Republic of the Philippines

UNIVERSITY OF NORTHERN PHILIPPINES

Tamag, Vigan City, Ilocos Sur

COLLEGE OF NURSING

A Case Study on a patient with Cholecystitis

who will undergo Cholecystectomy

In Partial Fulfillment of the Requirement in

Related Learning Experience
(Ilocos Sur Provincial Hospital Gabriela Silang)

Presented to:
MR. GERARDO JOVEN

Presented by:
GLAIZA MARIE R. SAVELLA

2021
TABLE OF CONTENTS
I. Introduction and………………………………………………………………………….1-2
Objectives……………………………………………………………………………………3-4
II. Patient’s Profile……………………………………………………………………………5
III. Nursing History of Past and Present Illness…………………………………..6
IV. PEARSON Assessment…………………………………………………………………..7-9
V. Diagnostic Procedure
A. Ideal…………………………………………………………………………………….…10-15
B. Actual……………………………………………………………………………………..16-17
VI. Anatomy and Physiology…………………………………………………………….…18-19
VII. Pathophysiology
A. Algorithm……………………………………………………………………….……….20-21
VIII. Management
Medical and Surgical
a. Ideal…………………………………………………………….………….22-24
b. Actual………………………………………………………..…………….25

Nursing Care Plans…………………………………………………………………………………..….26-34

Promotive and Preventive

IX. Drug Study……………………………………………………………………………………….35-39

X. Discharge Plan……………………………………………………………………………….…40-41
XI. Updates…………………………………………………………………………………………….42
XII. Bibliography……………………………………………………………………………………...43

I. Introduction
 The gallbladder is a small organ located under the liver that plays a major role in the

digestion of fat. Normally bile and digestive enzymes pass out of the gallbladder on their way to

the small intestine. If this flow becomes blocked, it will build up inside the gallbladder, causing

swelling, upper abdominal pain, and gallstones resulting in liver dysfunction.

Gallstones are solid particles that are formed from bile. Common risk factors in the

formation of gallstones include being female of childbearing age, overweight, certain

medications such as birth control pills or statins, rapid weight loss, poor dietary habits and

pregnancy. Gallstones can block the outflow of bile and digestive enzymes from the pancreas.

Cholelithiasis is the medical name for hard deposits (gallstones) that may form in the

gallbladder. Cholelithiasis involves the presence of gallstones, which are concretions that form

in the biliary tract, usually in the gallbladder. Choledocholithiasis refers to the presence of one

or more gallstones in the common bile duct (CBD). If this blockage persists, the gallbladder can

become inflamed causing cholecystitis. Cholecystitis is defined as an inflammation of the

gallbladder caused most commonly by the obstruction of the cystic duct.

The initial treatment of cholecystitis includes bowel rest, intravenous hydration,

analgesia and antibiotics. Outpatient management may be suitable however if surgical

treatment is indicated, laparoscopic cholecystectomy represents the gold standard of care. In

the diagnostic process for surgical interventions an ultrasound scan may be performed however

magnetic resonance cholangio-pancreatography (MRCP) is the diagnostic preference for

gallstones. MRCP is a non-invasive technique used for viewing the bile and pancreatic ducts and

gallbladder using magnetic resonance imaging (MRI).

 Patient Bongbong Robredo, a 55-year-old man from #66 Rizal St. Brgy. VIII, Vigan City,

Ilocos Sur, who sought consultation was referred to the ED for chief complaint of sudden and

rapidly intensifying pain in the upper the right hypochondriac region of his abdomen and

vomiting for 3 days. He was admitted at Ilocos Sur Provincial Hospital Gabriela Silang last

October 20, 2021. She was started on amoxicillin-clavulanate two days prior but has not

improved. On physical examination, she is alert, nontoxic, and not in respiratory distress. Chest

auscultation reveals decreased breath sounds and questionable rales in the left lower lobe. The

high fever and localized chest findings prompt you to obtain a chest x-ray that shows a large

left-sided pleural effusion. She is Diagnosed with Pediatric Community-acquired pneumonia and

was discharged last January 1, 2021.

OBJECTIVES AND GOALS OF THE STUDY

GENERAL OBJECTIVE:

After 3 days of holistic nursing care, the patient will be able to attain maximum level of
functioning and manifest positive response to medical and nursing interventions.

SPECIFIC OBJECTIVES:

A. STUDENT-NURSE CENTERED:
After 8 hours of holistic nursing care, the student nurse will be able to:
1. To know the appropriate nursing intervention of Cholecystectomy.

2. Establish rapport and a good working relationship with the client.

3. To acquire and in-depth knowledge of pathophysiology regarding Cholecystitis.

4. Describe the common characteristics of pneumonia.

5. Present informative data including the history of past and present illness of the

client.
 6. To assess the condition of the patient through the use of PEARSON Assessment

(Psychosocial, elimination, activity and rest, safe environment, oxygenation and

nutrition).

7. Relate the significance of laboratory results to client’s condition or the disease

process.

8. Present the anatomy and physiology of the system involved, in relation to the

condition of the patient.

9. Identify the indication, mechanism of actions, contraindications, dosages and

frequency, adverse effects, and nursing responsibilities or interventions of the

drug administered to the client.

10. To present nursing care plans formulated specifically based on client’s condition.

11. Recognize the medical and surgical interventions related to the patient and make

promotive and preventive management to help the client’s condition.

12. Formulate a comprehensive discharge plan realistic to the needs and compliance

of the client.

B. PATIENT-CENTERED OBJECTIVES:

After 1 week of holistic nursing care, the patient will be able to

1. Establish ng rapport and a good relationship with the student nurse.

2. Gain knowledge regarding the condition and the operative procedure

undergone.

3. Show positive response to medications.

4. Function normally and perform activities of daily living.

 C. FAMILY-CENTERED OBJECTIVES:

1. To inform the significant others to the different risk factors for cholecystectomy.

2. To be able to guide the family members throughout the care.

II. PATIENTS’ PROFILE

NAME: Bongbong Robredo

AGE: 55 years old

GENDER: Male

OCCPUPATION: Tricycle driver

CIVIL STATUS: Married

NATIONALITY: Filipino

ADDRESS: #66 Rizal St. Brgy. VIII, Vigan City, Ilocos Sur

RELIGION: Roman Catholic

BIRTHDAY: June 16, 1966

NATIONALITY: Filipino

NAME OF SIGNIFICANT OTHERS: Marites Robredo (Wife)

Admitting Hospital: Ilocos Sur Provincial Hospital Gabriela Silang

CHIEF COMPLAINT: The patient was brought to the hospital because of sudden and rapidly

intensifying pain in the upper the right hypochondriac region of his abdomen and is

suffering from fever for 3 days. “Tallo nga aldaw nga agsaksakit toy ngato nga parte tiyan

konu pay pitikek ket natibong ken agsarwa sarwa nak pay”, as verbalized by the patient.

DATE ADMITTED: October 20, 2021/8:25am

DIAGNOSIS: Chronic Cholecystitis

ATTENDING PHYSICIAN: Dra. Marlou Savella

SOURCE OF INFORMATION: Mr. Robredo (Patient)

III. A) HISTORY OF PRESENT ILLNESS

 Present medical history is often a crucial step in evaluating patients.

Information gathered by doing a thorough medical history can contribute to

a better diagnosis and treatment. One year ago, Mr. Robredo was brought to

the hospital due to abdominal pain that lasted for 2 days. He was subjected

to Endoscopic ultrasound/MRC and was diagnosed of Cholelithiasis. The

stones were extracted through Endoscopic retrograde cholangio-

pancreatography.

At present, the condition of Mr. Robredo started three days prior to

consultation. The patient claims that he has been suffering from pain in his

upper right abdomen and has episodes of vomiting. The wife brought him to

the Municipal Health Office last October 18, 2021 and was given pain

reliever. Condition persisted which prompted the wife to bring him to Ilocos

Sur Provincial Hospital Gabriela Silang hence, he was admitted for further

evaluation and treatment. Patient Bongbong was diagnosed with Gallstones

and undergone Cholecystectomy.

B) PAST HEALTH HISTORY

  In a medical encounter, a past medical history, is the total sum of a patient's

health status prior to the presenting problem. In the case of patient

Bongbong Robredo, 2 years ago, he was admitted at St. James Hospital due

to lethargy and confusion for two days. He was subjected to laboratory and

physical exam and was diagnosed of hepatic encephalopathy. Supportive

treatment was given such as intravenous fluid and was advised to avoid high-

protein foods sucha as poultry, red meat, eggs, and fish.

C) FAMILY HEALTH HISTORY

 The patient claims that they have a family history of hypertension and has no

history of Cholecystitis. The family is commonly experiencing cough, colds,

and fever. They are able to manage such illnesses by self medicating with

over-the-counter drugs such as Carbocistine for cough, Bioflu for colds,

Paracetamol for fever and Mefenamic Acid for headache. The said medicines

were effective and if unable to manage the illness, they seek medical

attention in their RHU. Furthermore, they also utilize herbal medicines to

treat common ailments such as preparing calamansi juice and oregano

decocation.

IV. PEARSON ASSESSMENT

ASSESSMENT
PSYCHOSOCIAL Integument
 The patient’s skin is pale which exhibits
light brown in color and no presence of foul
odor. There were no abnormalities present
 in the neck and forearm. The skin is sweaty
and feels clammy to the touch. It is warm
and has an elevated body temperature of
39.4°C.

The hair of the client is silky and thick. He

has a variable amount of body hair that is
evenly distributed. There were no visible
sightings of possible signs infection and
infestation observed. The client has light
brown nails and has the shape of convex
curve. These are well trimmed, soft, firm,
and nail plates are firmly attached to the
nail bed. Pink tone returns slowly to
blanched nail beds when pressure is
released. There is a presence of blubbing
and capillary test shows >2 seconds
exhibiting abnormal blood flow.

Head
 Head symmetrical, round and smooth
without lesions or bumps. There is an
involuntary bobbing. Bilateral temporal
arteries are elastic and not tender.
Temporomandibular joint denies swelling,
tenderness or crepitation with movement.
Mouth open and closes fully. The lower jaw
moves laterally.
Eyes and Vision
 The eyelid of the patient is symmetrical
with no discharges, eyebrow hairs are
evenly distributed, and pupils equally round
respond to light accommodation. The eyes
have normal vision of 20/20.
Ears and Hearing
 The client’s ears are symmetrical and has
the same color with his facial skin. The
auricles are aligned with the outer canthus
of the eye. Upon palpation, the auricles
exhibit mobile, firm, and not tender
texture.

Nose and Sinus

 The nose appeared symmetric, straight, and
uniform in color. There were no presence of
discharge and flaring. When lightly
palpated, there were no tenderness and
lesions on his sinuses. Nasal structure is
smooth and symmetric. No deformities of
the external. Green mucus is present which
the client is exhibiting nasal congestion.

Mouth and Neck

 The lips of the patient are uniformly pink in
color; moist, symmetric, and have a smooth
texture. There are no discoloration of the
 enamels and pinkish in color of gums.
Presence of two teeth loss and dental
caries. The buccal mucosa of the client
appeared uniformly pink moist, and soft.
The uvula of positioned in the midline of
the soft palate. The tongue is centrally
positioned, pink in color, and moist.
The neck muscles are equal in size. The
client showed coordinated, smooth head
movement with no discomfort. The lymph
nodes of the client are not palpable.
The trachea is placed in the midline of the
neck. The thyroid gland is not visible on
inspection and the glands ascend during
swallowing but are not visible.

Thorax, Lungs, and Abdomen

 The chest wall is intact with no tenderness
and masses. The expansion is symmetric
and full. The spine is vertically aligned. Right
and left shoulders, and the hips are of the
same height. There were no visible
pulsations on the aortic and pulmonic
areas. There is no presence of heaves or
lifts. The abdomen has a symmetric
contour. There was use of intercostal
muscles associated with patient’s
respiration.
 Extremities
 The muscles are not palpable with the
absence of tremors. These are normally
firm and showed smooth, coordinated
movements.
ELIMINATION The patient defecates once every day since
October 20, 2021. The stool is smooth, soft sausage
like (Normal). He exhibits a normal urinary pattern
with no urgency.
ACTIVITY AND REST Total bed rest due to not having enough sleep due
to restlessness. The client spends most of his time
watching television.
SAFETY AND SECURITY The bed side rails are raised and the patient wears
extra clothes and socs when needed. A watcher is
always present to assist the client when going to
the comfort room.
OXYGENATION Patient is not experiencing difficulty of breathing
with a normal O2 saturation of 98% with normal
breathing pattern.
NUTRITION The patient consumed medium portion of
vegetables, fruits, and meat for the past days. He
avoided the foods that the nurses instructed him
not to eat. Water therapy was also instructed
which the patient followed and drank adequate
amount of liquid daily.
 V. DIAGNOSTIC PROCEDURE

A. IDEAL
Ultrasound: Ultrasound testing uses sound waves to take images of the gallbladder. It is the
gold-standard to look for gallstones because it is simple and non-invasive. Ultrasound is very
good at highlighting gallstones within the gallbladder, as well as features, such as a thickened
gallbladder wall, that point to inflammation of the gallbladder (acute cholecystitis).
Liver function tests (LFTs): Although these tests are not done specifically for gallstone disease, a
simple blood test looking at the enzyme levels in the liver can show inflammation in the
gallbladder caused by gallstones. Other combinations of liver tests are arranged if gallstones fall
out of the gallbladder and are blocking the bile duct, which can lead to jaundice (the skin,
whites of the eyes and mucous membranes turn yellow).
Complete blood count (CBC): If there is inflammation caused by gallstones, the white blood cell
count is usually elevated (higher). In this situation, the patient will often have a fever.
Computed tomography (CT): This test uses X-rays to construct detailed images of the
abdominal organs. CT can give additional information on the bile ducts and liver, which may be
affected by gallstone disease.
HIDA scan (cholescintigraphy): During this test, a radioactive material called hydroxy
iminodiacetic acid (HIDA) is injected into the patient. The material is taken up by the gallbladder
and shows how the gallbladder is functioning. This test is useful when the ultrasound result is
inconclusive, especially if there is acute inflammation of the gallbladder and the outlet of the
gallbladder is blocked. It is also beneficial when the gallbladder is diseased but there are no
stones present (acalcalous cholecystitis).
Magnetic resonance cholangiopancreatography (MRCP): This test uses magnetic resonance
imaging (MRI) to produce detailed pictures of the biliary tree (liver, gallbladder and bile ducts).
It is of particular use to look at the bile ducts for signs of stones that have escaped from the
gallbladder and are blocking the bile duct, which can lead to jaundice.
Endoscopic retrograde cholangiopancreatography (ERCP): In this procedure, a tube is placed
down the patient’s throat, into the stomach, then into the small intestine. Dye is injected and
the ducts of the gallbladder, liver, and pancreas can be seen on X-ray. ERCP is now mainly used
to treat patients in whom a gallstone has blocked the bile duct causing pancreatitis
(inflammation of the pancreas), jaundice or cholangitis (infection of the bile)
B. ACTUAL
1. Transabdominal ultrasound (TUS): an imaging procedure that uses high-frequency
sound waves to examine the liver, gallbladder, spleen, kidneys, and pancreas
2. Abdominal CT scan: cross-sectional X-rays of the abdomen
3. Endoscopic ultrasound (EUS): an ultrasound probe is inserted on a flexible endoscopic
tube and inserted through the mouth to examine the digestive tract
4. Endoscopic retrograde cholangiography (ERCP): a procedure used to identify stones,
tumors, and narrowing in the bile ducts
5. Magnetic resonance cholangiopancreatography (MRCP): an MRI of the gallbladder, bile
ducts, and pancreatic duct
6. Percutaneous transhepatic cholangiogram (PTCA): an X-ray of the bile ducts
V. ANATOMY AND PHYSIOLOGY

The gallbladder is a gastrointestinal organ located within the right hypochondrial region
of the abdomen. This intraperitoneal, pear-shaped sac lies within a fossa formed between the
inferior aspects of the right and quadrate lobes of the liver.

The primary function of the gallbladder is to concentrate and store bile which is
produced by the liver. As part of the gustatory response, the stored bile is then released from
the gallbladder in response to cholecystokinin.

Anatomical Relations

The gallbladder is entirely surrounded by peritoneum, and is in direct relation to the

visceral surface of the liver.

It lies in close proximity to the following structures:

Anteriorly and superiorly – inferior border of the liver and the anterior abdominal wall.

Posteriorly – transverse colon and the proximal duodenum.

Inferiorly – biliary tree and remaining parts of the duodenum.

 Anatomical Structure

The gallbladder has a storage capacity of 30-50ml and, in life, lies anterior to the first part of the
duodenum. It is typically divided into three parts:

Fundus – the rounded, distal portion of the gallbladder. It projects into the inferior surface of
the liver in the mid-clavicular line.

Body – the largest part of the gallbladder. It lies adjacent to the posteroinferior aspect of the
liver, transverse colon and superior part of the duodenum.

Neck – the gallbladder tapers to become continuous with the cystic duct, leading into the biliary
tree.

The neck contains a mucosal fold, known as Hartmann’s Pouch. This is a common location for
gallstones to become lodged, causing cholestasis.
 The Biliary Tree

The biliary tree is a series of gastrointestinal ducts allowing newly synthesized bile from the
liver to be concentrated and stored in the gallbladder (prior to release into the duodenum).

Bile is initially secreted from hepatocytes and drains from both lobes of the liver via canaliculi,
intralobular ducts and collecting ducts into the left and right hepatic ducts. These ducts
amalgamate to form the common hepatic duct, which runs alongside the hepatic vein.

As the common hepatic duct descends, it is joined by the cystic duct – which allows bile to flow
in and out of the gallbladder for storage and release. At this point, the common hepatic duct
and cystic duct combine to form the common bile duct.

The common bile duct descends and passes posteriorly to the first part of the duodenum and
head of the pancreas. Here, it is joined by the main pancreatic duct, forming the
hepatopancreatic ampulla (commonly known as the ampulla of Vater) – which then empties
into the duodenum via the major duodenal papilla. This papilla is regulated by a muscular valve,
the sphincter of Oddi.

Vasculature

The arterial supply to the gallbladder is via the cystic artery – a branch of the right hepatic
artery (which itself is derived from the common hepatic artery, one of the three major branches
of the coeliac trunk).
Venous drainage of the neck of the gallbladder is via the cystic veins, which drain directly into
the portal vein. Venous drainage of the fundus and body of the gallbladder flows into the
hepatic sinusoids.
Lymph Drainage

Lymph from the gallbladder drains into the cystic lymph nodes, situated at the gallbladder neck.

The cystic nodes then empty into the hepatic lymph nodes, and ultimately, the coeliac lymph
nodes.

VI. PATHOPHYSIOLOGY OF THE DISEASE

A. ALGORITHM

Predisposing factor: Consumption Precipitating factor:

of high cholesterol foods Older age (55-year-old man)

Excess cholesterol
form into stones

Transabdominal
ultrasound

Probability of
gallbladder stones
 Endoscopic
ultrasound/MRC

Pain in the upper

Gallbladder stone
right portion of the
(Cholelithiasis)
abdomen

Stone extraction
(Endoscopic
retrograde cholangio-
pancreatography)

Reoccurrence of
gallstones

Obstruction of
biliary outflow

Endoscopic
ultrasound/MRC

Sudden and rapidly

Inflammation of the intensifying pain in the upper
gallbladder right portion of the abdomen
(Cholecystitis)

Vomiting

Laparoscopic
cholecystectomy

VII. MANAGEMENT
A. MEDICAL AND SURGICAL
a. IDEAL

A. MEDICAL
 In patients, who are unable and unwilling to undergo surgery, endoscopic
decompression by internal gallbladder stent can help prevent complications from
developing and can serve as palliative long-term treatment. Non-operative therapy,
which includes dissolution of gallstone using oral bile acids and shock wave lithotripsy,
may be another option in such patients. However, non-operative is time consuming and
is associated with high cost, low effectiveness, and high in recurrence rate. Nutrition
and lifestyle changes may be beneficial for the prevention and treatment of
cholelithiasis. Because obesity is associated with an increased risk of cholelithiasis,
weight loss may help prevent gallstone formation. However, excessively rapid weight
loss may promote gallstone formation. Dietary factors that may help prevent gallstone
formation include polyunsaturated fat, monounsaturated fat, fiber, and caffeine. Fish
oil and moderate alcohol consumption have been shown to lower triglycerides, lessen
bile cholesterol saturation, and increase HDL. The treatment of choice for symptomatic
cholelithiasis currently is laparoscopic cholecystectomy whereas previously it was open
cholecystectomy. Laparoscopic cholecystectomy as associated with a shorter hospital
stay and a faster recovery period than open cholecystectomy is. Contraindication to this
procedure include the inability to withstand general anesthesia, an intractable bleeding
disorder, and end stage liver disease.
ACTUAL

Patient undergone cholecystectomy last October 21, 2021 at 9am. Spinal anesthesia,
was administered. The procedure was finish at 10:50am successfully.

Types of Gallbladder Surgery

Open surgery: During this procedure, your surgeon will make a 5- to 7-inch incision (cut) on
your belly to take out your gallbladder. You’ll need open surgery if you have a bleeding
disorder. You may also need it if you have severe gallbladder disease, are very overweight, or
are in your last trimester of pregnancy.

Laparoscopic cholecystectomy: Doctors also call this “keyhole surgery.” Your surgeon doesn’t
make a big opening in your belly. Instead, they make four small cuts. They insert a very thin,
flexible tube that contains a light and a tiny video camera into your belly. These help your
surgeon see your gallbladder better. Next, they’ll insert special tools to remove the diseased
organ.

B. PROMOTIVE AND PREVENTIVE MANAGEMENT

PROMOTIVE

Nutritional Management
 -Eat more foods that are high in fiber, such as:

-fruits, vegetables, beans, and peas.

-whole grains, including brown rice, oats, and whole wheat bread.

-Eat fewer refined carbohydrates and less sugar.

-Eat healthy fats, like fish oil and olive oil, to help your gallbladder contract and
empty on a regular basis.

-Avoid unhealthy fats, like those often found in desserts and fried foods.

Pain Management

- Encourage patient to position frequently as indicated

- Provide comfort measures
- Administer analgesics or anti-inflammatory agents as prescribed

PREVENTIVE

Infection Prevention

- Daily personal hygiene

- Administer antibiotics agents as needed
- Don’t drive until you are no longer taking pain medication and can step on
the brake pedal without hesitation
 NURSING CARE PLAN
CLIENT: BONGBONG ROBREDO
CARE PLAN BY: GLAIZA SAVELLA

A. PRE-OPERATIVE PHASE NURSING CARE PLAN

ASSESSMENT DIAGNOSIS SCIENTIFIC GOAL INTERVENTION RATIONALE EVALUATION
BACKGROUND
S> “Nilalagnat ako, Fluid volume deficit The Patient is 55 Y/0 Short term goal: INDEPENDENT: Level of attainment:
tapos suka ako as evidenced by with complaints of After 2 hours of  Goal met.
ng suka at ang decreased blood vomiting. Nursing Intervention, a) Assess initial v/s a) Helps to
sakit ng tiyan ko” pressure of 100/60 the patient will be and closely determine for AEB:
as verbalized by mmHg and Increased able to maintain fluid monitor BP and appropriate After 3 hours of
the patient. body temperature of volume at a functional interventions of nursing intervention,
temperature.
O> Patient is 38 C° secondary to She was admitted with level as evidenced by underlying the patient’s vital
conscious and vomiting a diagnosis of vital signs within conditions. signs are stable with
alert but looking cholelithiasis and is normal limits. BP of 120/80, afebrile
subjected for open b) Provide tepid b) Enhances heat with a temperature of
anxious.
cholecystectomy as sponge bath. loss by 37.4 C°.
 Increased Body
Temperature surgical treatment. evaporation &
 Decreased conduction.
Venous filling; c) Promote bed
Hypotension c) Reduces body
Diarrhea and Vomiting rest, encourage heat
is one of the causes relaxation skills. production.
V/S Recorded
which decreases
TEMP: 38. C° d) Wrap
extracellular fluid, d) To minimize
PR: 78 bpm extremities with
including decreased shivering.
RR: 18 rpm cotton blankets.
circulating blood
 BP: 100/60
volume.
mmHg
adventitious
breath sounds
 noted e) Ingestion of ice-
 With white e) Provide ice cold water or
colored chips for the crushed ice may
sputum. This is an effect of loss help ease
patient
 Restlessness/ in total body sodium nausea.
 irritable at which results to
times. hypotension and f) Signs of
increased body f) Note presence dehydration are
temperature. of physical signs also detected
like dry mucous through color of
skin and its
membrane,
turgor.
Patients who poor skin turgor
experience vomiting or delayed
and diarrhea can capillary refill.
easily be dehydrated
resulting into Fluid g) For him to
g) Discuss
Volume Deficit. understand that
importance of
oral fluid
adequate fluid replacement
intake. avoids
dehydration due
to vomiting.

h) Intravenous
h) Provide present
fluids are given
IV Fluid of to replace
PNLSS water, sugar
and salt for
hydration
before the
procedure
 proper.

i) Closely monitor i) This will help

intake and determine if the
output of the patient’s intake
patient. is adequate or
inadequate.

DEPENDENT:

 Administer  Metoclopramide
metoclopramide is used to
prevent nausea
10 mg IV as
and vomiting
ordered by the
Physician.
B. INTRA-OPERATIVE PHASE NURSING CARE PLAN

ASSESSMENT DIAGNOSIS SCIENTIFIC BACKGROUND GOAL INTERVENTION RATIONALE EVALUATION

S >Ø Risk for aspiration The Patient is 55 Y/0 with Short term goal: INDEPENDENT: Level of attainment:
related to induction complaints of vomiting. After 1 hour of
O> Minimized of general nursing intervention, a) Assess initial a) Helps to  Goal met.
gag reflex anesthesia prior to the patient will show v/s and closely determine for
 Patient exhibits surgical incision as no signs of aspiration monitor. appropriate AEB:
difficulty evidenced by She was admitted with a for the duration of interventions
swallowing depressed diagnosis of cholelithiasis his time in the of underlying After 1 hour of
without swallowing and gag and is subjected for open hospital. conditions. nursing
choking. reflexes. cholecystectomy as surgical intervention, the
treatment. b) Clear b) Regurgitation patient’s Vital
 Depressed
secretions is often silent Signs are stable
cough and gag
from mouth in people with and shows no
reflexed.
and throat decreased sign of aspiration for
Prior to surgical incision, with a tissue or sensorium or the duration of her
V/S Recorded
general anesthesia is gentle suction. depressed time in
 TEMP: 37.4 C°
induced.. mental state. hospital.
 PR: 78 bpm
 RR: 18 rpm
 BP: 100/80 c) The risk for
c) Ensure a clear aspiration
mmHg
airway. increases due
It relaxes the muscles of the
to less
body and depresses the
supervision.
sensation of pain.
d) Some have
d) Determine
difficulty with
type of food
Thus, the gag and solids,
that is
swallowing reflex is whereas
troublesome
temporarily suppressed. others have
for patient.
difficulty with
Increased risk for liquids.
Aspiration
e) Position client e) Upright
properly. position uses
the force of
gravity to aid
downward
motion of
food and
decreases risk
for aspiration.
f) Position the
client with a f) This
decreased positioning
level of (rescue
consciousness positioning)
on their side. decreases the
risk for
aspiration by
promoting the
drainage of
secretions out
of the mouth
instead of
down the
pharynx,
where they
could be
aspirated.
C. POST OPERATIVE PHASE

ASSESSMENT DIAGNOSIS SCIENTIFIC GOAL INTERVENTION RATIONALE EVALUATION

BACKGROUND
S> “Nasakit toy dait Risk for infection The Patient is 55 Y/0 Short term goal: INDEPENDENT: Level of attainment:
ko” related to with complaints of After 2 hours of  Goal met.
cholecystectomy vomiting. nursing intervention a) Assess initial v/s a) For baseline
O> Disruption of the
secondary to impaired the patient will q15 for 2 hours and data; Helps to AEB:
skin from invasive monitor patient’s
procedure. tissue integrity. demonstrate determine for After 2 hours of
condition. Nursing intervention,
 4 stitches on techniques in appropriate
She was admitted reducing risk of the
the post- interventions.
with a diagnosis of having infection. patient already
surgical
cholelithiasis and is demonstrates
incision site in b) Observe proper b) A first line
subjected for open After 1 day of techniques in
RUQ of the handwashing
defense
cholecystectomy as nursing intervention, reducing risk of
abdomen. techniques.
surgical treatment. the patient will against having infection.
 Pain and
achieve timely wound nosocomial
redness
healing, be free of infection or After 1 day of
around the Incisions and sutures purulent drainage; nursing
incision site. have made in the RUQ afebrile. cross
intervention, the
V/S Recorded of the patient during contamination.
 TEMP: 37.9 C° patient have
the procedure. achieved timely
 PR: 78 bpm
c) Reinforce strict c) To establish wound healing,
 RR: 18 rpm
compliance to mechanism to free of purulent
 BP: 100/80 Due to the break in hospital control,
mmHg prevent drainage and
the continuity of the sterilization, and
occurrence of afebrile with a
aseptic policies.
first line of defense temperature of
infection.
which is the skin. 36.8C°

Pathogens will easily d) To keep the

d) Change surgical
invade the body’s post-surgical
wound dressing,
system. using aseptic incision site dry
techniques. and to avoid
Resulting to risk for
infection.
infection.
e) Assess for the e) Signs of
presence of local infection
infectious
include
processes around
the wound. localized
swelling,
redness, pain
or tenderness,
palpable heat.

f) Increase oral fluid f) To hasten

intake, if not wound healing.
contraindicated.

g) Tell the patient to g) To prevent the

comply to occurrence of
antibiotic therapy infection.
as prophylaxis.
h) To determine
h) Monitor
medication effectiveness
regimen and IV of therapy.
infused.

 Very high fever

accompanied by
sweating and chills
may indicate
 septicemia.

 Yellow or yellow-
green sputum is
indicative of
respiratory
infection.

 Effective means of
reducing, clearing
COLLABORATIVE: of infection.

 Administer or  Promotes
teach use of expectoration,
antimicrobial clearing of
(antibiotic) drugs infection.
as ordered.
 Ampicilin 200mg  Reduces likelihood
IV q °6. of exposure to
 Clarithromycin other infectious
125mg/5ml/2.5ml pathogens.
BID
 Patients with poor
nutritional status
may be anergic, or
unable to muster a
cellular immune
response to
pathogens and are
therefore more
susceptible to
infection.

 Antimicrobial
drugs include
antibacterial,
antifungal,
antiparasitic,
and antiviral
agents.
 Ampicillin is
used to treat
diseases
caused by
bacterial
infections.
 Treatment of
upper
respiratory
infections
caused by
streptococcus
pyogenes or S.
pneumonia.
 DRUG STUDY
(Paracetamol)
NAME OF DRUG INDICATIONS CONTRAINDICATIONS MECHANISM OF ACTION SIDE EFFECTS NURSING RESPONSIBILITIES
Generic name:  Treat mild to  Acute liver failure,  Paracetamol has a  Allergic reaction,  Assess patient’s fever or
Paracetamo moderate liver problem, central analgesic which can cause pain: type of pain, location,
l pain (from severe renal effect that is rash and swelling. intensity, duration, temperature,
headaches, impairment. A
Brand name: mediated through  Flushing, low and diaphoresis.
menstrual condition where
Acetaminophen activation of blood pressure  Assess allergic reactions:
periods, the body is unable
toothaches, to maintain descending and fast heartbeat rash;
Classification: backaches, adequate blood serotonergic – this can if this occur, drug may have to be
Aniline osteoarthritis flow called shock. pathways. Debate sometimes discontinued.
analgesics , or cold/flu exists about its happen when  Teach patient to recognize
aches and primary site of paracetamol is signs of chronic overdose: bleeding,
Dosage: pains) and to action, given in hospital bruising, malaise, fever, sore throat.
1 tab (250 mg) reduce fever.
which may into a vein in your  The nurse must
be inhibition of arm. orient the patient not to drink
prostaglandin  Blood disorder excessive quantities of alcohol
Frequency:
synthesis or through while taking paracetamol.
Every 4-6 such as
an active metabolite o Advise the patient to notify
hours thrombocytopeni
influencing prescriber for pain or fever lasting
cannabinoid a and leukopenia. for more than three days.
Route:
receptors.
Oral
 DRUG STUDY
(Amoxicillin)
NAME OF INDICATIONS CONTRAINDICATIONS MECHANISM OF ACTION SIDE EFFECTS NURSING RESPONSIBILITIES
DRUG

Generic name:  Amoxicillin is an  Diarrhea from an o Amoxicillin is in the class o Abdominal or o Monitor vital signs every 15
Amoxicillin antibiotic. It's infection with of beta-lactam stomach cramps or mins.
used to treat Clostridium antimicrobials. Beta- tenderness o Monitor signs of
Brand name: bacterial difficile bacteria lactams act by binding to o Stomach pains pseudomembranous colitis,
Amoxil infections, such mononucleosis, penicillin-binding o Nausea and including diarrhea, abdominal
as chest the kissing disease proteins that inhibit a vomiting pain, fever, pus or mucus in
Classification: infections liver problems process called o Diarrhea stool, and other severe or
Penicillin-like (including blockage of transpeptidation (cross- o Black, tarry stools prolonged GI problems (nausea,
antibiotics pneumonia), normal bile flow linking process in cell o Bleeding gums vomiting, heartburn). Notify
Dosage: dental severe renal wall synthesis), leading o Blood in the urine physician or nursing staff
40mg abscesses and impairment to activation of autolytic o Chest pain immediately of these signs.
urinary tract enzymes in the bacterial o Clay-colored stools o Watch for seizures; notify
infections cell wall. o Dark urine physician immediately if patient
Frequency: (UTIs). o Increased thirst develops or increases seizure
Every 8 hours Amoxicillin is o Inflammation of the activity.
for the joints o Instruct patient/ family to notify
Route: treatment of o Joint or muscle pain physician immediately of signs of
Oral genitourinary o Loss of appetite superinfection, including black,
tract o Muscle aches furry overgrowth on tongue,
infections, ear, o Pinpoint red spots vaginal itching or discharge, and
nose, and on the skin loose or foul-smelling stools.
throat o Puffiness or swelling o Instruct patient and
infections, of the eyelids or family/caregivers to report other
lower around the eyes, troublesome side effects such as
respiratory face, lips, or tongue severe or prolonged skin
tract o Red, irritated eyes problems (rash, itching) or GI
 infections, o Sores, ulcers, or problems (nausea, vomiting,
Helicobacter white spots in the diarrhea).
pylori mouth or on the lips
infections, o Sudden decrease in
pharyngitis, the amount of urine
tonsillitis, and o Swollen, lymph
skin and skin glands
structure o Tenderness
infections. o Tightness in the
chest
o Unusual tiredness
or weakness
o Unusual weight loss
o Yellow eyes or skin

DRUG STUDY
(Sinupret)
NAME OF INDICATIONS CONTRAINDICATIONS MECHANISM OF ACTION SIDE EFFECTS NURSING RESPONSIBILITIES
DRUG
Generic name:  In acute and  Sinupret dragees o Sinupret has o Drowsiness o Monitor vital signs every 15
Gentianae radix chronic must not be taken antimicrobial and o Dizziness mins.
inflammation in cases of antiviral effects, o Blurred vision o Make sure that it is taken by the
Brand name: of the hypersensitivity to secretolytic activity o Upset stomach patient.
Sinupret paranasal one of its active or (breaks down secretions, o Nausea o Assess patient for drowsiness,
sinuses and of inactive reduces the viscosity of o Nervousness dizziness, and upset stomach.
Classification: the respiratory ingredients. mucus) and anti- o Dry o Remind patient or family to
Rx tract, also as Hypersensitivity inflammatory activity. mouth/nose/throat notify the physician if there is an
supplementary to the active Combined medication of o Exanthema occurrence of side effect.
Dosage: measure in substances or to plant origin. o Erythema o Store the medication at
1 dragee (6mg) antibacterial any of the Pharmacological o Pruritus temperatures not exceeding 30
therapy. excipients of the properties are due to o Angioedema °C.
Frequency: medicinal biologically active o Dyspnea o Check for proper dosing
3x a day product. substances, members of o Face edema especially when giving to a
the drug. It has patient who is a child.
Route:
secretolytic,
Oral
sekretomotornym and
anti-inflammatory
effect. Restores the
protective properties
and reduces the swelling
of the mucous
membranes of the
respiratory tract. It
promotes the outflow of
fluid from the sinuses
and upper respiratory
tract.
VIII. DISCHARGE PLAN

MEDICATION Home medication instructed as follows:

Paracetamol 250mg q4-6hr

Amoxicillin 40mg q8hr

Sinupret 1 dragee TID

EXERCISE Advised patient to do low impact exercise
such as walking. Be safe by choosing a
walking route that is flat and well
illuminated.
Always bring water to keep hydrated.
TREATMENT Instructed the patient to mobilization and to
take adequate amount of rest.
HEALTH TEACHINGS Provides Health Education such as:

Breathe warm, moist air. This helps loosen

mucus. Loosely place a warm, wet washcloth
over the nose and mouth. A room humidifier
may also help make the air moist.
Drink liquids as directed. Ask a healthcare
provider how much liquid to drink each day
and which liquids to drink. Liquids help make
mucus thin and easier to get out of the body.
Gently tap the chest. This helps loosen mucus
so it is easier to cough. Lie with the head
lower than your chest several times a day
and tap your chest.
Get adequate rest because it helps the body
heal quicker.

Strengthen immune system by taking Vitamin

C such as Ceelin (Ascoric acid + Zinc).
OUT PATIENT Instructed patient for follow-up check-up
after a week that will be on January 8, 2021
at Northside Doctors Hospital.
DIET Eat fruits especially those that are rich in Vit.
C, and more of green leafy vegetables.
A diet rich in protein Foods like nuts, seeds,
beans, white meat and cold-water fishes like
 salmon and sardines have anti-inflammatory
properties. These also repairs the damaged
tissues and building the new tissues in the
body.
SAFETY AND SECURITY Home environment must be free from
slipping or accidental hazards.
IX. UPDATES

Five days after discharge, patient is slowly fully recovering from her illness (Pediatric
Community-Acquired Pneumonia). She exhibits minimal bouts of cough and no signs of
difficulty in breathing. Her mother claims that she is regaining her appetite and is able to
perform her usual activities of daily living. Further, she can now play with other children
but with supervision and precaution so as not to have a recurrence of the illness. The
parents make sure that she is continuously taking her home medications as advised
during her discharge. She is scheduled for follow-up check-up on June 8, 2021 in order
determine her full recovery.
 X. BIBLOGRAPHY

(Bloom et al, 2012; Mackillop & Williamson, 2010)

(Ali, Cahill, & Watson, 2004; Balentine, 2012; Mackillop & Williamson, 2010)
(Bignell et al., 2011; Chowbey et al., 2010; Farkas et al, 2012; Tsimoyiannis et al., 2009)