, digoxin, iron salts, ketoconazole: May interfere with absorption of these drugs
527. Drug
Interactions:
528.
Adver GI: abdominal pain. diarrhea, nausea
se Effects:
529. Nursing
Assess patient's condition before starting therapy and regularly thereafter to monitor drug's effectiveness
Be alert for adverse reactions and drug interactions
Responsibilities:
Page | 50
530.
Biblio
graphy:
531.
532.
2005 Lippincotts Nursing Drug Guide
536.
537.
538.
540.
541.
543.
Metronidazole
545.
546.
Hinders growth of selected organisms, including most anaerobic bacteria and protozoa
548.
549.
550.
551.
552.
553.
554.
556.
557.
558.
>amebic hepatic abscess

>intestinal amebiasis
>trichomoniasis
>retractory trichomoniasis
>bacterial infection caused by anaerobic microorganisms
>to prevent postoperative infection in contaminated colorectal surgery
>pelvic inflammatory disease
>hypersensitivity
>hypersensitivity to parabens
>first trimester of pregnancy
533.
534.
535.
Gener
ic Name:
539.
Class
ification:
542.
Order
ed Dose:
544.
Mode
Of Action:
547.
Indica
tions:
555.
Contr
aindications
:
Antibacterial
Antiprotozoal
500 g IV every 6h
Page | 51
559. Drug
Interactions:
565.
Adver
se Effects:
574. Nursing
Responsibilities:
560.
561.
562.
563.
564.
566.
567.
568.
569.
570.
571.
572.
573.
575.
576.
577.
578.
579.
580.
581.
582.
583.
584.
585.
586.
587.
588.
589.
590.
>cimetidine
>phenobarbital
>warfarin
>disulfiram
>fluorouracil
CNS: seizures, dizziness, headache
EENT: Tearing(topical only)
GI: abdominal pain, anorexia, nausea and vomiting, diarrhea, dry mouth, glossitis
Derm: rashes, urticarial, mild dryness, skin irritation
Hemat: leukopenia
Local: Phlebitis at Iv site
Neuro: peripheral neuropathy
Misc: superinfection
>assess pts. Infection
>watch carefully for edema because it may cause sodium retention
>assess skin for severity areas of local adverse reactions
>record number and character of stools
>assess pts and familys knowledge of drug therapy
During
>give drug with meals to minimize GI distress
>to treat trichomoniasis, give drug for 7days instead of 2-g single dose
>use only after T.vaginalis has been confirmed by wet smear
>tablets may be crushed for pts. with difficult swallowing
>do not use aluminium needles or hubs, color will turn orange/rust
After
>tell pt. that metallic taste and dark or red brown urine may occur
>instruct pt. to take oral form with meals to minimize reactions
>instruct to complete full course of therapy
>tell pt. not to use alcohol or drugs that contain alcohol.
Page | 52
592.
Biblio
graphy:
594.
595.
596.
597.
598.
599.
600.
Gener
ic Name:
602.
Class
ification:
604.
Order
ed Dose:
606.
Mode
Of Action:
608.
Indica
tions:
610.
Contr
aindications
:
612. Drug
Interactions:
591.
593.
>may cause dizziness/ light headedness

MIMS 113th edition 200
601.
Cefuroxime
603.
Antibiotic, Cephalosphorin (2nd gen)
605.
750 g IVTT q8 ANST
607.
Inhibits synthesis of bacterial cell wall causing cell death
609.
Perioperative prophylaxis
611.
Hypersensitivity to cephalosphorins and/or penicillins
Increased nephrotoxicity with aminoglycosides

Increased bleeding effects with anticoagulants
613.
Side
614.
Stomach upset, nausea, vomiting, diarrhea
Effect:
615.
Adver
CNS:, dizziness, lethargy, headache
se Effects:
Page | 53
CV: peripheral circulatory collapse, tachycardia, bradycardia, arrhythmia, palpitations, hypertension, hypotension
GI: nausea, vomiting, diarrhea, anorexia, abdominal pain, psuedomembranous colitis
GU: Nephrotoxicity
Hematologic: bone marrow depression, thrombocytopenia
616. Nursing
Responsibilities:
Culture infection before starting therapy

Have vitamin K available in case of hypoprothrombinemia
Discontinue if hypersensitivity occurs
Avoid alcohol while taking drug
Take only prescribed dosage
Complete antibiotic therapy, dont skip doses
Do not use extra medicine to make up the missed dose
Do not use drug if you are allergic to penicillins and cephalosporins
Antibiotic medicines can cause diarrhea, which may be a sign of a new infection. If you have diarrhea that is watery or has
blood in it, call your doctor.
Store at room temperature away from moisture, heat, and light
If you get a skin rash, do not treat yourself.
617.
Biblio
618.
graphy:
619.
620.
621.
Gener
ic Name:
622.
Metoclopramide
Page | 54
623.
624.
625.
626.
627.
629.
Classification:
Dopaminergic blocker
Ordered Dose:
Mode Of Action:
628.
10 g IV every 6 h
630.
Stimulates motility of upper GI tract without stimulating gastric, billiary, or pancreatic secretions; appears to sensitize tissues to action of
acetylcholine; relaxes pyloric sphincter, which, when combined with effects on motility, accelerates gastric emptying and intestinal transit; little
effect on gallbladder or colon motility; increases lower esophageal sphincter pressure; has sedative properties; induces release of prolactin.
631.
632.
633.
634.
635.
636.
637.
638.
639.
640.
641.
642.
Indications:
- Prophylaxis of postoperative nausea and vomiting when nasogastric suction is undesirable
643.
644.
- Decreased absorption of digoxin from the stomach

- Increased toxic and immunosuppressive effects of cyclosporine
Contraindications:
- Allergy to metoclopramide
- GI hemorrhage
- Mechanical obstruction or perforation
- Pheochromocytoma
- Epilepsy
Drug Interactions:
Page | 55
645.
- Increased neuromuscular blocking effect of succinylcholine
646.
Adverse Effects:
647.
CNS: Restlessness, drowsiness, fatigue, lassitude, insomnia, extrapyramidal reactions, parinsonism-like reactions, akathisia, dystonia,
myoclonus, dizziness, anxiety
648.
649.
CV: Transient hypertension
650.
651.
GI: Nausea, diarrhea
652.
653.
654.
655.
656.
657.
658.
659.
Nursing Responsibilities:
- Monitor BP carefully dring IV administration.
- Monitor for extrapyramidal reactions, and consult physician if they occur.
- Instruct patient to take drug exactly as prescribed.
- Instruct not to use alcohol, sleep remedies or sedatives; serious sedation could occur
Bibliography:
660.
661.

662.
663.
664.
Gener
ic Name:
667.
Class
665.
666.
668.
Paracetamol
Analgesics ( Non-opioid)
Page | 56
ification:
671.
Order
ed Dose:
673.
Mode
Of Action:
675.
Indica
tions:
678.
Contr
aindications
:
680.
Adver
se Effects:
687. Nursing
Responsibilities:
669.
670.
672.
Antipyretics
500 g IV every 4 h prn >38 C
674.
Paracetamol may cause analgesia by inhibiting CNS prostaglandin synthesis. The mechanism of morphine is
believed to involve decreased permeability of the cell membrane to sodium, which results in diminished transmission of
pain impulses therefore analgesia.
676.
Temporary relief of pain and discomfort from headache, fever, cold, flu, minor muscular aches, overexertion,
menstrual cramps, toothache, minor arthritic pain.
677.
679.
Hypersensitivity to the drug and its components
681.
682.
683.
684.
685.
686.
688.
689.
690.
691.
692.
693.
694.
695.
696.
Hematologic:
hemolytic anemia, leukopenia, neutropenia, pancytopenia, thrombocytopenia.
Hepatic:
liver damage, jaundice
Metabolic: hypoglycemia
Skin: rash, urticuria
Assess patients pain or temperature before therapy and regularly thereafter.
Asses patients drug history and calculate total daily dosage accordingly.
Be alert for signs of reactions
and drug interactions.
Assess patients and familys knowledge of drug therapy.
Page | 57
697.
Biblio
graphy:
698.
699.
700.
701.
702.

www.rxlist.com/zantacwww.medicinenet.com/ranitidine/article.htm
http://www.healthline.com/goldcontent/ranitidine
706.
Gener
ic Name:
708.
Brand
Name:
710.
Class
ification:
712.
Order
ed Dose:
714.
Mode
Of Action:
707.
Phytonadione
709.
Hema K
711.
Fat soluble vitamin; antifibrinolytic agent
713.
1amp now
716.
Indica
tions:
718.
Contr
aindications
:
717.
Preoperatively: to activate clotting factors to decrease chances of bleeding during surgical procedure
719.
Hypersensitivity to benzyl alcohol,
703.
704.
705.
715.
Vitamin K is required for the liver to make factors that are necessary for blood to properly clot (coagulate),
including factor II (prothrombin), factor VII (proconvertin), factor IX (thromboplastin component), and factor X (Stuart
factor).
Page | 58
720. Drug
Interactions:
722.
Side
Effect:
724.
Adver
se Effects:
726. Nursing
Responsibilities:
727.
Source
721.
Coumarin and indanedione derivatives
723.
No known side effects for this drug; bruising and bleeding are less likely to happen.
725.
No known adverse effects reported
Instruct patient to take only prescribed order

If a dose is missed, take as soon as remembered unless almost time for the next dose
Cooking does not destroy substantial amounts of Vitamin K
Caution patient to avoid IM injection and activities leading to injury
Patient should not drastically alter diet while taking Vitamin K
Use a soft toothbrush until coagulation effect is corrected
Advise patient to report any signs of bleeding/bruising
Patient should be advised not to take OTC drugs without advice of health care provider
Advise patient to inform health care provider of medication regimen prior to treatment or surgery
Emphasize importance of frequent lab test to monitor coagulation factors
728.
729.
http://www.nlm.nih.gov/medlineplus/druginfo/natural/patient-vitamink.html
730.
http://www.drugs.com/enc/vitamin-k.html
731.
732.
Gener
ic Name:
734.
Class
ification:
736.
Order
ed Dose:
733.
Celecoxib
735.
COX-2 Selective Inhibitor
737.
200 mg/ cap 1 cap BID P.O.
Page | 59
738.
Mode
Of Action:
739.
Celecoxib reduces pain and inflammation by blocking COX-2, an enzyme in the body.celecoxib does not block
COX-1, the enzyme involved in protecting the stomach from ulcers.Other anti-inflammatory medicines (NSAIDS) block
both COX-1 and COX-2.celecoxib relieves pain and inflammation with less risk of stomach ulcers compared to NSAID
740.
Indica
tions:
742.
Contr
aindications
:
741.
relief of acute pain
743.
Hypersensitivity to celecoxib
744. Drug
Interactions:
warfarin, a medicine used to prevent blood clots

rifampicin, an antibiotic used to treat tuberculosis and other infections
water pills (diuretics)
ACE inhibitors and angiotensin receptor blockers, medicines used to lower high blood pressure or treat heart failure
lithium, a medicine used to treat a certain type of depression
birth control pills
hormone replacement therapy
methotrexate, a medicine used to suppress the immune system
745.
Side
746.
Nausea, vomiting, diarrhea, Headache, Rash, Blurred vision, Difficulty in sleeping, Muscle cramps, Fatigue
Effect:
747.
Adver CNS: headache, malaise, dizziness, hallucinations, insomnia, vertigo, anxiety, drowsiness, confusion
se Effects:
CV: bradycardia, tachycardia, hypertension
Dermatologic: rash, urticaria
GI: constipation, diarrhea, nausea, anorexia, vomiting, abdominal pain, hepatic dysfunction, jaundice
Page | 60
GU: gynecomastia, impotence

Hematologic: leucopenia, granulocytopenia, thrombocytopenia, pancytopenia
Local: pain at IM site, local burning pain at injection site
748. Nursing
Responsibilities:
Take Celecoxib only when prescribed by your doctor.

For the relief of chronic musculoskeletal pain the recommended dose is 60 mg once a day.
If you have mild liver disease, you should not take more than 60 mg a day. If you have moderate liver disease, you should
not take more than 60 mg every other day.
When taking the tablets, swallow them with a glass of water. Do not halve the tablet.
Take your Celecoxib at about the same time each day.
Taking Celecoxib at the same time each day will have the best effect. It will also help you remember when to take the
dose.
It does not matter if you take Celecoxib before or after food.
Do not use Celecoxib for longer than your doctor says.
Do not take a double dose to make up for the dose that you missed.
If you get an infection while taking Celecoxib, tell your doctor. Celecoxib may hide fever and may make you think,
mistakenly, that you are better or that your infection is less serious than it might be.
749.
Biblio
750.
graphy:
751.
Page | 61
752.
Gener
ic Name:
754.
Brand
Name:
756.
Class
ification:
758.
Order
ed Dose:
760.
Mode
Of Action:
762.
Indica
tions:
765.
Contr
aindications
:
767.
Side
Effect:
769.
Adver
se Effects:
772. Nursing
Responsibilities:
776.
Biblio
graphy:
753.
Ferrous Sulfate
755.
Propan
757.
Supplement
759.
1 cap OD
761.
Elevates the serum iron concentration, which then helps to form Hgh or trapped in the reticuloendothelial cells
for storage and eventual conversion to a usable form of iron.
763.
Prevention and treatment to iron deficiency anemias
764.
Dietary supplement for iron
766.
Contraindicated with allergy to any ingredient; sulfate allergy; hemochromatosis, hemosiderosis, hemolytic
anemias
768.
Dizziness, sedation, drowsiness, impaired visual acuity, nausea, loss of appetite
770.
CNS: CNS toxicity, acidosis, coma and death with overdose
771.
GI: GI upset, anorexia, nausea, vomiting, constipation, diarrhea, dark stools, temporary staining of teeth
773.
Confirm the patient does have iron deficiency anemia before treatment.
774.
Give drug with meals (avoiding milk, eggs, coffee and tea) if GI discomfort is severe: slowly increase to build up
tolerance.
775.
Administer liquid preparations in water or juice to mask the taste and prevents staining of teeth; have the
preparations drink solution with a straw.
777.
778.
Page | 62
779.
Gener
ic Name:
781.
Brand
Name:
783.
Class
ification:
785.
Order
ed Dose:
787.
Mode
Of Action:
780.
Multivitamins
782.
AminoVita
784.
Vitamins and or Minerlas
786.
1 cap BID
788.
Providing vitamins and minerals to the body
789.
Indica
790.
Conditions associated with nutrient loss
tions:
791. Nursing
Encourage to take with meals
Responsibilities:
792.
Biblio
793.
graphy:
794.
795.
Gener
ic Name:
797.
Class
ification:
799.
Order
ed Dose:
801.
Mode
Of Action:
796.
Ciprofloxacin
798.
Antibiotic
800.
500 gm 1 tab BID
802.
Inhibits bacterial DNA synthesis by inhibiting DNA gyrase thus inducing death of susceptible bacteria
Page | 63
803.
Indica
tions:
806.
Contr
aindications
:
808.
Adver
se Effects:
817. Nursing
Responsibilities:
804.
Ciprofloxacin is used to treat infections of the skin, lungs, airways, bones, and joints caused by susceptible
bacteria.
805.
It is also frequently used to treat urinary infections caused by bacteria such as E. coli.
807.
Hypersensitivity to celecoxib
809.
CNS: Seizures, dizziness, drowsiness, headache, insomnia, acute psychoses, agitation, confusion,
hallucinations, increased intracranial pressure, tremors.
810.
GI: pseudomembranous colitis, abdominal pain, diarrhea, nausea, altered taste
811.
GU: interstitial cystitis, vaginitis
812.
Derm: rash
813.
Endo: hyperglycemia, hypoglycaemia
814.
Local: phlebitis at IV site
815.
MS: tendinitis, tendon rupture
816.
Misc: hypersensitivity reactions including anaphylaxis, Stevens-Johnson syndrome, lymphadenopathy
818.
-Assess for infection prior to and during therapy.
819.
820.
-Obtain specimens for culture and sensitivity before initiating therapy. First dose may be given before receiving
results. To prevent development of resistant bacteria, therapy should only be used to treat infections that are proven or
strongly suspected to be caused by susceptible bacteria.
821.
822.
-Observe for signs and symptoms of anaphylaxis (rash, pruritus, laryngeal edema, wheezing). Discontinue drug
and notify physician immediately if these problems occur. Keep epinephrine and resuscitation equipment close by in
case of an anaphylactic reaction.
823.
824.
-Encourage patient to maintain a fluid intake of at least 1500-2000 ml/day to prevent crystalluria.
825.
826.
-Advise patients that antacids or medications containing iron or zinc will decrease absorption and should not be
taken.
Page | 64
827.
828.
830.
-Caution patient that this may cause dizziness and drowsiness

832.
Gener
ic Name:
834.
Class
ification:
836.
Order
ed Dose:
838.
Mode
Of Action:
833.
Bearse
835.
Digestant
837.
1 cap BID
839.
Contains lipase that helps with the digestion of fats.
840.
Indica
tions:
842.
Contr
aindications
:
844.
Adver
se Effects:
847. Nursing
Responsibilities:
850.
Biblio
graphy:
841.
Conditions associated with inability to digest lipids
843.
Hypersensitivity to drug and its components
845.
846.
848.
849.
851.
GI: GI irritation
829.
Biblio
graphy:
831.
Assess for history of allergies to the drug

Encourage intake of food to prevent the development of GI complications
852.
Page | 65
853.
854.
855.
856.
857.
858.
859.
860.
861.
862.
863.
864.
865.
866.
867.
868.
PROCEDURAL REPORT
869.
Date of
operation:
870.
June 21, 2016
Page | 66
871.
Time of
Operation:
873.
Time Ended:
875.
Age:
877.
Diagnosis:
879.
Operation
Performed:
881.
Type of
Anesthesia:
883.
Name of
Surgeon:
885.
Anesthesiolo
gist:
872.
4:48 pm
874.
876.
878.
6:25 pm
43 years old
Cholecystitis
880.
Open Cholecystectomy
882.
General Endotracheal Anesthesia
884.
Dr. LSS
886.
Dr. JAO
887.
888.
889.
Procedural Report
A. Definition of Open Cholecystectomy

890.
The surgery to remove the gallbladder is called a cholecystectomy. The gallbladder is removed through a 5 to 8 inch long incision, or
cut, in the abdomen. The cut is made just below the ribs on the right side and goes to just below the waist. This is called open cholecystectomy.
891.
Open Cholecystectomy is a surgery in which the abdomen is opened to permit cholecystectomy -- removal of the gallbladder
892.
Page | 67
893.
894.
B. Nursing Responsibilities
Preoperative Phase
o Secure the informed consent for legal purposes and take note of the following things:
1. The surgeon must provide a clear and simple explanation of the surgical procedure.
895.
2. The nurse may witness the patients signature.
896.
4. If the patient needs additional information about the procedure, nurse notifies the surgeon.
897.
5. The nurse ascertains that the consent form has been signed before administering psychoactive drugs.
898.
6. No patient should be urged or coerced to sign an operative permit.
899.
7. Refusing to undergo a surgical procedure is a persons legal right and privilege.
o Assess for drug and alcohol abuse. Persons with history of chronic alcoholism often suffer from malnutrition and other systemic
problems that increase the surgical risk.
o Assess the respiratory status. The goal for potential surgical patients is optimal respiratory function.
o Assess the cardiovascular status. The goal in preparing any patient for surgery is to ensure a well functioning cardiovascular system
to meet the oxygen, fluid and nutritional needs.
o Assess the hepatic and renal functioning. Presurgical goal is optimal function of the liver and urinary system to enhance removal of
medications.
o Assess the immune functioning. An important function of the preoperative assessment is to determine the existence of allergies.
Page | 68
o Assess for the previous medication use. A medication history is obtained from each patient because of the possibility of drug
interactions
o Make nursing diagnoses, and prepare nursing care plans to address patients needs
o Teach deep-breathing, coughing and incentive Spiro meter to aid the patient post operatively
o Encourage mobility and active body movement to avoid complications
o Teach cognitive coping strategies such as imagery, distraction and optimistic self-recitation to reduce fear and anxiety
o Explain the activities that may occur inside the operating room to reduce anxiety
o Inform the patient on the following to impart knowledge on the part of the patient and to avoid delay in surgery due to noncompliance:
Scheduled date and time of the surgery and where to report
What to bring such as insurance card, list of medications and allergies
What to leave at home such as jewelry, watch, medications and contact lenses
What to wear which is loose-fitting, comfortable clothes and flat shoes
take nothing by mouth for six to 12 hours before the surgery.
o Acquire and document patients vital signs for baseline data and maintain the preoperative record
o Transport the patient to the presurgical area to prepare the patient for surgery
o Attend to the family needs to reduce the anxiety felt by the family
o Make sure that preoperative checklist which contains the following is accomplished:
Lab exam results in
OR services form accomplished
Patient is scheduled in OR
Anesthesiologist informed
Page | 69
Medicines in
Blood Typed and Matched
Field of Operation prepared
Sponged or bathed
Diet instruction given
Enema given
Make-up and nail polish removed
Jewelry removed
Oral hygiene given
Patient changed into patients gown
Indwelling catheter inserted
Pre-op meds given
Medicine for OR in
900.
Intraoperative phase
o Position the patient:
The patient is in a supine position reverse trendelenburg.
o Skin preparation
o Circulating nurse:
Manages the operating room
Page | 70
Protects patients safety and health by monitoring the activities of the surgical team
Checks and verifies the consent form
Ensures fire safety precautions, cleanliness, proper temperature, humidity and lighting of the operating room
Monitors safe functioning of the equipments
Coordinates with the surgical/ perioperative team and monitors aseptic practices
Documents operating room surgical activities
Count all needles, sponges and instruments together with the scrub nurse
901.
o For the scrub nurse:
Setting up sterile tables
Assisting the surgeon and assistant surgeon, taking care of tissue specimens
Count all needles, sponges and instruments together with the circulating nurse
902.
903.
Postoperative Phase
o Assess patient : appraise air exchanges status & note skin color; verify & identify operative status & surgeon performed; assess
neurological status (LOC)
o Perform safety checks good body alignment, side rails and maintain patent airway and cardiovascular stability
o Medication
Analgesics are administered as prescribed for pain.
Antibiotics are administered to prevent infection.

Page | 71
o Surgical dressing is assessed periodically and reinforced when necessary.

o HEALTH TEACHINGS
Inform the patient about the importance of complying with the prescribed medication.
Emphasize the proper dosage of the medications taken.
Educate the client about the importance of proper nutrition.
Encourage the client to have the prescribed diet for her condition.
Encourage to have early ambulation in order to promote circulation and wound healing.
Instruct to do splinting while performing deep breathing exercises to minimize pain.
904.
Page | 72
905.
NURSING CARE PLAN
906.
1.
2.
3.
4.
5.
Acute pain related to presence of surgical incision secondary to status post open cholecystectomy.
Impaired skin integrity related to surgical procedure: open cholecystectomy secondary to cholecystitis
Deficient knowledge regarding illness and treatment course related to lack of information presented.
Risk for infection related to presence of surgical incision.
Risk for imbalanced body temperature related to exposure to anesthesia secondary to status post open cholecystectomy.
907.
908.
Page | 73
909.
NURSING CARE PLAN
910.
1. Acute pain related to presence of surgical incision secondary to status post open cholecystectomy.
912.
911.
C
ues
ursing
915.
913.
Diagno
Objecti
914.
ve/Goal
Nursing
916.
Rationale
Interventions
917.
Evaluation
974.
GOAL MET
sis
918.
921.
923.
At the
925.
1. Monitor and
ubjecti
cute
end of my
assess vital signs every
ve
pain
care, the
2 hours.
Cues:
related
patient will be
926.
to
able to:
927.
Verbalize
presenc
d Sakit pa
e of
akong
opera, ngulngul pa.
bjectiv
e
Cues:
incision
second
919.
920.
surgical
ary to
status
post
open
cholecy
1. Report a
decrease in pain
intensity to a
928.
10.
930.
2. Demonstrate
signs are usually

altered in acute
pain
955.
2. Administer
Celecoxib) as ordered.
929.
R: Vital
analgesics (e.g
scale of 3 out of
954.
3. Evaluate the effectiveness
956.
975.
At the end of
rendering my care, the

patient was able to:
1. Report pain as relieved and
R:
controlled as evidenced by
Celecoxib is an
verbalization of client, Dili
NSAID. It is for
na man kaayo siya sakit,
relief of moderate
makaya na man. And
to severe pain.
reported a pain scale of 3
957.
non
of analgesic at regular
pharmacological
intervals after each
methods and/or
administration, also
analgesic dose
use of relaxation
observing for any signs and
may not be
958.
R: The
out of 10
2. Demonstrate non
pharmacological methods
and/or use of relaxation
Page | 74
pain scale of
stectom
skills and
symptoms of untoward
adequate to raise
skills and diversional
6 out of 10
y.
diversional
effects (e.g. respiratory
the clients
activities (e.g. patient
activities, as
depression, nausea and
Grimaced
indicated, for
face noted.
pain
maintained moderate high
vomiting)
threshold or may
back rest position; she also
individual
931.
be causing
performed diversional
Guarding
situation.
932.
intolerable or
activities such as talking
behavior
924.
933.
dangerous side
with her watcher)
noted.
noted.
Slow and
limited
movement
of the upper
extremities
Patient is 1
day post
operative
Incisions @
RUQ of the
abdomen.
Incisions
are covered
with dry and
922.
4. Monitor patients pain at
959.
960.
effects or
976.
Vital Signs: T-
least every hour while
both. Ongoing
36.4C; BP- 110/70; RR-
awake by the use of the
evaluation will
19; PR- 84.
pain scale.
assist in making
934.
necessary
935.
961.
adjustment
936.
s for effective pain
937.
management.
5. Instruct and demonstrate
962.
use of deep breathing
963.
R: Allows
exercise. Also instruct
evaluation of the
patient to do splinting while
severity of the
doing deep breathing
pain felt by the
exercises.
patient. Pain is a
938.
subjective
Page | 75
intact
939.
experience and
dressing.
940.
only the patient
Vital Signs:
941.
can describe the
T- 36.2C;
6. Position the patient properly
pain shes feeling.
BP- 100/70;
in bed. Elevate head of bed.
964.
RR-18; PR-
Maintain anatomic
965.
81.
alignment
breathing
942.
increases oxygen
7. Encourage diversional
R: Deep
in the body and
activities (TV/radio,
prevents
socialization with others,
atelectasis. Deep
mental imaging).
breathing exercise
943.
also provides
944.
comfort.Splinting
945.
while doing deep
946.
breathing is to
8. Provide rest periods to

facilitate comfort, sleep, and
relaxation
lessen the pain

upon respiration.
966.
R:
947.
Alignment helps
948.
prevent pain from
949.
malposition and it
Page | 76
9. Assist patient in doing her

activities of daily living
950.
951.
952.
10. Encourage patient to report
pain as soon as it starts and
allow her to verbalize pain
experienced or describe the
pain shes feeling.
953.
enhances comfort
967.
968.
R: These
highten ones
concentration
upon nonpainful
stimuli to decrease
one's awareness
and experience of
pain.
969.
970.
R: The
patient's
experiences of
pain may become
exaggerated as
the result of
fatigue. Adequate
rest helps provide
comfort
971.
R: Helps
reduce pain
Page | 77
brought about by
the exertion of
force necessary to
perform activities
972.
973.
R: Severe
pain is more
difficult to control
and increases the
clients anxiety
and fatigue.
977.
978.
979.
980.
981.
982.
983.
984.
985.
Page | 78
986.
987.
988.
2. Impaired skin integrity related to surgery: open cholecystectomy secondary to cholecystitis.
989.
Cues
995.
Subje
ctive:
996.
Giop
erahan ko
diri sa tiyan,
as
verbalized
by the
patient
997.
998.
tive:
Objec
999.
-post
open
cholecystect
omy
1000.
990.
Nursing
Diagnosis
991.
Objectiv
es/Goals
1005.
Impaired
1008.
At the
skin integrity
end of my
related to
carethe patient
surgery: open
will be able to:
cholecystectom
y secondary to 1. Display improvement
in wound healing as
cholecystitis.
evidenced by intact
1006.
incision site.
1009.
1007.
2. Remain free from
infection
as
evidenced by normal
vital
signs
and
absence of purulent
discharge.
1010.
3. Demonstrate
behaviors/techniques
to promote healing or
992.
Nursing
Interventions
1.
993.
Rationale
994.
Assess dressings/
wound every shift.
Describe wounds and
observe for changes.
1011. .
1035.
:Establish
es comparative
baseline providing
opportunity for
timely intervention
1012.
1.Maintain incision site and

dressing intact and dry.
1037.
: Keeping 1060.
incision site clean 2.Remain free from infection as
evidenced by normal vital signs
and dry prevents
(BP= 110/70; RR=18; PR=85;
infection; it also
Temp=36.3) and absence of
aids in the
purulent discharge.
process of wound
1061.
healing
2.
Keep the incision

site clean and dry,
carefully
dress
wounds.
1013. .
1014.
3.
Encourage
early
ambulation.
Assist
patient in doing active
and passive range of
motion exercises.
1015.
1058.
Evaluation
Goal Met
1059.
At the end of my
care, the patient was able
to:
1036.
3.Demonstrate
behaviors/techniques to
1039. :
Movement promote healing or prevent
stimulates
circulation complications (e.g patient
and assists in the washes hands after using the
bodys natural process
1038.
Page | 79
disruption of
the dermis,
epidermis,
and
subcutaneou
s tissues.
1001.
-with
incision at
the RUQ of
the
abdomen
1002.
incisions
covered with
dry and
intact
dressing
1003.
-skin
slightly warm
to touch.
Temperature
: 36.3C
1004.
prevent
complications
4.
Monitor temperature
every 4 hours.
1016.
1017.
1018.
1019.
5.
Place
in
semiFowlers position or
moderate high back
rest.
1020. .
1021.
1040.
1041.
: Early
recognition of
developing
infection enables
rapid institution of
treatment and
prevention of
further
complications.
comfort room, eats a balanced

diet, and takes antibiotic
medication (ciprofloxacin) as
ordered)
1042.
1043.
6.
Instruct to wear
clean, dry, loose-fitting
clothes,
preferably
cotton fabric
1022.
:Proper
positioning
decreases
tension in the
operative site and
promotes healing
1044.
1023.
1024.
1025.
1026.
7.
of repair.
Emphasize
1045. : Skin friction

caused by stiff or rough
clothes
leads
to
irritation of fragile skin
and increases risk for
infection. Loose clothing
Page | 80
importance
of
adequate nutrition and
fluid intake. Encourage
patient to eat foods
rich in protein, iron and
vit. C.
1027.
1028.
1029.
1030.
8.
Instruct the client in
proper
postoperative
skin care. Teach client
and her significant
others the importance
of
proper
hand
washing.
1031.
1032.
1033.
9.
Instruct the client to

observe for signs and
symptoms
of
complications such as
elevated temperature,
redness,
warmth,
swelling
near
the
reduces pressure on
compromised tissues,
which may improve
circulation/healing
1046.
1047. :
Improved
nutrition and hydration
will
improve
skin
condition. Protein and
iron helps in repair of
tissues. Vitamin C is
important for immune
system function and
increases resistance to
some pathogens.
1048.
1049. :
This is to
involve the patient in
caring
for
skin,
promoting comfort, and
preventing infection or
other
complications.
Proper
washing
of
hands deter the spread
of microorganisms.
Page | 81
surgical
incision,
purulent discharge, or
breakdown of sutures
around the incision,
and report to the
physician.
10.
Administer
antibiotics as indicated
(cefuroxime)
1034.
1050.
1051.
1052. : Provides for
prompt recognition of
complications
and
facilitates
prompt
treatment.
1053.
1054.
1055.
1056.
1057.
: May be
given
prophylactically or
to treat specific
infection and
enhance healing.
1062.
1063.
1064.
1065.
1066.
Page | 82
1067.
1068.
1069.
1070.
1071.
1072.
1073.
1074.
1075.
1076.
1077.
3.Deficient knowledge regarding illness and treatment course related to lack of information presented.
1078.
Cu
1079.
Su
g Diagnosis
1088.
Knowle
es
1084.
bjective
dge
cues:
regarding
Verbalized: Para
asa diay ni siya
(holds
Nursin
deficit
illness
and
treatment
course related
to
lack
of
1080.
Objecti
1081.
Nursing
ve/Goal
Interventions
1091.
At the 1. Assess the patients
1082.
Rationale
1151. R: Adults learn
end of my
current knowledge of the
best when teaching
care, the
medications and other
builds on previous
patient will be
doctors instructions and
knowledge or
able to:
nursing procedures and its
experience. Assessing
implications, the likelihood
recall of the physicians
of complications if these
explanations as well as
1092.
1.
1083.
1165.
1166.
Evaluation
Goal Met
At the end
of 2 hours nursing
intervention, the
patient was able
to:
Page | 83
medications)?
Verbalized: "Di
ko muinom lang
ana na tambal
kay pait"
1085.
Obj
ective
cues:
information
Verbalize
are not followed, and the
the patients past
presented.
understanding
likelihood of cure or
experiences and
karon ngano ginahatagan
1089.
of disease
disease control.
exposure to health
ko ug mga ing aning
1090.
process and
Specifically ask about the
information provides an
tambal, para pud
treatment.
physicians explanations
opportunity for
malabanan ang
and the patients past
evaluating attitudes and inpeksyon nako.

2. Initiate necessary lifestyle
the accuracy and
changes and participate
completeness of
in treatment regimen and
verbalized Sa sunod
knowledge.
mag-iwas na gyud ko ug
1152. R: People vary
mga taba kayo nga
pagkaon.
in the degree of detail
1167.
they find helpful. Those
1093.
2.
Initiate
necessary
lifestyle
Frequent
changes and
questioning
participate in
treatment
Incorrect verbal
regimen.
experiences.
1094.
2. Ask how much the patient
wants to know. Consider
patients preference for
information in planning and
feedback
teaching.
regarding
1095.
understanding of
treatment
1096.
regimen.
1097.
1086.
1098.
1087.
1099.
1. Verbalize kasabot nako
who cope with a

threatening experience
by avoiding it generally
want to know relatively
little about impending
experiences, whereas
those who cope by
learning as much as
possible about the
threatening experience
Page | 84
1100.
1101.
1102.
1103.
1104.
3. Determine learning needs.
want to know a great

deal.When possible,
supporting the patients
preferred learning style
shows respect for
individual differences.
1153. R: Learning
needs determine
Consider needs expressed
appropriate content.
by the patient and family.
Learning occurs most
1105.
1106.
1107.
1108.
1109.
rapidly when its

relevant to current
needs. Responding to
expressed needs
displays sensitivity to
the patients and
familys concern.
Identifying predictable
1110.
1111.
concerns and
responses and
necessary self-care
1112.
activities helps the

Page | 85
1113.
1114.
1115.
4. Present manageable
nurse fulfill learning

needs of which the
patient and family may
be unaware.
1154. R: Too much
amounts of information at
information at one time
any one time.
causes confusion. They
1116.
5. Inform the patient about
indication of medication,
drug interaction and its
side effects
1117. .
6. Inform the patient about
the diet specific for her
condition (low fat, high fiber
foods; avoid spicy foods,
alcohol and caffeine)
1118.
patient may lose sight

of key points.
1155. R: Allows patient
to be knowledgeable
about medication and
avoid misconceptions
1156.
1157. R: A patient who
has recently had
a gallbladder removed
may suffer from
diarrhea and bloating
after consuming foods
Page | 86
1119.
1120.
1121.
1122.
1123.
1124.
1125.
1126.
1127.
1128.
high in fat. Diarrhea

and bloating occur
because of two
reasons. One reason is
that fat inside the
intestine absorbs more
water, causing stomach
upset. A second reason
is that bacteria begins
to digest the fat within
the intestine and
ultimately produces
gas. When a person
with gallbladder proble
ms consumes spicy
1129.
1130.
foods, , unpleasant side

effects such as gas
and heartburn can
1131.
7. Provide simple
occur.
1158.
explanations, using easyto-understand terminology.
1159.
R:
Page | 87
1132.
1133.
1134.
8. Discuss to the patient and
to the family the
importance of complying
with the medications and
other doctors orders.
1135.
1136.
1137.
1138.
1139.
1140.
Ask for feedback.
Medical and
nursing jargon
distances the
patient and
family members.
Intricate
explanations
may confuse or
overwhelm
them.
1160. R: This lets the
patient be aware of the
significance of the
doctors instructions. It
also lets the patient
know the
consequences which
might occur if
instructions werent
followed. Knowing the
1141.
benefits of complying
with the instructions
Page | 88
1142.
1143.
1144.
1145.
10.Use review and repetition
judiciously, considering
individual factors.
1146.
11. During and after teaching,
determine what learning
has occurred.
1147.
1148.
1149.
12.Provide information about
encourages
participation.
1161.
R: The
patient may
initially feel
overwhelmed
and insecure
about learning
because of the
magnitude,
urgency or
unfamiliarity of
necessary
adaptations to
illness.
1162. R: The unit
additional learning
environment and the
resources, like the nearest
patients age may
baranggay health center in
contribute to a short
their area.
attention span and poor
1150.
retention.
Page | 89
1163. R: Determining
learning
accomplishment
permits resolution of
some learning needs
and provides guidance
for meeting others.
1164.
R:
Patients should
be informed that
there are health
services in the
health centers
which are for
free, so as to
persuade them
to avail it.
1168.
Page | 90
1169. FUNCTIONAL HEALTH PATTERN

1170.
1171.
1172.
1173.
FUNCTIONAL HEALTH PATTERN
1174.
USUAL
FUNCTIONAL PATTERNS
1178.
Healthperception Healthmanagement pattern
- General health in the past
year is good
- 3 years ago, was
hospitalized in NOpH for
the same reason but was
only given medications to
relieve pain and no
further actions were taken
as claimed
- Has a family history of DM
on both sides,
hypertension on maternal
side and gallbladder
disease on maternal side.
- No known disease
- Would take TUMS
(antacid) orally to relieve
epigastric pain had a
history of epileptic
1175.
-
INITIAL APPRAISAL
12 hours PTA, patient had onset of pain and

vomiting with food particles associated with RUQ
pain, it is continuous and non radiating
- Finds God and faith most important in her life right
now
- Vital signs
1179.
T=36.2c
1180.
PR= 72 BPM, strong and bounding
1181.
RR=19 CPM, shallow and with use of
accessory muscles
1182.
BP=100/80 mmHg
1176.
ONGOING
APPRAISAL(06-30-16)
Verbalized that she is
now feeling better and
feels that she can go
home already
was alert, conscious
and oriented
Shows interest to
recover easily and fast
as she participates and
listens to what the
health care team
instructs on what to do
and what to eat
1177.
ONGOING
APPRAISAL(07-01-16)
Shows great interest
in recovering fast
Participates during
health teaching
was alert, verbally
responsive and
oriented
Verbalized feeling
much better now
compared to
previous days
Claimed that she will
now be very
conscious on her
health and will
continue to seek
regular check ups
Page | 91
episodes, claimed that

the last attack was when
she was 1st year college
(1990). Sought no
consultation
1183.
Nutritional
Metabolic Pattern
- Good appetite
- Wound healing is good
- Able to consume food
- No eating discomforts or
allergies
- No dental problems or
skin problems
- No supplements taken
- Usually comsumes 8-10
glasses daily
- Claimed that her usual
weight is approx. 60 kg.
- On full, low fat diet

- consumed 4-5 glasses of water
- skin is relatively dry and warm to touch
- no presence of edema
- Medications:
1184.
Bearse 1 cap OD
1185.
Propan + iron 1 cap OD
1186.
Ciprofloxacin 500 mg 1 tab BID
1187.
Amino vita 1 cap BID
1188.
Celecoxib 200mg/cap 1 cap BID
Weight: 57 kgs
Height: 5 ft 2
Normal Body index22.4
Average Body
temperature- 36 c
On full low fat diet
Medications:
1189.
Bearse 1 cap OD
1190.
Propan + iron 1
cap OD
1191.
Ciprofloxacin
500 mg 1 tab BID
1192.
Amino vita 1
cap BID
1193.
Celecoxib 200mg/cap
1 cap BID
Consumed about 2-3
glasses of water and 1
glass of Non fat milk
skin is relatively dry
and warm to touch
Mucuous membranes
were moist but lips
were slightly cracked
color of conjunctiva
On full low fat diet

consumed about 500
ml of water
skin was relatively
dry and warm to
touch
Mucuous membranes
were moist but lips
were slightly cracked
Bowel sounds 8
clicks per minute
Medications:
1195.
Bearse 1 cap
OD
1196.
Propan + iron
1 cap OD
1197.
Amino vita 1
cap BID
1198.
Page | 92
1199.
Elimination
Pattern
- Bowel elimination:
1200.
Twice a day, early
morning and late evening
1201.
Brown color
1202.
Small, of a cup
full, solid
1203.
No discomforts on
eliminating
- Urinary elimination:
1204.
Aprrox. 4 times a
day
1205.
Uses a urinal
1206.
No discomforts
1207.
Straw-like color
1208.
1/8-1/4 of a cup full
depending of amt of fluid
intake
1209.
No problem
controlling urination
- Does note easily perspire
- Urinated once today

1210.
Straw-like color
1211.
Approx. of a cup
- No excessive perspiration noted
- No odor problems noted
- Urinalysis
1212.
TES
1213.
R
T
ESULT
1215.
Glu
1216.
N
cose
egativ
e
1218.
Prot
1219.
N
ein
egativ
e
1221.
Bilir
1222.
N
ubin
egativ
e
1224.
Uro
1225.
N
bilinogen
ormal
1227.
pH
1228.
6
1230.
od
Blo
1231.
N
egativ
e
1233.
one
Ket
1236.
Nitr
1234.
N
egativ
e
1237.
N
1214.
NO
RMAL
1217.
<5
0mg/dL
1220.
<3
0mg/dL
was pinkish
Bowel sounds 7 clicks
per minute
1194.
No pain or burning
sensation during
urination
Not yet defecated
Urinated twice.
characteristic of urine:
color- light yellow, no
unusual odor, approx.
24 cc
1253.
No pain or burning
sensation during
urination
Defecated once @ 5
am with firm brown
stool without
difficulty
Voided 2x
approximately 600 cc
no difficulty voiding
skin perspiration is
minimal
no notable body odor
1223.
<1
mg/dL
1226.
<2
mg/dL
1229.
4.5
-8
1232.
<5
10RBC/m
L
1235.
<5
mg/dL
1238.
Ne
Page | 93
1258.
8:00 takes bath.
1259.
8:30- Goes to her
aunt for work
1260.
9:00 eats snack
1261.
11:30 lunch
1262.
1:00 resume work
1263.
9:00 bedtime
- Perceived ability for
activities:
1264.
Feeding =lvl 0
1265.
Bathing = lvl 0
1266.
Toileting = lvl 0
1267.
Bed mobility = lvl 0
1268.
Dressing = lvl 0
1269.
Grooming = lvl 0
1270.
General mobility =
lvl 0
1271.
Cooking =lvl 0
1272.
Home maintenance
= lvl 0
1273.
Shopping = lvl 0
- Extremities function well
1299.
Sleep-rest
Pattern
- Generally rested and
ready for daily activities
after sleep
- No sleep onset problems
or sleep aids
- Onset: 9:00 pm
- Awakening: 5:00 am
- Amount of sleep: 8 hours
- No sleep interruptions
- Feels rested after sleep
1300.
Cognitive-
1290.
General mobility
= lvl 0
II
1296.
Grooming = lvl
0
1297.
General
mobility = lvl 0
1298.
Sleeps at 10 pm
wakes up at 7 am
Sleep is sometimes
interrupted by medical
procedures
claims to be generally
rested after sleep
PTA woke up in the middle of the night because of

onset of pain
takes nap whenever she feels like it
No sleep onset problems or sleep aids
Onset: 11:00 pm
Awakening: 6:00 am
Amount of sleep: 8 hours
Sleep often interrupted by coughing episodes and
health care providers
Feels a little rested after sleep
Appears tired
Complains of difficulty of breathing
Claimed pain to be
sleeps at 10 pm
wakes up at 7 am
claims to be sleepy
and drowsy after
taking meds
claimed to be
generally rested after
sleep
Responds well to
Page | 95
perceptual Pattern
- Far sighted
- History of sore eyes,
cannot remember details
- Several missing teeth
- Comfortable language to
use: Cebuano
- Visual learner
- No hearing problems
1302.
Self-perceptionself-concept Pattern
- Believes she is a religious
and godly person
- Does not subscribe to
vices
- Describes herself as hot
tempered but usually is
able to cope with it by
confronting
Visual and hearing condition is still the same

Appears to be oriented and responsive
claims to be under pain at times, rated 6/10 on pain
scale
- responds well to questions and answers
appropriately
- no sensory deficits
- claims to have no change on memory lately
1301.
- was very calm and cooperative
- very expressive about her feelings and thoughts
- major concern is her fast recovery
- trusts the medical team for taking care of her
1305.
Role relationship
Pattern
- Lives in their ancestral
home
- supports her son together
with the father
- close relationship with her
relatives
the father of her child is with her and claims that

they have a good relationship
visited by her sister frequently
single mother, lives with her son
1306.
Sexualityreproductive Pattern
claimed to be experiencing hot flashes

has no plans of having another child
intermittent but is
bearable and choose
not to take
medications
Performs deep
breathing exercises if
pain is felt
stimuli
Pain is less frequent
Performs relaxation
techniques
Slight grimacing
when moving around
1303.
- though weak
she still manages to
appear calm and
relaxed
- very hopeful and
positive to have a fast
recovery
- views herself as a
strong person and
hopes to be
discharged
immediately
1304.
- loves her family so
much
- visited by her sister
- well supported by the
family
does not involve self in

sexual acts
no change in attitude
still hopeful of a safe
and fast recovery
major concern is her
recovery
Still plays the role of

the mother despite
condition by means
of reminding
important matters to
her child
- frequently visited by
friends and family
from her church
1307.
-currently
experiences some
Page | 96
OB/GYN history: G2P1

menses are regular
experienced menarche
@11 yo
- no history of sexual
problems
1308.
Coping Stress
Tolerance Pattern
- Claimed that she is
mostly calm
- would sometimes feel
frustrated about condition
- no traumatic experiences
before
1309.
Value-belief
Pattern
- Religion: Jesus Christ of
Latter Day Saints
- claims that she is very
religious
- Religion is an important
thing in her life
- follows the doctrines of
the church
- claimed that generally
she does not always get
what she wants but thinks
that God has a plan for
her
- She goes to church with
her family and friends
1310.
symptoms of
menopause
claims that she is saddened over the fact that she

has to watch what she eats
her sister is by her side so she talks to her
whenever she is tense
Claims that she cant wait to go back to church

stated that she is thankful to God because of her
successful operation
takes a nap and rests

when tired
able to accept
situation by
cooperating with the
medical team
relaxed and calm

claimed that her
sister helped her
cope in the hospital
no restrictions in the
procedure brought by
religion
verbalized that her

faith is even stronger
that before and
believes this is a test
given by God to her.
Page | 97
1311.
1312.
1313.
1314.
1315.
1316.
1317.
1318.
1319. RELATED READING

1320.
Robotic surgery offers lower risks, faster recovery
1321.
By Dr. Kathryn Wheel
Ask the Doctor
1322.
In the case of gallbladder removal, doctors typically perform that procedure to provide permanent relief to patients suffering from gallstones
and other problems associated with the gallbladder, which is a small organ located on the underside of the liver that aids digestion. Unfortunately,
the gallbladder isnt always the most efficient organ and is also prone to develop gallstones hard deposits of substances in the bile that get stuck
inside the gallbladder that can cause infections to form, which can then cause bloating, nausea, vomiting and further pain. Gallstones can be as small
as a grain of sand or as large as a golf ball. Gallstone disease, called cholelithiasis, can cause short or lasting pains in the abdomen.
1323.
To remove the gallbladder, many surgeons use minimally invasive surgery and robotic techniques for this operation, called a cholecystectomy.
Quite simply, robotic surgery also known as robot-assisted surgery allows physicians to perform a variety of complex procedures with greater
vision and more precision, flexibility and control than is possible with conventional techniques that have been around for many years.
Page | 98
1324.
Robotic surgery with the da Vinci Surgical System was approved by the Food and Drug Administration in 2000. Since then the robotic
technique has been rapidly adopted by technologically advanced hospitals across the United States. During robotic-assisted surgery, surgeons
operate from a console near the patient that is equipped with two master controllers that precisely maneuver four robotic arms. By viewing a highdefinition 3-D image on the console, the surgeon is able to see the surgical procedure better than ever before, and computer software takes the
place of actual hand movements and can make movements precise. Robotic surgery allows doctors to perform delicate and complex procedures
through small incisions that may have been difficult or required invasive, or open surgery.
1325.
Robotic surgery goes hand in hand with minimally invasive surgery. During minimally invasive surgery, procedures are performed through
small incisions. Benefits of minimally invasive surgery include less pain, lower risk of infection, a shorter hospital stay, quicker recovery time, less
scarring and reduced blood loss during the procedure.
1326.
Along with gallbladder removal, some common treatment procedures for which robotic surgery is now available at Pocono Medical Center
include hernia repair; hysterectomy; female urologic surgery, such as bladder suspension; prostate surgery for prostate cancer; and colon surgery in
the near future. Not all hospitals perform all types of robotic surgery, so be sure to ask your doctor about treatment options if you are considering
robotic surgery.
1327.
The good news is, many people who require gallbladder removal are candidates for robotic, single-incision surgery which typically can be
performed in less than one hour as a same-day procedure. This method allows for a single incision at the belly button where instruments are placed
and the diseased organ is removed, with the benefits of minimal scarring, less pain and bleeding, and faster recovery.
1328.
However, robotic surgery isn't an option for everyone, so its always best to talk with your doctor about the benefits and risks of robotic
surgery and how it compares with other techniques, such as other types of minimally invasive surgery and conventional open surgery. Together you
can find an option that works best for you and that gets you quickly on the road to
Page | 99
1329. REFERENCES
Berman, A. et. al. (2008) Kozier & Erbs Fundamental of Nursing Concepts, Process and Practice 8 th Edition. Pearson Prentice Hall, volume Two,
Chapter 42, stress and coping
Boyer, M. (2006). Brunner and Suddarths Textbook of Medical-Surgical Nursing, 11th ed.
Carol Mattson Porth (2005). Pathophysiology, Seventh edition.
Crowley, L. (2010). An Introduction to Human Disease: Pathology and Pathophysiology Correlations, 8 th ed., p. 563. USA: Jones and Bartlett
Publishers.
Digiulio, M. & Jackson, D.(2007). Medical-Surgical Nursing Demystified, p. 288. USA: McGraw-Hill.
Everhart, JE, Khare, M, Hill, M, Maurer, KR. Prevalence and ethnic differences in gallbladder disease in the United States. Gastroenterology
1999; 117:632.
Ginsber, G. & Ahmad, N. (2006) The Clinicians Guide to Pancreaticobiliary Disorders, p. 121-123. USA: SLACK Incorporated.
Harrisons Principles of Internal Medicine, Tenth Edition 1983.
Iyengar, V. Elemental Analysis of Biological Systems: Biomedical, Environmental, Compositional and Methodological Aspects of Trace Elements,
Vol. 1, p. 49.
Kozier and Erbs, Fundamentals of Nursing, Chap. 20, page 352
Lippincott Williams and Wilkins Handbook of Diseases Third Edition, page 184
Talamini, M. (2006). Advanced Therapy in Minimally Invasive Surgery, p. 179. USA: Decker Inc.
Taylor, Lillis, LeMone and Lynn (2008),Fundamentals of Nursing: The Art and Science of Nursing Care, 6 th edition.
Understanding Medical Surgical Nursing by Williams and Hopper page 742
White, L. Foundations of Nursing: Caring for the Whole Person, p. 832.
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http://digestive.niddk.nih.gov/statistics
http://home.intekom.com/pharm/quatrom/q-hyosc.html
http://medical-dictionary.thefreedictionary.com/calculi
http://www.diabetesmonitor.com/learning-center/gallstones.htm
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http://www.drugs.com/arcoxia.html
http://www.drugs.com/enc/vitamin-k.html
http://www.drugs.com/mtm/ampicillin-and-sulbactam.html
http://www.drugs.com/ultram.html
http://www.healthline.com/goldcontent/ranitidine
http://www.learningplaceonline.com/stages/organize/Erikson.htm
http://www.medicinenet.com/hyoscine_butylbromide-oral/page2.htm
http://www.medicinenet.com/tramadol/article.htm
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http://www.rxlist.com/unasyn-drug.htm
http://www.turner-white.com/pdf/hp_nov00_murphy.pdf
http://www.webmd.com/drugs/drug-11276-Ultram+Oral.aspx
www.drugs.com/valium.html
www.medicinenet.com/diazepam/article.htm
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www.revolutionhealth.com/drugs-treatments/cefoxitin
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Page | 101

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COLLEGE OF NURSING

A Case Study on Cholecystitis

Submitted to: Asst. Prof. Maria Ellaine Adarna

Correctly recall the parts and functions of gallbladder

NURSING CARE PLAN......................................................................................................................................... 66

Educational Attainment: College Graduate

Address: San Jose St. Dumaguete City, Negros Oriental

Religion: Jesus Christ of Latter Day Saints

Doctor(s)-in-charge: Dr. JCC

Date and Time of Admission: June 11, 2016 0216H

Chief complaint(s): Pain @ RUQ, vomiting

DEFINITION OF COMPLETE DIAGNOSIS

In an acute cholecystitis, the blood flow to the gallbladder may become

its maximum demands upon them for social and civic

responsibility. It is the period of life to which they have looked

The patient is a secretary to her aunt who is an

by cleaning, washing clothes, doing other household

peaceful and organized home. She is also responsible

their everyday living.

The patient is doing her responsibilities as a Filipino

taxes (property tax and cedula) as part of her

Erik Eriksons Psychosocial Development Theory

22. The significant task is to perpetuate culture and

35. As a mother of, she is the one who

inculcates values in the family whom

she acquired from her parents. She

makes sure that her son will be

transmit values of the culture through the family

and production of something that contributes to the

relationships or goals changes, she may be faced with

major life changesthe mid-life crisisand struggle

doesn't get through this stage successfully, she can

raised with good attitude and as

Today, she is busy taking care of her

25. Creativity, productivity, concern for others or selfindulgence,

59. Level 3: Postconventional

contract and utilitarian

terms of societys law.

Laws can be changed,

maintaining respect for

self and others.

worth to be followed. She said that she follows

She doesnt want nuisance in the society because

she believes that to be able to live in a serene

respect with themselves and then to others.

93. She knows about universal laws, specifically

about justice. She is concerning about justice,

the persons concern for

malooy gyud ko sa mga tao nga dili matagaan

equality for all human

ug hustisya, labaw na ng mga pobre , as

verbalized by the patient.

those set by society or

laws. Justice might be

98. PHYSICAL ASSESSMENT

Patients Name: M.L.Y

Age: 43 yrs. old

Admitting Diagnosis: Cholelithiasis

Final Diagnosis: Cholecystitis

Chief Complaint: right upper quadrant pain, vomiting

Date of Assessment: June 29, 2016

Time of Assessment: 1:00 pm

Location of Assessment: NEM 7

Vital Signs upon physical assessment: