1

SCHOOL OF NURSING

Obstructive Jaundice Probably

Secondary to distal CBD structure probably secondary to
Pancreatic head tumor in severe ascending cholangitis,
Septic shock secondary, S/P ERCP, stenting

Presented to the
The Faculty of the School of Nursing
University of Baguio

In Partial fulfillment of the

Requirement for the subject
NCENL07

By:

Andres, Dylan Angelo

Catena, Dexter John
Dulay, Jason
Villena, Neil Ivan Renz
Espada, Maires
Esteban, Mary Jean
Ico, Kirsten Nina
Mojica, Thea Myla Ceasar
Payumo, Rainelyn
Sernadilla, Noella Mae
NDA-2

Clinical Instructor:
Ms. Myrizza Capili RN, MAN

October 2019
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TABLE OF CONTENTS

Title page . . . . . . . . . . . . . . . . . . . . . . . . 1
Table of Contents . . . . . . . . . . . . . . . . . . . . .2
Acknowledgement . . . . . . . . . . . . . . . . . . . . . .3
Chapter I. . . . . . . . . . . . . . . . . . . . . . . . 4-7
Introduction
Chapter II. . . . . . . . . . . . . . . . . . . . . . . .8-9
Patient’s Profile
Chapter III. . . . . . . . . . . . . . . . . . . . . . 10-16
13 Areas of Assessment
Chapter IV. . . . . . . . . . . . . . . . . . . . . . .17-26
Anatomy and Physiology
Chapter V. . . . . . . . . . . . . . . . . . . . . . . 27-29
Pathophysiology:
A. Schematic
B. Narrative
Chapter VI. . . . . . . . . . . . . . . . . . . . . . .30-36
Laboratory Results
Chapter VII. . . . . . . . . . . . . . . . . . . . . . 37-42
List of Problems
Prioritization and Justification
Nursing Care Plan
CHAPTER VIII. . . . . . . . . . . . . . . . . . . . . .43-47
Drug Study
CHAPTER IX. . . . . . . . . . . . . . . . . . . . . . .48-51
Summary of Care
Conclusion
Recommendation
CHAPTER X. . . . . . . . . . . . . . . . . . . . . . . . .52
Reference
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ACKNOWLEDGEMENT

Our group NDA-2, owes our deepest gratitude to the

following people for making this case study possible:

First and foremost, to the Creator, as source of life

and being;

To the University of Baguio, for being true to its

mission and vision of empowering its students, giving the
students the chance to develop their skills through
experience;

To the Dean, Ms. Helen Alalag, the Department Head, Ms.

Evangeline Soliba for making the student’s hospital nursing
involvement feasible;

To the Chief Nurse and Staff of Baguio General Hospital

and Medical Center for letting the students do nursing care
along with them;

Special thanks to the patients, for their cooperation

and permission for the nursing students to render their
service;

To the group’s Clinical Instructors, Mr. Derick Dave

Dulnuan and Ronald La Paz, whose intellectual, clinical and
practical insights and guidance made the student’s hospital
nursing experience appreciated and valued in all aspects.

Last but not the least, to their families who gave them
much needed motivation and reminders to believe in their
passion and pursue their dream.
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CHAPTER I

INTRODUCTION

We, Group NDA II from the University of Baguio, School

of Nursing under Derick Dave Dulnuan and Mr. Ronald La Paz

had our duty at Baguio General Hospital and Medical Center

from 7 am to 3 pm shift, held last October 14 to 16 and 21

to 23 at the Surgery West Ward.

Our group have been given a chance to have our duty at

the ward, and able to experience different task that will

help us nursing students to learn and to do different

procedures that is delegated to us. Also, it is our pleasure

to communicate with the staff and to our patients. We

encounter different patients with different cases from,

surgery ward. We monitored patient’s vital signs, regulated

and changed IVF, prepared and administered IV and oral

medicines under the supervision of our instructor and as

ordered by the doctor. We also, assisted in daily activities

and rendered bed side care to each patient that was task for

us.

Also, our group handled different cases such as open

wound, car accident injury, fall injury and post-operative

patients. But, the group had decided to have the case of

Obstructive Jaundice Probably secondary to pancreatic head

tumor in severe ascending cholangitis.

Obstructive jaundice is a condition caused by a

blockage in the bile duct. The bile duct is a channel that

carries bile from the liver to the duodenum (part of the

small intestine).
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The blockage causes bile to be retained in the body and

this makes the skin and whites of the eyes become yellow.

The urine also becomes dark and the stools (bowel motions)

are pale.

Jaundice can develop very quickly but can take several

weeks to disappear completely. When you are jaundiced you

will feel very tired and lethargic. Your appetite will be

affected and you may have symptoms such as indigestion and

bloating after meals. You may also feel your skin is very

itchy.

Obstructive jaundice leads to intrahepatic

inflammation, and jaundiced patients are at increased risk

for complications due to immunologic derangements (Armstrong

et al, 1984). Our group reported that bile duct ligation is

associated with expansion of immunosuppressive liver Tregs,

which inhibit T-cell responses to stimulation by DCs (Katz

et al, 2011).

According to Pancreatic Action Cancer Organization in

England and Wales, risk factors of Pancreatic Cancer are the

following:

 Cigarette Smoking- There is a direct relationship

between the amount you smoke and the risk of pancreatic

cancer.

 Age- The risk of developing pancreatic cancer increases

with age.

 Diabetes- There have been a number of reports which

suggest that diabetics have an increased risk of

developing pancreatic cancer.

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 Obesity- Research indicates that obesity is associated

with an increased risk of pancreatic cancer in men and

women.

 Chronic Pancreatitis- Long-term inflammation of the

pancreas (pancreatitis) has been linked to pancreatic

cancer.

 Pancreatic cancer by itself (not part of a known

syndrome) runs in some families. People with first

degree relatives (mother, father, brother, sister)

diagnosed with pancreatic cancer have an increased risk

of being in that type of family.

According to statistics, in patients with obstructive

jaundice (generally without cirrhosis), perioperative

mortality ranges from 8% to 28% and has not changed since

the 1970s, although endoscopic has replaced surgical

decompression as the preferred approach to urgent treatment.

In this patient group, predictors of postoperative mortality

include a hematocrit value less than 30%, an initial serum

bilirubin level greater than 11 mg/dL (200 μmol/L), and a

malignant cause of obstruction. When all three factors are

present, the mortality rate approaches 60%; when no factors

are present, the mortality rate is only 5% (Dixon et al,

1983). Other predictors of poor surgical outcome include

serum bilirubin level higher than 3 mg/dL (reflecting a

malignant cause), elevated serum creatinine,

hypoalbuminemia, and cholangitis (Meir Mizrah et al, 2019).

Moreover, Pancreatic Action Cancer Organization in England

and Wales state that, twenty seven people are newly

diagnosed with the disease each day and for those diagnosed
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in time for surgery, their chances of surviving beyond five

years increases by up to 30%. Currently, less than 7% of

those diagnosed survive beyond 5 years. Almost half of all

patients are diagnosed as an emergency in A&E, where it is

more likely that the cancer has already spread to other

parts of the body. Thus, Pancreatic cancer can affect any

adult. It occurs equally in men and women.

The case was chosen by the group for us to be able to

relate the diseas process of patient X and also, to study

and enhance our knowledge about the condition. Moreover,

this case study can also be a reference to help our fellow

students understand this kind of case and to conduct more

case study in relation to this study. Lastly, this case

study will be able to help us apply the information that we

will gain in our future clinical duties as health care

provider.
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CHAPTER II

PATIENT’S PROFILE

A. Biographical data

Name: Patient X

Age: 39 y/o

Sex: Male

Nationality: Filipino

Address: N/A

Religion: Roman Catholc

Occupation: Driver

Date of Admission: October 12, 2019 (11:10 PM)

Admitting Diagnosis: Obstructive Jaundice Probably

secondary to distal CBD structure probably secondary to

pancreatic head tumor in severe ascending cholangitis,

septic shock secondary, S/P ERCP, stenting

B. PRESENT MEDICAL HISTORY

A 39 years old man was admitted last October 12,

2019 to Baguio General Hospital and Medical Center,

with a chief complaint of jaundice and pain at

abdominal area. According to him it is his first time

to be admitted in the hospital.

A month prior to admission, with associated severe

epigastric pain radiating on left colicky and gradually

increasing in severity, patient X promptly consult.

Preliminary laboratory examinations and imaging studies

were done, findings revealed unremarkable. CT scan was

then requested, revealing hydrotropic gallbladder,

dilated intrahepatic bile ducts with measure with

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measures of 1.7 cm. ERCP was done, findings revealed

distal CBD stricture; multipancreatic duct stones head

to tail of pancreas. Sphicterotomy and stenting were

done however, jaundice persisted again, hence

admission.

C. PAST MEDICAL HISTORY

Three months prior to admission, patient noticed

yellowing of the eyes with no associated symptoms of

nausea and vomiting, abdominal pain, changes in bowel

movement and urination. No consult was done and

medications taken. Symptoms persisted until one month

prior to admission.

D. FAMILY HISTORY

Reportedly, Patient X doesn’t have significant

familial diseases in both father and mother side.

Moreover, his siblings are all in good health.

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CHAPTER III

13 AREAS OF ASSESSMENT

I. Psychosocial Status

Patient X is a 39 year-old male and married. He is

currently residing at Aurora Hill, Baguio City, but is

originally from Ifugao, together with father and siblings in

a bungalow-type house made out of concrete. Their house is

located in a congested area, their excreta disposal is with

water carriage. He practices Roman Catholic and have no

beliefs nor practices which might affect in providing health

care.

He is the fifth among 6 siblings. His father and mother

have separated since he was young. Both of his parents

already have their own families.

Based on Erik Erikson’s psychosocial development

theory, Patient X, a young adulthood, is classified under

intimacy vs. isolation. In this stage, young adulthood need

to form intimate, loving relationships with other people.

Success leads to strong relationships, while failure results

in loneliness and isolation. However, if other stages have

not been successfully resolved, young adults may have

trouble developing and maintaining successful relationships

with others. Erikson said that we must have a strong sense

of self before we can develop successful intimate

relationships. Adults who do not develop a positive self-

concept in adolescence may experience feelings of loneliness

and emotional isolation.

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After being diagnosed with Obstructive Jaundice, his

body image changed. He already began to change color and had

weight loss. He often covered himself up with a blanket and

seldom removed it. However, he is thankful that his father

and siblings are at him side to support him during these

hard times.

II. Mental and Emotional Status

Patient X is conscious and coherent, oriented to time

and place, high school undergraduate and is able to read,

write and follow instructions. His chronological age is

directly proportional to his developmental age where his

focus includes family, his job and getting better. He is in

pain however is still approachable, able to maintain eye-to-

eye contact and responsive to the questions of the student

nurses.

Prior to hospitalization, according to her father, she

was a hard working father to his children. He is able to

provide the basic needs of his family.

III. Environmental Status

The patient is staying at the Surgery West Ward, male

section. The section has 16 other beds often the beds are

occupied by other patients and seldom are that 1-2 beds

empty. The ward was clean and beddings are provided by the

hospital. Each bed is provided with a side table, a chair

and a small cabinet to place their things. The comfort room

for the single ward is just a meter away from her bed. The

ward has 2 air cons which are functional during a humid

weather.
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IV. Sensory Status

a. Visual

Patient X has round shaped eyes, pupils are equally

round and reactive to light accommodation, irises are light

brown in color, sclera are whitish to yellowish in color and

conjunctiva are pinkish and moist. The patient does not use

eyeglasses or contact lenses. Patient is also instructed to

follow the direction of a pen with his eyes following the

six cardinal positions and his eyes were able to move in

full range of motion in all directions without nystagmus.

Eyebrows and eyelashes are equally distributed. Patient is

able to identify the object across the room correctly which

was approximately 15 feet away from him.

b. Auditory

The auricles are symmetrical, has the same color with the

patient’s facial skin, and are aligned with the outer

canthus of the eye. Upon palpation, the auricles are mobile,

firm and non-tender. The pinna recoils when folded and

minimal amount of moist yellow serum is visualized in the

external canal. During conversations, the patient was able

to respond correctly to the questions asked and no

difficulty in hearing was observed. He also verbalized that

he does not hear any unusual buzzing or ringing.

c. Olfactory

The client’s nose is small, uniform in color and had no

deviations. No discharges where noted. Both nares were

patent during inspection. Upon palpation no tenderness were

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noted. Frontal and maxillary sinuses are non-tender. He was

also able to identify correctly the scent presented to her.

Patient has a nasal cannula to help him breath.

d. Gustatory

The client’s lips were uniformly light pink in color,

symmetric with a dry texture. The client is able to purse

his lips when asked to whistle. The enamels were yellowish

in color with presence of cavities noted. The gums were pale

in color. The buccal mucosa appeared moist, soft and with a

pale color. The tongue was centrally positioned and a

presence of whitish coating was noted on the top of the

tongue. The uvula of the patient is positioned in the

midline of the soft palate. He is able to identify the

flavor of the candy presented to him.

e. Tactile

The patient’s sense of touch was assessed by slightly

pinching his right and left hand; it resulted in the

patient’s verbalization of pain.

V. Motor

The patient is able to raise both arms but unable to

move his legs without ease and with difficulty; assistance

is needed in doing activities of daily living. He can’t bend

and straighten his elbows but can extend and spread his

fingers with ease. He stated that he is right-handed. He is

unable to walk and is confined to bed due to the pain and

weakness.
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VI. Nutritional

Prior to being diagnosed, the patient was able to

consume his food (100%) during meals. Now after being

hospitalized, he had a gradual change in his appetite.

Patient has an order of soft diet. He now only consumes 25-

75% of food served according to his father however he eats 3

times a day. He has a medium-sized body built, emaciated,

with a height of 5 feet and 5 inches and a current weight of

54 kg. BMI of the patient is 19.8 which is under normal BMI.

His abdomen is distended and a T-tube is inserted for

drainage. She observed that her abdomen gradually distended.

Soft clicks and gurgles heard at a rate of 7-10 per minute.

Percussion revealed dullness over the right upper and lower

quadrant while tympany over the left upper and lower

quadrants.

The patient was able to consume 7 PLRS 1L. He claimed

that he drinks 500-800mL of water in a day.

VII. Elimination Status

The patient has a connected IFC which is used for

urination. Prior to hospitalization, he would urinate every

other hour approximately 80 mL per void. During the shift

(7pm-3pm), we drained 300-500mL of urine. Urine appears to

be dark yellow and concentrated with +3 bilirubin. The

patient claimed that he defecates every morning.

VIII. Reproductive

The patient has a connected IFC and uses diaper for

defecation. During the shift we usually drain 300-500mL of

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urine. Prior to hospitalization, no burning sensation is

noted when urinating. Patient is circumcised and has a pubic

hair. No discharge from the penis is noted. Patient has no

swelling, pain, nodules and mass on the perinea area.

IX. Circulatory

Upon assessment, the patient’s pulse rate ranges from

69-180 beats per minute, strong, has regular rhythm and

taken at the left radial pulse. His blood pressure ranges

from 150-90/90-60 mmHg depending on the titration of his

norepinephrine it is taken while he is lying down and at the

left upper extremity.

X. Respiratory

His respiratory rate ranges from 16-22 breaths per

minute, has regular rhythm and normal depths of respiration

with no use of accessory muscles. He is connected with a

nasal cannula to help him breath with a 4-5 LPM. He also has

an oxygen saturation ranging from 91-95%. The patient claims

he has cessation smoking and has drinking history with

difficulty of in breathing.

XI. Temperature

His temperature ranges from 36.5 – 36.8˚C taken at the

left axilla. The ward is adequately ventilated and the

patient has a blanket to use whenever he may feel cold.

XII. Integumentary

Patient’s skin is yellowish due to jaundice, smooth and

without pigmentations and with good skin turgor. The patient

has light brown nails and has a convex curve. It is smooth

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and intact with the epidermis and has a capillary refill

within 1-2 seconds and is well-trimmed. Hair is observed to

be evenly distributed over his scalp. It is black, smooth

and no presence of lice. Edema is noted on the lower

extremities.

XIII. Comfort and Sleep

Patient is comfortable in his bed but does not get

enough rest at night about every hours he is awaken due to

vital signs monitoring. He rated his pain as 7/10, cramping

on this abdomen. Usually intermittent and relieved when

analgesics are taken. The patient also claimed that he wakes

up at night due to pain. He usually takes a nap during the

day time.
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CHAPTER IV

ANATOMY AND PHYSIOLOGY

PANCREAS

The pancreas is an elongated, tapered organ located

across the back of the belly, behind the stomach. The right

side of the organ—called the head—is the widest part of the

organ and lies in the curve of the duodenum, the first

division of the small intestine. The tapered left side

extends slightly upward—called the body of the pancreas—and

ends near the spleen—called the tail.

The pancreas is made up of 2 types of glands:

 Exocrine. The exocrine gland secretes digestive

enzymes. These enzymes are secreted into a network of

ducts that join the main pancreatic duct. This runs the

length of the pancreas.

 Endocrine. The endocrine gland, which consists of the

islets of Langerhans, secretes hormones into the

bloodstream.

The pancreas has digestive and hormonal functions:

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 The enzymes secreted by the exocrine gland in the

pancreas help break down carbohydrates, fats, proteins,

and acids in the duodenum. These enzymes travel down

the pancreatic duct into the bile duct in an inactive

form. When they enter the duodenum, they are activated.

The exocrine tissue also secretes a bicarbonate to

neutralize stomach acid in the duodenum. This is the

first section of the small intestine.

 The main hormones secreted by the endocrine gland in

the pancreas are insulin and glucagon, which regulate

the level of glucose in the blood, and somatostatin,

which prevents the release of insulin and glucagon

LIVER
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The liver is located in the upper right-hand portion of

the abdominal cavity, beneath the diaphragm, and on top of

the stomach, right kidney, and intestines.

Shaped like a cone, the liver is a dark reddish-brown

organ that weighs about 3 pounds.

There are 2 distinct sources that supply blood to the

liver, including the following:

 Oxygenated blood flows in from the hepatic artery

 Nutrient-rich blood flows in from the hepatic portal

vein

The liver holds about one pint (13%) of the body's blood

supply at any given moment. The liver consists of 2 main

lobes. Both are made up of 8 segments that consist of 1,000

lobules (small lobes). These lobules are connected to small

ducts (tubes) that connect with larger ducts to form the

common hepatic duct. The common hepatic duct transports the

bile made by the liver cells to the gallbladder and duodenum

(the first part of the small intestine) via the common bile

duct.

Functions of the liver

The liver regulates most chemical levels in the blood and

excretes a product called bile. This helps carry away waste

products from the liver. All the blood leaving the stomach

and intestines passes through the liver. The liver processes

this blood and breaks down, balances, and creates the

nutrients and also metabolizes drugs into forms that are

easier to use for the rest of the body or that are nontoxic.

More than 500 vital functions have been identified with the
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liver. Some of the more well-known functions include the

following:

 Production of bile, which helps carry away waste and

break down fats in the small intestine during digestion

 Production of certain proteins for blood plasma

 Production of cholesterol and special proteins to help

carry fats through the body

 Conversion of excess glucose into glycogen for storage

(glycogen can later be converted back to glucose for

energy) and to balance and make glucose as needed 

 Regulation of blood levels of amino acids, which form

the building blocks of proteins

 Processing of hemoglobin for use of its iron content

(the liver stores iron)

 Conversion of poisonous ammonia to urea (urea is an end

product of protein metabolism and is excreted in the

urine)

 Clearing the blood of drugs and other poisonous

substances

 Regulating blood clotting

 Resisting infections by making immune factors and

removing bacteria from the bloodstream

 Clearance of bilirubin, also from red blood cells. If

there is an accumulation of bilirubin, the skin and

eyes turn yellow.

When the liver has broken down harmful substances, its

by-products are excreted into the bile or blood. Bile by-

products enter the intestine and leave the body in the form
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of feces. Blood by-products are filtered out by the kidneys,

and leave the body in the form of urine.

LIVER CONDITIONS:

 Autoimmune hepatitis

This condition causes the body’s immune system to attack

itself and destroy healthy liver tissue. Autoimmune

hepatitis can lead to cirrhosis and other liver damage.

 Biliary atresia

Biliary atresia is a condition that adversely affects a

person’s bile ducts and bile flow when they’re an infant. If

left untreated, the condition can cause liver scarring and

affect liver tissue. Fortunately, there are treatments

available for the condition.

 Cirrhosis

Cirrhosis is a condition where scar tissue replaces

healthy liver tissue. A number of conditions can cause

cirrhosis. These include long-term excessive alcohol use,

chronic hepatitis, or rare genetic disorders, such

as Wilson’s disease.

 Hemochromatosis

This condition causes an excess of iron to build up in

the body. Too much iron can damage the liver.

 Hepatitis A

Viral hepatitis refers to a viral infection that causes

liver inflammation. The hepatitis types have different

letters, including A, B, C, D, and E. Each has different

causes and severity.

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Hepatitis A is more common in developing countries that

lack clean drinking water and have poor sanitation systems.

Most people can recover from hepatitis A without liver

failure or long-term complications.

 Hepatitis B

Hepatitis B can cause a short- or long-term infection. In

U.S. adults, the disease is most commonly spread through

sexual contact. However, a person can also get it through

sharing needles or accidentally injecting themselves with a

contaminated needle. The condition can cause serious

complications, including liver failure and cancer. There’s a

vaccination against the disease to prevent it.

 Hepatitis C

Hepatitis C can be an acute or chronic infection. It’s

most commonly spread by coming in contact with blood

containing the hepatitis C virus, such as through sharing

unclean needles to inject drugs or apply tattoos. Less

commonly, unprotected sexual contact with an infected person

can transmit the infection, too. This condition can cause

inflammation that can lead to cirrhosis, liver failure,

and liver cancer.

 Nonalcoholic fatty liver disease and NASH

These are conditions where fat builds up in the liver. An

excess of fat can damage the liver, causing inflammation.

Nonalcoholic steatohepatitis (NASH) is a form

of nonalcoholic fatty liver disease that causes scarring or

fibrosis. People who are obese and have conditions related

to obesity, such as type 2 diabetes, are more likely to have

this disease.
 23

GALLBLADDER

The gallbladder is a small pouch that sits just under

the liver. The gallbladder stores bile produced by the

liver. After meals, the gallbladder is empty and flat, like

a deflated balloon. Before a meal, the gallbladder may be

full of bile and about the size of a small pear.

In response to signals, the gallbladder squeezes stored

bile into the small intestine through a series of tubes

called ducts. Bile helps digest fats, but the gallbladder

itself is not essential. Removing the gallbladder in an

otherwise healthy individual typically causes no observable

problems with health or digestion yet there may be a small

risk of diarrhea and fat malabsorption.

GALLBLADER CONDITIONS:

 Gallstones (cholelithiasis): For unclear reasons,

substances in bile can crystallize in the gallbladder,

forming gallstones. Common and usually harmless,

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gallstones can sometimes cause pain, nausea, or

inflammation.

 Cholecystitis: Infection of the gallbladder, often due

to a gallstone in the gallbladder. Cholecystitis causes

severe pain and fever, and can require surgery when

infection continues or recurs.

 Gallbladder cancer: Although rare, cancer can affect

the gallbladder. It is difficult to diagnose and

usually found at late stages when symptoms appear.

Symptoms may resemble those of gallstones.

 Gallstone pancreatitis: An impacted gallstone blocks

the ducts that drain the pancreas. Inflammation of the

pancreas results, a serious condition.

BILE DUCT

The common bile duct is a small, tube-like structure

formed where the common hepatic duct and the cystic duct

join. Its physiological role is to carry bile from the

gallbladder and empty it into the upper part of the small

 25

intestine (the duodenum). The common bile duct is part of

the biliary system.

Bile is a greenish-brown fluid that helps digest fats

from our food intake. It is produced by the liver and stored

and concentrated in the gallbladder until it is needed to

help digest foods. When food enters the small intestine,

bile travels through the common bile duct to reach the

duodenum.

Gallstones are hard deposits that form inside the

gallbladder when there is too much bilirubin or cholesterol

in the bile. Although a person may have gallstones for many

years without feeling any symptoms, gallstones can sometimes

pass through the common bile duct, causing inflammation and

severe pain. If a gallstone blocks the common bile duct, it

can cause choledocholithiasis. Symptoms of

choledocholithiasis include pain in the right side of the

abdomen (biliary colic), jaundice, and fever.

Choledocholithiasis can be life-threatening if not diagnosed

and treated immediately.

BILE DUCT CONDITION:

Cholangitis is inflammation (swelling and redness) in

the bile duct. The American Liver Foundation notes that

cholangitis is a type of liver disease. It can also be

broken down more specifically and known as the following:

 primary biliary cholangitis (PBC)

 primary sclerosing cholangitis (PSC)

 secondary cholangitis

 immune cholangitis
 26

The bile ducts carry bile from the liver and gallbladder

to the small intestine. Bile is a green to yellow-brown

fluid that helps your body digest and absorb fats. It also

helps to clear waste from the liver.

When the bile ducts get inflamed or blocked, bile can back

up into the liver. This can lead to liver damage and other

problems. Some types of cholangitis are mild. Other kinds

can be serious and life-threatening.

There are two main types of cholangitis:

 Chronic cholangitis happens slowly over time. It can

cause symptoms over 5 to 20 years.

 Acute cholangitis happens suddenly. It can cause

symptoms over a short time period.


PATHOPHYSIOLOGY
A. SCHEMATIC DIAGRAM
Non-modifiable factors
-pancreatic cancer
Cells in the pancreas develop mutations
in their DNA which causes cells to grow
uncontrollably and to continue living
after normal cells would die
These accumulating cells can form a tumor
Untreated pancreatic cancer spreads to
nearby organs and blood vessels
The bile ducts are damaged causing them
to narrow
The strictures of the bile ducts block
the release of bile
Unreleased bile associated with
inflammation and infection
27
CHAPTER V
Modifiable factors
-fatty food (often eats street food)
-chronic alcohol drinker (for 24 years)
The body breaks down the Cholecystokinin is the
alcohol consumed into principle stimulus for
acetaldehyde delivery of pancreatic
enzymes and bile into the
small intestine
Acetaldehyde is a chemical
that damages the DNA and
also prevents the body from Dietary fat inhibits the
repairing the damage release of cholecystokinin
Obstructive jaundice Unreleased bile can get
-also associated obstruction stuck in the body’s system
of biliary duct
ACUTE PAIN Jaundice is a sign of an
underlying disease process
that causes weakness
INEFFECTIVE IMPAIRED BED
TISSUE PERFUSION MOBILITY
 28

B. NARRATIVE

In the case of our patient, modifiable risk factors

associated to his diagnosis is being a chronic alcohol

drinker for 24 years and fan of eating fatty foods such as

street foods. Alcohol is metabolized by several processes or

pathways. The most common of these pathways involve two

enzymes—alcohol dehydrogenase (ADH) and aldehyde

dehydrogenase (ALDH). These enzymes help break apart the

alcohol molecule making it possible to eliminate it from the

body. First, ADH metabolizes alcohol to acetaldehyde, a

highly toxic substance known as carcinogen. Then, in a

second step, acetaldehyde is further metabolized down to

another less active by product called acetate, which then is

broken down into water and carbon dioxide for easier

elimination. Although acetaldehyde is short lived, usually

existing in the body only for a brief time before it is

further broken down into acetate, it has a potential to

cause significant damage. This is particularly evident in

the liver where the bulk of alcohol metabolism takes place.

Moreover, Cholecystokinin is secreted by cells of the upper

small intestine. Its secretion is stimulated by the

introduction of hydrochloric acid, amino acids, or fatty

acids into the stomach or duodenum. Cholecystokinin

stimulates the gallbladder to contract and release stored

bile into the intestine. It also stimulates the secretion of

pancreatic juice and may induce satiety. However, due to

engaging in high fatty diet, the ability of CCK to inhibit

gastric emptying are lessening due to compromised bile

production.
 29

On the other hand, the non-modifiable risk factor of

our patient is having a pancreatic cancer in the head of

pancreas, a tumor or a pressure from an enlarged organ. The

obstruction was caused by the bile not to flow normally into

the intestine but is backed up into the liver substance

resulting now to cholangitis which is known as the

inflammation and infection of the bile duct. It is then

reabsorbed into the blood and carried throughout the entire

body, staining the skin, mucous membrane and sclera known as

jaundice. Making the tissue perfusion altered and may

experience pain, fatigue, weakness leading to impaired

mobility. In addition, because of the decreased amount of

bile in the intestinal tract, the stool became light or

clay-colored. Dyspepsia and intolerance to fatty foods may

develop because of impaired fat digestion in the absence of

intestinal bile.
 30

CHAPTER VI

LABORATORY RESULTS

COMPLETE BLOOD COUNT RESULT FORM

Date: 10-12-19

TEST NAME RESULT REFERENCE RANGE

Hemoglobin 120 140-180 g/L

Hematocrit 0.35 0.40-0.54L/L

WBC Count 20.76 5.0-10.0^9/L

Interpretation:

Hemoglobin, a normal hemoglobin is 140-180g/L but patient’s

CBC is 120 can indicate anemia

Hematocrit, a lower than normal hematocrit can indicate an

insufficient supply of healthy red blood cells

WBC, a high WBC indicates an infection

DIFFERENTIAL COUNT

Neutrophils 88 50-70%

Lymphocytes 5 20-40%

Monocytes 7 0-10%

Eosinophils 0 0-7%
 31

Basophils 0 0-1%

Total 100

RBC COUNT 4.21 4.69-6.13 10^12/L

Platelet Count 194 150-400 10^9/L

RBC INDICES

MCV 82.90 80-100 fL

MCH 28.50 27-31 pg

MCHC 343.00 310-360 g/L

RDW-CV 15.20 11-16%

RDW-SD 46.10 35-56 fL

MPV 9.00 6.5-12 fL

Interpretation:

RBC count, a low production of RBC indicates anemia

Neutrophils, an increase in neutrophils can indicate an

acute inflammation

Lymphocytes, a low level is considered as lymphocytopenia

X-RAY RESULT FORM

Date: 10-12-19
 32

CHEST:

Hypoaerated lungs

Reticular densities are seen in both lungs probably vascular

crowding

Heart is not enlarged

Hemidiaphragms and costophrenic sulci are intact

Visualized osseous and soft tissue structures are

unremarkable

IMPRESSION:

Hypoaerated Lungs Otherwise Normal Cardiopulmonary Findings

PROTHROMBIN TIME/ PARTIAL THROMBOPLASTIN RESULT FORM

Date: 10-12-19

Test Name Result Reference Range

Prothrombin Time

Patient 13.10 11-14 seconds

Control 11.50 10.6-13.4 seconds

INR 1.15

% Activity 80.50

Activated Partial

Thromboplastin Time

Patient 44.20 26.6-38.9 seconds

 33

Control 33.60 32.6-41.4 seconds

Interpretation:

Activated Partial Thromboplastin Time: A normal activated

partial thromboplastin time is 26.6-38.9 seconds but patient

aPTT is 44.20 seconds this can indicate bleeding disorder to

liver

ROUTINE CHEMISTRY

Date: 10-12-19

SI Unit Conventional Unit

Test Name Instrument Result Unit Range Result Unit Range

Sodium C XI-921 136.50 mmol/L 135-

145

Potassium C XI-921 3.52 mmol/L 3.5-

5.5
 34

Chloride C XI-921 96.60 mmol/L 98-108

Creatinine Pentra400 61.00 umol/L 71-115 0.69 mg/dL 0.80-

1.30

SGOT/AST Pentra400 65.20 U/L 0-36

SGPT/ALT Pentra400 44.88 U/L 0-40

Alkaline AU480 270.48 U/L 30-120 270.48

Phosphatase

Total Pentra400 649.69 umol/L 3-17 37.99 mg/dL 0.18-

Bilirubin 0.99

Direct Pentra400 487.69 umol/L 0-3 28.52 mg/dL 0-0.18

Bilirubin

Indirect AU480 162 umol/L 1.7- 9.47 mg/L 0.1-1.0

Bilirubin 17.1

Albumin Pentra400 28.16 g/L 38-55 2.82 g/dL 3.8-5.5

Amylase Pentra400 14.50 U/L 0-100 14.50

Lipase Pentra400 10.34 U/L 0-60 10.34

Remarks: Sample collected from unit.

Interpretation:

Chloride: a decrease chloride indicates hypochloremia

Creatinine: a decrease creatinine indicates the need to

dispose waste in the blood/ unable to remove waste

SGOT/AST: an increase SGOT/AST indicates a sign of liver

damage

SGPT/ALT: an increase SGPT/ALT indicates of liver damage

Alkaline Phosphatase: an increase alkaline phosphatase

indicates liver disease or bone disorders

 35

Total Bilirubin: an increase total bilirubin indicates liver

damage or disease

Direct Bilirubin: an increase direct bilirubin indicates

that the liver is not clearing bilirubin properly

Indirect Bilirubin: an increase indirect bilirubin may

indicate haemolytic anemia

Albumin: a decrease albumin indicate hypoalbuminemia (lack

of protein albumin in the bloodstream)

ATERIAL BLOOD GAS

Date: 10-12-19

pH 7.45 (7.35-7.45)

PaCO2 28.3 (35-45)mmHg

PaO2 78.3 (80-100)mmHG

HCO3 20.00 (22-26)mmol/L

SaO2 96.3 %

BE -2.0 (+/-2)mmol/L

FiO2 21 %

Thb -- g/Dl

Hct --

Interpretation:

Metabolic Acidosis
 36

IMMUNOCHEMISTRY

Date: 10-13-19

Test Instrument Result Unit Reference Range

CA19-9 89910.000 U/mL 0-19.0

Remarks: Dilution done

Interpretation:

CA19-9: normal CA19-9 is 0-19.0 U/mL but patient CA19-9

level is 89910.000 U/mL this may indicate a pancreatic

cancer or tumor is growing

SEROLOGY RESULT FORM I

Date: 10-13-19

Test Method Result Cut-off Value Interpretation

Anti- CMLIA 0.42 S/CO <0.80 Nonreactive

HAV Igm Nonreactive |0.80-1.2
Grayzone|>1.20
Reactive

SEROLOGY RESULT FORM I

Date: 10-13-19

Test Method Result Cut-off Value Interpretation

Anti-HAV CMLIA 0.42 S/CO <1.00 Nonreactive

Igm Nonreactive|>=1.00
 37

Reactive

HBsAg CMLIA 0.34 S/CO <1.00 Nonreactive

Nonreactive|>=1.00
Reactive

URINALYSIS RESULT

Date: 10-13-19

PHYSICAL EXAMINATION

Color: DARK YELLOW

Appearance: SLIGHTLY TURBID

CHEMICAL EXAMINATION

Specific Gravity: 1.006 Glucose: NEGATIVE

pH: 6.0 Ketones: NEGATIVE

Leukocyte Esterase: NEGATIVE Urobilinogen: NORMAL

Nitrates: NEGATIVE Bilirubin: POSITIVE 3

Protein: NEGATIVE Erythrocyte: NEGATIVE

MICROSCOPIC EXAMINATION

RESULTS CRYSTAL
 38

Pus Cells: 2-4 / hpf Uric Acid: NONE/lpf

Red Blood cells: 0-2/hpf Calcium oxalate: NONE/lpf

Yeast cells: NONE/hpf Triple Phosphate: NONE/lpf

Bacteria: RARE/hpf CAST

Epithelial Cells: RARE/hpf Fine granular: NONE/lpf

Mucus Threads: NONE/hpf Coarse granular: NONE/lpf

Amorphous materials: NONE/hpf Hyaline: NONE/lpf

Waxy: NONE/lpf

Bilirubin, a normal bilirubin in the urine should be

negative while in the patient’s result positive 3 can

indicate liver damage or disease such as hepatitis A.

BACTERIOLOGY RESULT FORM I

Date: 10-13-19

TEST PERFORMED: GRAMSTAIN

SPECIMEN TYPE: Bile

No microorganism seen
 39

CHAPTER VII
LIST OF PROBLEMS, PRIORITIZATION,
JUSTIFICATION & NURSING CARE PLAN

LIST OF PRIORITIZATION

 ACUTE PAIN
 IMPAIRED BED MOBILITY
 RISK FOR IMBALANCED NUTRITION: LESS THAN BODY
REQUIREMENT

PROBLEM JUSTIFICATION
ACUTE PAIN It is an actual problem and a
subjective feeling so this
should be manage first ,
according to Maslow’s hierarchy
of needs pain is under the
physiologic needs and before
meeting the second step in
Maslow’s hierarchy which is the
safety needs this problem
should be address first.
IMPAIRED BED MOBILITY It also an actual problem but
according to Maslow’s hierarchy
of needs impaired mobility fall
under the safety needs, before
addressing this problem
physiologic needs must be met.
RISK FOR IMBALANCED Since it is a potential problem
NUTRITION:LESS THAN BODY it should be managed lastly, it
RESUIREMENT also falls under the nutrition
but since it is a potential
problem no immediate
intervention must be done.
 40

NURSING CARE PLAN

ACTUAL:

Assessment Explanation of Goals Nursing Rationale Evaluation

the Problem Interventions
Subjective: Blockage of any
duct that STO:  Assessed the  Provide STO:
“Nahihirapan carries bile
akong gumalaw” from the liver Within 6 physical baseline Goal partially
to the activity level information for
Objective: hours of Met because
gallbladder or and mobility of formulating nursing
gallbladder to the patient goals during goal after 6 hours
 Limited effective setting
the intestine,
range of nursing
motion on resulted to of effective
both arms biliary  To help nursing
interventions, interventions,
obstruction or
 Assisted accumulation of determine patient’s
the patient will the patient was
ADL’s bilirubin or  Monitored current health
bile salt in status and evaluate
be able to do able to:
 Mostly the blood and vital signs and effectiveness of
lying in the failure of record. nursing
ADLs alone and  Do ADLs
the bed intervention
bile to reach
its proper to participate rendered. but with
destination. in minimal
Nursing  To determine assistance and
High levels of
Diagnosis: self-care
bilirubin in the capacity of participated in
the blood now activities. patient in doing
Impaired happens causing self-care
 41

now yellow
Physical stain on the  Have the ADL’s activities.
Mobility skin, sclera
related to and mucous LTO: patient perform
weakness membrane known the activity LTO:
as jaundice Within 2 days more slowly, in
Goal fully
which resulted a longer time
of effective with more rest
to experience Met because
nursing or pauses or
of impaired
mobility due to with assistance after 2 days of
interventions,
fatigue and if necessary
weakness. effective
the patient will
 Assist to do nursing
 To minimize interventions,
be able to
active range of
fatigue and to the patient
maintain motion exercise
evaluate his
activity like flexing of
capabilities in able to:
both
doing such
level within extremities. Let
 Maintain
the patient
capabilities accomplish tasks activity level
at his or her within
as evidenced own pace. Do not
absence of hurry the capabilities as
difficulty patient.
Encouraged evidenced by
accomplishing ta independent absence of
sks activity as able difficulty
accomplishing
and safe.
task.
 42

 Turned and

positioned
patient every 2
hours.

 Taught
patient
 Position
or significant
others on changes optimize
maintaining circulation to all
hazard free and tissues and relieve
safe environment pressures.

 Promoted rest  A safe

and comfort environment will

help prevent injury
related to falls.
 43

 To conserve

energy

Assessment Explanation of Goals Nursing Rationale Evaluation

the Problem Interventions
Subjective: Acute STO:
Cholangitis  Assessed pain  Assessment of STO: After 8
“Masakit yung Within 8 hours of
superimposed on hours of
tiyan ko” nursing
an obstruction characteristics pain experience is nursing
intervention the
of the biliary quality, the first step in intervention
patient will be
tree diminishes severity, planning pain
Objective: able to: the patient
host location, onset, management
antibacterial duration, strategies. was able
 Pain is  Know ways to
defenses, causes precipitating or
rated 7/10, relieve pain like to:
immune relieving
repositioning and
dysfunction and factors.
 Facial deep breathing  Know ways
subsequently
grimace and report pain
increases small  Monitored vital
is relieved, with to relieved
bowel bacterial
 limited colonization.
the pain scale of signs pain
movement Bacteria gain
2/10.  To have a
like
access to the
 guarding biliary tree by
baseline data repositioning
behavior LTO: prior to planning
retrograde
of nursing care. and deep
ascent from Within 2 days of
 Noted client’s breathing and
Nursing duodenum from nursing
 Pain is a reported that
Diagnosis: portal venous intervention:
attitude toward pain was
blood. As a
 44

Acute Pain result infection

related to ascends into  Pain will be pain. Accepted subjective relieve to
inflammation hepatic ducts eradicated. experience and 2/10
of bile duct causing serious client’s must be described
infection , description of by the client in
jaundice fever pain order to plan
and right upper effective
quadrant pain. treatment.

 To promote non

 Observed non pharmacological

pain management.
verbal cues and
comfort measures,
quiet environment
and calm
activities.

 Administered
 To relieve mild
medication as
LTO:
ordered or moderate pain
After 2 days
 Encouraged of nursing
intervention:
diversional  To distract
activities and  Pain was
relaxation attention and
techniques such reduce tension
eradicated as
 45

as deep breathing evidenced by

Provided no further
verbalization
comfort measures of pain.
like
repositioning.

 Encouraged

adequate rest
periods and sleep

 To alleviate

pain.
 46

Potential:

Assessment Explanation of Goals Nursing Rationale Evaluation

the Problem Interventions
Objective: With the patient STO: STO:
having a After 3 days of  Assessed the  Provide data After 3 days of
diagnosis of nursing nursing
 Weight loss
obstructive intervention, the intervention, the
of 13 kls. jaundice, bile patient will be weight of the baseline about the patient was able
From 67 to ducts was able to: client client. to:
54. inflamed that
lead to  Demonstrate  Determined  To assess the  Demonstrated
obstruction in lifestyle lifestyle changes
 Order of soft the bile which changes to client’s usual food that he to regain weight
diet helps in the regain weight
digestion of food nutritional eats.
LTO:
intake. Lack of status
LTO: After 1 month of
bile in the After 1 month of  Psychological nursing
 25%-75% food intestine causes  Determined the
nursing intervention the
consumption inability to intervention the factors towards patient was able
digest food which patient will be to:
client’s attitude
causes the able to:
patient to be towards eating eating may affect
Nursing  Demonstrated
ordered on soft the person’s
Diagnosis:  Will weight gain.
Risk for diet that may be appetite and also
demonstrate
Imbalanced at risk for to know the eating
gain of weight.
imbalanced habits
Nutrition: Less
nutrition: less
than Body than body,
Requirement

 Observing

 Observed and caloric

 47

recorded the intake/lack of

patient’s food quality food
intake consumption

 Little food can

 Give food a reduce

vulnerabilities
little but often and increase input
and/or eat also prevents
between meals gastric distention

CHAPTER VIII

DRUG STUDY

DRUG NAME MECHANISM OF INDICATION AND SIDE EFFECTS NURSING CONSIDERATION

ACTION CONTRAINDICATION
 IV use: Dilute with 0.9%
Generic Name: An anti- INDICATION:  Dizziness sodium chloride for
Vitamin K hemorrhagic injection, D5W, or D5W
actor that Hypoprothrombinemia  transient in 0.9% sodium chloride
promotes secondary to vitamin K hypotension after for injection. Give IV
hepatic malabsorption, drug IV administration by slow infusion over 2
Brand Name: formation of therapy, or excessive to 3 hours. Rate
Mephyton active vitamin A dosage; shouldn’t exceed 1
 rapid and weak
prothrombin. hypoprothrombinemia mg/minute in adults or 3
pulse,

secondary to effect of oral
anticoagulants; prevention
Dosage:10 mg of hemorrhagic disease of
newborn prevention of
hypoprothrombonemia related
to vitamin K deficiency for
Frequency: q8 long-term parenteral
nutrition; prevention of
hypoprothrombinemia in
infants receiving less than
Route: 0.1 mg/liter vitamin K in
Intravenous breast milk or milk
substitute.
Classification:
vitamins CONTRAINDICATION:
 General Information
 Biliary tract disease,
hepatic disease, jaundice
 Hypoprothrombinemia,
thromboembolic disease
 Anticoagulant therapy.
 Pregnancy
 Breast-feeding
48
mg/m2/minute in
 Diaphoresis children.
 Effects of IV injection
 Flushing are more rapid but
shorter-lived than SC or
IM injections.
 Erythema
 Protect parenteral
products from light.
 Pain
Wrap infusion container
with aluminum foil.
 swelling
 Monitor PT to determine
dosage effectiveness as
 hematoma at ordered.
injection site.  If severe bleeding
occurs, don’t delay
other measures, such as
fresh frozen plasma or
whole blood.
Alert: watch for signs
of flushing, weakness,
tachycardia and
hypotension; may
progress to shock.
 49

 Intramuscular
administration,
intravenous
administration, serious
hypersensitivity reactions
or anaphylaxis.
 50

DRUG NAME MECHANISM OF ACTION INDICATION AND SIDE EFFECTS NURSING CONSIDERATION
CONTRAINDICATION

Generic Name: Centrally acting INDICAION:  Sedation  Assess bowel function

Tramadol opiate receptor routinely. Minimize
Hydrochloride agonist that  Moderate to  dizziness/vertigo constipation. Assess
inhibits the uptake moderately severe previous analgesic
of norepinephrine pain  headache history. Tramadol is not
Brand Name: Zydol and serotonin, recommended for opiod
suggesting both  Confusion dependent patients
Dosage: 50 mg opioid and non- (withdrawal symptoms).
opioid mechanisms CONTRAINDICATION:  Dreaming
Monitor patients for
of pain relief. May seizures.
produce opioid-like  Pregnancy  anxiety
Frequency: every
effects, but causes  Instruct the patient on how
6 hours PRN
 Allergy to tramadol  seizures
less respiratory and when to ask for pain
depression than medication.
 Hypotension
morphine.  Acute intoxication
Route: with alcohol opioids  Caution to avoid activities
 Tachycardia
Intravenous psycho tropic drugs requiring alertness until
or other centrally  Bradycardia response to medication is
acting analgesics unknown.
Classification:  Sweating
Analgesic  lactation.  Caution to avoid alcohol or
 51

 Pruritus rash other CNS depressants

 Pallor  Discontinue drug and

notify physician if S&S
 Urticaria of hypersensitivity
occur.
 Nausea

 Vomiting

 Drymouth

 Constipation

 Flatulence
Potential for
abuse

 Anaphylactic
reactions

DRUG NAME MECHANISM OF ACTION INDICATION AND SIDE EFFECTS NURSING

CONTRAINDICATION CONSIDERATION
 52

GENERIC NAME: Metronidazole is INDICATION: Stomach pain, History: CNS or

converted to diarrhea; dizziness, hepatic disease;
Metronidazole reduction products  Acute infection with loss of balance; candidiasis
vaginal itching or
that interact with susceptible anaerobic (moniliasis); blood
discharge; dry mouth
DNA to cause bacteria or unpleasant metallic dyscrasias;
destruction of  Acute intestinal taste; cough, pregnancy;
BRAND NAME: helical DNA structure lactation Physical:
amebiasis sneezing, runny or
and strand leading to  Amebic liver abscess stuffy nose; or. Reflexes, affect;
Apo-Metronidazole swollen or sore
a protein synthesis skin lesions, color
 Trichomoniasis (acute tongue.
inhibition and cell (with topical
and partners of
death in susceptible application);
patients with acute
organisms. It is abdominal
CLASSIFICATION: infection)
effective against a examination, liver
 Preoperative, Adverse effect
Antibiotic, wide range of palpation;
intraoperative, GI disturbances e.g.
Antibacterial, organisms including urinalysis, CBC,
postoperative nausea, unpleasant
Amebicide, E. histolytica, T. LFTs
prophylaxis for metallic taste,
Antiprotozoal vaginalis, Giardia,
patients undergoing vomiting, diarrhoea or
anaerobes e.g.
colorectal surgery constipation. Furred
Bacterioides sp, tongue, glossitis, and
Fusobacterium sp, stomatitis due to
DOSAGE:700mg Clostridium sp, overgrowth of Candida.
Peptococcus sp and CONTRAINDICATION: Rarely, antibiotic-
Peptostreptococcus associated colitis.
sp, and moderately History of Weakness, dizziness,
FREQUENCY:Q8 active against hypersensitivity to ataxia, headache,
Gardnerella sp and metronidazole or other drowsiness, insomnia,
Campylobacter sp. nitroimidazole changes in mood or
derivatives. Pregnancy mental state. Numbness
ROUTE:Intravenous
 53

(1st trimester) and or tingling in the

lactation. extremities,
epileptiform seizures
(high doses or
prolonged treatment).
Transient leucopenia
and thrombocytopenia.
Hypersensitivity
reactions. Urethral
discomfort and
darkening of urine.
Raised liver enzyme
values, cholestatic
hepatitis, jaundice.
Thrombophlebitis (IV).

Potentially Fatal:
Anaphylaxis.
54
 55

CHAPTER IX

SUMMARY OF CARE, CONCLUSION AND RECOMMENDATION

SUMMARY OF CARE

Patient X, 39 years old from Aurora Hill, Baguio City

was admitted at Baguio General Hospital and Medical Center

on Surgey West Ward with admitting diagnosis of Obstructive

jaundice secondary to distal CBD structure probably

secondary to pancreatic head tumor in severe ascending

cholangitis, septic shock secondary, s/p ERCP, stenting

Upon admission of Patient X, he was seen and examined

by Doctor Kerubine L. Kis-ing, M.D.

Patient X was admitted to the Surgery West ward and was

promoted comfort and rest. Vital signs were closely

monitored to assess for significant change in patient`s

health every 1 hour, while intake and output were also

monitored.

During his stay in Baguio General Hospital and Medical

Center the attending physician of patient X ordered

diagnostic and laboratory test such as urinalysis, CBC, ABG,

X-Ray, PT/aPTT, Immunochemistry and routine chemistry to

further aid in knowing the diagnosis and the detection of

the disease.
 56

CONCLUSION

After 3 days duty in Baguio General Hospital, we had

chosen the case of Obstructive jaundice secondary to distal

CBD structure probably secondary to pancreatic tumor in

severe ascending cholangitis; we were able to develop new

knowledge and skills regarding the presented case.

Pancreatic tumor is quite common among adults. Most cases

last few months, during which time it is important for the

patient to stay at the hospital for further laboratory test.

Having a clear understanding of the disease and its

process, with consideration of the feeling and beliefs of

the parents; most especially, will aid the nurse in skill

fully meeting the patient’s needs.

It is indeed a good opportunity to test our abilities

as a student nurses, by sharing the knowledge, skills and

good attitudes that we acquired in the university; we were

able to understand the real meaning and importance of

clinical nursing practice.

 57

RECOMMENDATIONS

For the patient and his immediate family:

1. They must be observant and aware of each other’s health

status as well as the people around them and their

environment for them to protect themselves in any

contagious, communicable diseases, and injuries.

2. If any signs and symptoms have been felt and observed,

they must immediately consult a physician or go to the

nearest medical facilities.

3. They must practice proper hygiene and maintain clean

environment to avoid acquiring any infections or diseases.

For student nurses:

1. To be able to perform their duties, student nurses must

be responsible and finish the entire task given.

2. Skills or trainings learned from the school must be

correctly applied in the actual setting in the hospital.

3. They must be observant and vigilant of any danger signs

and symptoms of the patients and must refer or report

immediately to the Clinical Instructor or any health care

team.

For the health care providers:

1. They must continue to provide seminars that will help

each individual to be aware of their health status and be

able to protect themselves from any contagious diseases.

 58

2. They must provide adequate trainings and programs to

improve the skills and responsibilities of any health care

team to be able to accommodate their patient’s needs and

perception about their health concerns and to continue

giving tender, loving, care.

3. To continue the right service for patients and students

in accommodating their needs and concerns.

For the University of Baguio, School of Nursing:

1. To continue sending nursing students at Baguio General

Hospital and Medical Center, to broaden their knowledge

and skills as future nurses needed in their profession.

2. To continue providing trainings and programs for

students to enhance their skills and ability in an

actual situation.

For the nursing research:

1. To continue allowing students to perform case

presentations to gather new information’s regarding

different disorders.
 59

CHAPTER X

REFERENCES:

https://www.medicinenet.com/script/main/art.asp?
articlekey=2632
Definition of Pancreatic Tumor. (n.d.). Retrieved from
https://www.medicinenet.com/script/main/art.asp?
articlekey=2632
(2012). Tuberculosis and respiratory diseases, 72(5), 401-8.
https://www.emedicinehealth.com/liver/article_em.htm
s://www.webmd.com/g0/billiaryducts-
ekgshttps://nursekey.com/gastric-lavage/
https://www.wisegeek.com/what-is-a-obstructive-jaundice.htm
https://empendium.com/mcmtextbook/chapter/B31.IV.24.15.
https://radiopaedia.org/cases/traumatic-jaundice-insertion?
lan
https://www.rnspeak.com/-nursing-procedure/
http://nursing-resource.com/iv-insertion/
https://www.rnspeak.com/risk-for-nanda/
https://www.healthline.com/health/acute-pain/
https://healthquestions.medhelp.org/complete-blood-count-
glucose
https://www.webmd.com/a-to-z-guides/complete-blood-count#1