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SCOPE AND DELIMITATION

Scope:

The group will be able to present the following:

 Health History (Biographical Data and History of Illness)

 Physical Examination/ Assessment

 The Anatomy and Physiology of Billiary System

 Discussion about the Overview of the Disease & Pathophysiology

 Present Diagnostic Test, Medical-Surgical Management and Nursing Management

 Present spiritual aspect

 5 Drug Studies which includes: Morphine Sulfate 2 mg, Imipenem and Cilastatin

(Primaxin) 500 mg, Augmentin 500 mg, Celebrex 200mg and Sodium Ascorbate 500mg

 Present Two (2) Actual Nursing Care Plan and One (1) Risk Nursing Care Plan

Delimitation:

 The data are limited on the case scenario given.

Definition of Terms

Cholecystectomy- is the surgical removal of the gallbladder. Cholecystectomy is a common

treatment of symptomatic gallstones and other gallbladder conditions.

Cholecystitis- is a redness and swelling (inflammation) of the gallbladder. This happens

when a digestive juice called bile gets trapped in gallbladder. The gallbladder is a small

organ under liver. It stores bile which is made in the liver.

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

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Endoscopic Retrograde Cholangiopancreatogram (ERCP)- is a technique that combines

the use of endoscopy and fluoroscopy to diagnose and treat certain problems of the biliary or

pancreatic ductal systems. It is primarily performed by highly skilled and specialty trained

gastroenterologists.

Hypertension- is a common condition in which the long-term force of the blood against your

artery walls is high enough that it may eventually cause health problems, such as heart

disease.

Hypercholesterolemia- the presence of high plasma cholesterol levels, with normal plasma

triglycerides, as a consequence of the rise of cholesterol and apolipoprotein B (apoB)-rich

lipoproteins, called low-density lipoprotein (LDL).

Intraoperative cholangiogram- is a special kind of X-ray imaging that shows those bile

ducts. It's used during surgery. With a typical X-ray, you get one picture. But a

cholangiogram shows your doctor a live video of your bile ducts so they can see what's

happening in real-time.

Jaundice- a medical condition with yellowing of the skin or whites of the eyes, arising from

excess of the pigment bilirubin and typically caused by obstruction of the bile duct, by liver

disease, or by excessive breakdown of red blood cells.

Laparoscopic cholecystectomy (“lap chole”) - is minimally invasive surgery to remove the

gallbladder. It helps people when gallstones cause inflammation, pain or infection. The

surgery involves a few small incisions, and most people go home the same day and soon

return to normal activities.

Papillotomy- refers to a variety of endoscopic techniques used to gain access to the bile (or

occasionally the pancreatic) duct. In most patients, precut papillotomy is followed by

conventional sphincterotomy, which permits completion of therapies such as stone extraction

and biliary drainage.

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Total abdominal hysterectomy- is a surgical procedure that removes your uterus through an

incision in lower abdomen.

OVERVIEW OF THE CASE

Mrs. B.U, a 55-year-old elementary school teacher, was admitted from the emergency

department (ED) to Bulacan General Hospital's Surgery Ward on October 2, 2020. The NOD

notice that she is trembling and nearly doubled over with severe abdominal pain when arrived.

Mrs. B.U. indicates that she is experiencing acute pain in his abdomen's right upper quadrant

(RUQ) that radiates to her mid-back as a deep, sharp, and boring pain. Rather of resting flat in

bed, she prefers walking or sitting leaning forward. She stated she's had many bouts of

abdominal discomfort in the last month, but "none as bad as this." She also stated that she's

nauseated but hasn't vomited, despite the fact that she did a week before during a similar

incident. Mrs. B.U. experienced an acute onset of pain after eating fried pork and chips at a fast-

food restaurant earlier today. She is not happy to be in the hospital and is grumpy that his

daughter insisted on taking her to the Emergency Department for evaluation.

I. BIOGRAPHICAL DATA

Name: Mrs. B.U

Age: 55 years old

Sex: Female

Provider of History: Client

Chief Complaint: Severe pain in the right upper quadrant (RUQ) of abdomen that radiates

through mid-back as a deep, sharp, boring pain

II. REASON FOR SEEKING HEALTH CARE

Reason for Seeking Healthcare

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Mrs. B.U is a 55-year-old elementary school teacher who is admitted to the Surgery Ward

of Bulacan General Hospital from the emergency department (ED) on October 2, 2020. On

arrival, she is trembling and nearly doubled over with severe abdominal pain. Also, she indicates

that she has severe pain in the right upper quadrant (RUQ) of his abdomen that radiates through

to her mid-back as a deep, sharp & boring pain.

A. HISTORY OF ILLNESS

History of Present Health Concern

Mrs. B.U. indicates that she has severe pain in the right upper quadrant (RUQ) of his

abdomen that radiates through to her mid-back as a deep, sharp, boring pain. Rather of resting

flat in bed, she prefers walking or sitting leaning forward. She says she's had many bouts of

abdominal discomfort in the last month, but "none as awful as now." She says she's sick but

hasn't vomited, despite the fact that he did a week before during a similar incident. Mrs. B.U.

experienced an acute onset of pain after eating fried pork and chips at a fast-food restaurant

earlier today. She is not happy to be in the hospital and is grumpy that his daughter insisted on

taking her to the Emergency Department for evaluation.

After orienting her to the room, the NOD performs physical assessment. The findings are

as follows:

 She is awake, alert, and oriented, and he moves all extremities well.

 She is restless, is constantly shifting his position, and complains of fatigue.

 Breath sounds are clear to auscultation.

 Heart sounds are clear and crisp, with no murmur or rub noted and with a regular

rate and rhythm.

 The abdomen is flat, slightly rigid, and very tender to palpation throughout,

especially in the RUQ; bowel sounds are present.

On the other hand, admitting vital signs are as follows:

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 BP 164/100

 PR 132 beats/min

 RR 26 breaths/min

 T: 37.8° C

 SpO2 96% on 2 L of oxygen by nasal cannula.

Mrs. B.U.'s abdominal ultrasound demonstrates several retained stones in the common

bile duct and a stone-filled gallbladder. Mrs. B.U. is admitted, NPO status, and is scheduled to

undergo an Endoscopic Retrograde Cholangiopancreatogram (ERCP) that afternoon.

During an ERCP, the patient is sedated, and an ERCP scope is inserted through the

mouth, past the stomach, to the outlet of the common bile duct, the ampulla of Vater. Mrs. B.U.’s

laboratory results also reviewed. The patient undergoes the ERCP, and stones and bile are

released, but imaging reveals that a stone is still retained within the cystic duct, and multiple

stones remain within the gallbladder itself. A surgical consult is obtained, and laparoscopic

cholecystectomy (“lap chole”) is planned. Mrs. BU is medicated with morphine sulfate 2 mg IV

push (IVP) q2h as needed. After the first dose, she reports that on a scale of 1 to 10, his pain has

decreased from a 10 to a 4 within 30 minutes

At 11: 30 pm, Mrs. B. U’s spikes a temperature of 101.5° F (38.6° C) (tympanic). Her

SpO2 on 2 L oxygen per nasal cannula is now 90%, the nurse immediately increases the flow

rate to raise his O2 saturation and inform the on-call surgeon, and orders a STAT chest x-ray and

a broad-spectrum antibiotic—Imipenem and Cilastatin (Primaxin) 500 mg IV now, then q6h.

Mrs. B.U. undergoes a successful laparoscopic cholecystectomy the next morning. An

intraoperative cholangiogram shows that the ducts are finally cleared of stones after the surgery.

When she returns to the nursing unit, her stomach is soft but quite distended.

B. Past Health History

Her past medical history is significant for hypertension and hypercholesterolemia. She is

status post a total abdominal hysterectomy 1 year ago.

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C. Family History

We assume that the data in the family health history were unremarkable that is why it is

not included in the case.

III. PHYSICAL ASSESSMENT

GENERAL APPEARANCE

Mrs. B.U upon arrival is trembling and nearly doubled over with severe abdominal pain.

She is awake, alert, and oriented, and he moves all extremities well. She is restless, is constantly

shifting his position, and complains of fatigue. During the admission, VS has been obtained and

they are as follows:

 BP 164/100 mmHg

 PR 132 beats/min

 RR 26 breaths/min

 T: 37.8° C

 SpO2 96% on 2 L of oxygen by nasal cannula.

ABDOMEN

Mrs. B.U. indicates that she has severe pain in the right upper quadrant (RUQ) of his

abdomen that radiates through to her mid-back as a deep, sharp, boring pain. She admits to

having several similar bouts of abdominal pain in the last month, but this is incomparable to

what she felt right now. The abdomen is flat, slightly rigid, and very tender to palpation

throughout, especially in the RUQ; bowel sounds are present.

Upon palpation, NOD deeply palpate the costal margin in the RUQ and ask Mrs. BU to

take a deep breath. This causes Mrs. B.U. to stop inspiration abruptly, midway, and exclaim

that there is a pain felt.

SPIRITUAL ASPECT

MANAGEMENT RATIONALE
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Assess the spiritual concerns of the patient by
including their significant other in the plan of care.
Make sure to respect the client and their families’
social, cultural and spiritual beliefs.
Support the client and their families’ spiritual and
cultural issues in an open and nonjudgmental
manner
Create a trusting relationship with the client and
their significant other.
Join the client and their family in praying
specifically in times of upheaval.
Be conscious of the patient and relative’s culture,
belief, social and spiritual preferences.
Give attention to the client and relative one’s life
and their practices as an individual.
Stay with the client and support person.
Help client and the support person to develop
awareness of self, understanding of the meaning and
purpose of life, and their relationship to a higher
power.
The spiritual assessment also allows nurses to
identify spiritual beliefs, practices, and resources that
may positively impact the client’s health.
To make the client feel respected and valued.
To make sure that people receiving spiritual aspect
can experience heightened emotions and may value
the opportunity to express their identity and culture
and to practice their spiritual and religious rituals.
Nurses need to enhance their ability to respond to
people's individual wishes so that they can provide
quality and respectful care.
To openly discussed any religious concerns or
practices.
To strengthen and enhance their spirituality and
religion since this is critical sources of strength for
many clients. This can also help them to establish
and build a deeper relationship with the Divine
being.
To show respect and understand their own beliefs,
feelings, experiences, intentions and think about
things from another point of view.
To bring the client and their family a sense of
belongingness, responsibility and compassion in
relation to their spiritual life as part of their personal
growth.
Anger, denial, fear, and anxiety are all normal
reactions to unfavorable diagnosis. Thus, staying
with them will allow the support person and client to
have the chance to work through the emotions. How
long this takes varies for everyone. It may be a few
days, a few weeks, or longer, but the family and the
patient should eventually reach some level of
acceptance regarding the diagnosis.
To meet the spiritual care needs of the patient
including understanding of the meaning and purpose
of life which can lead to physical healing, reduction
of pain, and personal growth.
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ACTUAL NURSING CARE PLAN

CUES NURSING NURSING OBJECTIVES NURSING RATIONALE EXPECTED OUTCOME
Subjective/Objective DIAGNOSIS INTERVENTION
Subjective: Ineffective Breathing At the end of 3-4 days of Independent Nursing Independent Nursing After 3-4 days of imparting
Pattern related to imparting nursing Intervention: Intervention: nursing intervention and health
 report of severe unsuccessful intervention and health 1. Maintain and 1. Using therapeutic skills teachings to the client, the
abdominal pain in postoperative pain and teachings to client, the established a trusting need to be directed patient was able to:
right upper decreased energy/ patient will be able to: relationship with the toward putting the
quadrant of respiratory muscle client through the use client and the guardian  Established a normal,
abdomen fatigue as evidenced by  Establish a normal, of therapeutic at ease. This can also effective respiratory
 report of radiating, RR of 26bpms, reduced effective respiratory communication. use to establish rapport. pattern as evidence by
deep, sharp dull vital capacity and pattern. 2. Observe respiratory 2. Shallow breathing, decreased of RR from 26
pain from abdomen holding of breath  Demonstrate rate, depth. splinting with bpms down to 19 bpms.
through mid-back secondary to total appropriate coping 3. Auscultate breath respirations, holding  Demonstrated
abdominal behaviors. sounds. breath may result in appropriate coping
 feeling of hysterectomy 4. Assess for thoracic and hypoventilation. technique such as;
restlessness abdominal pain. 3. Areas of decreased or putting one hand on
 history of 5. Teach the patient about absent breath sounds abdomen just below ribs
hypertension Scientific Explanation pursed-lip breathing, suggest atelectasis or a and the other hand on
Inspiration and/or abdominal breathing, complete or partial chest and breathing out
Objective: expiration that does not 6. Utilize pulse oximetry collapse of the entire through pursed lips in
provide adequate to check oxygen lung or area (lobe) of order to breathe more
 oxygen ventilation. saturation and pulse the lung. comfortably.
dependency (SPO2 rate. 4. Pain can result from
of 96% via nasal Reference: 7. Show the patient how shallow breathing.
cannula) Nurse’s Pocket Guide, to splint incision in the 5. These measures allow
 blood pressure of Diagnoses, Prioritized postoperative area. the patient to
164/100 mmHg Interventions, and Instruct effective participate in
 PR of 132 bpms Rationales. M. breathing techniques. maintaining health
 RR of 26 bpms Doenges, M. 8. Elevate the head of status and improve
bed, maintain low- ventilation.
Moorhouse A. Fowler’s position. 6. Pulse oximetry is a
Murr.12th Edition. Page. 9. Support abdomen when helpful tool to detect
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107-113 coughing, ambulating. alterations in

10. Encourage sustained oxygenation.
deep breaths such as; 7. It facilitates lung
highlighting slow expansion. Splinting
inhalation, holding end provides incisional
inspiration for a few support and decreases
seconds, and passive muscle tension to
exhalation, utilizing promote cooperation
incentive spirometer with the therapeutic
and requiring the regimen.
patient to yawn. 8. Maximizes expansion
11. Teach the patient about of lungs to prevent or
pursed-lip breathing, resolve atelectasis.
abdominal breathing, 9. Facilitates more
effective coughing,
Dependent Nursing deep breathing, and
Intervention: activity.
1. Administer oxygen via 10. These techniques
nasal cannula whenever promote deep
experiencing difficulty inspiration, which
of breathing when increases oxygenation
needed. and prevents
atelectasis. Controlled
breathing methods may
also aid slow
respirations in
tachypneic patients.
Prolonged expiration
prevents air trapping.

Dependent Nursing
Intervention:
1. To deliver
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supplemental oxygen or
increased airflow to a
patient or person in
need of respiratory help