Bulacan State University

City of Malolos, Bulacan

College of Nursing

A CASE STUDY OF A 64 YEAR OLD MALE WITH

CHOLECYSTOLITHIASIS/ CYSTITIS
CHOLEDOCHOLELITHIASIS
WITH BILIARY ECTACIA

SUBMITTED BY:

CARATING, MANILEN

DE JESUS, HERNILY ANGELICA

DE JESUS, MARIA THERESA

GAN, LOVELY SHANE

LOPEZ, LARISSE

MARCIAL, DHANILIE

MORELOS, JENNIFER

REYES, ANNA MARIE

PAYONGAYONG, ACEY BRYLLE

SORIANO, JERICO

BSN4A- GROUP # 4
I. INTRODUCTION

This is a case study of a 64 year old male client who were rushed at Lubao Clinic at Lubao, Pampanga complaining of severe pain on the right upper
quadrant of the abdomen. After performing abdominal ultrasound, the result shows that he has Cholecystolithiasis/cystitis and choledocholelithiasis with
secondary biliary ectacia. He was then diagnosed with cholecystocholedocholithiasis and was referred by Dr. G to Dr. PB of Bulacan Medical Center. He was
admitted at Bulacan Medical Center last August 27, 2010 at 12:32 p.m. and was scheduled for cholecystectomy with billiary exploration.

Cholecystocholedocholithiasis is presence of gallstone in both gallbladder and common bile duct, in turn leading to bile obstruction and gallbladder
irritation. Gallstones are crystalline bodies formed within the body by accretion (increase by natural growth) or concretion (formation of stone-like substance) of
normal or abnormal bile components, it can occur anywhere within the biliary tree, including the gallbladder and common bile duct. The bile is a fluid produced
by the liver that aids in digestion of lipids and neutralizing of partly digested foods, it is stored in the gallbladder and upon eating it is discharged to the duodenum
(the first part of the small intestine) by passing to a duct called common bile duct. The gallbladder is an organ which aids in the digestive process. Its function is to
store and concentrate bile. The common bile duct is a tube-like structure that is formed by the union of the common hepatic duct and the cystic duct. Its primary
function is conduction of concentrated bile from the gallbladder to the duodenum. Cholecystectomy is a surgical removal of gallbladder. Fortunately, the
gallbladder is an organ that people can live without. Despite of the importance of gallbladder in the digestion of fat, many people are unaware of it. That is why
they often neglect to take care of their gallbladder. And biliary exploration is done to search for any gallstone present in the biliary tree.

Cholecystocholedocholithiasis can affect both men and women but it is more prevalent in women at the age of 40 years old. People who have a history of
gallstones are at increased risk for having this kind of disease. In the international level, gallstones are prevalence among people of Scandinavian descent, Pima
Indians, and Hispanic populations, whereas gallstones are less common among individuals from sub-Saharan Africa and Asia. It affected 20.5 million people (1988-
1994) with a mortality record of 1,077 deaths in 2002. Hospitalizations total up to 636,000 in the same year and over 500,000 have undergone cholecystectomies.
In the Philippines alone, an extrapolated prevalence of 5,073,040 people are affected by the disease last 2007. (http://digestive.niddk.nih.gov/statistics)
 No unanimous consensus has been achieved regarding the ideal management of cholecystocholedocholithiasis. The treatment of gallbladder and common
bile duct stones may be achieved currently according to a two-step-protocol (endoscopic sphincterotomy associated with laparoscopic cholecystectomy) or by a
one-step laparoscopic procedure, including exploration of the common bile duct and cholecystectomy. Endoscopic sphincterotomy is reported to have
considerable morbidity/mortality and common bile duct stone recurrence rates, whereas laparoscopic common bile duct clearance is a demanding procedure,
which to date has not spread beyond specialized environments. (http://pubget.com/paper/19466493#)

Significance of the study

We, the student nurses have chosen this case as we see it fit for the peri-operative concept as the patient has had undergone cholecystectomy with billiary
exploration and cholechoduodenostomy. Moreover, despite the Cholecystocholedocholithiasis’ low incidence, we would like to give credit and to know more of
the nature and function of the gallbladder. Much often this small organ is not given importance. Thus we are in a pursuit for knowledge to be able to impart it to
others. Furthermore, this case is quite interesting since it does not always affect only females and elderly. It can affect everyone. It can be alarming since many
people are confused and unaware of the symptoms presented.
As teen-agers living in a fast-phased world and governed by schedules, we too are predisposed to lifestyle modification – especially diet and food
preferences which can contribute to the disease. With this study, we hope to apply our learning in taking care not only of our patients but also of ourselves.
As nursing students and future nurses, we would want to understand and appreciate more on what is happening to a patient with
Cholecystocholedocholithiasis. Consequently, we are interested on what will be the necessary management that will be given. Through this, we are hoping that
we will be able to find the right plan of care and sound interventions, not forgetting the patient’s rights as a person. All in all, these will help us to become efficient
nurses and better persons later on.
OBJECTIVES

General Objective:

Our first main goal is to gain knowledge through the completion of the case study and to impart this learning to Mr. BM and to those directly and indirectly
involve with the completion of this case. In psychomotor aspect, our goal is to apply all what we have learned during the process of completing this case study to
improve nursing care that will meet Mr. BM’s need for the improvement of his general welfare. With the knowledge gained and through the application of this
knowledge, another goal is that we will be able to empathize with the current situation of the patient and to gain some values like the value of patience and
calmness which is important for us to have in order to become better nurses in the future.

Specific Objectives:

 Conduct a thorough physical assessment and to interpret the assessment in order to give the care the patient need.
 Research and understand the disease process of the patient’s illness and also the possible causes and the symptoms the patient experienced that may
suggest the current condition of the patient.
 Integrate knowledge of nursing care in post Cholecystectomy with biliary exploration client to formulate a quality nursing care plan.
 Implement appropriate nursing intervention to satisfy the patient’s needs.
 Use critical thinking to evaluate the effectiveness of the nursing intervention given in meeting the needs of the patient.
PATIENT’S PROFILE

BIOGRAPHIC DATA

NAME: Mr. BM
AGE: 64 years old
SEX: Male
BDAY: October 28, 1945
ADDRESS: Sta. Cruz Lubao, Pampanga
STATUS: Married
Position in the family: Head of the family
Nationality: Filipino
Religion: Roman Catholic
Care Financing: Philhealth and SSS
Date of Admission: August 27, 2010
Time of Admission: 12:32 PM
Final Diagnosis: Cholecystocholedocholithiasis
II. NURSING HEALTH HISTORY

A. CHIEF COMPLAINT

A.1 Chief complaint on admission

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

A.2 During the interaction

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

B. HISTORY OF PRESENT ILLNESS

One month prior to admission (August, 2009), Mr. BM experienced tolerable pain in the right upper quadrant of his abdomen with a tolerable pain of
6/10.. He does not seek medical attention yet and he does not take any medication. By august 22, 2010, he experienced intolerable pain of 10/10. He was worried
about his condition so he seeks medical attention, Mr. BM consult a doctor at Lubao, Clinic, and he undergone abdominal ultrasound. The result shows
Cholecystolithiasis/cystitic choledocholelithiasis with secondary biliary ectacia and he was diagnosing of having cholecystocholedocholithiasis. He was reffered to
Dr. PB of Bulacan Medical Center by Dr. G of Lubao Clinic and some medications were prescribed to him such as omeprazole20 mg capsule, ciprofloxacin 500mg
tab and tramadol 50 mg tab. Three days prior to admission (August 24, 2010), he noticed a yellowish discoloration on his skin, dark urine and clay-colored stool.
By August 25, 2010, he exhibited nausea and vomiting resulting in a decrease in appetite but still he was not able to consult Dr. PB. He also had a fever (38.4 ˚C)
on that day.Until August 27, 2010, he went to Bulacan Medical Center to consult Dr. PB to present the referral slip of Dr. G. Laboratory exam were done such as;
hematology, CBC, Createnine, PT and PTT. He received IVF of D5Lr 1L regulated at 30gtts/min. He was scheduled for cholecystectomy with billiary exploration and
cholechoduodenostomy.
 C. PAST HISTORY

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

D. FAMILY HISTORY OF ILLNESS

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

GENOGRAM

MATERNAL SIDE PATERNAL SIDE

A1/89 A2/88 A3/86 A4/85 A5/80 A6/78 A7/76 B1/95 B2/92 B4/85 B5/82
B3/89 B6/77 B7/72 B8/75

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

FEMALE PATIENT HYPERTENSION DIABETES MELLITUS RHEUMATOID ASTHMA

ARTHRITIS
FUNCTIONAL MALE
HEALTH PRIOR DURING
DECEASED CARDIOVASCULAR
LUNG CANCER LIVER CANCER
ACCIDENT UNKNOWN UNKNOWN
PATTERN
I. Health Prior to admission, the patient stated that being a healthy person is During admission, the patient stated that its hard for him to follow
Perception and being free from diseases. And to keep himself healthy, he eats balanced some of the doctor’s order in terms of the foods that are not allow
Health and nutritious foods and regular exercise as well. for him to eat.
Management
Pattern

II. Nutritional and Prior to admission, the patient’s usual food preferences are vegetables, During admission, the usual foods that the patient eats are the
Metabolic Pattern fish and seafood. The client’s fluid intake was around 1000-1500mL of foods offered by the hospital. After the surgery her daily fluid intake
water per day. His skin is dry but does not have any lesions or other skin is 600-700mL of water.
problems.

AUGUST 24, 2010 AUGUST 27, 2010

BREAKFAST BREAKFAST
 1 cup of rice  120mL of hot coffee
 ½ milk fish (pangat)  2 pcs of pandesal(regular)
 150mL of water  1 pc of fried egg
LUNCH LUNCH
 1 cup of rice  1 cup of rice
 1 cup of milk fish (sinigang)  ½ fried milk fish
 360 mL of water  1 small bowl of chopseuy
 1 pc of regular banana  360mL of water
DINNER
DINNER  1 cup of rice
 1 cup of rice  1 fried of fish(galunggong)
 1 fried of gigi fish  1 small bowl of milk fish (sinigang)
 175mL of water  240mL of water
 AUGUST 28, 2010
AUGUST 25, 2010
BREAKFAST
BREAKFAST  1 cup of rice
 1 cup of rice  1 pc of boiled egg
 2pcs boiled eggplant  150 mL of water
 2pcs of fish (sardines)
 240mL of water LUNCH
LUNCH  1 cup of rice
 1 cup of rice  1 small cup of pakbet
 1 pc of fried tilapia  240mL of water
 300mL of water DINNER
DINNER  1 cup of rice
 1 cup of rice  1 small fried chicken
 1pc gigi fish (pangat)  150mL of water
 150mL
 1pc of regular banana
AUGUST 29, 2010
AUGUST 26,2010
BREAKFAST
BREAKFAST  2pcs of pandesal (regular)
 120mL of hot coffee.  120mL of water
 4pcs of hot pandesal(regular)
LUNCH LUNCH
  1 cup of rice  1 cup of rice
 4 pcs of crabs  1 small cup of pakbet
 3 pcs of big shrimp  200 mL of water
 280mL of water

DINNER DINNER
 1 cup of rice  1 cup of rice
 2 pcs of banana (regular)  1 small fried chicken
 120 mL of water
III. Elimination Pattern Prior to admission, the patient defecates once a day. The stool was pale During admission, the patient defecated once a day, and the stool
in color, firm, acolic stool (3 days prior). The patient said that defecation was brown in color, and firm. The patient urinates 7 times a day
is not hard for him. The patient urinates 9 times a day depending on because of the infused intravenous fluid and oral fluid intake. He
how much his fluid intake was. According to him, he noticed a dark- does not perspire excessively and no body odor problems.
colored urine 3days before admission.

Color Frequency Consistenc Odor difficul Color Frequen Consiste Odor Difficulty
y ty cy ncy
Stool Clay- 1x/day Formed foul None Stool Clay- 1x/day Formed Foul none
colored/g colored
ray Aromatic
Urine Dark- 7x/day clear None
Urine Dark- 9x/ day Clear aromatic none colored
colored
vomit None
vomit None
IV. Activity Exercise Prior to hospitalization, the patient had sufficient energy to do During hospitalization, the patient didn’t have enough energy to do
Pattern his entire task and still he can manage their farm independently. his task. His only form of exercise was early ambulation and some
active and passive range of motion.
0 – Full self care.
Activity Level
1 – use of
equipment

2 – assistance Feeding 0
from other
person Bathing 2
0

3- assistance Bed mobility 0

from other
person and Dressing 2
0
devices
Grooming 2
0
4- dependent
Toileting 2
0

V. Sleep Rest Pattern Prior to hospitalization, he had 8 hours of continuous sleep a day; she During hospitalization, he has only 6 hours of sleep and it’s not
slept at 9PM and wake as early as 5AM. He took naps in the afternoon continuous like before due to surrounding. He usually sleeps at 10
at least 30-1hour. PM and awakens at 4AM.

VI. Cognitive Perceptual Prior to hospitalization, the client stated that he had no hearing Prior to hospitalization, the client stated that he had no hearing difficulty
Pattern difficulty and his memory were still intact because he can still remember and his memory were still intact because he can still remember the
the information being asked to him. information being asked to him
VII. Self –Perception Prior to hospitalization, the patient described himself as a good person The patient described himself as a good person but during the
and Self-Concept and approachable. occurrence of the disease he easily get irritated and he feels moody
Pattern most of the time.

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

XI. Sexuality- According to the patient, they can’t practice sexual intercourse due to They can’t participate on sexual activity due to their age. The patient also
Reproductive Pattern their age. stated that they used to take care of their grandsons and daughters and
just enjoying their remaining time.

X. Coping Stress According to the patient he feels tense every time he feels dizzy. Her The patient stated that he doesn’t feel any tension during this time because
Tolerance Pattern wife was the most helpful person in taking things over. He is taking his he feel safe and secured coz they can easily contact a doctor if there’s any
home medication to cope with it most of the time. But if some stress problem encounter.
triggered his feelings the patient went to farm to get some fresh air and
to feel relax. Her husband was the most helpful person in taking things
over.

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

THEORY STAGES NORMAL FINDINGS ACTUAL FINDINGS RESOLUTION

Freud’s psychosexual Genital phase At this point, learned to
theory (13 years and older) desire members of the
opposite sex and to fulfill
instincts to procreate and
thus ensure the survival
of the human species.
He is married and has 3 Positive (+) the development of relationship and
children. also have his own family.
Mr. BM and his wife were
remains sweet to each
other.
Erikson’s Psychosocial Stage 8 – Feeling of self acceptance, Mr. BM has a sense of self Positive (+) Mr. BM has a feeling of self
theory Ego Integrity vs. sense of dignity, worth worthiness, meaningless satisfaction and worthiness.
Despair and importance. and hopeless with self
satisfaction in activities.

.
Kohlberg’s Moral Post conventional Higher Law and Mr BM understands the Positive (+). Mr. BM follows rules according to his
Development theory Stage conscience orientation. different roles of the knowledge and willingness.
Orientation to internal society, and can distinguish
Stage 6 – Universal discussion of conscience what is right or wrong
ethical principle but without clear based on internalized rules
orientation. rationale or universal on conscience rather than
principle. social law. According to
“I must follow rules him, she will follow the
because my conscience entire doctor’s order that
tells me”. will help to make his
condition better. He also
said that he does things if
he knows that it is good for
him and according to his
willingness.

Fowlers spiritual Conjunctive faith Here there must also be a
development theory new reclaiming and
reworking of one's past.
There must be an opening
to the voices of one's
"deeper self."
Importantly, this involves
Mr. BM said that even if he Positive (+). He integrates other perspectives
does not always go to about faith into own definition of truth.
church regularly, it is still a
must for him to pray and
thank God for his graces
and ask guidance for his
current condition.
 a critical recognition of
one's social unconscious-
the myths, ideal images
and prejudices built
deeply into the self-
system by virtue of one's
nurture within a
particular social class,
religious tradition, ethnic
group or the like.

Piaget’s cognitive Formal operations Able to see relationships Mr. BM said that he thinks Positive (+). Mr. BM can think reasonably.
development (12 - adulthood) and to reason in the logically for the possible
abstract. solution and learn to think
and reason in abstract
terms.

IV. ANATOMY AND PHYSIOLOGY

LIVER
  Largest organ in the body
 Lies under the diaphragm; occupies most of the right hypochondrium and part of the epigastrium.
 Weighing 1.5 kgs.

LIVER LOBES AND LOBULES

 The liver has two lobes, separated by the falciform ligament

 Left lobe- about one sixth of the liver
 Right lobe- about five sixth of the liver.

BILE DUCTS

 Right hepatic duct- drains bile from the right functional lobe of the liver
 Left hepatic duct- drains bile from the left functional lobe of the liver
 Common hepatic duct-is the duct formed by the convergence of the right hepatic duct and the left hepatic duct ; Length: Usually 6–8 cm. Approximate width: 6 mm in
adults; merges with cystic duct to form common bile duct, which opens into the duodenum.
 Cystic duct- is the short duct that joins the gall bladder to the common bile duct.
 Common bile duct- formed by the union of the common hepatic duct and the cystic duct (from the gall bladder).

FUNCTIONS OF THE LIVER

  The liver stores a multitude of substances, including glucose (in the form of glycogen), vitamin A (1–2 years' supply), vitamin D (1–4 months' supply),
vitamin B12, iron, and copper.
 Glucose metabolism- after meal, glucose is taken up from the portal venous blood by the liver and converted into glycogen (glycogenesis), which is stored
in the hepatocytes. Glycogen is converted back to glucose (glycogenolysis) and release as needed into the blood stream to maintain normal level of the
blood glucose
 Ammonia conversion- use of amino acid from protein for glucogenesis result in the formation of ammonia as a by product. Liver converts ammonia to
urea.
 Protein metabolism- liver synthesizes almost all of the plasmas protein including albumin, alpha and betaglobulins, blood clotting factor plasma
lipoproteins.
 Fat metabolism- fatty acid can be broken down for production of energy and production of ketone bodies.
 Bile formation- bile is formed by the hepatocytes
- Composed of water, electrolytes such as sodium, potassium, calcium, bicarbonate, lecithin, fatty acids, cholesterol, bile salts
- Collected and stored in the gallbladder and emptied in the intestine when needed for digestion.

BILE

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

 to carry away waste

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

TRANSPORT OF BILE

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

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

3. The common hepatic duct then joins with the cystic duct from the gallbladder to form the common bile duct, which runs from the liver to the duodenum
(the first section of the small intestine).

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

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

GALLBLADDER

 The gallbladder is a small organ whose function in the body is to store bile and aid in the digestive process.
 A hallow pear- shaped sac from 7- 10 cm (3-4 inches) long and 3 cm broad. It consists of a fundus, body and a neck.
 Fundus - the lower free and the expanded end of the Gall bladder.
  Body - the body of the gall bladder is the portion that is lying between that of the fundus and also the neck. The direction of the body is upwards,
backwards, and to the left.
 Neck-it is the “S” shaped curve present above the body, and extends up to the cystic duct. Direction is upwards, forwards and then takes a turn and
becomes downwards and backwards.
 It can hold 30 to 50 ml of bile.
 It lies on the undersurface of the liver’s right lobe and attached there by areolar connective tissue.
 The cystic duct connect the gallbladder to the common hepatic duct to form common bile duct.

FUNCTION OF THE GALLBLADDER

Stores bile that enters it by way of the hepatic and cystic duct. During this time the gallbladder concentrates bile five folds to ten folds. Then later when digestion
occurs in the stomach and in the intestines, the gallbladder contracts, ejecting the concentrated bile into the duodenum. Jaundice, a yellow discoloration of the
skin and the mucosa, results when obstruction of bile flow into the duodenum occurs. Bile is thereby denied its normal exit from the body in the feces. Instead, it
absorbed in the blood, and an excess of bile pigments with a yellow hue enters the blood and is deposited in the tissues.

The gallbladder stores bile, which is released when food containing fat enters the digestive tract, stimulating the secretion of cholecystokinin (CCK). The bile,
which is produced in the liver, emulsifies fats and neutralizes acids in partly digested foods.
V. PATHOPHYSIOLOGY

Predisposing Factors Precipitating Factors

Bile is supersaturated Unconjugated Bilirubin tends

with cholesterol to form insoluble precipitates
Advancing age (age 40 and with
Liverbile
Biliary salts and
excrete cholesterol
conjugated
infection (bacteria) Dietexcrete
Liver (high cholesterol/fat)
relatively high
above)
Decreased bilirubin into bile along with
Formation of solid proportion of cholesterol in
gallbladder motility bile salts and cholesterol
Crystals Formation of stones the bile
 Mild to moderate pain/biliary colic in the right
part of the abdomen – due to functional spasm
of the cystic duct; irritation of the viscera

(August, 2009)

Obstruction of the bile ducts

Clay-colored stool – may result from problems

in the biliary system; due to absence of bile in Jaundice – due to Dark-colored
the duodenum; warning signal that’s obstruction of urine
something wrong with digestion bile flow
(August 24,
(August 24, 2010) (August 24, 2010)
Continues irritation of the gallbladder 2010)
 Inflammation of the gallbladder

CHOLECYSTOCHOLEDOCHOLITHIASIS

Fever – due to Nausea and Severe Pain/biliary

elevated WBC because vomiting – may colic – due to
of bacteria invasion in accompany a inflammatory
the injured gallbladder gallbladder attack process

(August 25, 2010) (August 25, 2010) (August 22, 2010)

Decrease in
appetite

(August 25,
2010)

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

Rationale

Biliary Colic The most common symptom is in pain the right upper part of the abdomen or epigastrium. This can cause an attack of abdominal pain,
called biliary colic, which: develops quickly, is severe, lasts about one to three hours before fading gradually, isn't helped by over-the-
counter and isn't helped by passing wind. The pain may radiate to the back, right scapula or shoulder. The pain often begins suddenly
following a meal. The pain of biliary colic is caused by the functional spasm of the cystic duct when obstructed by stones, whereas pain in
acute cholecystitis is caused by inflammation of the gallbladder wall.
Fever Gallstones sometimes get trapped in the neck of the gallbladder and can cause persistent pain that lasts more than several hours and is accompanied by
fever, also due to the irritation and inflammation of the gallbladder wall.

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

Loss of appetite The pain often begins suddenly following a large or rich meal. People tend not to eat, especially fatty or oily foods, in order not to experience that pain.
Fat absorption is also impaired for the lack of bile salts, As a result, rapid loss of weight and anorexia can occur.

Jaundice Due to obstruction of the bile flow

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

Precipitating Factors

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

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

Biliary Infection (bacterial) Brown pigment stones are frequently found in the intrahepatic bile ducts and are always associated with infection by colonic organisms usually
E.coli, or parasitic infestation (Ascaris lumbricoides, or other helminthes). Intraductal stones developing after cholecystectomy are invariable
associated with bile stasis, biliary tree infection, and/or retained suture material.

Predisposing Factor

Factor Rationale

Advancing Age The incidence increases with age. Less than 5-6% of the population under age 60 has stones, in contrast to 25-30% of those over 80. It usually
affects people with age of over 40 but it is more prevalent after 60 years of age. It is primarily due to decreased gallbladder motility of older
person that may result in releasing of inadequate amount of bile to help digest fats.

VI. DIAGNOSTIC AND LABORATORY RESULTS

Diagnostic Date Indication or Result Normal Analysis and Nursing Responsibilities

Laboratory Purpose values interpretatio
Procedures n of the
Ordered Result prior during After
results
in

HEMATOLOGY August August A white blood WBC 5.6 3.5- 10.0 NORMAL -Check if -Use standard -Label the
27, 2010 27, 2010 cell count is a x109/L x109/L there’s a precaution specimen
determination
doctor’s and sterile container with
of number of
WBC or order for technique name, age,
leukocytes/uni CBC when getting date and time
t volume in a
specimen the specimen
sample of
-Explain
venous blood. was
The test is the >apply
obtained,room
used to detect procedure pressure on
no., the doctor
infection or to the the
inflammation who ordered
and also used patient venipuncture
the specimen.
to help site after
monitor the withdrawing -Send the
body’s specimen to
specimen
response to the laboratory
various immediately
treatments and
to monitor
bone marrow
function, and
to determine
the need for
further tests,
such as
differential
count.

Red blood
cells, which
are made in RBC 4.17 3.80- Within normal
the bone x1012/L 5.80 range
marrow, carry x1012/L
oxygen from
the lungs to
the cells of
organs in the
body and
transport
carbon dioxide
from those
cells back to
the lungs.
When the
values of the
RBC count
and
hemoglobin
decrease
below the
established
reference
range, the
patient is said
to be anemic.
When the
values increase
above this
range, the
patient is said
to be
polycythemic.

Hemoglobin is HGB 119 g/L 110-165 Within normal

an important g/L range
component of
red blood cells
that carries
oxygen and
carbon dioxide
to and from
tissues. The
hemoglobin
determination
test is used to
screen for
diseases
associated
with anemia
and in
determining
acid-base
balance. The
oxygen
carrying
capacity of the
blood is also
determined by
the
Hemoglobin
concentration

Measures the HCT 0.352 . Within normal

percentage of LL/L 350-.500 range
RBC in a LL/L
blood volume.
The test is
performed to
help diagnose
blood
disorders, such
as
polycythemia,
anemia or
abnormal
dehydration,
blood
transfusion
decisions for
severe
symptomatic
anemias, and
the
effectiveness
of those
transfusions.

The smallest PLT 302 150 – Within normal

formed 310 range
elements in
blood that X109/L
promote blood
clotting after
an injury. The
test is
performed to
determine if
blood clots
normally,
evaluate
platelet
production,
and to
diagnose and
monitor a
severe increase
or decrease in
 platelet count

A small white Lymphocytes 21.6 17.0- Within normal

blood cell 48.0 range
(leukocyte)
that plays a
large role in
defending the
body against
disease.
Evaluate
bacterial and
viral infection,
immune
disease,
leukemia, and
ulcerative
colitis
PT AND PTT August August Prothrombin 13.99 10-14 Within normal
28,2010 28,2010 time sec sec range

Activity 95% 70-100% Within normal

range

INR 1.20 1.14 Within normal

range

Partial 35-45 38.7 Within normal

thromboplastin sec range
Time
Abdominal To visualize >> Explain >> Explain >> Patient can
ultrasound abdominal the purpose the following: expect to
structures by IMPRESSION
and the resume
using non-
>patient will
invasive > Cholecystolithiais/cystitis procedure her/his normal
diagnostic be ask to lie
>Choledocholithiases with secondary biliary of the test. activities
technique in on the
ectacia immediately.
which high-
> Instruct examination
frequency
sound waves him not to couch next to >inform
patient
are passed into eat solid ultrasound
regarding the
internal body food for 12 machine result
structures.
hours prior
>the area to
to exam to
be scanned
allow
will be
greatest
exposed and a
dilation of
clear water-
the
soluble gel
gallbladder
will be
>Inform applied to the
patient that
skin for the
ultrasound
is a transmission
noninvasiv of sound
e
waves into the
procedure.
patient’s body

>a scan probe

will then be
placed in
contact with
patient’s body
and move
over the skin
to examine
the tissues
below.

>the parient
will
experience no
pain during
the procedure

>Ultrasound
scans take
approximately
30 min. to
 complete.

VII. PATIENT AND HIS CARE

 MEDICAL MANAGEMENT DATE ORDERED/ DATE GENERAL DESCRIPTION INDICATIONS/ PURPOSES CLIENTS RESPONSE TO THE
TREATMENT PERFORMED TREATMENT

IVF Date ordered: Non-pyrogenic intravenous  Used as a means of route The client is well hydrated
(PNSS 1L) August 30, 2010 fluid, ideal for the initial for medications
correction of extracellular  Ideal for patient needs
Date discontinue: fluid fluid replcement
September 2, 2010

NURSING RESPONSIBILITIES FOR IV THERAPY

PRIOR DURING AFTER

1. Explain the procedure to the
client.
2. Review physician’s order for IV
infusion (type of solution,
amount to be administered,
rate of flow of infusion, if there
are medicine to be added /
time to be completed)
MEDICAL MANAGEMENT TREATMENT
1. Assess the client’s response to the IV, rate of IV
flow, how much has infused, how much fluid
remains to be infused, and condition of the IV
insertion site.
2. Inspect for IV tubing patency
3. Assess IV site for fluid infiltration, phlebitis,
bleeding.
4. In changing the IV container, obtain the correct
solution container, flow rate, amount of solution.
5. Use aseptic technique when changing IV solution
container, apply new IV tag.
DATE ORDERED/ DATE GENERAL DESCRIPTION
PERFORMED
1. Check for physician’s order for
discontinuing IV infusion therapy
2. Assessed for venipuncture site (if
there is bleeding, inflammation,
phlebitis) for amount of fluid
infused
3. Document relevant information,
type solution used, date and time of
discontinuing the infusion.
INDICATIONS/ PURPOSES CLIENTS RESPONSE TO THE
TREATMENT
 IVF Date ordered: -hypertonic solution that - Treatment for persons Client exhibits natural fluid
August 29, 2010 contains some form of needing extra calories and electrolyte balance.
5% Dextrose in Lactated Ringer’s carbohydrate and varying who cannot tolerate Client does not experience
Solution Date shifted: amount of electrolytes fluid overload. any dehydration
August 30, 2010 - Treatment of shock.
-For rehydration
-To increase the blood
volume

NURSING RESPONSIBILITIES

PRIOR DURING AFTER

1. Explain the procedure to the client.
2. Review physician’s order for IV infusion
(type of solution, amount to be
administered, rate of flow of infusion, if
there are medicine to be added / time
to be completed)
1. Assess the client’s response to the IV, rate of IV flow,
how much has infused, how much fluid remains to be
infused, and condition of the IV insertion site.
2. Inspect for IV tubing patency
3. Assess IV site for fluid infiltration, phlebitis, bleeding.
4. In changing the IV container, obtain the correct
solution container, flow rate, amount of solution
5. Use aseptic technique when changing IV solution
container, apply new IV tag.
1. Check for physician’s order for
discontinuing IV infusion therapy
2. Assessed for venipuncture site (if there is
bleeding, inflammation, phlebitis) for
amount of fluid infused
3. Document relevant information, type
solution used, date and time of
discontinuing the infusion

MEDICAL MANAGEMENT DATE ORDERED/ DATE GENERAL DESCRIPTION INDICATIONS/ PURPOSES CLIENTS RESPONSE TO THE
TREATMENT PERFORMED TREATMENT

Oxygen therapy (3-6L/min) facial Date ordered: -Administration of oxygen at a -post anesthesia recovery No response from the patient
 mask August 30,2010 concentration greater than
that found in the
Date discontinued: environmental atmosphere.
August 30,2010
-Facial mask is used to provide
moderate oxygen support and
higher concentration of
oxygen and humidity
because he is sedated.
-to increase amount of oxygen
in the blood ,reduces the
extra work of the heart, and
decreases shortness of breath
-To maintain adequate
ventilation.

Medical Management Date General Descriptions Indication/purposes Client Response

Treatment Ordered/Performed

Catheterization Date ordered: Urinary catheterization, or Catheterization allows the Bladder distension is
August 31,2010 "cathing" for short, a plastic tube patient's urine to drain freely from relieved.
 known as a urinary catheter is
Foley Catheter August 31,2010 inserted into a patient's bladder
(3 way FC) via their urethra.
Retained by means of a balloon at
the tip which is inflated with
sterile water. The balloons
typically come in two different
sizes: 5 cc and 30 cc. which are
commonly made in silicone rubber
or natural rubber.
NURSING RESPONSIBILITIES
PRIOR DURING
1. Verify the doctor’s orders for the type of 1. Monitor for indication of obstruction,
catheter to be used. infection, or complications before the
2. Explain procedure to the client. catheter is changed.
3. Asses the time the client last voided, the 2. Monitor and record the output.
the bladder for collection, or to
inject liquids used for treatment
or diagnosis of bladder condition.
Providing relief for persons with
an initial episode of acute urinary
retention, allowing their bladder
to regain its normal muscle tone
AFTER
1. Checked for the doctor’s orders for removal
of catheter.
2. Reassess the patient to determine the
response to catheterization.
 client’s age, developmental stage and sex. 3. Perform catheter care. 3. Document the time, date the catheter is
removed.
4. Document significant findings.

Medical Management Date Ordered/Performed General Descriptions Indication/purposes Client Response

Treatment
Date ordered:
Penrose Drain August 31,2010 Is consists of a soft rubber tube - Prevent the area from
placed in a wound area, to prevent accumulating fluid, such as blood,
Date Discontinue: the build up of fluids. Promoting which could serve as a medium for
--- drainage NURSING
of blood, pus and other
RESPONSIBILITIES bacteria to grow in.
PRIOR fluids helps reduce
DURINGthe risk of - Removes fluid from a woundAFTER
infection and keeps the patient area.
1. Review the physicians order for the drain more comfortable.
1. Position the patient to a 1. Place a dressing over the Penrose drain to contain
2. Explain the procedure to the client comfortable position drainage.
3. Place the bed at an appropriate and 2. Assist the physician while doing the 2. Secure a large safety pin on the tube outside the
comfortable working height procedure wound
3. A large safety pin is placed on the 3. Always check the dressing if it is damp
tube outside the wound to 4. Clean the area around the drain and incision. Apply
maintain its position. a new dressing change or gauze after this.
5. Assess the wound area by checking for signs of
infection and drainage. Record the amount, color,
consistency, and odor of any drainage. Make sure
the drain is patent or free of any blockage.
DRUG STUDY

Date ordered, Client response

Route of
taken/given General action, Indications/ to the
administration
Name of drug Classification, medication, Nursing Responsibilities
Date changed/ , dosage, Purpose
Mechanism of Action actual side
D/C frequency
effects

Generic Name: Date ordered: 1.5g (vial) TIV Classification: second- Reduce incidence Prior:
generation of certain post-
cefuroxime August 29,2010 cephalosporin operative infection -verify physician’s order
undergoing -check expiration date
Brand Name: 9:50am surgical
General action: procedures -check for hypersensitivity to
August 30, 2010 750mg TIV q8
treating or preventing
12:30pm bacterial infections by cefuroxime or other cephalosporin
stopping the growth
Date given: of bacteria -assess condition of the patient

August 30, 2010 -explain possible side effect

Mechanism of action: -check for any discoloration of the

Date changed: 500mg tab TID
drug
September 2, 2010 Inhibits cell-wall
synthesis, promoting -check the IV site (for
osmotic instability; inflammation, redness or swelling)
usually bactericidal During:

-administer as prescribed

-administer over 3 to 5 minutes

-do not take a double dose to

make up for a missed one

After :

-monitor for adverse effect

-report loose stools or diarrhea

promptly

-document administration of the

drug
 Date ordered, Route of
taken/given General action, Indications/ Client response to
administration,
Name of drug Classification, the medication, Nursing Responsibilities
Date changed/ dosage, Purpose
Mechanism of Action actual side effects
D/C frequency

Prior:

Generic Name: Date ordered: 30 mg TIV Classification: Short-term Pain was relieved - Assess patient for
management of contraindication.
Ketorolac August 30,2010 NSAID pain (up to 5 days) - Assess for baseline data.
Brand Name: General action: of moderately
Date given: severe acute pain. No actual side - Tell patient that he may
Toradol Analgesic, relieve pain It is most open experience side effects brought
August 30, 2010 effects
used after surgery. upon by the drug.
Mechanism of action:
During:
Anti-inflammatory
and analgesic activity; -provide comfort measures
inhibits prostaglandins
 and leukotriene -administer the drug slowly
synthesis
After:

- Provide comfort measures if

headache occurs.

-Instruct to report intolerable side

effects for prompt intervention

- Instruct to report signs of

bleeding such as black tarry stool,
weakness and dizziness upon
standing.

Date ordered, Route of

taken/given General action, Indications/ Client response to
administration
Name of drug Classification, the medication, Nursing Responsibilities
Date changed/ , dosage, Purpose
Mechanism of Action actual side effects
D/C frequency

Generic Name: Date ordered: Classification: Management of Prior:

short term relief
Buspirone HCl August 30,2010 Anxiolytic - Assess for contraindication.
of symptoms of - Assess for baseline data.
General action: anxiety.
Brand Name: Date given:
- Tell patient that he may
Buspar August 30, 2010 experience side effects
Mechanism of action: During:
 Mechanism of action - Monitor for occurrence of
not known; lacks adverse effects
antiseizure, sedative,
or muscle relaxant After:
properties; binds -Monitor vital signs carefully,
serotonin receptors, drug depresses the pulmonary
but the clinical and cardiac system.
significance is unclear
-Monitor for side effects.

- Oral care if vomiting occurs.

Date ordered, Route of

taken/given General action, Indications/ Client response to
administration
Name of drug Classification, the medication, Nursing Responsibilities
Date changed/ , dosage, Purpose
Mechanism of Action actual side effects
D/C frequency

Prior:

Generic Name: Date ordered: 2 tab BID Classification: Indicated to - Do not open foil-wrapped
prevent powders and tablets before use.
Potassium chloride August 28,2010 Potassium salt hypokalemia
- Do not self prescribe laxatives.
General action: Chronic laxative use has been
Brand Name: Date given:
maintains potassium associated with diarrhea-induced
Kalium durules August 28, 2010 K+ loss
levels
Discontinue: - Do not use salt substitute unless
August 29, 2010 Mechanism of action: specifically ordered by Dr.

Replaces potassium - Avoid licorice, large amounts

and maintains cause both hypokalemia and Na+
potassium levels retention

During

- Instruct patient to avoid salt

substitutes or low-salt milk or
food unless approved by health
care professional.

After

- Notify Dr. of persistent vomiting

because losses of K+ can occur

- A missed dose should be taken

as soon as remembered within 2
hr; if not, return to regular dose
schedule.

- Instruct patient to report dark,

tarry, or bloody stools; weakness;
unusual fatigue; or tingling of
extremities.
 Client
Date ordered, Route of response to
taken/given General action, Indications/
administration the
Name of drug Classification, Nursing Responsibilities
Date changed/ , dosage, Purpose medication,
Mechanism of Action
D/C frequency actual side
effects

Prior:

Generic Name: Date ordered: 10mg 1 amp Classification: Prevention of - Assess for contraindication.
IM q8 bleeding, Vitamin - assess for baseline data.
Vitamin K August 28,2010 Fat soluble vitamin K malabsoption,
hypo- - Tell patient that he may experience
General action: side effects brought about by the
Brand Name: Date given: prothrombinemia
Plays an important role drug and to report intolerable ones
Aqua-Mephyton August 28, 2010 so as prompt interventions be done.
in blood clotting

Mechanism of action: During:

 Vitamin K is essential for - do not to take with other
the hepatic synthesis of supplements
factors II, VII, IX, and X,
all of which are essential After:
for blood clotting. - monitor for bleeding,
Vitamin K deficiency pulse and BP
causes an increase in -Instruct patient to report adverse
bleeding tendency, effect that he may experience.
demonstrated by
ecchymoses, epistaxis, -Instruct patient to report symptoms
hematuria, GI bleeding. of bleeding: bruising, nosebleeds,
bleack tarry stools, hematuria.

Date ordered, Route of

taken/given General action, Indications/ Client response to
administration
Name of drug Classification, the medication, Nursing Responsibilities
Date changed/ , dosage, Purpose
Mechanism of Action actual side effects
D/C frequency

Prior:

Generic Name: Date ordered: 50mg tab STAT Classification: Treatment of - Assess patient’s blood pressure
hypertension, before starting therapy and
losartan August 29,2010 Antihypertensive alone or in regularly and pulse rate.
combination with
Brand Name: Date given: other - Assess for hydration status:
General action: mucous membranes and skin turgor
antihypertensive
Cozaar August 29, 2010 agents
Reduce blood - Ensure that patient is not pregnant
pressure level before beginning therapy, suggest
Mechanism of action: using barrier birth control while
using losartan.
Selectively blocks the
binding of angiotensin - Obtain baseline liver and renal
II to specific tissue function before therapy and
receptors found in the regularly assess kidney function
vascular smooth BUN and creatinine.
muscle and adrenal
gland; this action During:
blocks the - Take drug without regard to meals.
vasoconstriction Do not stop taking this drug without
effect of the renin- consulting your health care
angiotensin system as provider.
well as the release of
aldosterone leading to After:
decreased blood
pressure. - Tell patient to avoid sodium
substitutes because it may contain
potassium which can cause
hyperkalemia

-Teach patient to avoid sunlight or

wear sunscreen because
photosensitivity may occur.

- Monitor patient closely in any

situation that may lead to a
decrease in blood pressure.

- Report fever, chills, dizziness,

pregnancy.
 Date ordered, Route of General action,
taken/given Indications/ Client response to
administration, Classification,
Name of drug the medication, Nursing Responsibilities
Date changed/ dosage, Mechanism of Purpose actual side effects
D/C frequency Action

Prior:
Generic Name: Date ordered: 50mg tab PO BID Classification: Hypertension -Monitor V/S for baseline data.
and chronic -Assess for asthma,emphysema,
metoprolol August 27,2010 Anti-hypertensive angina pectoris
drug, Beta-blocker depression,circulation problems,
liver or kidney disorders; may
Brand Name: Date given:
General action: preclude drug therapy.
Neobloc August 27 2010 During:
Reduce blood -Take with food.
pressure level -Do not crush or chew; swallow
tablets whole.
Mechanism of
-Take at same time each day; do
action:
not stop suddenly.
 A selective beta After:
blocker that -Do not discontinue the drug
selectively blocks abruptly.
beta 1 receptors, -Avoid activities that require
decreases cardiac mental alertness until drugs
output, peripheral effect realized.
resistance and -Continue with diet, regular
cardiac oxygen exercise and weight loss in the
consumption and overall plan to control BP
depresses rennin
secretion.

Date ordered, Route of

taken/given General action, Indications/ Client response to
administration
Name of drug Classification, the medication, Nursing Responsibilities
Date changed/ , dosage, Purpose
Mechanism of Action actual side effects
D/C frequency

Generic Name: Date ordered: 75mg tab SL Classification:  Hypertension, Not taken Prior:
used alone or
clonidine August 29,2010 PRN >160/100 Antihypertensive as part of - Assessment hypersensitivity to
combination clonidine or severe coronary
mmHg General action:
Brand Name: therapy insufficiency, recent MI,
Reduce blood cerebrovascular disease.
Catapres pressure level -Note evidence of alcohol, drug
Mechanism of action: or nicotine addiction.

Stimulates CNS alpha2- Monitor V/S especially the BP.

adrenergic receptors, During:
inhibits sympathetic
cardioaccelerator and - Take this drug exactly as
vasoconstrictor prescribed. Do not miss doses.
centers, and -If taken PO, take last dose of the
decreases day at bedtime to ensure
sympathetic outflow overnight control of BP.
from the CNS.
After:

-Do not engage in activities that

require mental alertness such as
operating machinery and driving.

-Do not discontinue the drug

abruptly.

-Record weight daily, in the

morning.

- Report urinary retention,

changes in vision, blanching of
fingers, rash.
 Date ordered, Route of
taken/given General action, Indications/ Client response to
administration
Name of drug Classification, the medication, Nursing Responsibilities
Date changed/ , dosage, Purpose
Mechanism of Action actual side effects
D/C frequency

Generic Name: Date ordered: 300mg IV q 4 Classification: For fever and mild Not taken Prior administration:
pain
Paracetamol August 31,2010 >37.5 C non-opioid analgesic -Verify physician’s order

Brand Name: General action: -check for the expiration date

Acetaminophen produce analgesia by -check hypersensitivity to the

blocking pain impulses drug

Mechanism of action: -explain for possible side effect

inhibits synthesis of
-assess the type, location and
prostaglandin that intensity of pain
may serve as
PO-assess for vomiting
mediators of pain
primarily in the CNS or During administration:
other substances that
sensitize pain -administer as prescribed
receptors to
IV-slowly administer at least over
stimulation
3-5 minutes

PO-take with food

-take with full glass of water

After administration:

-assess for pain relief

-monitor and report for side

effects

-document administration of the

drug
 Date ordered, Route of
taken/given General action, Indications/ Client response to
administration
Name of drug Classification, the medication, Nursing Responsibilities
Date changed/ , dosage, Purpose
Mechanism of Action actual side effects
D/C frequency

Generic Name: Date ordered: 200mg cap BID PRIOR

Classification: Indication:
celecoxib September 2,2010 Nonsteroidal -Acute and long-  Determine any GI bleed/ulcer
history, sulfonamide allergy,
Brand Name: Date given: Anti- inflammatory term treatment of aspirin and other NSAID-
Drug signs and induced asthma, urticaria,
celebrex September 2,2010 allergic type reaction
General Action symptoms of  Monitor sign and symptoms
rheumatoid  Assess for liver or renal
Pain Reliever dysfunction; reduce dose
arthritis and
DURING
Mechanism of Action osteoarthritis
 Take with foods; decreases
 -Inhibits prostaglandin -Management of stomach upset
synthesis, primarily by acute pain AFTER
inhibiting cyclo- -Treatment of  Monitor CBC and electrolytes
oxygenase-2 thus primary  Determine any G.I bleed
decreasing dysmenorrhea
inflammation.

Date ordered,
taken/given Route of General action, Indications/ Client response to
Name of drug administration, Classification, the medication, Nursing Responsibilities
Date changed/ dosage, frequency Mechanism of Action Purpose actual side effects
D/C

Generic Name: 80mg 1/2 tab OP OD Classification: An adjunct to diet Prior:

Simvastatin Anti-hyperlipedimia
General action:
Brand Name:
Catalyzes the early rate-
Zocor
limiting step in the
synthesis of cholesterol.
Mechanism of action:
Inhibit an enzyme, 3-
hydroxy-3-
when the response
-Obtain base line data of
to a diet restricted the patient.
in saturated fat and
cholesterol and -Instructed patient that
this medication should
other
be used in conjunction
nonpharmacologic
with diet restrictions
measures alone has (fat, cholesterol,
been inadequate. carbohydrates, and
In patients with alcohol), exercise, and
coronary heart cessation of smoking.
methylglutaryl-
coenzyme A (HMG-CoA)
reductase, which is
responsible for catalyzing
an early step in the
synthesis of cholesterol.
disease (CHD) or at During:
high risk of CHD.
- Instruct patient to take
medication as directed
and not to skip doses or
double up on missed
doses.
- Advise patient to avoid
drinking more that 1
qt/day of grapefruit
juice during therapy.
After:
- Instruct patient to
notify health care
professional if
unexplained muscle
pain, tenderness, or
weakness occurs.
- Advise patient to wear
sunscreen and
protective clothing to
prevent photosensitivity
reactions (rare).
-Emphasize the
importance of follow-up
exams to determine
effectiveness of the
drugs.
 Date ordered,
taken/given Route of General action, Indications/ Client response to
Nursing
Name of drug administration, Classification, Mechanism the medication,
Date changed/ Purpose Responsibilities
dosage, frequency of Action actual side effects
D/C

Classification: Treatment of Prior:

Generic Name: Date ordered: Angiotensin-converting hypertension -assess history of
enzyme (ACE) inhibitor alone or in allergy to drug
captopril August 30,2010 Antihypertensive combination with -inform the patient for
thiazide-type possible side effects
Date given:
General action: diuretics
Brand Name:
August 30, 2010 Reduce level of blood During:
Capoten pressure -Administer 1 hour
before meal
Mechanism of action: -monitor patient
Blocks ACE from converting closely for drop in BP
angiotensin I to angiotensin
II, a powerful Post:
vasoconstrictor, leading to - mark patient's chart
decreased blood pressure, with notice that
 decreased aldosterone captopril is being
secretion, a small increase taken
in serum potassium levels, -instruct to consult
and sodium and fluid loss; health care provider if
increased prostaglandin light-headedness or
synthesis also may be dizziness occurs,
involved in the
antihypertensive action.

Date ordered, Client response

Route of
taken/given General action, Indications/ to the
administration,
Name of drug Classification, medication, Nursing Responsibilities
Date changed/ dosage, Purpose
Mechanism of Action actual side
D/C frequency
effects

Prior
Generic Name: Date ordered: 80mg tab OD Classification: -Improve glycemic - Check doctors order for latest
control in clients dosage, frequency & route.
Metformin August 27,2010 Antidiabetic, oral; - assess for history of allergy to
with type 2
diabetes. drug
Brand Name: Date given: Biguanide
- Inform the patient about the
Fortamet, August 27 2010 General Action: - Extended- possible side effects that
Release form used he/she can feel upon
Glucophage,
Antidiabetic to treat type 2 administration of drug
Glumetza, Riomet
diabetes as initial
Mechanism of Action: During
therapy. -avoid using alcohol while
Decreases hepatic taking these drug
glucose production, -instruct to swallow extended-
release tablets whole
 decreases intestinal -do not crush,cut or chew
absorption of glucose,
and increases After
-monitor urine or serum
peripheral uptake and
glucose levels frequently to
utilization of glucose. determine effectiveness of drug
-instruct to do not discontinue
drug without the doctors order.

DIET

Specific Client Nursing Responsibilities

Type of Date General Indication/
Date Change foods/fluids Respons
diet Started Description Purposes Prior During Post
taken e

NPO(Noth An instruction This diet is none Feels -asses the level of -Strictly -Educate the client
ing Per meaning to usually very understanding of monitor of what kind of
Orem) withhold oral ordered for hungry the patient clients food he can eat
foods and preparation and -Explain the behavior after NPO diet
fluids prior to thirsty importance of in
but for surgery following strictly following
patients who specially who NPO diet in terms NPO diet
will undergo will undergo that the client can
surgery the general understand and
physician will anesthesia to then evaluate
allow before prevent
intake of aspiration
 medication pneumonia

General Diet that Before DAT -Asses the level of -Strictly -Educate the client
Liquid allows intake diet is understanding of monitor of what kind of
Diet of fluid or instructed the the patient clients food he can eat
liquid forms of physician first -Explain the behavior after General
food only ordered importance of in Liquid diet
general liquid following strictly following
diet to train General Fluid diet General
the normal in terms that the Liquid diet
digestion and client can
to bring back understand and
the normal then evaluate
digestion -Emphasize what
process kind of foods the
client can eat
during this diet.

DAT (until It is a diet that Instructed -Asses the level of -Strictly -Educate the client
(diet as discharge) allows the following a understanding of monitor of what kind of
tolerated) patient to eat general liquid the patient clients food he can now
all types/kinds diet for better -Explain that behavior eat that he can
of foods as source of immediate shifting in tolerate
long as the good of foods from NPO following
client can nutrition to General Fluids to DAT diet
tolerate it DAT without
undergoing soft
diet can result to
 constipation thats
why we need to
emphasize eating
first soft foods
before eating any
solid foods

ACTIVITY AND EXERCISE

TYPE OF EXERCISES DATE STARTED GENERAL DESCRIPTION INDICATION AND CLIENT RESPONSE TO NURSING
PURPOSE EXERCISE RESPONSIBILITY

An exercise -Helps keep joint and PRIOR:

ACTIVE ROM accomplished by the muscle as healthy as - Ensure that the patient
patient without possible understand the reason
assistance. Activities -Increases muscle for doing the exercise
include turning from side strength - Assist client to sit on
to side and from back to bed
abdomen and moving up
and down on bed. DURING:
- Assist patient while
doing the exercise if
necessary.
- Check if there is
difficulty in breathing
- Check if he feels any
pain while doing the
exercise
 AFTER:
- Check if he feels any
pain after the exercise
- Monitor the V/S of the
patient to check if there
is changes

TYPE OF EXERCISES DATE STARTED GENERAL DESCRIPTION INDICATION AND CLIENT RESPONSE TO NURSING RESPONSIBILITY
PURPOSE EXERCISE

A type of exercise that  aids in good The patient tolerated PRIOR:

AMBULATION requires the patient to circulation the exercise but he -Assess patients ability to
move by feet felt little bit tired tolerance the procedure
 facilitate voiding -Assess the patient if she
Act of travelling by foot needs assistance
 stimulate performing the procedure
Walk from place to place peristalsis -Explain the procedure to
the client
 prevent
thromboembolis DURING:
m -Assess the client if needed
-Encourage client to
ambulate independently if
she is able, but walk beside
 the client
-Be alert for signs of
activity intolerance

AFTER
-Assess vital signs
-Document significant
findings
VIII. SURGICAL MANAGEMENT

Open Cholecystectomy with Biliary Exploration

Choledochoduodenostomy

Definition:

A cholecystectomy is the surgical removal of the gallbladder

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

Discussion:
Type of Cholecystectomy may be performed to treat chronic or acut cholecystitis, with or without cholelithiasis, or to resect a malignancy.
operation
Choledochoduodenostomy may be performed for a biliary bypass operation are benign biliary strictures and malignant obstruction of the
biliary system caused by pancreatic or biliary ductal carcinomas.Indicated mainly in patients with recurrent stones, giant stones, or
concominant common bile stricture and stones.

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

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

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

Instrumentation/ Device Number Size Comments

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

Laparoscope 1 3.5- Available in 0° and angled views; we prefer to use a 30°

10mm 5 mm diameter laparoscope
Atraumatic grasping forceps 2-4 2-10mm Selection of graspers should allow surgeon choice
appropriate to thickness and consistency of gallbladder
wall; insulation is unnecessary
Large-tooth grasping forceps 1 10mm Used to extract gallbladder at end of procedure

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

Scissors 2-3 2-5mm One curved and one straight scissors with rotating shaft
and insulation; additional microscissors may be helpful
for incising cystic duct
Clip appliers 1-2 5-10mm Either disposable multiple clip applier or 2 manually
loaded reusable single clip appliers for small and
medium-to-large clips; 5 and 10 mm diameter
Dissecting electrocautery hook or spatula 1 5mm Available in various shapes according to surgeon’s
preference; instrument should have channel for suction
and irrigation controlled by trumpet valve(s); insulation
required
High-frequency electrical cord 1 Cord should be designed with appropriate connectors
for electrosurgical unit and instruments being used
Suction-irrigation probe 1 5-10mm Probe should have trumpet valve controls for suction
and irrigation; may be used with pump for
hydrodissection
10-to-5 mm reducers 2 Allow use of 5 mm instruments in 10 mm trocar
without loss of pneumoperitoneum; these are often
unncessary with newer disposable trocars and may be
built into some reusable trocars
5-to-3 mm reducer 1 Allows use of 2–3 mm instruments and ligating loops
in 5 mm trocars
Ligating loops

Endoscopic needle holders 1-2 5mm

Cholangiogram clamp with catheter 1 5mm Allow passage of catheter and clamping of catheter
in cystic duct
Veress needle 1 Used if initial trocar is inserted by percutaneous
technique
Allis or Babcock forceps 1-2 5mm Allow atraumatic grasping of bowel or gallbladder
 Long spinal needle 1 14gauge Useful for aspirating gallbladder percutaneously in
cases of acute cholecystitis or hydrops
Retrieval bag 1 Useful for preventing spillage of bile or stones in
removal of infl amed or friable gallbladder; facilitates
retrieval of spilled stones

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

A right subcostal incision is usually performed.The duodenum is widely mobilized by generous Kocher maneuver, so that it can be approximated to the common
bile duct without tension. A 2.0- 2.5 cm longitudinal incision is made in the distal common bile duct as close as possible to the area of stenosis or obstruction in
patients with benign disease. In patients with a stricture, the bile duct is divided and the stricture excised. The duodenum and duct are joined by a posterior or
row of interrupted 3-0 silk sutures. The duodenum is opened longitudinally for a distance of 2.0- 2.5cm and a second row of interrupted 3-0 or 4-0 chromic
catgut. Sutures is placed to approximate the ductal and duodenal mucosa. A T-tube is used in patients with thin walled ducts or difficult anastomosies. A final row
of interrupted 3-0 silk sutures completes the anterior row of anastomosies.

Procedure Preparation of the Patient:

Antiembolitic hose may be put on the legs, as requested. The patient is supine; both arms may be extended on padded
armboards. A pillow may be placed under the sacrum and/ or under the knees to avoid straining back muscles. Pad all bony
prominences and areas vulnerable to skin and neurovascular pressure of trauma. A nasogastric tube may be inserted by the
anesthesia provider. A foley catheter is not routinely placed. An electrosurgical dispersive pad is applied.
Skin Preparation:
Begin at the intended site of incision, either right subcostal (most frequently used), right paramedian, or medline,
extending from the axilla to the pubic symphysis and down to the table on the sides.
 Draping:

 4 folded towels and a laparotomy sheet

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

NURSING RESPONSIBILITY

Preoperative  All care that is given and observations made regarding the patient (e.g., condition of skin preoperatively) must
be documented in the operative record for continuity of care and for medicolegal reasons.
 The nurse conveys to the patient that he will act as the patient’s advocate by speaking for him while the patient
is in surgery.
 Assess health factors that affects the patient preoperatively: nutritional status, drug or alcohol use,
cardiovascular status, hepatic and renal function, endocrine function, immune function, previous medication
use, psychosocial factors, as well as the spiritual and cultural beliefs.
 When the circulator reviews patient allergies with the patient, he ascertains that the patient has no history of
allergy to radiopaque dye.
 Inform the patient of the scheduled date and time of the surgery and where to report
 Instruct what to bring (insurance card, list of meds & allergies)
 Check the chart for patient’s sensitivities and allergies e.g. allergy to iodine. Document allergies noted
 preprocedure and document alternative used.
 Instruct what to leave at home such as jewelry, watch, medications and contact lenses
 Instruct what to wear ( loose fitting, comfortable clothes and flat shoes)
 Remind the patient not to eat or drink if directed
 The patient may have fear and anxiety regarding the surgical procedure and the unfamiliar environment. Explain
nursing procedures before performing them and the sequence of perioperative events.
 Assess and document patient’s anxiety level and level of knowledge regarding the intended procedure. Clarify
misconceptions by answering the patient’s questions in a knowledgeable manner and refer questions to the
surgeon as necessary.
 Decrease fear
 Teach deep-breathing, coughing or incentive spirometer
 Provide emotional support to the patient regarding feelings of altered body image by providing the patient an
opportunity to express her feelings.
 Respect cultural, spiritual and religious beliefs

Intraoperative  It is imperative that the patient be positioned over the correct area on the table to ensure accurate visualization
of the biliary tract.
 A protective facial shield is suggested for those scrubbed to avoid inadvertent splashing of contaminated fluids
onto mucous membranes and eyes.
 All medications, dyes, etc., on the opening field must be labeled. Scrub person should use a marking pen on
labels to identify all solutions. All medication containers should be kept in the room until the completion of the
procedure.
 Instruments used on the gallbladder are isolated in a basin (considered contaminated)
 Prevent musculoskeletal injuries to team members by employing ergodynamic measures when positioning the
patient.
 Take appropriate measures to maintain patient’s body temperature e.g., offer warm blanket or raise room
temperature as necessary.
  Keep the patient adequately covered to maintain patient’s privacy, expose only the immediate area involved for
the procedure.
 Strictly follow the principles of surgical asepsis
 Keep surgical conscience
 Count all instruments and sharps with circulating nurse before and after the procedure
 Know the name and use of the instrument
 Never pile the instruments on top of each other
 Know the name and use of the instrument and handle the instrument individually
 Hand the surgeon the correct instrument
 Pass the instrument firmly and decisively
 Be careful in handling of sharp instruments at all times
 The scrub person sets up the instruments on the back table for the surgeon.
 Scrub person needs to have a right angle clamp (Mixter) available throughout the dissection of the biliary tree.
 Usually a stab wound is made in the cystic duct using a #11 blade. The incision is extended with Pott’s scissors.
 Have T-tubes available following common duct exploration
 One syringe is filled with saline, and a second syringe is filled with radiopaque dye diluted to half strength
(labeled accordingly)
 Scrub person takes care to make certain that the saline or dye catheters are devoid of air bubbles (which can be
confused for calculi)
 Use a small basin to accept the specimen
 Aerobic and anaerobic cultures may be taken of the bile or gallbladder bed.

Postoperative  The circulator accompanies the anesthesia provider and the patient to the PACU; he/she gives the PACU
perioperative practioner a detailed intraoperative patient report regarding the course of events as they apply
to the individual.
 Assess the patient: appraise air exchanges status & note skin color; verify & identify operative status & surgeon
performed; assess neurological status (LOC)
 PACU nurse observes the patient’s breathing, monitors blood pressure and vital signs, and documents all
pertinent information.
 PACU nurse assumes the role as the patient’s advocate..
  Report for abnormalities especially for signs and symptoms of shock
 Perform safety checks – good body alignment, side rails and maintain patent airway and cardiovascular
stability
 Relieve pain and anxiety

Pre operative:
 Patient complaint of pain on right upper quadrant
 Feeling of fear to the procedure.
Intra Operative:
Client Response  Patient is sedated
Post operative:
 Patient finds it hard to sleep because of pain felt on the incision site
 Client appears weak
Skin color improvement from jaundice to slight jaundice as of August 24, 2009
IX. NURSING CARE PLAN

ASSESSMENT NURSING BACKGROUND PLANNING NURSING RATIONALE EXPECTED

DIAGNOSIS KNOWLEGDE INTERVENTION OUTCOME

Subjective: Elevated body Exogenous pyrogen Short term goal: Independent: Short term goal:
“Nilalamig ako”as temperature (expose to foreign After 30 minutes of  Provide tepid sponge  To decrease The patient
verbalized by the related to microorganism) nursing intervention bath body temperature was
client. Infection. the patient temperature decrease from 39.2
o
temperature will through C to 37.5 oC.
Objective: Bacterial invasion decrease from 39.2 evaporation
 cold clammy o
C to 37.5 oC.  Encourage to wear  To provide Long term goal:
skin hypothermic comfort After 1-2 days of
 hot flsh Long term goal: clothing  To regain loss nursing intervention
 warm to touch Release of After 1-2 days of  Promote bed rest energy due to the patient vital
 v/s as follows: substances nursing intervention illness process sign was on normal
T- 38.3*C (activation of TNF, the patient vital sign  To adapt on the range especially the
PR- 77 bpm interleukins and will be on normal  Promote inatake of increasing temperature.
RR- 22 cpm interferons) range especially the caloric rich food and metabolism of
temperature. rich in vitamin C the client during
fever. Vitamin C
boosts immune
system and
Hypothalamus resistance to
signals increase in infection.
heat production

Dependent:  To decrease
 Administer body
medication as temperature
Fever
ordered by the
physician Source:

Mattson Porth, Nurses pocket guide

Essentials of
Pathophysiology Diagnoses,
Concepts of Altered prioritize
Health Status, intervention and
Lippincott Williams rationale, 11th
and Wilkins 2007 Edition.
 ASSESSMENT DIAGNOSIS SCIENTIFIC BACKGROUND PLANNING INTERVENTION RATIONALE EVALUATION

Subjective: Impaired skin Surgical incision on the right Short term:  Place in a  To prevent Short term:
“nangangati yung tahi integrity related upper quadrant and After 3 hours of comfortable back aches or Goal met, patient
ko”, as verbalized by to inadequate epigastric area of the nursing position muscle aches was verbalized an
the client. primary defences abdomen intervention the  Monitor and  To note any understanding of
(surgical incision) patient will record vital significant the condition and
verbalize signs changes that causative factor.
Objective Trauma to the skin understanding of may be
 Moist intact condition and brought about Long term:
dressing at the causative factor. by the disease Goal met, patient
right lower Thus, impairing the integrity  Practiced  Reduce risk for displays
quadrant. of the skin Long term: aseptic infection progressive
 Feeling of After 2 days of technique for improvement in
itchiness nursing cleaning, wound healing.
 Destruction of Source: intervention the dressing,
skin surface http://www.nlm.nih.gov/me patient displays medicating
d progressive wound  To maintain
lineplus/ency/article/002930. improvement in  Emphasize general good
htm wound healing. importance of health and skin
 proper turgor
nutrition and  To limit
fluid intake metabolic
 Encourage demands,
adequate remain energy
period of rest available for
and sleep healing and
meet comfort
needs
 Promote
circulation and
 Promote early prevent
ambulation excessive
tissue
pressure.

Source:
Nurses pocket
guide
Diagnoses,
prioritize
intervention and
rationale, 11th
Edition.
 ASSESSMENT DIAGNOSIS SCIENTIFIC PLANNING INTERVENTION RATIONALE EVALUATION
BACKGROUND

Subjective: Risk for infection Surgical Incision Short term: Independent: Short term:
related to After 2 hours of  Monitor Vital  Suggestive of Goal met, patient
Ø inadequate primary nursing intervention signs. Note onset presence of was verbalized an
defences (surgical Traumatized tissue the patient will of fever, chills infection or understanding to
incision). on the injured site verbalize and diaphoresis. developing prevent or reduce
Objective understanding to  Practice hand sepsis. risk of infection.
 Presence of prevent or reduce washing and  Reduce risk of
an incision Increasing risk of risk of infection. aseptic wound spread of
site on right infection care. bacteria or Long term:
lower  Inspect incision prevent cross Goal met, patient
quadrant. Long term: and dressing. contamination. was able to
 s/p May result to further After 2 days of  Provide early demonstrate
cholecystecto complication if not nursing intervention detection of techniques to
my with prevented the patient will be Dependent: developing promote timely
biliary able to demonstrate  Administer infectious wound healing
exploration. techniques to medications as process. without any
promote timely prescribed complication.
Mattson Porth, wound healing (antibiotics).  Prevent invasion
Essentials of without any of bacteria or
Pathophysiology complication. microorganism at
Concepts of Altered  Cleanse incision site and
Health Status, site with eventually
Lippincott Williams povidone iodine. prevents possible
and Wilkins 2007 infection.
 Disinfect site and
prevent
 Instruct not to multiplication of
wet incision site. microorganism
which may cause
infection.
 Microorganism
 Emphasise thrives at damp
importance of areas and makes
adequate it conducive for
nutritional and replication.
fluid intake.  Maintain general
 Encourage good health and
ambulation as skin turgor.
tolerated.

 To enhanced
good circulation.

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

ASSESSMENT DIAGNOSIS SCIENTIFIC PLANNING INTERVENTION RATIONALE EVALUATION

BACKGROUND

Subjective: Deficient Lack in information After 4 hours of  Determine  Individual may Goal met, patient
“hindi ko nga alam kung Knowledge related resources nursing ability or not be was verbalized an
paano ako nagkaron ng bato to unfamiliarity intervention the readiness and physically, understanding of
sa apdo e” as verbalized by with information patient will barriers to emotionally or condition or
the client. resources. verbalize learning. mentally disease process or
Feeling of understanding of  Identify support capable. treatment.
unawareness condition or persons or SO  May need to
disease process or requiring help SO to
Objective treatment. information. learn.
 Unawareness  Note personal
Deficient factors such as
Knowledge age, cultural  To facilitate
influences, learning.
religion, and
level of
education.
 Provide positive
 reinforcement.  Can encourage
continuation of
 Provide mutual effort.
goal setting and  Clarifies
learning expectation of
contracts. teacher and
learner.
 Provide written  Reinforces
information or learning
guidelines and process, allows
self learning to proceed at
modules. own pace.
 Begin with  Can allows
information interest and
already know limits sense of
and move to being
what does not overwhelm.
know.
 ASSESSMENT DIAGNOSIS SCIENTIFIC PLANNING INTERVENTION RATIONALE EVALUATION
BACKGROUND

Subjective: Readiness for Verbalization of Short term  Verify client’s  Provides Short term
“pauwi na ako, enhance willingness to After 4hours of knowledge/understandi opportunity to Goal met, patient was
meron na lang therapeutic follow home nursing ng of therapeutic assure accuracy assumed responsibility
akung iinuming regimen health intervention the regimen and completeness for managing
gamut sa amin,” management maintenance patient will of knowledge base treatment regimen.
as verbalized by assume for future learning
the client. responsibility for  Identify steps necessary  Understanding the Long term
managing to reach desired goal process enhances Goal met, patient was
Readiness for treatment commitment and remain free of
Objective enhance regimen. the likehood of preventable
therapeutic achieving the complications/progres
 Willingn regimen Long term  Accepts clients goals. sion of illness.
ess to management After 2 days of evaluation of own  Promotes sense of
follow nursing strengths/ limitations self-esteem and
 Assumes intervention the while working together confidence to
responsi patient will to improve abilities. continue efforts
bility in remain free of  Acknowledge
 maintain preventable individuals efforts/
ing complications/pr capabilities to reinforce  Provides positive
health ogression of movement toward reinforcement
illness. attainment of desired encouraging
outcomes. continued progress
 Assist in implementing toward desired
strategies for goals
monitoring progress/  Problem proactive
responses to problem solving
therapeutic regimen.

X. HEALTH TEACHINGS

HEALTH TEACHING RATIONALE

1. Encourage to decrease intake of foods high in fat/ cholesterol. After cholecystectomy, the liver still produce bile but in a slow tickle process,
therefore if the diet is high in fat, the malabsorption of fat occurs because the
minimal production of bile cannot handle the normal absorption process

2. Explain the importance of ambulation. To promote good circulation.

3. Explain to the patient the importance of deep breathing exercises/
divertional activities.
4. Explain to the patient the importance of splinting.
5. Explain to the patient not to touch the incision site with bare hands.
6. Explain to the patient the importance of eating small frequent meals
Deep breathing exercises/ divertional activities help to reduce pain.
Splinting reduces the pressure in the abdomen thus reducing the pain.
To prevent infection
Since cholecystectomy is done, the liver will compensate by excreting slow and
low level of bile that can cause the malabsorption of fat.
(preferably 4-6 meals) rather that to eat 3 times a day.
Prevent the spread of microorganism/ cross contamination
7. Explain the importance of proper hygiene
To reduce the risk of infection and to promote patient’s comfort.
8. Explain to the patient the importance of maintaining a clean and well
ventilated environment.

XI. DISCHARGE PLANNING

MEDICINES:

 Instructed to continue home medication

 Give relevant information about the drugs, their side effects and their adverse effects
 Teach the following to the client with regards to proper administration of the prescribed medication
-right patient -right assessment
-right drug -right documentation
-right time -right to educate
-right dose -right to evaluate
-right route -right to refuse

ENVIRONMENT AND EXERCISE

 Encourage to establish a clean and well ventilated environment

 Avoid strenuous exercise that cause tension on the affected area and further deprivation
  Daily activities should be spaced to provide rest periods between times of exercise

TREATMENT

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

HEALTH TEACHING

 Explain to patient what to expect afterwards. As the anesthetic wears off, there is likely to be some pain. The anesthetist will prescribe pain killers.
Suffering from pain san slow down recovery, so it’s important to discuss any pain with the doctors or nurses
 Instruct caring for the stitches, hygiene and bathing and will arrange an outpatient appointment for the stitches to be removed.
 Instruct patient to comply with the home medications that would be given by his physician.
 Encourage the patient to do the recommended light exercises such as walking. Avoid doing strenuous activities which could low down his recovery
 Encourage him to comply with the dietary modifications; limit the intake of saturated fat to prevent the occurrence of serious post-cholecystectomy side
effects
 Explain to the patient to refer for unusualities immediately

OUT PATIENT CARE

 Instruct to visit the physician for follow-up check-up

 If any of the following symptoms are noted he should contact his doctor

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

-if the abdomen swells

-if the pain is not relived by the prescribed painkillers

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

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

SPIRITUAL/SAFETY

 Encourage going to church and asking for guidance, encourage praying

 Avoid strenuous activity.

XII. CONCLUSION

Generally, we, the student nurse’s 3 days exposure and duty at Bulacan Medical Center have been a memorable experience to us. The exposure had been an
avenue for further development and enhancement of our skills and capabilities in rendering care and promoting holistic wellness to our clients. It reminded us again
that nursing profession entails a deep sense of responsibility and challenging tasks.

After 3 days of exposure at BMC Medical Ward, we the student nurse has identified and understood the causative factors of cholecystitis, its signs and
symptoms, clinical manifestations, diagnostic studies, medical, pharmacological and nursing interventions through obtaining cues and health history in conjunction
to the disease process. We underwent extensive research in order to comprehensively understand our patient’s condition. Upon learning his case, it challenged and
motivated us to work hard to provide the appropriate and effective nursing intervention and care.

Moreover, cholecystitis is the most common problem resulting from gallbladder stones. It occurs when a stone blocks the cystic duct, which carries bile from
the gallbladder. Predisposing factors can include heredity, age, sex and race. With the presented factors that cannot already be modified, one has to take action
towards preventing the disease to happen. The only one who can help yourself is you alone. With the proper knowledge about the nature of the disease as well as its
preventive measures along with responsibility and sense of will, one can surely direct himself away from the complications.

“No matter how the disease has already reached an alarming incidence rate or not, it is a duty of every human person to take care of his own body, not just for the
sake of other people that depend on him, but most especially for himself ~ a primary obligation that he must fulfill.”

XIII. BIBLIOGRAPHY

 http://www.nottingham.ac.uk/nursing/sonet/rlos/bioproc/resources.html
 http://www.le.ac.uk/pa/teach/va/anatomy/case2/frmst2.html
 http://www.le.ac.uk/pa/teach/va/anatomy/case5/frmst5.html
 http://digestive.niddk.nih.gov/statistics
 Barbara Howard, Clinical and Pathologic Microbiology, 2nd Edition
 Carol Porth, Pahtophysiology Concepts of Altered Health Sciences, 7th Edition
 Pathology 3rd Edition by Stanley L. Robbins, M.D.

 Tortora et. Al., Microbiology An Introduction, 8th Edition

 Kasper et. Al., Harrison’s Principle of Internal Medicine, 16th Edition
 Deglin, Judith H., Vallerand, April H. Davis’s Drug Guide for Nurses, 10th ed. F.A. Davis Company, Philadelphia, Pennsylvania,2007.
 Damjanov, I., Linder, J. Anderson’s Pathology. 10th edition USA: Mosby-
 Yearbook 1996.
 Fauci A. et al. Harrison’s Principles of Internal Medicine. 16th edition. USA: The
o McGraw-Hill Companies 2005.
 Bullock, B. Henze, R. Focus on Pathophysiology. Philadelphia, USA:Lippincott,
o Williams and Wilkins 2006.
 Clinical Applications of Nursing Diagnoses. F.A. Davis Company, Philadelphia.
o 4th edition.
 Nutritional Therapy and Pathophysiology. Nelms, Sucher, Long. 2007. Thomson
o Brooks/Cole, The Thomson Corporation. 10 Davis Drive Belmont, CA, USA.
 Bare, Brenda G., Cheever, Kerry H., Hinkle, Janice L., Smeltzer, Suzanne C.
o Brunner & Suddarth’s Textbook of Medical- Surgical Nursing, 11th ed. Vol.1.
o Lippincott Williams & Wilkins, 2008.
 Doenges, Marilynn E., Moorhouse, Mary Frances, Murr, Alice C. Nursing Care
o Plans 7th ed. F.A. Davis Company, Philadelphia, Pennsylvania,2006.
 Karch, Amy M. 2007 Lippincott’s Nursing Drug Guide. Lippincott Williams &
o Wilkins, 2007.
 MIMS, 108th ed. CMPMedica Asia Pte Ltd, Singapore, 2004.
 Porth, Carol M. Essentials of Pathophysiology: Concepts of Altered Health States.
o 2nd ed. Lippincott Williams & Wilkins, 2007.

 pp. 148-153, Maxine A. Goldman 2008, Pocket Guide to the Operating Room. 3rd edition
F.A. Davis Company.Philadelphia