A Case Study on

Choledocholithiasis

Submitted by:

Jaelynn Faith Ombina

Angelika Isona
Warline R. Hyberts
Kenneth Pagasian
Christelle Cadiente
 Table of Contents
Chapter I Introduction
Chapter II Objective
Chapter III Patient’s Data
Chapter IV Genogram
Chapter V History of Illness
Chapter VI Definition of Complete Diagnosis
Chapter VII Developmental Milestone
Chapter VIII Physical Assessment
Chapter IX Anatomy and Physiology
Chapter X Etiology and Symptomatology
Chapter XI Pathophysiology
Chapter XII Doctor’s Order
Chapter XIII Diagnostic and Laboratory Result
Chapter XIV Drug Study
Chapter XV Medical Surgical Management
Chapter XVI Discharge Planning/ Health Teaching
Chapter XVII Nursing Care Plan
Chapter XVIII Prognosis
Chapter XIX References
Chapter XX Acknowledgement
 Introduction

Choledocholithiasis refers to the presence of gallstones within the common

bile duct. According to the National Health and Nutrition Examination Survey
(NHANES III), over 20 million Americans are estimated to have gallbladder
disease (defined as the presence of gallstones on transabdominal ultrasound or a
history of cholecystectomy). Among those with gallbladder disease, the exact
incidence and prevalence of choledocholithiasis are not known, but it has been
estimated that 5 to 20 percent of patients have choledocholithiasis at the time of
cholecystectomy, with the incidence increasing with age.

In Western countries, most cases of choledocholithiasis are secondary to the

passage of gallstones from the gallbladder into the common bile duct. Primary
choledocholithiasis (i.e., formation of stones within the common bile duct) is less
common. Primary choledocholithiasis typically occurs in the setting of bile stasis
(e.g., patients with cystic fibrosis), resulting in a higher propensity for intraductal
stone formation. Older adults with large bile ducts and periampullary diverticular
are at elevated risk for the formation of primary bile duct stones. Patients with
recurrent or persistent infection involving the biliary system are also at risk, a
phenomenon seen most commonly in populations from East Asia.

The causes of primary choledocholithiasis often affect the biliary tract diffusely, so
patients may have both extrahepatic and intrahepatic biliary stones. Intrahepatic
stones may be complicated by recurrent pyogenic cholangitis.
Gallstones in Southeastern Asia (Extrapolated Statistics): extrapolated prevalence
is 5,073,040; Population Estimated Used is 86,241,6972.
 Objectives
This case study will help and serve us to enhance our
k n o w l e d g e t o u n d er s t a n d Choledocholithiasis by assessing, analyzing
and interpreting the collected data. This will in turn give us a better idea of how we
could give proper nursing care making the right evaluation and right
intervention to our clients with this condition; And so that we may apply them on
our future exposures as students and eventually as nurses. We also did this case
study as part of our requirement in our clinical exposure.

 Define Choledocholithiasis by identifying their signs and symptoms,

as well as its clinical manifestations.
 Acquire baseline data.
 Analyze the signs and symptoms and clinical manifestation elicited by the
patient and other problems that the pt. may develop so that the student nurse
may prioritize theses problem to be able to render care in a systematic and
logical order.

 Illustrate the pathophysiology of the pt. condition and interrelate with it.

 Apply appropriate nursing intervention and shallot aid the student nurses
produces competent and reliable plan of care to help the patient health and
medical understanding as such conditions.

 Develop specific nursing care plan, measure and attainable, realistic and
time bounded.

 Recommend appropriate discharge planning the patients so that the pt. will
develop knowledge and understanding at home for faster recovery.
 Patient’s Data
PERSONAL DATA
Patients Name: Mrs. Ling
Age: 39
Gender: Female
Birth Date: January 1, 1977
Civil Status: Married
Occupation: None
City Address: Osmeña, Compostella PRU-2
Nationality: Filipino
Religion: Roman Catholic
Educational Attainment: College Undergraduate
Source: Patient’s Chart

CLINICAL/ADMITTING DATA
Date of admission: 4/18/2016
Time of admission: 1:20 PM
Hospital: Davao Medical School Foundation
Ward: Surgical
Room No: 324 - 4
Attending Physician: Dr. Velasco
Admitting Diagnosis: Choledocholithiasis
VITAL SIGNS ON E.R. ADMISSION
Date of Admission: April 18, 2016
Time: 1:20 PM
Temperature: 36.1 Degrees Celsius
Pulse Rate: 78 pm
Respiratory Rate: 20 cpm
Blood Pressure: 120/80 mm/Hg
Height: 143 cm
Weight: 67.5 kg
Genogram
 History of Illness
After establishing rapport with the patient, I asked about her age and what brought
her to the hospital. The patient verbalized that she is 39 years of age and began to
experience pain roughly two months prior admission but did not pay it any mind.
On March 8, 2016, she experienced pain in the back so she went to the hospital for
another checkup. As the days went by, the pain seemed to be getting worse, so on
April 18, 2016 she decided to go back to the hospital and was admitted.
When I asked about her lifestyle and her eating habits, the patient verbalized that
she used to eat fatty foods, especially in her college days. When I asked her if she
has any allergies to medications and if she ever had any surgical procedure done
before, the patient stated “No”. The patient is happily married. She has one son and
owns a sari-sari store. The patient verbalized she is very grateful to GOD that the
surgery went well.

Social Health History

Patient does not consume alcoholic beverages. She stays home majority of her time
with family. Her family are very close and spends time with each other on
Sundays, while going to church.

Family History
The patient’s family does not exhibit any history of Hypertension, Diabetes
Mellitus, Asthma, Cancer, Angina, Abdominal Pain, Flank Pain, Heat and Cold,
Headache.
 Definition of Complete
Diagnosis

1. Choledocholithiasis is the presence of at least one gallstone in the common

bile duct. The stone may be made up of bile pigments or calcium and
cholesterol salts.
Reference: https://www.nlm.nih.gov/medlineplus/ency/article/000274.htm

2. Choledocholithiasis denotes the presence of gallstone within the bile ducts

(common hepatic duct and/or common bile duct).
Reference: http://radiopaedia.org/articles/choledocholithiasis

3. Choledocholithiasis is a disease of the common bile duct which forms at the

junction of the cystic duct from the gallbladder and the common hepatic duct
(from liver).
Reference: http://www.myvmc.com/diseases/common-bile-duct-stone-choledocholithiasis-
cholangitis-obstructive-jaundice/
 Nursing Theories

Environmental Theory
Florence Nightingale
Nursing is an act of utilizing the environment of the patient to assist him in his recovery that
involves the nurse`s initiative to configure environmental settings appropriate for the gradual
restoration of the patient`s health, and that external factors associated with the patient`s
surroundings affect life on biologic and physiologic process and his development.

Rationale:
Us nurses need to give care and comfort to our patient because Florence Nightingale believed
that the environment has a big participation for faster recovery of the patient. Similar to our
patient, Ling, she surrounds herself in a good environment so that she was able to achieve faster
recovery not only with the help of the health care team but as well as the environment.

Nursing Need theory

Virginia Henderson
The Nursing Need Theory was developed by Virginia A. Henderson. To define the unique focus
of the nursing practice, the theory focuses on the importance of increasing the patient’s
independence to hasten their progression in the hospital.

Rationale:
As nurses, we not only provide care for our patients but encourage the patient’s ability to care for
himself. This can only be attained by promoting the patient’s independence. This theory was
applied with our patient, Ling, who just came from having a major operation done,
Cholecystectomy, and was limited in movement due to pain from surgery, by assisting her in
transferring from bed to chair but allowing her to use her arms and legs as well. In due time, she
will gain back her strength and be able to do things on her own again.
Care, Cure, Core Nursing Theory
Lydia Hall
Care, cure and core are the three C’s of Lydia Hall, where care is the sole function of nurses. The
Cure and Core are shared with other members of the health care team.

Rationale:
Us nurses give therapeutic care and provide for teaching and learning activities to our patient.
We have a goal, an intervention and planning for the patient’s care in order for him/her to get
well. This includes giving medication and other means of treatments. We provide therapeutic
care by educating our patient with their health, proper self-care and by diverting the patient’s
attention from their pain to recovery. One way we accomplish this is by providing entertainment
and well-meaning conversations.
 Developmental Milestone

Erikson`s Stage of Psychosocial Development

Erikson’s (1959) theory of psychosocial development has eight distinct stages. Like
Freud, Erikson assumes that a crisis occurs at each stage of development. For Erikson
(1963), these crises are of a psychosocial nature because they involve psychological
needs of the individual (i.e. psycho) conflicting with the needs of society (i.e. social).

According to the theory, successful completion of each stage results in a healthy

personality and the acquisition of basic virtues. Basic virtues are characteristic
strengths which the ego can use to resolve subsequent crises.

Failure to successfully complete a stage can result in a reduced ability to complete

further stages and therefore a unhealthier personality and sense of self.  These stages,
however, can be resolved successfully at a later time.

Stage Description Result Justification

We begin to share Achieved Patient Ling is 39
Intimacy vs. years old and
Isolation ourselves more
married. She is
intimately with very much happy
Young Adulthood others. We explore as a mother of
(ages 18 to 40 relationships only son. She
yrs.) decided to own
leading toward
and run a small
longer term sari-sari store, to
commitments with be able to care for
someone other her son while also
earning an
than a family income.
member.
Successful
completion of this
stage can lead to
comfortable
relationships and a
sense of
commitment,
safety, and care
within a
relationship.
Avoiding
intimacy, fearing
commitment and
relationships can
lead to isolation,
loneliness, and
sometimes
depression.
Success in this
stage will lead to
the virtue of love.
Kohlberg`s Theory
The significance of this theory is focused on the moral development of an
individual. Moving from an orientation of selfishness of the law and order stage,
without passing through the good boy/girl stage. This theory helps us understand
that morality starts from the early childhood years and can be affected by several
factors.

Stage Description Result Justification

Conventional The stage where Achieved Patient is a hands
Morality Law and most adolescents on mother. She
Order and adult frame chose to teach her
their moral only son good
behavior and values and good
understand the moral which can
importance of contribute
others and the goodness in the
basic principles of society.
agency part of the
society has
established values
that should dictate
moral behavior.
Havighurst’s Developmental Task Theory
This theory suggests six stages of life: the infancy of early childhood which lasts
from infancy to early childhood. These are babies who are just learning to walk
and talk and figuring out the world around them. Middle childhood, lasts from ages
6 to age 12. During this time, children become more self-sufficient as they go to
school and make friends. Adolescence, which lasts from age 13 to age 18, comes
with hormonal changes and learning about having a life partner. Early adulthood,
lasts from age 19 to age 30 which involves finding an occupation, as well as
finding that life partner. Middle age, lasts from age 30 to age 60. This is the time
when most people start a family and settle into their adults lives. Later maturity lies
around the age of 60. During this time people adjust to life after work and begin to
prepare themselves for death.

Stage Description Result Justification

Maintaining Achieved Mrs. Ling has a
Middle Age economic living happy family and
(36-60 yrs. old) and performing lives under one
civic social roof with her
responsibility mother & father.
Relating to spouse She is a full time
as a person and mom and wife.
adjusting to She also runs her
physiological very own sari-sari
changes store.
 Physical Assessment
General Survey:

Assessment was done in 1:40 PM of April 20, 2016 at DMSF hospital recovery
room

Vital Signs:

Patient is lying in a supine position and conscious, weak and appears slightly
chilling, fully covered with a blanket. With IVF plain PNSS 1L to run at 100cc x2
cycle.

CEPHALOCAUDAL: From head to toe inspection, we observed the patient’s

willingness to cooperate during entire period of assessment. She is able to stand
but she cannot perform extra activity.

SKIN: The client’s skin is uniform in color, no scars noted unblemished and no
presence of any foul odor. He has a good skin turgor and skin’s temperature is
within normal limit

HAIR: The patient’s scalp is lighter than the color of his skin and has no areas of
tenderness. The hair is evenly distributed thick and it has little white hair no presence of lice,
no scars noted or papules.

MOUTH: The lips of the client are uniformly pink; moist, symmetric and have a
smooth texture. There is no discoloration of the enamels, no retraction of gums,
pinkish in color of gums. The buccal mucosa of the client appeared as uniformly
pink; moist, soft, glistening and with elastic texture. The tongue of the client is
centrally positioned. It is pink in color, moist and slightly rough. There is a
presence of thin whitish coating. The smooth palates are light pink and smooth
while the hard palate has a more irregular texture. The uvula of the client is
positioned in the midline of the soft palate.
NOSE: The patient nose color is same as face-symmetrical appearance- the nose is
at the center no redness in the nasal mucosa no rashes noted no nodules upon
palpation.
EYE: Hair is evenly distributed. The client’s eyebrows are symmetrically aligned
and showed equal movement when asked to raise and lower eyebrows. Eyelashes
appeared to be equally distributed and curled slightly outward. There was no
presence of discharges, no discoloration and lids close symmetrically with
involuntary blinks.

EAR: The Auricles are symmetrical and has the same color with his facial skin.
The auricles are aligned with the outer canthus of eye. When palpating for the
texture, the auricles are mobile, firm and not tender. The pinna recoils when
folded. During the assessment of Watch tick test, the client was able to hear ticking
in both ears.

NECK: The neck is in the center same with facial skin no deformities noted no
nodules noted upon palpation

THORAX: There`s no sign of deformities no discoloration. The chest wall is

intact with no tenderness and masses. There’s a full and symmetric expansion and
the thumbs separate 2-3 cm during deep inspiration when assessing for the
respiratory excursion. The client manifested quiet, rhythmic and effortless
respirations. The spine is vertically aligned. The right and left shoulders and hips
are of the same height.

HEART: There were no visible pulsations on the aortic and pulmonic areas. There
is no presence of heaves or lifts upon auscultation

ABDOMEN: The abdomen of the client .is no discoloration The abdomen has a
symmetric contour. flat or rounded symmetrical bilaterally because of the presence
of incision and op site dressing

UPPER EXTREMITIES: Able to perform full ROM not swelling or

inflammation noted no discoloration. Good skin turgor no nodules noted no rashes
noted; have same size and length coordinated movement no present of tremor.

NAILS: no discoloration no deformities, nails are clean no scar noted no nodules

noted upon palpation.
INSPECTION AND PALPATION OF LOWER EXTRIMITIES: The
extremities are symmetrical in size and length. The muscles are not palpable with
the absence of tremors. They are normally firm or showed smooth, coordinated
movements. There was no presence of bone deformities, tenderness and
swelling. There was no swelling, tenderness and joints move smoothly.
LEGS: Feet no discoloration, no deformities, no rashes noted, no nodules upon
palpation. normal deep tendon reflex upon percussion normal.

GERITOURINARY: Patient verbalized she has normal hair distribution and no

presence of body lice in the genitalia. We don’t include the genitals part of our
patient because we respect the decision and maintain the privacy of the patient.
The menstruation of our patient is normal 3 - 4 days she`s stated. And there`s no
presence of burning sensation when she urinates.
 Anatomy and Physiology
Your digestive system is uniquely constructed to perform its specialized function
of turning food into the energy you need to survive and packaging the residue for
waste disposal. To help you understand how the many parts of the digestive system
work together, here is an overview of the structure and function of this complex
system.

Mouth
The mouth is the beginning of the digestive tract; and, in fact, digestion starts here
when taking the first bite of food. Chewing breaks the food into pieces that are
more easily digested, while saliva mixes with food to begin the process of breaking
it down into a form your body can absorb and use.
Esophagus
Located in your throat near your trachea (windpipe), the esophagus receives food
from your mouth when you swallow. By means of a series of muscular
contractions called peristalsis, the esophagus delivers food to your stomach.
Stomach
The stomach is a hollow organ, or "container," that holds food while it is being
mixed with enzymes that continue the process of breaking down food into a usable
form. Cells in the lining of the stomach secrete a strong acid and powerful enzyme
that are responsible for the breakdown process. When the contents of the stomach
are sufficiently processed, they are released into the small intestine.
Small Intestine
Made up of three segments — the duodenum, jejunum, and ileum — the small
intestine is a 22-foot long muscular tube that breaks down food using enzymes
released by the pancreas and bile from the liver. Peristalsis also is at work in this
organ, moving food through and mixing it with digestive secretions from the
pancreas and liver. The duodenum is largely responsible for the continuous
breaking-down process, with the jejunum and ileum mainly responsible for
absorption of nutrients into the bloodstream.
Contents of the small intestine start out semi-solid, and end in a liquid form after
passing through the organ. Water, bile, enzymes, and mucous contribute to the
change in consistency. Once the nutrients have been absorbed and the leftover-
food residue liquid has passed through the small intestine, it then moves on to the
large intestine, or colon.
Pancreas
The pancreas secretes digestive enzymes into the duodenum, the first segment of
the small intestine. These enzymes break down protein, fats, and carbohydrates.
The pancreas also makes insulin, secreting it directly into the bloodstream. Insulin
is the chief hormone for metabolizing sugar.
Liver
The liver has multiple functions, but its main function within the digestive system
is to process the nutrients absorbed from the small intestine. Bile from the liver
secreted into the small intestine also plays an important role in digesting fat. In
addition, the liver is the body’s chemical "factory." It takes the raw materials
absorbed by the intestine and makes all the various chemicals the body needs to
function. The liver also detoxifies potentially harmful chemicals. It breaks down
and secretes many drugs.
Gallbladder
The gallbladder stores and concentrates bile, and then releases it into the
duodenum to help absorb and digest fats.
Colon (large intestine)
The colon is a 6-foot long muscular tube that connects the small intestine to the
rectum. The large intestine is made up of the cecum, the ascending (right) colon,
the transverse (across) colon, the descending (left) colon, and the sigmoid colon,
which connects to the rectum. The appendix is a small tube attached to the cecum.
The large intestine is a highly specialized organ that is responsible for processing
waste so that emptying the bowels is easy and convenient.
Stool, or waste left over from the digestive process, is passed through the colon by
means of peristalsis, first in a liquid state and ultimately in a solid form. As stool
passes through the colon, water is removed. Stool is stored in the sigmoid (S-
shaped) colon until a "mass movement" empties it into the rectum once or twice a
day. It normally takes about 36 hours for stool to get through the colon. The stool
itself is mostly food debris and bacteria. These bacteria perform several useful
functions, such as synthesizing various vitamins, processing waste products and
food particles, and protecting against harmful bacteria. When the descending colon
becomes full of stool, or feces, it empties its contents into the rectum to begin the
process of elimination.
Rectum
The rectum (Latin for "straight") is an 8-inch chamber that connects the colon to
the anus. It is the rectum's job to receive stool from the colon, to let the person
know that there is stool to be evacuated, and to hold the stool until evacuation
happens. When anything (gas or stool) comes into the rectum, sensors send a
message to the brain. The brain then decides if the rectal contents can be released
or not. If they can, the sphincters relax and the rectum contracts, disposing its
contents. If the contents cannot be disposed, the sphincter contracts and the rectum
accommodates so that the sensation temporarily goes away.
Anus
The anus is the last part of the digestive tract. It is a 2-inch long canal consisting of
the pelvic floor muscles and the two anal sphincters (internal and external). The
lining of the upper anus is specialized to detect rectal contents. It lets you know
whether the contents are liquid, gas, or solid. The anus is surrounded by sphincter
muscles that are important in allowing control of stool. The pelvic floor muscle
creates an angle between the rectum and the anus that stops stool from coming out
when it is not supposed to. The internal sphincter is always tight, except when
stool enters the rectum. It keeps us continent when we are asleep or otherwise
unaware of the presence of stool. When we get an urge to go to the bathroom, we
rely on our external sphincter to hold the stool until reaching a toilet, where it then
relaxes to release the contents.
 The Gallbladder

The gallbladder is a pear-shaped, hollow structure located under the liver and on
the right side of the abdomen. Its primary function is to store and concentrate bile,
a yellow-brown digestive enzyme produced by the liver. The gallbladder is part of
the biliary tract, which are the organs and ducts that create and store bile and
release it into the duodenum (the small intestine).

The gallbladder serves as a reservoir for bile while it’s not being used for
digestion. The gallbladder's absorbent lining concentrates the stored bile. When
food enters the small intestine, a hormone called cholecystokinin is released,
signaling the gallbladder to contract and secrete bile into the small intestine
through the common bile duct.

The bile helps the digestive process by breaking up fats. It also drains waste
products from the liver into the duodenum, a part of the small intestine.
An excess of cholesterol, bilirubin, or bile salts can cause gallstones to form.
Gallstones are generally small, hard deposits inside the gallbladder that are formed
when stored bile crystallizes. A person with gallstones will rarely feel any
symptoms until the gallstones reach a certain size, or if the gallstone obstructs the
bile ducts. Surgical removal of the gallbladder (cholecystectomy) is the most
common way to treat gallstones.

The cystic duct joins the gallbladder to the bile duct and is one of the important
structures needing proper identification and division during a standard
cholecystectomy. The cystic duct may run a straight or a fairly convoluted course.
Its length is variable and usually ranges from 2 to 4 cm. Around 20% of cystic
ducts are less than 2 cm. Hence there may be very little space to put clips or
ligatures. True absence of the cystic duct is extremely rare and if the duct is not
seen is more likely to be hidden. The cystic duct is usually 2–3 mm wide. It can
dilate in the presence of pathology (stones or passed stones). The normal bile duct
is also around 5 mm and hence can look like a mildly dilated cystic duct. In
general, a cystic duct larger than 5 mm (or the need to use a very large clip to
completely occlude the duct) should arouse a suspicion of mistaken identity with
the bile duct before it is clipped or ligated.
The cystic duct joins the gallbladder at the neck and this angle may be fairly acute.
Also the mode of joining may be smooth tapering or abrupt. On the bile duct side
its mode of union shows significant variations. Since such variations are not
uncommon it may not be safe to try and dissect the cystic duct to its junction with
the bile duct. It is important to remember that even in the low insertion variety the
cystic duct rarely goes behind duodenum and therefore a ductal structure passing
behind the duodenum is more likely to be the bile duct itself. Double cystic ducts
are described but are exceedingly rare and therefore two ductal structures entering
the gallbladder should always be viewed with suspicion. Also the cystic duct does
not have vessels traveling on its surface whereas the bile duct has such visible
vessels.

C
holecystitis (ko-luh-sis-TIE-tis) is inflammation of the gallbladder. Your
gallbladder is a small, pear-shaped organ on the right side of your abdomen,
beneath your liver. The gallbladder holds digestive fluid that's released into your
small intestine (bile).
In most cases, gallstones blocking the tube leading out of your gallbladder cause
cholecystitis. This results in a bile buildup that can cause inflammation. Other
causes of cholecystitis include bile duct problems and tumors. If left untreated,
cholecystitis can lead to serious, sometimes life-threatening complications, such as
a gallbladder rupture. Treatment for cholecystitis often involves gallbladder
removal

Etiology
PREDISPOSING PRESENT/ABSENT RATIONALE JUSTIFCATION
FACTOR
Women between
20 - 60 years of
age are twice as
likely to develop
gallstone than
men.

Estrogen
Female increases The patient is
cholesterol levels female.
in bile and
decrease
gallbladder
movement; both
of which can lead
to gallstone
formation.
Many of the
body’s system
and protective
mechanism
Age: 39 Years Old become less The patient is 39
efficient with years old.
age.

Body system and

 processes
become sluggish.
Asians are more
genetically
Race: Asian predisposed to Our patient is
having Filipino.
pigmented stones
compared to
those living in
Western
Countries.
Patient with
diabetes
generally have
high levels of
Diabetes
Mellitus X fatty acids called
Triglyceride.
The patient has no
diabetes.

These fatty acids

increase the risk
for gallstone
formation.
PRECIPATATING PRESENT/ABSENT RATIONALE JUSTIFICATION
FACTOR
Excess estrogen
from pregnancy
Pregnancy
X increases risk of
gallstone
formation.
The patient is not
pregnant.

Birth control
pills appears to
increase
cholesterol levels
Pills in bile, resulting The patient is
in the decrease of using birth control
gallbladder pills.
movement; both
of which can lead
 to gallstone
formation.
The body
Rapid metabolizes fat No rapid weight
Weight
Loss X during weight
loss, which
causes the liver
loss was noted by
the patient.

to secrete extra
cholesterol into
the bile,
contributing to
gallstone
formation.
Obesity most
likely tends to
reduce the
amount of bile
salt in bile,
Pain resulting in more The patient is
cholesterol build obese.
up.

Obesity
decreases
gallbladder
emptying.
Pain that is
localized to the The patient
epigastrium or verbalized that the
RUQ, sometimes pain is present in
Pain radiating to the the RUQ of the
right scapular tip abdomen and
because of radiates to the back
forming of stone of the shoulder.
in the
gallbladder.
When the
common bile
duct becomes Our patient
Chills clogged by a verbalized
 gallstone, there is that it is very cold.
blockage of bile
to the common
bile duct.
Symptoms and
Nausea and complications The patient always
Vomiting result from vomits
effects occurring
within the
gallbladder or
from stones that
escape the
gallbladder to
lodge in the
CBD.
 Symptomatology
SYMPTOMS PRESENT/ABSENT RATIONALE JUSTIFICATION

Pain that is
localized to the
epigastrium or The patient
Pain in the RUQ right upper verbalized that the
that radiates to quadrant, pain is present in
the back of the sometimes the RUQ of the
shoulder radiating to the abdomen and
right scapular tip radiate to the back
because of of the shoulder
forming of stone
in the gall
bladder
Symptoms and
complications
Nausea & result from
Vomitting effects occurring The patient always
within the vomits
gallbladder or
from stones that
escape the
gallbladder to
lodge in the
CBD.
 Jaundice
X Not present with
our patient

Dark Urine
X Not present with
our patient

Fever
X Not present with
our patient

When the
common bile duct
clogged by a gall Our patient said
Chills stone there was a that it’s very cold
blockage of bile in
the common bile
duct
Pathophysiology
 Doctor’s Order
MEDICAL ORDER SHEET
Patient Name: Mrs. Ling
Age: 39 years old
Gender: Female
Admission Date: April 18, 2016

Date and Time Doctor’s Order Rationale

BP- 120/80 mmHg VSq4 -To have a baseline data.
PR- 78 bpm
RR- 20 cpm IVF PNSS 1L @ 100/hr. -To replace fluid balance
patient is NPO or can’t
T- 36.1*c Right arm. drink any fluid.
WT- 67.6 kg
HT- 143 cm -To reduce the formation
LSLF of the stone.

CBC -Blood test used to

evaluate your overall
health and detect a wide
 range of disorder.
Tramadol -Our patient is
experiencing pain,
Tramadol is an analgesic
April 19, 2016 ERCP which relieves pain.
-Is the technique that
uses x-ray to view patient
Ling’s bile and
pancreatic duct.

IVF PNSS 1L @ 100

cc/hr -To replace fluid or
hydration for our patient.

X-RAY for the lungs

-Is an imaging test that
uses radiation to look at
the lungs of our patient.

Anesthesia pre-op
-Is to provide framework
for considering cardiac
risk of non-cardiac
surgery in a variety of the
patient and operative.

Ampimax -Treatment for following

infection.

NPO post- midnight

-To prevent nausea and
vomiting.
 IVF- PNSS 1 L
@100cc/hr
4/19/16
-Replacement of fluid.
ERCP today.

-is the techniques that

Tranexamic. uses X-ray to view
patient, and bile
pancreatic.
-Prevent excessive
Omeprazole. nausea and vomiting.

Metoclopramide. -To prevent excessive

4/19/16 bleeding.

-S/P ERCP.
-is used to treat nausea
-back to the room. and vomiting.

NPO 4hrs. -done ERCP.

6/20/16
-VSq30 once stable. -Prevent nausea and
vomiting after the
-Ampimax procedure.
-for monitoring.
-UDCA -antibacterial.

-Omeprazole -To help dissolve stones

from the CBD.
-Prevent excessive
-Tranexamic Acid
 bleeding.

-to treat nausea and

vomiting.

Diagnostic and Lab Results

Name: Mrs. Ling Physician: Dr. Velasco
Date: April 18, 2016 Room: 324 – 4

CHEMICAL CHEMISTRY
Test Name Result Unit Range Rationale Justificatio
Reference n
SGPT/ALT # 152 u/L 0.00-3400

Remarks: Sample run twice-control in range.

BLOOD CHEMISTRY
Test Results Unit Normal Value Rationale
Sodium 135.6 mmol/L 135-148 Used to
detect
abnormal
concentratio
n of the
urine.
Potassium 3.57 mmol/L 3.5-5.3 This test
measures the
amount of
potassium in
 fluid protein.
Calcium 1.15 mmol/L 1.13-1.15 Is ordered to
screen for
diagnose.
Chlorine mmol/L 95-108 Is used to
detect
abnormal
concentratio
n of chloride.
Magnesium mmol/L 0.74-0.99 Used to
measure the
level of
magnesium
in the blood.

HEMATOLOGY
Test Result Normal Clinical Indication
Values
Hemoglobin 121 120- Measures the amount of
150 Hemoglobin in your blood
hemoglobin is a protein in your red
blood cells and used to detect low
hemoglobin and describe as being
anemic, nutritional iron
polycythemia etc.
Hematocrit 0.36 0.38- The ratio of the volume of red blood
0.40 cells to the total volume of blood.

Decreased,
Bleeding, bone marrow
Nutritional problems.

When increase COPD congenital

heart disease or severe dehydration.

Erythrocytes 4.20 4.0-6.0 Red blood cells (RBCs), also called

erythrocytes, are the most common
type of blood cell and the vertebrae
 organism's principal means of
delivering oxygen (O2) to the body’s
tissues.

Decrease chronic heart failure sickle

cell anemia.

Spherocytosis, High Fibrogen

Anemia.

Leukocytes 6.1 5.0- A colorless cell that circulates in the

10.0 blood and body fluids and is
involved in counteracting foreign
substances and disease.

Decreased

 Leukemia
 Tuberculosis
 Hyperplenism
MCV 85 80-100

MCH 29 27-32

MCHC 34 32-36

Neutrophil 0.56 0.45- Neutrophil (also known

0.65 as neutrophils or
occasionally neutrocytes) are the
most abundant type
of granulocytes and the most
abundant (40% to 75%) type
of white blood cells in most
mammals. They form an essential
part of the innate immune system.


  Decrease:
 Ulcers
 Abscesses (collections of pus)
 Rashes
 Wounds that take a long time
to heal.

Lymphocytes 0.35 0.20- A form of small leukocyte (white

0.35 blood cell) with a single round
nucleus, occurring especially in the
lymphatic system.

Decrease

The number of lymphocytes can

temporarily decrease during

 Certain viral infections (such

as influenza and hepatitis)

 Fasting

 Times of severe physical

stress

 Use of corticosteroids (such

as prednisone)

 Chemotherapy and/or
radiation therapy for cancer

Monocyte 0.06 0.02- Monocytes are a type of white

0.06 blood cells, or leukocyte. They are
the largest type of leukocyte,
and differentiates into: macrophages
; 
dendritic cells; and foam cells. As a
 part of the vertebrate innate immune
system monocytes also influence the
process of adaptive immunity.

Decrease:

When monocytes decrease

infections include flu-like
symptoms,
coughing,
sore throat,
chills and fever,
frequent urination.

Eosinophil 0.03 0.02- Eosinophils are a type of disease-

0.4 fighting white blood cell.

Decrease

Chronic myelogenous leukemia,

Churg-Strauss syndrome, Crohn's
disease, Drug allergy, Eosinophilic
leukemia, Hay fever, Hodgkin's
lymphoma (Hodgkin's disease)

Basophil 0.00 0.00- Basophil is a type of white blood

0.01 cell. They are the least common of
the granulocytes, representing about
0.5 to 1% of circulating white blood
cells. But they are the largest
granulocytes. They are responsible
for inflammatory reactions during
immune response of acute and
chronic allergic diseases.
 Decreased
in anaphylaxis,
asthma,
atopic dermatitis
hay fever

Thrombocytes 235 150-450 Platelets, also

called thrombocytes (throm
b + cyte, "blood clot cell"),
are a component of blood
whose function is to stop
bleeding by clumping and
clotting blood vessel
injuries.

Decreased
Bruising easily.

Tiny red spots, or petechiae,

under the skin.

Unusual bleeding from the

gums or nose.

A lot of or long-lasting
bleeding from a small cut or
injection site.

Blood in the urine, which

may look pink, red or brown
blood in the stool or black-
colored stool.

Vomiting blood or
something that looks like
coffee grounds.

Vaginal bleeding that is

different from and lasts
 longer than the normal
menstrual period.

Constant headache, blurred

vision or change in level of
consciousness.

URINALYSIS
Parameters Result Results Rationale
Range Unit Reference Reference
Range
Physical Examination
Color Light Yellow The color of the
urine is helpful in
predicting the
concentration of
the specimen.
Clarity Clear Useful in
predicting the
presence of the
contaminants such
as cells or mucus.
Chemical Analysis
pH 7.0 Urine pH level test
is a test that
analyzes the
acidity or
alkalinity.
Specific Gravity 1.0% Is a measure of the
concentration of
the solute in the
urine.
Glucose Negative Test measures the
level of glucose or
sugar in your
urine.
Protein Negative A protein urine
 test measures the
amount of the
protein in the
urine.
Urine
Flowcytometry
WBC 3 0-17/uL 1 0-3 Is help to diagnose
and infection.
RBC 1 0-17/uL 0 0-3 To check if there
was bleeding.
Epith Cells 3 0-17/uL 1 0-3 Used in guided
tissue
regeneration.
Cast 0-1/uL 0 0-03 Urinary casts are
tiny tube shaped
particles that can
be found when
urine is examined
under the
microscope.
Bacteria 115 0-278/uL 21 0-50 To check what
specific bacteria.
Mucus Thread To identify if there
was a serious
condition that
medical needs.
Crystal Is the rationale for
urinary
alkalization in
patient.
 Drug Study
SULTAMICILLIN

Brand: Ampimax, Alfasid, Ampisid, Amplipen, Bactesul, Bactesyn, Bitammon,

Combicid, Devasid, Duobak, Duobaktam, Duocid, Fipexiam, Nobecid, Picyn,
Sulamp, Sulbamox IBL, Sulcid, Sultamat, Sultamicilina, Sultasid, Sultibac, Unacid
PD oral, Unasyna, Viccillin-SX, Ampigen SB, Begalin, Bitammon, Sinif, Unacid
PD oral, Unasyn
Generic: Sultamicillin Tocilate
Classification: antibiotic

Dosage: Oral dosage

For treating Urinary Tract infections, respiratory tract infections and Otitis media:

In case of adults: 375 to 750 mg to be used at regular intervals.

For children below 30 Kg: 25 to 50 mg per kilogram per day in 2 separated doses;

For children above 30 Kg: 375 to 750 mg to be used at regular intervals.

Uncomplicated gonorrhea

Adult: 2.25 g of Sultamicillin along with probenecid 1 g.

Mode of Action: Chemical Effect: Inhibits beta lactamases in penicillin-resistant

microorganisms and it acts against sensitive organisms during the stage of active
multiplication by inhibiting biosynthesis of cell wall mucopeptide Therapeutic
Effect: Kills susceptible bacteria Oral Onset: unknown Peak: 2 hr Duration: 6-8 hr
Indication: Uncomplicated gonorrhea, Otitis media, Respiratory tract infection
Contraindication: hypersensitive to drug or any other penicillins, use cautiously in
patients with other drug allergies (especially to cephalosporins) because of possible
cross-sensitivity and in those with mononucleosis because of high risk of
maculopapular rash
Side Effects: CNS: thrombophlebitis, vein irritation GI: nausea, vomiting, diarrhea
glossitis, stomatitis, black hairy tongue, enterocolitis Hematologic: anemia,
thrombocytopenia, purpura, eosinoophilia, leukopenia, agranulocytosis Skin: pain
at injection site Other: hypersensitivity reactions, anaphylaxis, overgrowth of
nonsusceptible organisms
Nursing Responsibilities:
1. Assess hypersensitivity to drug or other penicillins
2. Assess patient’s infection before starting therapy
 3. Obtain specimen for culture and sensitivty
References/Source: Mosby’s Nursing Drug Reference 2001

OMEPRAZOLE

Brand: Losec, Prilosec, Prilosec OTC, Zegerid

Generic: Omeprazole
Classification: substituted benzimidazole
Dosage: Adults with GERD who are unresponsive to H2-receptor antagonist: 20
mg P.O. daily for 4 – 8 weeks. May increase dosage to 40mg daily if needed and
extend therapy up to 12 weeks.
Action: Chemical effect: Inhibits acid (proton) pump and
Children 2 to 16 years weighing less than 20 kg: 10 mg P.O daily
Children 2 to 16 years weighing 20 kg or more: 20 mg P.O daily
Indication: Erosive esophagitis; symptomatic, poorly responsive gastroesophageal
reflux disease (GERD); Pathologic hypersecretory conditions (such as Zollinger-
Ellison syndrome); Duodenal ulcer; Gastric ulcer; Heartburn on 2 or more days per
week; Posterior laryngitis
Contraindications: Contraindicated in patients hypersensitive to the drug or any of
its components. In pregnant women, use cautiously. In breast-feeding women, use
cautiously; it’s unknown if the drug appears I breast milk. In children ages 2 to 16
years, drug may be used to treat GERD, erosive esophagitis, and for maintenance
of healing in erosive esophagitis (tablets and capsules only).
Drug Interactions: Ampicillin esters, iron derivatives, ketoconazole: May decrease
absorption. Give separately. Clarithromycin: May increase level of either drug.
Monitor patient for drug toxicity. Diazepam, phenytoin, warfarin: May decrease
hepatic clearance of these drugs, possibly leading to increased levels. Monitor
patient closely. Sucralfate: May delay absorption and reduce omeprazole
bioavailability. Separate administration times by 30 minutes or more.
Adverse Effects: dizziness, headache, abdominal pain, constipation, diarrhea,
flatulence, nausea, vomiting, back pain, cough, rash

Nursing Responsibilities:
1. Assess patient’s condition before starting therapy and regularly thereafter to
monitor drug’s effectiveness.
2. Be alert for adverse reactions and drug interactions.
3. If adverse GI reaction occurs, monitor patient’s hydration.
4. Assess patient’s and family’s knowledge of drug therapy
5. Give tablets or capsules 30 minutes before meals; powder for oral
suspension 1 hour before meals.
6. Use 2 tbs of water to mix 1 packet of powder for oral suspension; don’t use
any other liquids or food
7. Lower doses aren’t needed for patient’s with renal or hepatic impairment
8. Explain importance of taking drug exactly as prescribed.
9. Warn patient not to crush or chew tablets or capsules.
 10.Explain to patient how to reconstitute powder for oral suspension: Empty
packet contents into a small cup containing 2 tbsp. of water; stir well and
drink immediately. Refill cup with water and drink.

References/Sources: Springhouse Nurse’s Drug Guide 2008 pg.921

TRAMADOL

Generic Name: Tramadol

Brand Name: Ultram, Ultram ER
Indications: Carbamazepine (Tegretol, Tegretol XR, Equetro Carbatrol)reduces the
effect of tramadol by increasing its inactivation in the body. Quinidine
(Quinaglute, Quinidex) reduces the inactivation of tramadol, thereby increasing the
concentration of tramadol by50%-60%. Combining tramadol with
monoamineoxidase inhibitors (for example, Parnate) or selective serotonin
inhibitors (SSRIs, for example, fluoxetine Prozac]) may result in severe side
effects such as seizures or a condition called serotonin syndrome.
Contraindications: Tramadol may increase central nervous system and respiratory
depression when combined with alcohol, anesthetics, narcotics, tranquilizers or
sedative hypnotics.
Actions: Tramadol is used in the management of mode rate to mode rate severe
pain. Extended release tablets are used for moderate to moderately severe chronic
pain in adults who require continuous treatment for an extended period.
Side effects: Tramadol is generally well tolerated, and side effects are usually
transient. Commonly reported side effects include nausea, constipation, dizziness,
headache, drowsiness, and vomiting. Less commonly reported side effects include
itching, sweating, dry mouth, diarrhea, rash, visual disturbances, and vertigo. Some
patients who received tramadol have reported seizures. Abrupt withdrawal of
tramadol may result in anxiety, sweating, insomnia, rigors, pain, nausea, diarrhea,
tremors, and hallucinations.
Nursing Responsibilities:
1. Assess type, location, and
intensity of pain before and 2-3 hr (peak) after administration.
2. Assess BP & RR before and periodically during administration. Respiratory
depression has not occurred with recommended doses.
3. Assess bowel function routinely. Prevention of constipation should be
instituted with increased intake of fluids and bulk and with laxatives to
minimize constipating effects.
4. Assess previous analgesic history. Tramadol is not recommended for
patients dependent on opioids or who have previously received opioids for
more than 1 wk; may cause opioid withdrawal symptoms.
5. Prolonged use may lead to physical and psychological dependence and
tolerance, although these may be milder than with opioids. This should not
prevent patient from receiving adequate analgesia. Most patients who
receive tramadol for pain d not develop psychological dependence. If
tolerance develops, changing to an agonist may be required to relieve pain.
6. Tramadol is considered to provide more analgesia than codeine 60 mg but
less than combined aspirin650mg/codeine 60 mg for acute postoperative
pain.
7. Monitor patient for seizures.
8. May occur within recommended dose range. Risk increased with higher
doses and inpatients taking antidepressants (SSRIs, tricyclics, or Mao
inhibitors), opioid analgesics, or other drugs that decrease the seizure
threshold.
 9. Overdose may cause respiratory depression and seizures. Naloxone
(Narcan)may reverse some, but not all, of the symptoms of overdose.
Treatment should be symptomatic and supportive. Maintain adequate
respiratory exchange.
10.Encourage patient to cough and breathe deeply every 2 hr to prevent
atelactasis and pneumonia.

METOCLOPRAMIDE

Brand Name: Plasil

Generic Name: Metoclopramide

Indication: prevention of chemotherapy-induced emesis, treatment of postsurgical

and diabetic gastric stasis, facilitation of small bowel intubations in radiographic
procedures, management of esophageal reflux, treatment and prevention of
postoperative nausea and vomiting when nasogastric suctioning is undesirable
Drug Classification: Anti-emetics

Mechanism of Action: it blocks dopamine receptors and makes the GI cells more
sensitive to acetylcholine, leading to increased GI activity and rapid movement of
food through the upper GI tract.

Dosage: Tab Adult: 1tab tid, Syr Adult: 10 ml tid, children: 5-14 yr 2.5-5 mg tid,
3-5 yr 2mg bid

Special precaution: patients with history of depression, diabetic patients, pregnancy

and lactation children and geriatric patients

Pregnancy risk category: B

Adverse reaction: CNS: drowsiness, extrapyramidal reactions, restlessness,

anxiety, depression, irritability, tardive dyskinesia CV: arrhythmias, hypertension,
hypotension GI: constipations, diarrhea, dry mouth, nausea Endo: gynecomastia

Contraindicated to: hypersensitivity, possible obstruction or hemorrhage, history of

seizure disorders, pheochromocytoma, Parkinson’s disease

Form: solution (oral concentrate), syrup (sugar free), tablet, ampule

Nursing responsibilities:
1. Assess client for abdominal pain distention, bowel sound
2. Assess client for extrapyramidal reactions
3. Monitor for tardive dyskinesian

TRANEXAMIC ACID
Brand Name: Hemostan

Generic Name: Tranexamic Acid

Indications: antihemorrhagic and antifibrinolytic for effective hemostasis in

various surgical and clinical cases, in traumatic injuries, post-tooth extraction and
other dental procedures.

Drug Classification: Antihemophilic Agent

Mechanism of Action: Forms a reversible complex that displaces plasminogen

from fibrin resulting in inhibition of fibrinolysis, it also inhibits the proteolytic
activity of plasmin

Dosage: Capsule: 250 – 500 mg tid-qid. Injections: 250-500mg IM, or by slow IV

inj bid tid. During or after operation, 500-2500mg if necessary by IV drip.

Special precaution: Not advisable to use for prolonged periods in patients

predisposed to thrombosis. Not recommended for prophylaxis during pregnancy
and before delivery. Opthalmic exam before and during therapy required if patient
is treated beyond several days; caution in patients with cardiovascular, renal,
cerebrovascular disease.

Pregnancy risk category: B

Adverse reaction: GI disorders: nausea, vomiting. CNS: anorexia, headache

impaired renal insufficiency, hypotension when IV injection is too rapid.
Contraindication: patients predisposed to thrombosis. Prophylaxis during
pregnancy and before delivery.

Form: 100mg/ml (10 mL) injection; 500mg tablet

Nursing Responsibility:
1. Dosage modification required in patients with renal impairment
2. Watch out for any signs of bleeding

Reference/Sources: https://www.scribd.com/doc/201340912/Tranexamic-Acid-
drug-study

URSODEOXYCHOLIC ACID

Brand:
Generic Name: Ursodiol, UDCA
Classification:
Indications: Note: Bracketed information in the indications section refers to uses
that are not included in U.S product labeling
Mechanism of Action: Anticholelithic—Although the exact mechanism of
ursodiol's anticholelithic action is not completely understood, it is known that
when administered orally ursodiol is concentrated in bile and decreases biliary
cholesterol saturation by suppressing hepatic synthesis and secretion of cholesterol,
and by inhibiting its intestinal absorption. The reduced cholesterol saturation
permits the gradual solubilization of cholesterol from gallstones, resulting in their
eventual dissolution.
Adverse Effects: Ursodiol increases bile flow. In chronic cholestatic liver disease,
ursodiol appears to reduce the detergent properties of the bile salts, thus reducing
their cytotoxicity. Also, ursodiol may protect liver cells from the damaging activity
of toxic bile acids (e.g., lithocholate, deoxycholate, and chenodeoxycholate), which
increase in concentration in patients with chronic liver disease.
Precautions to Consider

Cross-sensitivity and/or related problems

Patients sensitive to other bile acid products may be sensitive to ursodiol

also {01} {13}.

Carcinogenicity/Tumorigenicity

Studies in rats with intrarectal instillation of lithocholic acid and other metabolites
of ursodiol and chenodiol did not show evidence of tumorigenicity, except when
these substances were administered in conjunction with a carcinogenic agent.
Epidemiologic studies suggest that bile acids might be involved in the pathogenesis
of human colon cancer in patients who have undergone a cholecystectomy;
however, conclusive evidence is lacking. {01} {05}

Pregnancy/Reproduction

Pregnancy—
Adequate and well-controlled studies have not been done in humans {05}.

Studies in rats at doses 20 to 100 times the human dose, and in rabbits at doses 5
times the human dose, have not shown that ursodiol causes adverse effects in the
fetus.

FDA Pregnancy Category B.

Breast-feeding
It is not known whether ursodiol is distributed into breast milk {05} {13}. However,
problems in humans have not been documented.

Pediatrics
Appropriate studies on the relationship of age to the effects of ursodiol when used
as an anticholelithic have not been performed in the pediatric population. However,
studies performed to date in children and infants with cholestatic liver disease and
biliary atresia have not demonstrated pediatrics-specific problems that would limit
the usefulness of ursodiol in children. {33} {34} {40}

Geriatrics
Appropriate studies on the relationship of age to the effects of ursodiol have not
been performed in the geriatric population. However, geriatrics-specific problems
that would limit the usefulness of this medication in the elderly are not
expected. {13}

Drug interactions and/or related problems

The following drug interactions and/or related problems have been selected on the
basis of their potential clinical significance (possible mechanism in parentheses
where appropriate)—not necessarily inclusive (» = major clinical significance):
Reference/Sources: http://www.drugs.com/mmx/ursodeoxycholic-acid.html
Medical & Surgical Management
ERCP (Endoscopic Retrograde Cholangio-Pancreatography) ERCP is a
procedure that enables your physician to examine the pancreatic and bile ducts. A
bendable, lighted tube (endoscope) about the thickness of your index finger is
placed through your mouth and into your stomach and first part of the small
intestine (duodenum). In the duodenum a small opening is identified (ampulla) and
a small plastic tube (cannula) is passed through the endoscope and into this
opening. Dye (contrast material) is injected and X-rays are taken to study the ducts
of the pancreas and liver.

PROCEDURE
You lie on your side on a couch. The doctor will ask you to swallow the first
section of the endoscope. Modern endoscopes are quite thin (thinner than an index
finger) and quite easy to swallow. The doctor then gently pushes it down your
esophagus into your stomach and duodenum.

The doctor looks down the endoscope via an eyepiece or on a TV monitor which is
connected to the endoscope. Air is passed down a channel in the endoscope into
the stomach and duodenum to make the lining easier to see. This may make you
feel 'full' and want to belch.

The endoscope also has a 'side channel' down which various tubes or instruments
can pass. These can be manipulated by the doctor who can do various things. For
example:

Inject a dye into the bile and pancreatic ducts. X-ray pictures taken immediately
after the injection of dye show up the detail of the ducts. This may show narrowing
(stricture), stuck gallstones, tumors pressing on the ducts, etc.
Take a small sample (biopsy) from the lining of the duodenum, stomach, or
pancreatic or bile duct near to the papilla. The biopsy sample can be looked at
under the microscope to check for abnormal tissue and cells.
If the X-rays show a gallstone stuck in the duct, the doctor can widen the opening
of the papilla to let the stone out into the duodenum. A stone can be grabbed by a
'basket' or left to be passed out with the stools (feces).
If the X-rays show a narrowing or blockage in the bile duct, the doctor can put a
stent inside to open it wide. A stent is a small wire-mesh or plastic tube. This then
allows bile to drain into the duodenum in the normal way. You will not be aware of
a stent,
The endoscope is gently pulled out when the procedure is finished. An ERCP can
take anything from 30 minutes to over an hour, depending on what is done.

CHOLECYSTECTOMY
Cholecystectomy (koh-luh-sis-TEK-tuh-me) is a surgical procedure to remove
your gallbladder — a pear-shaped organ that sits just below your liver on the upper
right side of your abdomen. Your gallbladder collects and stores bile — a digestive
fluid produced in your liver.

Cholecystectomy may be necessary if you experience pain from gallstones that

block the flow of bile. Cholecystectomy is a common surgery, and it carries only a
small risk of complications. In most cases, you can go home the same day of your
cholecystectomy.

Cholecystectomy is most commonly performed by inserting a tiny video camera

and special surgical tools through four small incisions to see inside your abdomen
and remove the gallbladder. Doctors call this laparoscopic cholecystectomy. In
some cases, one large incision may be used to remove the gallbladder. This is
called an open cholecystectomy.

PROCEDURE
Placement of ports and instruments
A 1.5-cm longitudinal incision is made at the inferior aspect of the umbilicus, then
deepened through the subcutaneous fat to the anterior rectus sheath. A Kocher
clamp is used to grasp the reflection of the linea alba onto the umbilicus and
elevate it cephalad.
A 1.2-cm longitudinal incision is made in the linea alba with a No. 15 blade. Two
U stitches, one on either side of the fascial incision, are placed with 0 polyglactin
suture on a curved needle.
 The peritoneum is elevated between two straight clamps and incised so as to afford
safe entry into the abdominal cavity. An 11-mm blunt Hasson trocar is placed into
the abdominal cavity, and insufflation of carbon dioxide is initiated to a maximum
pressure of 15 mm Hg.
A 1.2-cm incision is made three fingerbreadths below the xiphoid process and
deepened into the subcutaneous fat. An 11-mm trocar is advanced into the
abdominal cavity under direct vision (see the image below) in the direction of the
gallbladder through the abdominal wall, with care taken to enter just to the right of
the falciform ligament.
The table is then adjusted to place the patient in a reverse Trendelenburg position
with the right side up to allow the small bowel and colon to fall away from the
operative.

Treatment
Treating gallstones in the bile duct focuses on relieving the blockage. These
treatments may include:

 stone extraction
 fragmenting stones (lithotripsy)
 surgery to remove the gallbladder and stones (cholecystectomy)
 surgery that makes a cut into the common bile duct to remove stones or help
them pass (sphincterotomy)
 biliary stenting
The most common treatment for gallstones in the bile duct is biliary endoscopic
sphincterotomy (BES). During a BES procedure, a balloon- or basket-type device
is inserted into the bile duct and used to extract the stone or stones. About 85
percent of bile duct stones can be removed with BES (Attasaranya et al., 2008).
If a stone does not pass on its own or cannot be removed with BES, doctors may
use lithotripsy. This procedure is designed to fragment stones so they can be
captured or passed easily.

Patients with gallstones in the bile duct and gallstones still in the gallbladder may
be treated with cholecystectomy (gallbladder removal). While performing the
surgery, your doctor will also inspect your bile duct to check for remaining
gallstones.

If stones cannot be removed completely or you have a history of gallstones causing

problems but do not wish to have your gallbladder removed, your doctor may place
biliary stents (tiny tubes to open the passage). These will provide adequate
drainage and help prevent future choledocholithiasis episodes. The stents can also
prevent biliary sepsis (inflammation) and infection.

Discharge Planning & Health

Teaching
M edicine
  Advice patient to continue taking his prescribed medications such
as: Sultamicillin and Tramadol.

E nvironmental and Exercise

 Maintain a quiet and pleasant environment to promote relaxation.
 Provide clean and comfortable environment.
 Encourage walking every day.

T reatment
 Continue home medications.
 Teach patient about wound care.
 Encourage patient to take multivitamins for immunity.

H ealth Teaching
 Provide written and oral instruction about wound care, activity,
diet recommendations, medication and follow up visits.
 Instruct patient to limit his activity for 24 to 48 hrs. after
discharge.

O ut Patient Follow Up
 Patient will be advised to go back in the hospital in a specific date
to have follow–up checkup after discharge.
 Consult doctors for are any problems or complication encountered.

D iet
 Encourage patient to increase protein intake for tissue repair.
 Advice patient to eat smaller-than-normal amount of at mealtime.

S piritual
 Encourage patient to communicate with God.
 Encourage patient to communicate with other people.

Nursing Care Plan

DATE ASSESSMEN NURSING N PLANNING IMPLEMENTATION/ EVALUATION
 AND T DIAGNOSIS E INTERVENTION
TIME E
D
April 19, Subjective: Acute pain C At the end of 2-4 1.) Establish GOAL MET:
2016 related to O hours of my care, rapport with At the end of 4
8:00 AM Patient surgical G patient will be patient. hours of my
verbalized incision N relieved from pain as R: Gain trust shift, patient was
“sakit ilihok secondary to I evidenced by: for cooperation. able to verbalize
akong kilid sa cholecystecto T 2.) Monitor VS. pain scale of 3
tuo.” my I a.) Verbalizing R: To have and be able to
V pain scale baseline data. move without
E of 3 or 3.) Provide privacy complaining of
Objective: below to patient. pain.
P R: Respect for
 Pain E b.) be able to individual’s
scale R move more status.
of 8 C without 4.) Teach patient
E discomfort to do proper
 Genera P handwashing.
lized T R: Prevent
weakn U spread of
ess A microorganism
noted L s.
5.) Note response
 Restles P to medication
sness A and report to
noted T physicians if
T pain is not
 Difficu E being relieved.
lty R R: Severe pain
sleepin N not relieved by
g routine
noted measures may
indicate
developing
complication or
need further
intervention.
6.) Promote bed
rest allowing
patient to
assume
position of
comfort.
R: Reduces
irritation and
bed sores.
7.) Instruct patient
not to touch the
incision.
R: Avoid
infection.
8.) Instruct patient
to do 15 min
ROM
 exercises.
R: Strengthen
muscles.
Improve blood
circulation.

DATE ASSESSMEN NURSING N PLANNING IMPLEMENTATION/ EVALUATION

AND T DIAGNOSIS E INTERVENTION
TIME E
D
April 19, Subjective: Deficient A After the end of 1.) Establish GOAL MET:
2016 knowledge C my shift, patient rapport. At the end of shift,
8:00 AM Patient about self- T should: R: Gain trust patient fully
verbalized care activities I and cooperation. understood simple
“Sige related to V a.) Verbaliz 2.) Monitor VS. techniques of
matandog incision care. I e R: To have proper self-care
akong kilid, T understa baseline data. and demonstrated
nahadlok ko Y nding of 3.) Teach patient it independently by
basin ma self-care proper performing self-
unsa.” E routine. handwashing care routines and
X b.) Avoid technique. exercises.
Objective: E inapprop R: Prevent
R riate spread of
 Verbal C actions microorganisms.
ization I that may 4.) Discuss with the
of S cause patient how to
proble E irritation follow self-care
m or routine.
P infection. R: To help
 Grima A patient cope
ce face T easier, step by
as T step.
observ E 5.) Instruct patient
ed R to eat proper
N diet.
 Cohere R: Maintain
nt good health.
6.) Provide privacy
for the patient.
R: Respect
individual’s
status.
7.) Encourage
patient to take
simple exercise.
R: Help
flexibility and
muscle strength.
8.) Instruct patient
to take a rest
frequently.
R: To maintain
good mood and
 have peace of
mind.
9.) Provide clean
and fresh
environment.
R: Promote
mental wellness.

DATE ASSESSMEN NURSING N PLANNING IMPLEMENTATION/ EVALUATION

AND T DIAGNOSIS E INTERVENTION
TIME E
D
April 19, Subjective: Fear/Anxiety S After 2-4 hours of 1.) Establish rapport GOAL MET:
2016 related to lack E my care, patient R: Gain trust and After 4 hours of
8:00 AM “Naga-kulba ko of L will be able to cooperation. nursing intervention
basig magka understandin F identify to prevent 2.) Teach patient the patient was able
problema g of - or reduce risk of proper to achieve timely
akong opera.” diagnosis, PE infections as handwashing wound healing and
diagnostic R evidenced by: technique free from signs and
Objective: tests, and C R: Handwashing symptoms of
treatments EP a.) Achieve is the single most infection.
 Facial T timely effective way to
grimac IO wound prevent
e noted N healing infection.
b.) Free 3.) Instruct on
 Cohere S from proper wound
nt E signs and care.
L symptom R: For first line
 Patient F s of of defense
is - infection against cross-
cooper C contamination.
ative O 4.) Encourage to eat
to give N vitamin C rich
inform C foods like dark
ation E leafy greens,
related P peas and papaya.
to her T R: Vitamin C
conditi helps boost
on P immune system.
A 5.) Provide privacy
T for the patient.
T R: Respect
E individual’s
R status.
N 6.) Wash puncture
site with mild
soap and water.
R: Avoid
infection that can
cause pain.
7.) Encourage
patient to
exercise and not
to stay in bed
 majority of time.
R: Help
flexibility and
muscle
strengthening.
8.) Instruct patient
to eat proper
diet.
R: Acquire
adequate
nutrition.
9.) Instruct patient
to sleep at least 8
hours.
R: Sleep
promotes good
mood and well-
being.

DATE ASSESSMEN NURSING N PLANNING IMPLEMENTATION/ EVALUATION

AND T DIAGNOSIS E INTERVENTION
TIME E
D
April 19, Subjective: Risk for N At the end of my 1.) Establish rapport GOAL MET:
2016 electrolyte U shift, the patient R: Gain trust and At the end of my
8:00 AM “Tag gagmay imbalance T will be able to cooperation. shift, patient was
lang mainom related to R maintain 2.) Monitor VS. able to maintain
nako na tubig.” decrease in I electrolyte R: To have electrolyte balance
bodily fluid. T balance as baseline data. as evidenced by:
Objective: IO evidenced by: 3.) Instruct patient
N to drink water. a.) Good skin
 100ml A a.) Adequate R: Avoid turgor.
previo L urinary dehydration. b.) Stable VS.
us output 4.) Monitor IV c.) Normal
shift: M b.) Good Fluids. Urinary
Urine E skin R: Measure output of
output T trugor intake and 30ml/hr.
is less A output.
than B 5.) Collaborate with
normal O physicians in the
(30ml/ L fluid therapy.
hr) I R: To have a
C good
 Urine manifestation of
color P a patient illness.
is deep A 6.) Test skin turgor.
orange T R: Check
T hydration.
 Drynes E 7.) Provide patient
s of R privacy.
skin N R: Respect
noted individual’s
status.
 8.) Observe for
 Drynes signs of
s of dehydration.
lips R: To acquire
noted baseline data
 Deepn 9.) Administer
ess of medication.
eyes R: For fast
noted recovery.

DATE ASSESSMEN NURSING N PLANNING IMPLEMENTATION/ EVALUATION

AND T DIAGNOSIS E INTERVENTION
TIME E
D
April 19, Subjective: Risk for N After 2-4 hours of 1.) Establish rapport GOAL MET:
2016 imbalance U care, patient will R: Gain trust and After 4 hours of
8:00 AM “Wala ko’y nutrition less T increase appetite cooperation. nursing intervention,
gana mukaon”, than body R as evidenced by: 2.) Monitor VS. patient verbalized:
as verbalized by requirements I R: To have
the patient. related to lack T a.) Eating baseline data. a.) I ate half of
of appetite. IO her next 3.) Encourage my meal
Objective: N meal patient to eat for lunch.
A b.) Eating proper diet. b.) I am more
 Pallor L small R: Acquire eager to
noted snacks in nutritional needs. eat.
M between 4.) Instruct patient
 Weakn E meals to rest.
ess T R: Promote good
noted A mood and well-
B being.
 Fatigu O 5.) Teach proper
e L hygiene.
I R: Risk for
 Did C cross-
not eat contamination.
breakf P
ast A
T
T
E
R
N

Prognosis
CRITERIA POOR FAIR GOOD JUSTIFICATION
 (1) (2) (3)
Duration of 2 Days before
Illness  operation

Onset of Illness  It takes time for

her to go to the
hospital and know
the findings
Precipitating 
Factors

Compliance  Never refuse to

take medication
Predisposing  She is 39 high risk
Factors to have develop
gallstones

Age  High risk to

develop gallstone
disease.
Environment  She has a very
supportive family,
relatives and have
a good
environment.

References
http://www.uptodate.com/contents/choledocholithiasis-clinical-manifestations-diagnosis-
and-management
https://www.nlm.nih.gov/medlineplus/ency/article/000274.htm
http://radiopaedia.org/articles/choledocholithiasis
http://www.myvmc.com/diseases/common-bile-duct-stone-choledocholithiasis-
cholangitis-obstructive-jaundice/
http://www.drugs.com/mmx/ursodeoxycholic-acid.html
https://www.scribd.com/doc/201340912/Tranexamic-Acid-drug-study

Springhouse Nurse’s Drug Guide 2008 pg.921

Mosby’s Nursing Drug Reference 2001
http://www.healthline.com/human-body-maps/gallbladder

Acknowledgement
In the process of putting this research together, we would like to thank first and
foremost, our patient and her family for trusting us and providing us with the
information needed for our case study; the DMSF Nursing Staff, for making us feel
welcome and aiding us with whatever we needed in learning by allowing us to
acquire more information from our patient’s diagnosis; and to our beloved dean,
Mrs. Brenda Morales R.N M.N, our clinical instructors, Mr. Richard Dionisio R.N.
and Miss Princess Recabe R.N. who have relentlessly encouraged us to give our
best and guiding us throughout the course. This experience has hastened our skills
in assessing our patients, writing up Nursing Care Plans, acquiring the skill to
detect the signs and symptoms of the disease before it further develops into a stage
where surgical management is necessary. Most importantly, we now have a much
more in-depth understanding of the disease by identifying the root cause of
Choledocholithiasis. Lastly, we want to thank the time and effort of each and every
individual of our groupmates who have contributed to making this case study to
completion.