Acute Cholecystolithiasis - G4 SB2

A Case Study on
ACUTE CHOLECYSTOLITHIASIS
In Partial Fulfillment of the

Requirements in NCM 209 - RLE
OB NURSING ROTATION
Submitted to:
Merianne R. Palada, RN
Clinical Instructor
Submitted by:
Jilliary Alexandra S. Murcia, St.N
Ceejay Romano, St.N
Gilia Jean Sab, St.N
John Salido, St.N
Jhon Rommel Subingsubing, St.N
Channtalle Nichole D. Sucaldito, St.N
Norjen Hannah O. Sundungan, St.N
Krizelle Tabsing, St.N
Kyla Marie Villodres, St.N
BSN2R - Group 2 Subgroup 2
February 15, 2023

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TABLE OF CONTENTS
I. Introduction and Objectives………………………………………………………….3-6

II. Data Base………………………………………………………………………….…6-10
a. Biographical Data
b. Clinical Data
c. Family Health History
d. Past Health History
e. History of Present Illness
f. Developmental Task
III. Physical Assessment……………………………………………………………...10-12
IV. Definition of Diagnosis………………………………………………………………...12
V. Anatomy and Physiology………………………………………………………….12-13
VI. Pathophysiology……………………………………………………………………13-29
a. Etiology
b. Symptomatology
c. Disease Process
VII. Medical Management……………………………………………………………...29-90
a. Diagnostic Exam and Lab Tests
b. Therapeutics and Drug Studies
VIII. Nursing Management……………………………………………………………91-123
a. NCP
b. Discharge Planning
IX. Nursing Theory………………………………………………………………….124-126
X. Review of Related Literature/Studies…………………………………………126-129
XI. References……………………………………………………………………………130
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I. INTRODUCTION AND OBJECTIVES

Introduction
Gallstones are calcified collections of gastrointestinal fluid that can develop in the
gallbladder (Mayo Clinic, 2021). Cholecystolithiasis is a condition that describes the
presence of stones in the gallbladder. A little organ underneath the liver is the
gallbladder wherein it stores digestive fluid called bile and releases it into the small
intestine. Gallstones vary in sizes, ranging from a grain of sand, called sludge, to a golf
ball. One gallstone may form in some individuals while multiple stones may form
simultaneously in others. Gallstones may not show any signs or symptoms at all.
Nonetheless, if a gallstone becomes lodged in a duct and creates a blockage, there
may be symptoms such as: abrupt and rapidly escalating pain in the center and upper
right quadrant of the abdomen; back pain between the shoulder blades; right shoulder
discomfort; and it may induce nausea and vomiting (Cleveland Clinic, 2020). Unless
they induce symptoms, gallbladder stones are not thought to be a disease. When there
appear to have symptoms, it is referred to as gallbladder disease (Zakko, 2022). Any
disorder that deteriorates the gallbladder's health is referred to as gallbladder disease.
Cholelithiasis and cholecystitis are two conditions that are frequently used
interchangeably in relation to cholecystolithiasis. In accordance with Cleveland Clinic
(2020), gallstone production is referred to as cholelithiasis whereas when the
gallbladder becomes inflamed, it is referred to as cholecystitis. Gallstone formation may
potentially be a byproduct of high bilirubin levels, and if the gallbladder is not properly
drained, bile can condense and result in gallstones, otherwise known as cholelithiasis.
Bile typically has the ability to dissolve the amount of cholesterol that the liver excretes.
However, excess cholesterol may crystallize if the liver produces more of it than bile can
disintegrate. When crystals get stuck in the mucus of the gallbladder, gallbladder sludge
develops. Gallstone disease then develops when the crystals over time enlarge to form
stones and clog the ducts (Cloud Hospital, 2021). Gallstones that have clogged the
cystic duct, preventing bile from leaving the gallbladder, are a typical cause of
cholecystitis. The gallbladder swells up and may develop a bacterial infection. Less
frequent reasons for gallbladder inflammation include viral infections, clogged bile ducts
caused by scarring, decreased blood supply to the gallbladder, tumors that impede the
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passage of bile from the gallbladder, and reduced blood flow to the gallbladder
(Cleveland Clinic, 2020).
Globally, over a million Americans receive a cholelithiasis (gallstones) diagnosis
annually, adding to the estimated 38 million people who already have the condition
(Zakko, 2022). The vast majority of cholelithiasis patients, however, do not exhibit any
symptoms and do not need medical attention. Additionally, Tanaja, J., Lopez, R. A., &
Meer, J. M. (2022) stated that gallstones are present in 6% of men and 9% of women in
the US, with the majority being asymptomatic. Cholelithiasis is reported to be more
common among European descent, in Hispanic and Native American cultures,
meanwhile it is less prevalent in Asians and African American populations (Terrie,
2020). According to National Organization for Rare Disorders (2023), acute cholecystitis
is treated yearly for around 120,000 Americans. 12% of men and 25% of women will
develop gallstone disease by the age of 65. Cholecystitis develops in about 10% of
individuals with symptomatic gallstones in which men are more likely than women to
have gallstones, despite the fact that women make up 60% of acute cholecystitis
patients.
Nationally, BS Biology students from De La Salle University Manila stated that
gallstone incidence, risk factors, and awareness are currently not included in any official
publications in the Philippines. However, according to the 2013 Philippine Health
Statistics, in 100,000 population, 0.7% mortality rate is caused by cholelithiasis and
other disorders of the gallbladder and biliary tract, having 723 numbers of people in
total, in which 352 are males and 371 are females. Additionally, it was stated that
cholecystitis is one of the top ten causes of morbidity in Olongapo city in the year 2019
and 2020, with a number of 169 and 64 deaths in total, respectively (Ecological Profile
Olongapo City, 2021).
Locally, it has been reported that one of the leading causes of mortality rate of all
ages in the year 2004 is diseases of the digestive systems, some of which includes
disorders of the gallbladder, biliary tract, and the pancreas, having a total number of 708
people with a rate of 17.5% per 100,000 population in Davao Region, Philippines
(Health Research Priorities Region 11, 2006-2010).
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The case analysis outlines the significance of comprehending how acute

cholecystolithiasis impacts people as well as potential indicators and therapies that may
be used in such situations. This case analysis is done in order to contribute to the
nursing sector as well as to the limits of client awareness. It provides essential things for
nursing clients, including managing health, reducing illness development, improving
diagnosis, and increase the standard of nursing practice competency. In addition, the
health education provided in this case analysis will disseminate data and understanding
to the public, student nurses, and other healthcare professionals. This study can help
upcoming researchers produce more information to enhance treatments, medicine
manufacture, and other data regarding acute cholecystolithiasis. It will also aid patients,
nursing students, other healthcare workers, and experts who are working on studies
that will address the topics this case analysis did not discuss.
Objectives
a) General Objective
Within 4 weeks of primary nursing rotation, the student nurses of BSN 2R Group
2 Subgroup 2 will be able to develop a comprehensive case study about Acute
Cholecystolithiasis using the concepts and teachings provided during the RLE
skills lab and nursing lectures, which will equip them with knowledge about the
disease, its signs and symptoms, and the management necessary to develop
skills in order to deliver holistic care for a patient when confronted with a situation
similar to this in a face-to-face setting, thereby encouraging patience and
understanding.
b) Specific Objectives
In order to achieve the general objective, the student nurses specifically aim to:
a. Construct an in-depth introduction providing an overview of Acute
Cholecystolithiasis, relevant statistics from the international, national, and
local aspects, and implications of the study to nursing education, practice,
and research;
b. Formulate objectives that follow specific, measurable, attainable, realistic,
and time-bounded standards;
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c. Present the biographical data, clinical data, family health history, past
health history, and developmental tasks related to the patient;
d. Show the results of the physical and neurological assessments done on
the patient;
e. Provide an overview regarding the definition of the diagnosis;
f. Recognize the organ systems affected by the disease;
g. Discuss the pathophysiology of the disease including the etiology,
symptomatology, and the disease process;
h. Identify different managements to be given that are specific to the signs
and symptoms of the disease;
i. Determine the possible diagnostic evaluation and tools to diagnose such
disease;
j. Create therapeutics and drug studies applicable to the disease;
k. Generate five nursing care plans, three of which are actual diagnoses and
two of which are potential/risk diagnoses;
l. Discuss the discharge planning of the patient;
m. Associate at least two nursing theories that can be applied to the
condition;
n. Review at least three related literature and studies from credible sources
about the case that are not later than five years from the date of
publication;
o. Cite all sources utilized in the making of this study.
II. DATA BASE
Biographical Data
The patient’s name is M.G.J. She is a 43 year old Filipina currently residing at
NHA Buhangin, Davao City. She was born on February 23, 1980 in Lupon, Davao
Oriental. She is the daughter of M.C. and R.C. and she is the 7th out of her 11 siblings.
She is happily married with two daughters, one is a 12 year old and the other 7 year old.
She currently works at the Philippine Army, Panacan.
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Clinical Data
Lab tests were done to the patient in order to help in the diagnosis of her
condition. She had an electrolyte test, CBC test, chest x-ray, and etc. These are the
findings of her electrolyte test: Sodium with a result of 138.5 mmol/L, Potassium with a
result of 3.37 mmol/L, Calcium with the results of L 2.04 mmol/L, and Magnesium with
the results of 0.69 mmol/L. The CBC results were hemoglobin with the results of 104
g/L, RBC with the results of 3.78 10^12L, MCH 27.4 pq, MCV 84 H, MCHC 32.7 g/L,
WBC 11.4 10^g/L, neutrophil 77%, lymphocyte 15%, Monocyte 5%, Eosinophil 3%,
Pasophil 0%, Hematocrit 0.32%, Platelet count of 353 10^q/L, total bilirubin of 13.0
mmol/L, direct bilirubin of 3.00, andirect of 10, alkaline phosphatase of 103.00 U/L, and
a magnesium of 0.82 mmol/L. The radiologic findings were lung fields are clear, heart of
great vessels are unremarkable, diaphragm and costophrenic sulci are intact, osseous
structures show no abnormal gross anomalies, and no other significant findings. With
the impression of a negative chest x-ray. VS taken @ 4PM; Temp: 36.9°C, PR: 81
bpm, CR: 85 bpm, RR: 25 cpm, and BP: 120/80 mmHg. VS taken @ 8PM; Temp:
36.3°C, PR: 83 bpm, CR: 86 bpm, RR: 20 cpm, and BP: 120/80 mmHg.
Family Health History

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The patient’s family health history is presented in the genogram above. The
genogram shows the father, mother, siblings, children, and husband. The father side of
the patient has a history of diabetes mellitus. The mother side of the patient has a
history of hypertension. Her parents have 11 offspring altogether. Her eldest sister and
eldest brother both have diabetes, her 3rd sibling is an alcoholic and has asthma, her
5th sibling is anemic, and her 8th sibling has arthritis. The patient’s 4th, 9th, 10th, and
11th sibling does not manifest signs of diseases present in their family. The patient’s
two daughters does not also manifest signs of diseases present in their family.
Past Health History

The patient has no known significant past health history aside from a cesarean
section procedure done last 2015. The patient does not manifest signs of diseases that
were found in her parents and siblings, such as hypertension, diabetes mellitus, and
asthma. The patient was pregnant with her first child in 2011 and she gave birth in the
same year. She had a normal spontaneous vaginal delivery (NSVD) and did not have
any complications like preeclampsia and gestational diabetes mellitus. She mentioned
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that she was cautious of her lifestyle during her first pregnancy, which ultimately lead to
a healthy pregnancy and labor. The patient was pregnant with her last child in 2014 and
she gave birth in 2015. She had a cesarean section procedure. According to the patient,
her last child was delivered through cesarean section because the baby’s head was not
head down and that the baby was in a transverse position.
History of Present Illness

5 days prior to the admission of the patient, the patient noted epigastric pain
radiating to the back, with a pain scale of 3/10. The patient tolerated the condition with
no medications taken. Prior to admission the patient noted right upper quadrant (RUQ)
pain with a 10/10 pain scale, in which the patient has taken buscopan tabs to relieve
pain. The patient went to a physician and ultrasound was requested with the following
findings; Hepatomegaly with mild fatty infiltration, non dilated ducts, cholecystolithiasis,
no pancreatic and splenic detected, upper abdominal aorta normal, no need pathology,
given medication HNBBS tabs, clonazepam 2mg 2x a day. Cefixime 200mg cup 2x a
day, UDCA 300 mg a day, fenofibrate 100 mg 1 cup once per day, The patient was
advised by a physician to come back and was advised for admission or if icteric sclera
symptoms persisted with untolerated pain. 5 hours prior to admission, patient’s
symtpoms persisted and texted the physician and was advised for admission and done
to serum amylase, thus prompting admission.
Developmental Task
Erik Erikson was a German-American psychologist and psychoanalyst best
known for his theory of the eight stages of psychosocial development. Erikson’s eight
stages of psychosocial development are eight successive stages of personal human
development, with each stage being influenced by biological, psychological, and social
variables throughout the course of a lifetime. Gerontology, personality development,
identity formation, life cycle development, and other disciplines of research have all
been influenced by this bio-psychosocial approach (Orenstein & Lewis, 2021). Robert
Havighurst is another individual who is best known for his theory of development.
Havighurst’s development tasks have six stages, and his theory states that all through
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life, from conception to death, there is constant change and progress (Bialowas & Boyd,
2022). The client is a 43-year-old female, therefore she belongs to the middle adulthood
stage of psychosocial development and Havighurst's developmental tasks. The stage of
middle adulthood is a stage wherein adults must produce or nurture things that will last
when they are gone, frequently through bearing children or influencing a change for the
better in society. Failure results in a superficial engagement with the world, whereas
success produces feelings of utility and accomplishment. According to Erik Erikson, the
developmental tasks during middle adulthood are the following: launching children into
their own lives; adjusting to home life without children; dealing with adult children who
return to live at home; losing parents or caregivers and experiencing associated grief;
becoming grandparents; preparing for late adulthood; and acting as caregivers for aging
parents or caregivers or spouses. The developmental tasks during middle adulthood,
according to Robert Havghurst, are the following: achieving adult civic and social
responsibility; assisting teenage children to become responsible and happy adults;
developing adult leisure-time activities; and accepting and adjusting to the physiologic
changes.
Data was gathered regarding the developmental task of the client. The client’s
parents died when she was a freshman in college. She expressed how hard it was for
her to see her parents become weak. The client has two daughters, one 12 years old
and the other 7 years old. She said that she is strict towards her children, and she
wants them to learn how to become independent so that they would know how to live
and survive by themselves. Her children are still young, so she still lives with her
children. She also lives with her sibling because her sibling will be the one to watch over
her children. When the time comes that her children will become adults, she hopes that
they will visit her from time to time. She also couldn’t imagine herself being a
grandparent since her children are still young. She has been preparing for her
retirement since she started working. She and her husband have a business, and she is
planning to relax after retirement.
III. PHYSICAL ASSESSMENT

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GENERAL SURVEY
The client has a mesomorph body type, medium bone structure and athletic
body. The client is oriented and well-groomed. The client's initial Vital sign at 4:00 pm
on February 4, 2023 has a temperature of 36.9°, a heart rate of 85 bpm, a pulse rate of
81 bpm, a respiratory rate of 25 cpm and a blood pressure of 120/80 mmHg everything
is normal range of an adult and no unusualities observed.
HEAD
The client's head is symmetrical and normocephalic. The head is generally
round, with prominences in the frontal and occipital area. The client has
smooth, fine hair that is distributed evenly and normally, and a clean,
healthy scalp. The jaw has normal strength, and the face moves
symmetrically.
EYES
The client's pupils are round and react to responsiveness and
accommodation. The eye structures are normal with eyebrows
symmetrical in both alignment and movement. The eyelids are
symmetrical with thick eyelashes curled outward. Both irises are brown,
while her conjunctiva is pinkish. Normal of the lacrimal duct while cornea
and lens are both clean and smooth. There is no sign of excessive tearing.
Her eyes' reaction towards the light is brisk.
NOSE
The client's nose is of typical shape. The septum is midline, both nostrils
are patent, and the nasolabial folds are symmetrical. Lesions weren't seen
at all.
MOUTH
The client's lips are dry and symmetrical. The gums, mucosa, and palate
are all pinkish in color. The tongue is midline and the teeth are complete. The
client’s upper and lower lips are symmetrical and are uniformly pinkish. Her
trachea, is located at midline. Upon assessment, there were no lesions or
masses found.
EARS
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There are no apparent tumors, pus, or bleeding, and the client's ears are
in the normal size and shape. The face's skin tone and the color of the ears are
the same. Both ears have normal hearing abilities. There were no unusual
events, including lesions or ears that folded back into their original positions.
SKIN AND NAILS
The complexion and color of the client are both uniformly fair. Normal skin
pigmentation is light brown. The skin is smooth, warm, clammy and dry and has
good skin turgor. Absence of abrasions, lesions, rashes, bruises Edema and
ulcerations on the skin were absent. Her nails are trimmed neatly, both of the
nails are translucent, and firm in texture. Nail beds and fingernails are pink.
PHARYNX
Her oral mucosa is pink and displays zero symptoms of swelling, and her
uvula is positioned in the midline. Her pharynx appeared normal, and her tonsils
did neither expand or exudate.
UPPER EXTREMITIES
Both limbs are identical in color and have symmetrical proportions. A
physical examination revealed no edema, lesions, or scabs. Her fingers are all
complete, and her palms are fair. When her fingers were examined, there were
no abnormalities detected.
LOWER EXTREMITIES
The client's legs appear fair in tone and proportionate. Her legs also seem
to be the same length and width. Upon assessment, there were no lesions or
edema. The client's knees and ankles had some pigmentation that was just
barely noticeable.
IV. DEFINITION OF DIAGNOSIS

Cholelithiasis is the development of gallstones or calculi in the gallbladder. The
most frequent symptom of cholelithiasis, especially when gallstones obstruct the
common bile duct, is discomfort in the right upper quadrant of the abdomen, which is
frequently elicited during physical examination and recognized as a positive Murphy's
sign. Cholelithiasis is commonly accompanied with referred discomfort to the right
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supraclavicular area and/or shoulder, nausea, and vomiting. Cholelithiasis may lead to
problems, such as cholecystitis, which is an inflammation of the gallbladder that
develops over hours; typically, a stone becomes lodged in the cystic duct and
continually obstructs it, resulting in acute inflammation.
V. ANATOMY AND PHYSIOLOGY

One of the organs that makes up the digestive system is called the gallbladder.
The gallbladder is a pear-shaped organ that stores and secretes bile. The liquid known
as bile, which is made by the liver, aids in the digestion of dietary fats. It is in the upper
right quadrant of the abdomen. It is located right beneath the liver.The primary purpose
of it is to store bile. Bile aids the digestive system in breaking down lipids. It is a
compound composed primarily of cholesterol, bilirubin, and bile salts. Through a
network of bile ducts known as the biliary tract, the gallbladder is connected to the rest
of the digestive system. The biliary tract transports bile from the liver to the small
intestine. Before food enters the stomach, the gallbladder is already filled with bile. The
gallbladder receives signals to contract and press the stored bile through the biliary
system when food is consumed. The common bile duct, the largest bile duct, is where
the bile ultimately ends up. The duodenum, the first section of the small intestine, is
where the common bile duct allows bile to enter and mix with the food that is waiting to
be digested. After a meal, the gallbladder is devoid of contents and has the appearance
of a balloon that has lost its air and is currently waiting to be refilled.
VI. PATHOPHYSIOLOGY
A. Etiology
Table 1.1: Predisposing Factors of Acute Cholecystolithiasis
PREDISPOSING PRESENT RATIONALE

FACTORS
Age over 40 years old / According to Cleveland

Clinic (2022), Gallstones
can happen to anyone,
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even children, but they

happen more often after
age 40. This is because
gallstones take a long time
to form. Gallstones may
take 10 to 20 years to get
big enough to cause a
blockage.
Female /
They are more common in
women. This is caused by
female hormones. Estrogen
reduces gallbladder
spasms whereas estrogen
boosts cholesterol.Women
are more likely to gain and
lose weight. Cholesterol
levels rise with increased
body fat. Obesity boosts
estrogen. Rapid weight loss
resembles rapid weight
growth. When a person
rapidly loses a large
quantity of body fat, the
liver processes an
abnormally large volume of
cholesterol, which ends up
in the bile (Cleveland
Clinic,2022).
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Fertile / Fertile women were

thought to be at higher risk
due to higher estrogen
levels and the connection
between gallstones and
pregnancy (Metz, L.,2019)
Ethnicity/Race (Hispanic, x According to Zagaria(2021)

American, Native White, Mexican, and Native
American) Americans frequently
develop gallstones. By age
50, 70% of Native
American men and 80% of
Native American women
had cholelithiasis. Native
Americans are prevalent
among Mexican
Americans. Asians,
Africans, and their
ancestors are at lower risk.
Family history of x Gallstones run in families.

gallbladder disease Family members who are
above 40 are covered.
There may be a genetic link
that can be passed down
that increases the risk of
gallstone development in
family members.
Researchers believe it's
due to inherited gene
abnormalities. The defect
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causes a rise in bilirubin

and cholesterol. Risk may
rise as a result of gene
mutations that control how
cholesterol is transported
from the liver to the bile
duct (Onewelbeck,2023).
Multiple pregnancy / According to Hossain,G.A.

et al. (2019), The chance of
developing gallstones is
increased when a woman
has more than one
pregnancy. This is because
numerous pregnancies
alter the kinetics of the
gallbladder, which leads to
stasis and the production of
stones.
Use of oral contraceptives x It appears that birth control

pills boost cholesterol
levels in the bile and
reduce gallbladder mobility,
both can increase the risk
of developing gallstones
(Johns Hopkins,2020).
Estrogen x According to Wang, H. H.

et al. (2021), Estrogen
stimulates the liver to
secrete biliary cholesterol,
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which increases bile

cholesterol saturation and
increases the incidence of
cholesterol gallstones in
humans and animals.
Table 1.2: Precipitating Factors of Acute Cholecystolithiasis
PRECIPITATING PRESENT RATIONALE

FACTORS
Obesity x Particularly in women,

obesity is a serious risk
factor for cholelithiasis. The
production of gallstones in
the gallbladder is more
likely in overweight women
with BMIs greater than or
equal to 30 kg/m2. One of
the main pathogenic factors
is hypersecretion of
cholesterol, which is
connected to obesity. The
local distribution of fat and
high central adiposity has
also been connected to
gallstone disease. Higher
body fat levels cause
cholesterol levels to rise,
which is too risky to aid in
the development of
gallstones (Zahra, 2019).
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Metabolic syndrome x A risk factor for GS is

insulin resistance. Insulin
resistance may be a
significant factor in the
pathophysiology of GS,
encouraging the formation
of bile that is
supersaturated in
cholesterol and changing
the function of the
gallbladder. According to
Nakeeb et alresearch, .'s
gallbladder dysmotility—
which can lead to
acalculous cholecystitis or
gallstone formation—may
be caused only by insulin
resistance (Jiang et al.,
2020).
Excessive weight loss x Gallstone disease may also

be present in patients who
lose weight quickly on low-
calorie diets. When
following deliberate weight
loss regimens, gallstone
production may get
complex. In such
circumstances, bile is
released with activated
cholesterol from adipose
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tissue, which results in

cholesterol supersaturation
and reduces gallbladder
contraction (Zahra, 2019).
Certain medications x The risk of gallstones is

increased by medications
that lower blood cholesterol
by increasing the quantity
of cholesterol produced in
bile. One of the most
frequent causes of acute
cholestatic damage that
can mimic biliary blockage
is amoxicillin/clavulanic
acid (John Hopkins
Medicine, 2021).
High fat diet / Bile can build up and result

in cholecystitis if something
prevents the gallbladder
from emptying. Foods high
in fat should be avoided if
you have cholecystitis.
Fried foods, canned fish,
processed meats, full-fat
dairy items, baked goods,
fast food, and the majority
of packaged snack foods
fall under this category
MedicineNet (2021).
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Cirrhosis x Your liver can produce

excessive amounts of
bilirubin if you have certain
medical diseases, such as
liver cirrhosis, biliary tract
infections, and some blood
abnormalities. Gallstone
development is influenced
by the excess bilirubin
(Mayo Clinic, n.d.).
B. Symptomatology
Table 2: Symptomatology
SYMPTOMS PRESENT RATIONALE
Presence of Stones in tha / For individuals with

Gallbladder
Asymptomatic gallbladder
diseases, presence of
gallstones are detected,
they are not obstructive
and does not cause
discomfort. According to
Littlefield and Lenahan
(2019), bile that has built
up in the gallbladder
crystallizes into gallstones.
These stones develop
when the bile's
components are out of
balance and one or more
of them precipitate into a
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solid compound.
Gallstones are classified
into two types: cholesterol
and pigment. Pigment
stones, which are primarily
composed of calcium
bilirubinate, are further
classified as either black or
brown stones.
Furthermore, the
hormones progesterone
and estrogen may cause
cholesterol stones to form.
Estrogen stimulates
cholesterol secretion while
inhibiting bile salt
secretion. Progesterone
decreases bile salt
production and slows
gallbladder emptying to
smooth muscle relaxation,
resulting in gallbladder
stasis.
Right Upper Quadrant / For individuals with

Abdominal Pain (Biliary
Symptomatic gallbladder
Colic)
disease may result to
Biliary Colic or pain due to
gallstone formation. These
stones develop when the
level of cholesterol
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exceeds the bile's capacity

to keep it in solution.
Moreover, when gallstones
obstruct the common bile
duct, the individual may
experience biliary colic,
which is characterized by
painful spasms in the right
upper quadrant of the
abdomen. (Littlefield &
Lenahan, 2019)
Elevated White Blood Cell / Studies have shown that

Count
individuals with Acute
cholecystitis may
experience elevated White
blood cell count. Rather
than microbial invasion, it
is caused by the intense
inflammatory response to
the necrotic changes in the
gallbladder wall (Teefey et
al., 2018).
Nausea and Vomiting / Biliary colic is usually

associate by nausea and
vomiting. Nausea and
vomiting are the most
common complaints in
individuals that are
experiencing gallstones. In
a case presented by
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McGowan et al. (n.d.), a

patient came in and
complained about vomiting
that contained solid
substance, which was later
determined to be
gallstones. As other
causes of vomiting would
not have caused
retrograde flow of the
gallstones into the stomach
to enable their expulsion
by vomiting, the discovery
of gallstones in the vomitus
led to the diagnosis of
small bowel obstruction.
Increased Cholesterol / According to Cleveland

Production
Clinic (n.d.), healthcare
providers have discovered
that there are 75% of
gallstones are made up of
excess cholesterol. High
blood cholesterol levels
result in increased
cholesterol content in the
bile. Before sending bile to
your gallbladder, your liver
filters cholesterol from your
blood and deposits it in bile
as a waste product. Bile
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chemicals (lecithin and bile

salts) are thought to
dissolve cholesterol.
However, if there is an
excess of it, these
chemicals may not be
adequate.
Increased Gas / A mechanical intestinal

obstruction brought on by
gallstone impaction in the
colon is referred to as a
gallstone ileus. Patients
can have gallbladder
symptoms as bloating,
belching, fullness, nausea,
and vomiting due to having
undigested fats in the
intestine when there is a
problem moving bile into
the intestine after a fatty
meal. Bacteria in the
intestines break down
these lipids, resulting in the
production of foul-smelling
gas. (What Causes
Gallbladder Symptoms?,
2021)
Fever x Gallbladder inflammation

may result from a gallstone
that becomes stuck in the
25
gallbladder's neck
(cholecystitis).
Cholecystitis can result in
fever and excruciating
pain. (Gallstones -
Symptoms and Causes,
2021)
Jaundice x In a study conducted by

Edlund, et. al. (n.d.), in
acute cholecystitis,
jaundice is induced by
decreased excretion, which
might be caused by
gallbladder pressure on the
ducts.
Steatorrhea x Chronic steatorrhea is

typically brought on by
biliary tract, pancreatic, or
gastrointestinal disorders.
It's because appropriate
intestinal motility and
absorption, pancreatic
lipases, and bile are all
necessary for fat
absorption. (Varshney,
2022).
C. Disease Process
26
27
D. Narrative Pathophysiology
Gallstones, which resemble hard, rounded stones, clog the cystic duct. Bile
sludge, a viscous mixture of glycoproteins, calcium deposits, and cholesterol crystals in
the gallbladder or biliary ducts, is frequently present prior to the development of
gallstones. In the US, bile that has been oversaturated with cholesterol makes up the
majority of gallstones. This hypersaturation, which occurs when the concentration of
cholesterol exceeds the proportion of that soluble in water, is predominantly brought on
by hypersecretion of cholesterol as a result of abnormal hepatic cholesterol metabolism.
The crystallization of cholesterol in bile can also be sped up by an unbalanced ratio of
pronucleating (crystallization-promoting) and antinucleating (crystallization-inhibiting)
proteins in the bile. It has been established that mucin, a combination of glycoproteins
released by biliary epithelial cells, is a pronucleating protein. It is thought that the
reduced ability of lysosomal enzymes to degrade mucin leads to the development of
cholesterol crystals.
Gallstone development is also influenced by diminished sphincteric contraction
and decreased muscle mobility of the gallbladder wall. This hypomotility causes
reduced reservoir function and protracted bile stasis (delayed gallbladder emptying).
28
Bile builds up when there isn't enough flow, which increases the likelihood that stones
may form. Hypomotility can lead to inefficient filling and a larger percentage of hepatic
bile redirected from the gallbladder to the small bile duct.
Bilirubin, a substance created by the regular breakdown of RBCs, can
occasionally be found in gallstones. The production of bilirubin stones has been linked
to increased enterohepatic bilirubin cycling and biliary tract infection. Patients with
chronic hemolytic disorders or biliary tract infections are more likely to develop bilirubin
stones, also known as pigment stones (or damaged RBCs). More pigment stones occur
in Asia and Africa.
Gallstones are not usually present in cholecystitis, although their impaction in the
bladder neck, Hartmann's pouch, or the cystic duct is the etiology of the condition. The
gallbladder experiences increased pressure, enlargement, wall thickening, decreased
blood flow, and potential exudate formation. Cholecystitis can be either acute or chronic,
with chronic cholecystitis possibly developing as a result of recurrent bouts of acute
inflammation. Different microbes, including gas-forming ones, can infect the gallbladder.
If neglected, an inflamed gallbladder may develop necrosis, gangrene, and eventually
clinical sepsis. An uncommon but potentially fatal complication of untreated cholecystitis
is gallbladder perforation. If stones dislodge down to the sphincter of Oddi and are not
removed, blocking the pancreatic duct, cholecystitis can also result in gallstone
pancreatitis.
Gallstone development results from the combination of hereditary and
environmental factors, few of which are as immutable and unchangeable as age and
genetic make-up. Traditional risk factors for gallstones include the four "Fs" of female,
fertile, fat, and age 40, with some adding the fifth "F" of fair skin. Genetic factors,
advanced age, female gender, parity, ethnicity, rapid weight loss, various medications
(estrogen replacement therapy, oral contraceptives), westernized diet, obesity, Type 2
diabetes mellitus, metabolic syndrome, dyslipidemia, hyperinsulinemia, increased
enterohepatic circulation of bilirubin, and defective gallbladder motility are some of the
intrinsic and extrinsic risk factors for the development of various types of gallstones.
29
Furthermore, the treatment of cholelithiasis is determined by the symptomatology

and the presence or absence of othe complications. Generally, the management is
multifaceted, encompassing lifestyle and dietary changes, along with the medication.
For individuals with infrequent episodes of right upper quarant pain and mild symptoms
an benefit from pharmacological management alone. But, for individuals who have
recurrent right upper quadrant pain or signs and symptoms of inflammation, refferal for
surgical evaluation is indicated, especially in the cases of acute cholecystitis.
Pharmaologic management entails pain relief (NSAIDs), antiemetics, and, if necessary,
dissolution agents. In individuals that manifest symptomatic cholelithiasis, surgical
intervention such as Laparoscopic Cholecystectomy, is required. If the disease is early
detected, the prognosis is good and it can lead to recovery. But, if the disease is left
untreated and worsens, the chance for recovery is poor which can lead to death.
VII. MEDICAL MANAGEMENT

A. Diagnostic Exam and Lab Tests
1. Complete Blood Count (CBC)
DEFINITION NURSING RESPONSIBILITIES
Complete blood count (CBC) is a test that a. Explain test procedure.

counts the cells that make up your blood: Rationale: Explain that slight discomfort
red blood cells, white blood cells, and may be felt when the skin is punctured.
platelets. The findings in the CBC give
valuable diagnostic information about the b. Encourage to avoid stress if possible
hematologic and other body systems, Rationale: Altered physiologic status
prognosis, response to treatment, and influences and changes normal
recovery. hematologic values.
c. Explain that fasting is not necessary.

Rationale: Fasting is not necessary,
however, fatty meals may alter some test
results as a result of lipidemia.
30
d. Monitor the puncture site for oozing or

hematoma formation.
Rationale: Symptoms of a
bruise/haematoma include pain,
tenderness to touch, swelling, and
discoloration.The blood in a bruise or
hematoma is broken down and is
eventually reabsorbed and put back to
use by the body.
2. Bilirubin Blood Test
A bilirubin blood test is a test done in a. Instruct the patient to not eat or drink
order to measure the levels of bilirubin in and take any medications at least 4 hours
your blood. This test is done in order to before the test.
check the health of your liver, if the liver is Rationale: Some foods, drinks, or
healthy it will remove the majority of medications can alter the bilirubin levels,
bilirubin from our bodies. If it is damaged, which will alter the results.
bilirubin can leak out from our livers and
into our blood. b. Explain the procedure to the patient .
Rationale: To elicit the cooperation of the
client, and prepare them for the insertion
of needle for the blood sample.
c. Clean the puncture site with an alcohol

swab.
Rationale: To prevent infections.
Assess the puncture site for hematoma

31
formation, if hematoma forms apply direct

pressure.
Rationale: to prevent pain and
discomfort.
3. Creatinine Test
A creatinine test is done in order to a. Explain the procedure to the patient.

measure creatinine levels in our blood Rationale: To elicit cooperation with the
and/or urine. Creatinine levels are a major client.
factor in determining the estimated
glomerular filtration rate which marks the b. Clean puncture site and perform
standard of kidney health, creatinine can venipuncture and collect the sample in a
build up in our blood and less will be 3-4 cc clot activator tube.
released through urine. If levels are not Rationale: To prevent infection
normal in blood and urine, it can be a sign
of a kidney malfunction or disease. c. Assess the puncture site for hematoma
Creatinine levels are a major factor in formation, if hematoma forms apply direct
determining the estimated glomerular pressure.
filtration rate which marks the standard of Rationale: to prevent pain and discomfort.
kidney health.
4. Capillary Blood Glucose (CBG) Test
A blood glucose test is a blood test that a. Determine if the test requires special
mainly screens for diabetes by measuring timing; for example, before or after meals.
the level of glucose (sugar) in your blood. Blood glucose monitoring is usually done
Capillary blood glucose test: A healthcare prior to meals and the administration of
professional collects a drop of blood —
32
usually from a fingertip prick. These tests antidiabetic medications.

involve a test strip and glucose meter Rationale: Blood glucose levels are
(glucometer), which show your blood affected by diet, and the test may be
sugar level within seconds. scheduled at very specific intervals.
Diet and medication orders are based on
the assumption that the test results are
accurate.
b. Gather equipment needed ahead of

time
Rationale: Having equipment prepared
and available promotes organization,
safety, and timeliness.
c. Assess patient’s sites for skin puncture.

Rationale: Skin integrity at the puncture
site minimizes the risk of infection and
promotes healing.
d. Perform hand hygiene.

Rationale: Hand hygiene prevents the
transfer of microorganisms.
e. Have patient wash hands with soap

and warm water or clean with alcohol
swab, and position the patient
comfortably in a semi-upright position in
bed or upright in a chair. Encourage
patient to keep hands warm.
Rationale: Washing reduces transmission
of microorganisms and increases blood
33
flow to the puncture site.
f. Select appropriate puncture site and

perform skin puncture.
Rationale: Your patient may have a
preference of site used. For example, the
patient may prefer not to use a specific
finger for the skin puncture. Or the site
may be contraindicated.
g. Gently squeeze above the site to

produce a large droplet of blood.
Rationale: Do not contaminate the site by
touching it. The droplet of blood needs to
be large enough to cover the test pad on
the reagent strip.
h. Transfer the second drop of blood

Rationale: The test pad must absorb the
droplet of blood for accurate results.
Smearing the blood will alter results.
i. Apply pressure, or ask patient to apply

pressure, to the puncture site using a 2 x
2 gauze pad or clean cotton ball .
Rationale: This will stop the bleeding at
the site.
j. Review test results with the patient.

Rationale: To promote patient
34
participation in health care.
5. Electrolyte Test
An electrolyte test is done in order to find a. Explain the procedure to the

out if our body has a fluid or acid and patient
base imbalance. In some cases this test Rationale: To elicit the cooperation
is done in order to check for levels of of the client, and prepare them for
sodium and potassium, which indicates the insertion of needle for the
how well our liver and kidneys are blood sample.
working, whereas electrolyte disorders b. Clean the puncture site with an
like potassium, sodium, and magnesium alcohol swab
are often associated with renal failure. Rationale: To prevent infections
c. Assess the puncture site for
hematoma formation, if hematoma
forms apply direct pressure.
discomfort.
d. Assess the patient for any
abnormalities
injuries.
6. Alanine Aminotransferase (ALT) Test
Alanine aminotransferase test or ALT, is a a. Explain the procedure to the

blood test that is done in order to patient
measure the amount of ALT in the blood, Rationale: To elicit the cooperation
because when there is a high amount of of the client, and prepare them for
35
ALT in our blood it could be a sign of liver the insertion of needle for the
damage or disease. blood sample.
b. Clean the puncture site with an
alcohol swab
Rationale: To prevent infections
discomfort.
d. Monitor vital signs
Rationale: to record and prevent
any abnormalities.
.
7. Prothrombin Time (PT) Test
Prothrombin time test is done in order to a. Explain the procedure to the

calculate the international normalized patient.
ratio. These are needed to measure the Rationale: To elicit cooperation
time needed for blood clots, in which the with the client.
liver synthesizes the proteins necessary b. Clean puncture site and perform
for blood clotting. An abnormal PT result venipuncture and collect the
can indicate an acute or chronic liver sample in a 3-4 cc clot activator
disorder. Wherein an increasing PT tube.
indicates progression to liver failure. Rationale: To prevent infection
discomfort.
36
d. Monitor vital signs

Rationale: to record and prevent
any abnormalities.
8. Chest X-ray (CXR)
Chest x-ray is used to produce pictures of A.Remove all metallic objects

the inside of the chest.It is used to assess Rationale: Items such as jewelry, pins,
the heart, lungs, and chest wall and may buttons etc can hinder the visualization of
be used to diagnose injuries, fever, chest the chest.
pain, shortness of breath, and chronic
coughing. Various lung disorders like B. No preparation is required.
pneumonia, emphysema, and cancer may Rationale: Fasting or medication
also be diagnosed and treated with its restriction is not needed unless directed
assistance. Chest X-rays are very helpful by the health care provider.
in emergency diagnosis and treatment
because they are quick and simple.In C. Ensure the patient is not pregnant or
order to create images of the interior of suspected to be pregnant.
the chest, chest x-rays need a very small Rationale: X-rays are usually not
dosage of ionizing radiation. recommended for pregnant women
unless the benefit outweighs the risk of
damage to the mother and fetus.
D. Instruct patient to cooperate during the

procedure.
Rationale: The patient is asked to remain
still because any movement will affect the
clarity of the image.
9. Electrocardiogram (ECG) 12 Leads Test

37
A 12-lead electrocardiogram (ECG) is a A. Provide privacy and explain the

medical test that is recorded using leads, procedure to the client.
or nodes, attached to the body. Rationale: Explain that the test records
Electrocardiograms, sometimes referred the heart's electrical activity and that it
to as ECGs, capture the electrical activity may be repeated at certain intervals.
of the heart and transfer it to graphed Emphasize that no electrical current will
paper. enter the body. Tell the client that the test
typically takes about 5 minutes.
B. Advice the client lie supine position in

the center of the bed with arms at his
sides. You may raise the head of the bed
to promote comfort.
Rationale: Expose the arms and legs and
cover the client appropriately. The arms
and legs should be relaxed to minimize
muscle trembling, which can cause
electrical interference. Make sure the feet
are not touching the bed board.
C. Select flat, fleshy areas to place the

limb lead electrodes
Rationale: Avoid muscular and bony
areas. If the client has an amputated limb,
choose a site on the stump
D. If an area is excessively hairy, clip it.

Rationale: Clean excess oil or other
substances from the skin with alcohol pad
38
to enhance electrode contact
E. Expose the client's chest. Put a pre-

gelled electrode at each electrode
position.
Rationale: If your client is a woman, be
sure to place the chest electrodes below
the breast tissue. In a large-breasted
woman, you may need to displace the
breast tissue laterally.
F. Ask the patient to lie still, avoid talking,

breathe normally, and relax when
recording ECG
Rationale: For accurate findings
G. Machines have a display screen

Rationale: You can preview waveforms
before the machine records them on
paper
H. Press the PRINT button. Observe the

tracing quality.
Rationale: The machine will record all 12
leads automatically, recording three
consecutive leads simultaneous.
I.When the machine finishes recording

the 12-lead ECG, remove the electrodes
and clean the client's skin
Rationale: To make the patient
39
comfortable
J. Record the results

Rationale: To be efficient
10. Transabdominal Ultrasound
A procedure used to examine the organs A.Ensure that the probe and machine are
in the abdomen. An ultrasound transducer cleaned before entering a patient room.
(probe) is pressed firmly against the skin Rationale: The correct probes should be
of the abdomen. High-energy sound connected to the machine.
waves from the transducer bounce off B. Explain to patient the procedure and its
tissues and create echoes. The echoes purpose
are sent to a computer, which makes a Rationale: To gain cooperation
picture called a sonogram. Also called C. Instruct patient to void
abdominal ultrasound. Rationale: To save time and be efficient
D. Assist patient in lying in a supine
position on a stretcher with his or her
abdomen exposed.
Rationale: Care should be taken to avoid
unnecessary exposure with the use of
towels tucked around the gown and
undergarment edges. This will also aid in
keeping unexposed areas clean from
ultrasound gel.
E. The lights should be dimmed if
possible.
Rationale: For evaluation of the
gallbladder, being in a fasting state aids in
the engorgement of the gallbladder and
40
better visualization.
B. Therapeutics and Drug Studies

Non-Pharmacological Therapeutics
1. Intravenous Fluid Therapy (IVT)
DEFINITION RATIONALE NURSING

RESPONSIBILITIES
Intravenous fluid therapy is Intravenous fluid therapy is 1. Establish rapport with

a treatment that infuses done in order to administer the client.
various solutions, blood, medications of intravenous R: To elicit cooperation.
blood products, and route directly and quickly,
medications via and in some cases to 2. Explain procedure to the
intravenous route. prevent dehydration of a client.
patient in NPO or with a R:To explain the risk, and
fluid deficit, and to lessen anxiety of patient.
replenish lost nutrients of a
recovering patient. 3. Check medication order,
and verify physician's order
to make sure the patient
has no allergies to the
medication or solution to
be administered.
R: To prevent harm.
4. Regulate infusion rate.

R: To avoid fluid overload
or deficit.
5. Check the bag and the

components needed for
41
IVT, for leaks, damages,

etc.
R: To prevent the spread
of microorganisms and
infection.
6. Assess IV site for any

abnormalities.
R: Watch out for
abnormalities such as
redness, swelling, or
tenderness.
2. Laparoscopic Cholecystectomy

RESPONSIBILITIES
Laparoscopic This is done in order to 1. Establish rapport.

cholecystectomy or which remove any gallstones that R: To establish
is also known as the migrate outside the bladder cooperation with the
minimally invasive which can block the flow of patient.
cholecystectomy, is bile causing problems and
performed through 4 small is called 2. Explain procedure to the
incisions which utilizes a cholecystolithiasis. client.
camera to see inside the R: To explain the risk, and
abdomen in unison with lessen anxiety of patient.
long tools to remove the
gallbladder. 3. Discourage patient to
not eat or drink at least 8
hours before the procedure
is done.
42
R: For safety precautions.
4. Observe signs of
bleeding from surgical
wounds.
R: Prothrombin is reduced
and coagulation time is
prolonged if bile flow is
blocked, which increases
the risk for bleeding or
hemorrhage.
5. Administer IV fluids, and

blood products, as
indicated.
R: Maintains adequate
circulating volume. Aids in
replacement of clotting
factors.
3. Bowel Rest

RESPONSIBILITIES
The basic definition of One advantage of bowel 1. Establish rapport with

bowel rest is the intentional rest is that there is no need the client.
restriction of intake of for medications. The R: To elicit cooperation.
nutrients via oral intake, for purpose of bowel rest is to
patients with intentionally restrict intake 2.Administer IV as ordered
gastrointestinal diseases. of food and water via by the Doctor.
43
mouth, to allow the small R: Maintains adequate

intestines to recover, and circulating volume. Aids in
is often used as a replacement of lost
treatment for cholecystitis. nutrients.
3. Monitor patient VS.

R: To ensure the stable
condition of the patient.
4. Slowly reintroduce food.

R: To prevent shock.
4. Endoscopic retrograde cholangiopancreatography

RESPONSIBILITIES
Endoscopic retrograde In most cases ERCP is 1. Establish rapport with

cholangiopancreatography, done due to finding the the client.
is a procedure used to cause of unexplained R: To elicit cooperation.
diagnose problems with yellowing of the skin and
our liver, gallbladder, and eyes, or abdominal pain. In 2. Explain procedure to the
bile ducts, and treat them. the case of our patient this client.
procedure was done in R: To explain the risk, and
order to check and treat lessen anxiety of patient.
stones found in the bile
ducts. 3. Monitor vital signs of
patients, and assess for
any abnormalities.
R: Watch out for fever,
pain in stomach, neck or
chest,etc.
44
4. Drink lots of fluids or the

prescribed amount by the
physician.
R: Nausea can be
prevented by starting with
a light diet.
5. Endoscopic gallbladder drainage

RESPONSIBILITIES
This procedure allows an This relieves the 1. Assess the vital signs
endoscopist to access the gallbladder obstruction and frequently and inform the
gallbladder under resulting infection. doctor if there is any
endoscopic ultrasound abnormality.
guidance and place stents R: To ensure the stability
through the wall of the of the patient’s overall
small intestine into the condition.
gallbladder.
2. Assess abdominal pain
through physical
examination, nausea, and
vomiting.
R: To prevent injuries, and
ensure safety of patient.
3. Start IV fluid and pain

medications as prescribed.
R: To prevent dehydration.
45
4. Prepare the patient for

the operative room by
keeping him/her NPO,
5. teach the patient about

the procedure steps, and
about the postoperative
management.
R: Safety precautions.
6. Electrolyte Imbalance Correction

RESPONSIBILITIES
Electrolytes are minerals Any electrolyte (particularly 1. Weigh patient daily.

that control important potassium, magnesium, R: Regular monitoring of
physiologic functions of the calcium, and phosphorus) patient’s weight will
body. An electrolyte abnormality or acid-base indicate if there is fluid
imbalance occurs when imbalance should be volume excess which could
your body’s mineral levels corrected. cause changes in
are too high or too low. electrolyte levels.
This can negatively affect
vital body systems. 2. Administer pain
Electrolytes must be medication as appropriate.
evenly balanced for your R: Electrolyte
body to function properly. abnormalities may cause
Severe electrolyte discomfort and patients
imbalances can cause may need treatment for
serious problems such as pain.
coma, seizures, and
46
cardiac arrest. 3. Provide intravenous or

oral hydration as needed.
R: Patients are more prone
to electrolyte imbalances
when experiencing
vomiting and/or diarrhea –
ensure the patient is
maintaining appropriate
hydration status.
4. Supplement electrolyte
levels as appropriate and
as ordered by the
healthcare provider.
R: If patients’ electrolyte
levels are low additional
supplements may be
needed orally or
intravenously to maintain
appropriate levels,
administer these as
ordered by the healthcare
provider.
5. Administer oxygen as
needed.
R: Electrolyte imbalances
can cause respiratory
distress/failure – monitor
closely and if needed
supply supplemental
47
oxygen therapy.
6. Educate patient and

family on signs and
symptoms of electrolyte
abnormalities.
R: This will help to provide
the patient with more
independence at home in
managing their care and
preventing further
complications or episodes
of electrolyte
abnormalities.

family member on the
importance of balanced
nutritional state and
importance of hydration.
R: This will help patients to
understand how their
nutritional status affects
their electrolyte levels.

family members on the
importance of taking
medications as prescribed
and what their specific
medications are used for.
48
R: Understanding their
individualized medication
regimen will help the
patient to develop more
independence in their care
and can help them to be
more compliment with their
medications.
7. Foley Catheter

RESPONSIBILITIES
A foley catheter is a thin A foley catheter is used in 1. Establish rapport with

flexible catheter used to the patient due to the the client
drain urine from the gallbladder not being able R: To elicit cooperation
bladder through the urethra to drain all the bile by itself,
of the patient. thus a catheter will be 2. Explain procedure to the
inserted to drain the patient
gallbladder of bile and to R: To elicit cooperation of
decompress it. the patient
3. Do handwashing
R: to prevent the spread of
microorganisms.
4. Insert the catheter

slowly and do not force if
resistance is observed.
49
R: To prevent damage to
urethra.
5. Monitor output, and

patient for any
unusualities,
R: To prevent the
overfilling of the catheter,
and prevent pain.
Drug Study
GENERIC NAME Ampicillin/Sulbactam
BRAND NAME Unasyn
CLASSIFICATION Pharmacologic class: Aminopenicillin/

beta-lactamase inhibitor
Therapeutic class: Anti-infective
ORDERED DOSE 1.5g IV q8
SUGGESTED DOSE (By Manufacturer) Usual Adult Dose for Intra Abdominal
Infection :1.5 to 3 g IV or IM every 6
hours
Usual Adult Dose for Bacterial Infection:
50
1.5 to 3 g IV or IM every 6 hours

Usual Adult Dose for Skin and Structure
Infection: 1.5 to 3 g IV or IM every 6
hours
Usual Adult Dose for Surgical
Prophylaxis: Preoperative dose: 3 g IV or
IM once, starting within 60 minutes before
surgical incision Redosing interval (from
start of preoperative dose): 2 hours
MODE OF ACTION Destroys bacteria by inhibiting bacterial

cell-wall synthesis during microbial
multiplication. Addition of sulbactam
enhances drug’s resistance to beta-
lactamase, an enzyme that can inactivate
ampicillin.
INDICATION Intra-abdominal, gynecologic, and skin-

structure infections caused by susceptible
beta-lactamase-producing strains
PREGNANCY CATEGORY B
CONTRAINDICATION Hypersensitivity to penicillins,

cephalosporins, imipenem, or other beta-
lactamase inhibitors
SIDE EFFECTS Frequent: Diarrhea, rash (most com-

mon), urticaria, pain at IM injection site,
thrombophlebitis with IV administration,
oral or vaginal candidiasis.
Occasional: Nausea, vomiting,
headache, malaise, urinary retention.
51
ADVERSE EFFECTS CNS: lethargy, hallucinations, anxiety,

confusion, agitation, depression, fatigue,
dizziness, seizures
CV: vein irritation, thrombophlebitis, heart
failure
EENT: blurred vision, itchy eyes
GI: nausea, vomiting, diarrhea,
abdominal pain, enterocolitis, gastritis,
stomatitis, glossitis, black “hairy” tongue,
furry tongue, oral and rectal candidiasis,
pseudomembranous colitis
GU: hematuria, hyaline casts in urine,
vaginitis, nephropathy, interstitial
nephritis
Hematologic: anemia, eosinophilia,
agranulocytosis, hemolytic anemia,
leukopenia, thrombocytopenic purpura,
thrombocytopenia, neutropenia Hepatic:
nonspecific hepatitis Musculoskeletal:
arthritis exacerbation Respiratory:
wheezing, dyspnea, hypoxia, apnea
Skin: rash, urticaria, diaphoresis Other:
pain at injection site, fever,
hyperthermia,superinfections,hyper-
sensitivity reactions, anaphylaxis, serum
sickness
DRUG INTERACTION Allopurinol: increased risk of rash

Chloramphenicol:synergisticorantag-
onistic effects
Hormonal contraceptives: decreased
52
contraceptive efficacy, increased risk of

breakthrough bleeding
Probenecid: decreased renal excretion
and increased blood level of ampicillin
Tetracyclines:reduced bactericidal effect
NURSING RESPONSIBILITIES ● Monitor for signs and symptoms of

hypersensitivity reaction.
● Check for signs and symptoms of
infection at the injection site. Monitor for
seizures when giving high doses.
● Watch for bleeding tendency and
hemorrhage.
● Check the patient's temperature and
watch for other signs and symptoms of
superinfection, especially oral or rectal
candidiasis.
● Instruct patient to immediately report
signs and symptoms of hypersensitivity
reaction, such as rash, fever, or chills.
● Tell patient to report signs and
symptoms of infection or other problems
at the injection site.
● Advise patient to minimize GI upset by
eating small, frequent servings of food
and drinking plenty of fluids.
● Inform patient that the drug lowers
resistance to certain infections. Instruct
him to report new signs or symptoms of
infection, especially in the mouth or
rectum.
53
● Inform patient taking hormonal

contraceptives that the drug may reduce
contraceptive efficacy. Advise her
to use an alternative birth control method.
● Instruct patient to avoid activities that
can cause injury. Advise him to use a soft
toothbrush and electric razor to avoid
gum and skin injury.
GENERIC NAME Celecoxib
BRAND NAME CeleBREX®
CLASSIFICATION Chemical Class: Pyrazole; 1H-pyrazole

Therapeutic Class: NSAIDs; COX-2
inhibitors
ORDERED DOSE PO 200 mg tablets b.i.d.
SUGGESTED DOSE (By Manufacturer) ➢ For OA: 200 mg per day

administered as a single dose or
as 100 mg twice daily.
54
➢ For RA: 100 mg to 200 mg twice

daily.
➢ For JRA, the dosage for pediatric
patients (age 2 years and older) is
based on weight.
○ For patients ≥10 kg to ≤25 kg:
50 mg twice daily.
○ For patients >25 kg: 100 mg
twice daily.
➢ For AS (ankylosing spondylitis):
200 mg daily in single (once per
day) or divided (twice per day)
doses.
➢ For managing acute pain and
Treating primary Dysmenorrhea:
400 mg initially, followed by an
additional 200 mg dose if needed
on the first day. On subsequent
days, the recommended dose is
200 mg twice daily as needed
MODE OF ACTION Due to the selective cyclooxygenase-2

(COX-2) inhibitor, it is in charge for the
inhibition of prostaglandin synthesis that
exhibits anti-inflammatory, and antipyretic
effects.
INDICATION A type of nonsteroidal inflammatory

(NSAIDs) that is used to relieve mild to
moderate pain. It can also help relieve the
symptoms of arthritis, stiffness,
55
inflammation, and swelling.
PREGNANCY CATEGORY Class B3
CONTRAINDICATION Contraindicated with patients with known:

➔ Hypersensitivity
➔ Active peptic ulceration or
gastrointestinal bleeding
➔ Inflammatory bowel disease
➔ CHF (NYHA II-IV)
➔ established ischaemic heart
disease
➔ Cerebrovascular disease or
Peripheral Arterial disease
➔ Severe Renal impairment
➔ hepatic disease (Child-Pugh class C or
≥10 score)
➔ 3rd trimester pregnancy and
lactation
SIDE EFFECTS ➢ General disorders and

administration site conditions:
Influenza-like symptoms.
➢ Gastrointestinal disorders: Nausea,
abdominal pain, diarrhea, vomiting
➢ Nervous system disorders:
Headache
➢ Psychiatric disorders: Insomnia
➢ Respiratory, thoracic and
mediastinal disorders: Sinusitis,
cough
➢ Skin and subcutaneous tissue
56
disorders: Rash, pruritus
ADVERSE EFFECTS ➢ Blood and lymphatic system

disorders: Anaemia.
➢ Cardiac disorders: Angina pectoris.
➢ Gastrointestinal disorders:
dyspepsia, flatulence, dysphagia,
GERD, irritable bowel syndrome.
➢ Investigations: Increased blood
creatinine, weight increased,
elevated ALT or AST.
➢ Musculoskeletal and connective
tissue disorders: Arthralgia.
➢ Nervous system disorders:
hypertonia.
➢ Renal and urinary disorders:
Nephrolithiasis, UTI.
➢ Reproductive system and breast
disorders: Benign prostatic
hyperplasia.
➢ Respiratory, thoracic and
mediastinal disorders: upper
respiratory tract infection,
pharyngitis, dyspnea, rhinitis,
DRUG INTERACTION Celecoxib will increase the risk of

gastrointestinal ulceration when taken
with anticoagulants, antiplatelet agents,
SSRIs, corticosteroids, and other
NSAIDs. It may also decrease the
antihypertensive effect of ACE inhibitors,
57
β-blockers and other antihypertensive

agents. It may boost the nephrotoxic
effect of cyclosporine and tacrolimus. It
may also boost the serum concentration
with CYP2C9 inhibitors, such as
fluconazole. And, reduce the plasma
concentration with CYP2C9 inducers,
such as rifampicin and barbiturates.
NURSING RESPONSIBILITIES 1. Monitor any signs and symptoms

of DRESS (fever, rash, facial
swelling, and lymphadenopathy)
from time to time during treatment.
Stop the treatment if symptoms
occur
2. Monitor for rashes or any skin
reactions such as itching,
dermatitis, and hives.Directly
inform the attending physician
since certain skin reactions may
indicate serious hypersensitivity
reactions.
3. Assess for range of motion, muscle
strength, and pain to record if the
drug is effective.
4. Watch out for dizziness. Notify
immediately to the physician once
such problems occur.
5. Assess for peripheral edema by
using girth measurements and
volume displacement. Directly
58
inform the attending physician

when increases of swelling occur
or fluid retention.
6. Monitor for any sign of MI, such as
pain radiating into jaw or arm,
shortness of breath, sudden chest
pain, nausea, and sweating.
7. Watch out for stroke symptoms
may be nausea, vomiting,
numbness, sudden severe
headache, visual disturbance, and
speech problems.
8. Check for any signs and symptoms
of GI bleeding, which may include:
vomiting of blood, tarry stools,
abdominal pain, blood in stools.
GENERIC NAME FENOFIBRATE
BRAND NAME Fenoflex
CLASSIFICATION Antilipemic Agents
ORDERED DOSE 100mg 1cap o.d

59
SUGGESTED DOSE (By Manufacturer) Adults:

Antara®: At first, 130 milligrams (mg)
once a day with a meal. Your doctor may
adjust your dose as needed.
Lipofen®: At first, 150 mg once a day with
a meal. Your doctor may adjust your dose
as needed.
Lofibra™: 200 mg once a day with a
meal.
MODE OF ACTION Fenofibrate activates peroxisome

proliferator activated receptor alpha
(PPARα), increasing lipolysis, activating
lipoprotein lipase, and reducing
apoprotein C-III. PPARα is a nuclear
receptor and its activation alters lipid,
glucose, and amino acid homeostasis.
Activation of PPARα activates
transcription of gene transcription and
translation that generates peroxisomes
filled with hydrogen peroxide, reactive
oxygen species, and hydroxyl radicals
that also participate in lipolysis. This
mechanism of increased lipid metabolism
is also associated with increased
oxidative stress on the liver. In rare cases
this stress can lead to cirrhosis and
chronic active hepatitis.
INDICATION Fenofibrate is indicated as adjunctive

therapy to diet to reduce elevated LDL-C,
Total-C, Triglycerides, and Apo B, and to
60
increase HDL-C adults with primary

hypercholesterolemia or mixed
dyslipidemia. Fenofibrate is also indicated
to treat adults with severe
hypertriglyceridemia.
PREGNANCY CATEGORY C
CONTRAINDICATION -Known hypersensitivity

-Severe renal impairment, including those
with end-stage renal disease and those -
receiving dialysis
-Active liver disease
-Gallbladder disease
-Nursing mothers
SIDE EFFECTS -headache

-back pain
-nausea
-indigestion
-stuffy or runny nose
-stomach pain
ADVERSE EFFECTS -Dark urine

-muscle cramps, spasms, stiffness,
swelling, or weakness
-trouble breathing
-unusual bleeding or bruising
-unusual tiredness or weakness
-yellow eyes or skin
-Back pain
-diarrhea
61
-eye irritation
-gas
-increased sensitivity of the skin to
sunlight
DRUG INTERACTION -Fenofibrate may decrease the excretion

rate of Abacavir which could result in a
higher serum level.
-The serum concentration of Fenofibrate
can be increased when it is combined
with Abametapir.
-The metabolism of Fenofibrate can be
increased when combined with
Abatacept.
NURSING RESPONSIBILITIES 1. Conduct thorough physical

assessment before beginning drug
therapy to establish baseline
status, determine effectivity of
therapy and evaluate potential
adverse effects.
2. Assess any muscle pain,
tenderness, or weakness,
especially if accompanied by fever,
malaise, and dark-colored urine.
3. Monitor signs of hypersensitivity
reactions, including pulmonary
symptoms (tightness in the throat
and chest, wheezing, cough,
dyspnea) or skin reactions (rash,
pruritus, urticaria). Notify physician
immediately if these reactions
62
occur.
4. Report signs of gallstones
(cholelithiasis), including sudden
intense pain in the abdomen or
right side, jaundice, chills, and
fever.
5. Assess heart rate, ECG, and heart
sounds, especially during exercise
(See Appendices G, H). Report
any rhythm disturbances or
symptoms of increased
arrhythmias, including palpitations,
chest discomfort, shortness of
breath, fainting, and
fatigue/weakness.
6. Obtain baseline status for weight
while noting recent manifestations
that increases or decreases to
determine patient’s fluid status.
7. Assess bowel elimination patterns,
including frequency of stool
passage and stool characteristics
to monitor the development of
constipation and possible fecal
impaction.
8. Assess closely patient’s heart rate
and blood pressure to identify
cardiovascular changes that may
warrant change in drug dose
9. Inspect abdomen for distention and
auscultate bowel sounds to assess
63
for changes in GI motility.

10. Monitor results of laboratory tests,
particularly serum cholesterol and
lipid levels to evaluate the
effectiveness of drug therapy.
GENERIC NAME hyoscine butylbromide (HnBB)
BRAND NAME Buscopan
CLASSIFICATION Antispasmodic; Anticholinergic
ORDERED DOSE HNBB 2mg IVTT q8
SUGGESTED DOSE (By Manufacturer) IV:

● 20mg in 1ml (solution)
● Dilute required dose to 10ml with
normal saline. Inject slowly over 3-
5 minutes.
PO:
● Buscopan 10mg (white)
64
MODE OF ACTION Hyoscine-N-butylbromide (HNBB) acts by

interfering with the transmission of nerve
impulses by acetylcholine in the
parasympathetic nervous system.
Buscopan exerts a spasmolytic action on
the smooth muscle of the gastrointestinal,
biliary and urinary tracts. As a quaternary
ammonium derivative, hyoscine-N-
butylbromide does not enter the central
nervous system. Therefore,
anticholinergic side effects at the central
nervous system do not occur. Peripheral
anticholinergic effects result from a
ganglion-blocking action within the
visceral wall as well as from anti-
muscarinic activity.
INDICATION Buscopan Tablets are indicated for the

relief of spasm of the genito-urinary tract
or gastrointestinal tract and for the
symptomatic relief of Irritable Bowel
Syndrome
65
CONTRAINDICATION Buscopan Tablets should not be

administered to patients with myasthenia
gravis, megacolon and narrow angle
glaucoma. In addition, they should not be
given to patients with a known
hypersensitivity to hyoscine-N-
butylbromide or any other component of
the product.
SIDE & ADVERSE EFFECTS ● CNS: dizziness, anaphylactic

reactions, anaphylactic shock,
increased ICP, disorientation,
restlessness, irritability, dizziness,
drowsiness, headache, confusion,
hallucination, delirium, impaired
memory
● CV: hypotension, tachycardia,
palpitations, flushing
● GI: Dry mouth, constipation,
nausea, epigastric distress
● DERM: flushing, dyshidrosis
● GU: Urinary retention, urinary
hesitancy
● Resp: dyspnea, bronchial plugging,
depressed respiration
● EENT: mydriasis, dilated pupils,
blurred vision, photophobia,
increased intraocular pressure,
difficulty of swallowing.
DRUG INTERACTION May decrease the absorption of oral

medicines due to decreased gastric
66
motility and delayed gastric emptying.

The sedative effect of hyoscine may be
enhanced by other CNS depressants.
Other drugs with anticholinergic
properties (e.g. amantadine,
antihistamines) may enhance the effects
of hyoscine.
NURSING RESPONSIBILITIES ● Hyoscine may make a patient

dizzy or cause vision problems;
use caution engaging in activities
requiring alertness such as driving
or using machinery.
● Instruct the client to avoid or
minimize drinking alcoholic
beverages.
● Caution is advised when using this
drug in the elderly because they
may be more sensitive to the
effects of the drug.
● Inform the patient to consult the
doctor immediately if he or she
experiences any of the following
while using this medicine: red and
painful eye, possibly with
headache, loss of vision, or seeing
halos around lights. These
symptoms may be caused by an
increase in pressure inside the
eyeball and require urgent
investigation by the doctor.
67
● If the patient missed a dose, inform

him or her to use it as soon as you
remember. If it is near the time of
the next dose, skip the missed
dose and resume your usual
dosing schedule. Remind the
patient not double the dose to
catch up.
● Raise side rails as a precaution
because some patients become
temporarily excited or disoriented
and some develop amnesia or
become drowsy.
● The medication should be stored at
room temperature between 59 and
86 degrees F away from light and
moisture.
● Hyoscine should not be placed in
the refrigerator.
● Symptoms of overdose may
include: irregular heartbeat,
reddened skin, drowsiness.
Instruct the patient to immediately
alert the physician once these are
noticed or experienced.
GENERIC NAME ketorolac

68
BRAND NAME Toradol, Sprix
CLASSIFICATION NSAIDs
ORDERED DOSE 30mg p.o once
SUGGESTED DOSE (By Manufacturer) Intravenous (IV): 30 mg as a single dose

or 30 mg every 6 hours; not to exceed
120 mg/day
Intramuscular (IM): 60 mg as a single

dose or 30 mg every 6 hours; not to
exceed 120 mg/day
Oral: 20 mg once after IV or IM therapy,

THEN 10 mg every 4-6 hours; not to
exceed 40 mg/day
MODE OF ACTION Prostaglandin synthesis in bodily tissues

is inhibited by at least two COX
isoenzymes, COX-1 and COX-2.
INDICATION Ketorolac is used to alleviate moderate to

severe pain in the short term. It is typically
used prior to, during, or following medical
treatments or surgery. It reduces swelling,
69
discomfort, and fever.
PREGNANCY CATEGORY C, D
CONTRAINDICATION Ketorolac is contraindicated in NSAID-

allergic people. Due to bleeding risk, it is
not suggested intraoperatively or
preoperatively. It's not advised during
childbirth. Ketorolac is contraindicated in
renal disease and failure. Ketorolac
contraindications include active peptic
ulcer disease, recent GI bleeding, and GI
perforations.
SIDE EFFECTS ● Sting or burn your eyes for 1-2

minutes
● Eye redness
● Headache
ADVERSE EFFECTS ● Drowsiness

● Indigestion
● Stomach or abdominal pain
● Nausea
● Diarrhea
● Dizziness
● Itching
● Swelling (edema)
● Increased blood urea nitrogen
(BUN)
● Constipation
● Purpura
● Increased serum creatinine
70
● Drowsiness
● High blood pressure (hypertension)
DRUG INTERACTION When combined with other drugs that can

cause bleeding, this medication may
increase the risk of bleeding. Antiplatelet
medications such as clopidogrel and
"blood thinners" such as
dabigatran/enoxaparin/warfarin are
examples.
NURSING RESPONSIBILITIES 1. Monitor signs of GI bleeding,

including abdominal pain, vomiting
blood, blood in stools, or black,
tarry stools. Report these signs to
the physician immediately.
2. Monitor injection site for pain,
swelling,irritation,signs of allergic
reactions and anaphylaxis,
including pulmonary symptoms
(laryngeal edema, wheezing,
cough, dyspnea) or skin reactions
(rash, pruritus, urticaria). Be
especially alert for exfoliation,
dermatitis, and other severe skin
reactions that might indicate
serious hypersensitivity reactions
(Stevens-Johnson syndrome, toxic
epidermal necrolysis). Notify
physician immediately if these
reactions occur.
3. Assess pain and other variables
71
(range of motion, muscle strength)

to document whether this drug is
successful in helping manage the
patient's pain and decreasing
impairments.
4. Assess signs of paresthesia,
including numbness and tingling.
Perform objective tests, including
electroneuromyography and
sensory testing to document any
drug-related neuropathic changes.
5. Assess blood pressure (BP)
periodically and compare to normal
values. NSAIDs can increase BP in
certain patients.
6. Be alert for signs of prolonged
bleeding time such as bleeding
gums, nosebleeds, and unusual or
excessive bruising. Report these
signs to the physician.
7. Assess peripheral edema using
girth measurements, volume
displacement, and measurement of
pitting edema. Report increased
swelling in feet and ankles or a
sudden increase in body weight
due to fluid retention.
8. Assess symptoms of
bronchospasm and asthma,
including wheezing, coughing,
dyspnea, and tightness in chest.
72
Perform pulmonary function tests

to quantify suspected changes in
ventilation and respiration.
9. Monitor signs of kidney toxicity,
including blood or pus in urine,
increased urinary frequency,
decreased urine output, weight
gain from fluid retention, and
fatigue. And also monitor and
report euphoria, abnormal thinking,
or other psychic disturbances.
Report these signs to the
physician.
10. Assess dizziness and drowsiness
that might affect gait, balance, and
other functional activitie. Report
balance problems and functional
limitations to the physician, and
caution the patient and
family/caregivers to guard against
falls and trauma.
GENERIC NAME Midazolam

73
BRAND NAME mezolam
CLASSIFICATION Sedatives or Benzodiazepines
ORDERED DOSE 2 mg via IVTT on call or to OR
SUGGESTED DOSE (By Manufacturer) The initial intravenous dose for sedation
in adult patients may be as little as 1 mg,
but should not exceed 2.5 mg in a normal
healthy adult. Administer over at least 2
minutes interval.
MODE OF ACTION Midazolam's activities are mediated

through the inhibitory neurotransmitter
gamma-aminobutyric acid (GABA), which
is one of the main inhibitory
neurotransmitters in the central nervous
system. Benzodiazepines increase GABA
activity, resulting in sedation, induction of
sleep, and anesthesia. Benzodiazepines
bind to the benzodiazepines site on
GABA-A receptors, which increases the
frequency of chloride channel opening
and so potentiates the effects of GABA.
74
INDICATION intravenously as a sedative /anxiolytic

/amnesic drug before or during
diagnostic, therapeutic, or endoscopic
procedures.
PREGNANCY CATEGORY D
CONTRAINDICATION Midazolam is contraindicated in patients

with a known hypersensitivity to the drug.
Due to the presence of the preservative
benzyl alcohol in the dose form,
midazolam is not intended for intrathecal
or epidural administration.
SIDE EFFECTS ● shallow breathing,

● breathing that stops during sleep
● nausea
● vomiting
ADVERSE EFFECTS we ● headache

● cough
● drowsiness
● hiccups
● oversedation
● pain, swelling, redness, blood clots
and muscle stiffness at the
injection site
DRUG INTERACTION When Midazolam is taken with

Benzodiazepine, the risk or severity of
undesirable effects can be enhanced.
Midazolam may reduce the elimination
rate of Abacavir, resulting in a greater
75
serum level. When coupled with

Abametapir, the serum concentration of
Midazolam can be enhanced. When
coupled with Abatacept, the metabolism
of Midazolam can be enhanced. When
coupled with Midazolam, Abemaciclib's
metabolism can be slowed. When
coupled with Abiraterone and
Acalabrutinib, the serum levels of
Midazolam can be raised. Aceclofenac
and Acemetacin may reduce Midazolam
elimination, resulting in a greater serum
level. When coupled with Midazolam, the
serum concentration of Acenocoumarol
can be enhanced.
NURSING RESPONSIBILITIES 1. Monitor Vital signs

2. Have oxygen and resuscitation
equipment ready in case of severe
respiratory depression before
administering.
3. Check site for redness and
swelling
4. Monitor and record the patient's
response to medication as well as
the level of sedation.
5. Examine the area for
extravasation.
6. Keep an eye out for any negative
responses.
7. Cardiorespiratory monitoring is
76
continuous.
8. Monitor for signs of pain
9. Monitor for adverse effects.
10. Monitor O2 saturation
GENERIC NAME nalbuphine
BRAND NAME Nubain
CLASSIFICATION Opioid
Opioid analgesic
ORDERED DOSE 5mg IVq6 PRN for severe pain
SUGGESTED DOSE (By Manufacturer) 10-20 mg/70 kg IV/IM/SC q3-6hr PRN;
MODE OF ACTION Binds with and stimulates kappa and mu

opiate receptors in the spinal cord and
higher levels in the CNS. In this way,
nalbuphine alters the perception of and
emotional response to pain.
INDICATION To relieve pain severe enough to require

an opioid analgesic and for which
alternative treatment options such as
nonopioid analgesics or opioid
combination products are inadequate or
not tolerated.
77
CONTRAINDICATION ● Acute or severe bronchial asthma

in an unmonitored setting or in the
absence of resuscitative
equipment;
● gastrointestinal obstruction,
including paralytic ileus;
● hypersensitivity to nalbuphine or
any of its components; significant
respiratory depression.
SIDE EFFECTS ● Drowsiness

● Dizziness
● spinning sensation;
● dry mouth;
● headache;
● sweating;
● cold,
● clammy skin;
● or. nausea,
● vomiting.
ADVERSE EFFECTS ● CNS: Confusion, depression,

dizziness, euphoria, fatigue
● CV: Hypertension, hypotension,
tachycardia.
● ENDO: Adrenal insufficiency
● GI: Abdominal cramps, anorexia,
constipation, nausea, vomiting
● GU: Decreased libido, decreased
urine output, impotency, infertility,
78
lack of menstruation, ureteral

spasm
● RESP: Dyspnea, pulmonary
edema, respiratory depression,
wheezing
DRUG INTERACTION Profound sedation, respiratory

depression, coma, and death may result
from the concomitant use of NUBAIN with
benzodiazepines or other CNS
depressants (e.g., non-benzodiazepine
sedatives/hypnotics, anxiolytics,
tranquilizers, muscle relaxants, general
anesthetics, antipsychotics, other opioids,
alcohol).
NURSING RESPONSIBILITIES 1. Assess the overall health status of

the client and alcohol usage before
giving nalbuphine
2. Explain procedure to the patient
3. Clean puncture site before
administration
4. Place pressure on puncture site
until bleeding stops
5. Implement proper manual therapy
techniques to reduce pain
6. Monitor vital signs especially blood
pressure for any abnormalities.
7. Help patient to explore other
nonpharmacologic methods to
reduce chronic pain eg. Exercise
8. Monitor for adverse effects
79
9. Teach patient about the risk of falls

due to dizziness, sedation, or
blurred vision
10. Assess exercise tolerance
frequently via anaerobic exercise
etc.
GENERIC NAME omeprazole
BRAND NAME Omepron
CLASSIFICATION Proton Pump Inhibitor
ORDERED DOSE IVTT 40 mg once on NPO
SUGGESTED DOSE (By Manufacturer) For eradication of H. pylori, peptic ulcer

disease, gastric and duodenal ulcers,
GERD, and NSAID-associated ulcers:
IVTT 40 mg once daily for 20-30 minutes
For Zollinger-Ellison syndrome:

IVTT 2 divided doses of 60 mg daily,
infuse for 20-30 minutes
For eradication of H. pylori, peptic ulcer

disease:
80
PO
Adult: 20 mg bid for 1 week in
combination of specific antibiotics
Children: >4 years old 15-30kg - 10 mg
bid; 31-40 kg - 20 mg bid. Combine with
specific antibiotics
For peptic ulcer:

PO
Adult: 20 mg or 40 mg once daily.
Treatment duration: 4 weeks (duodenal
ulcer); 8 weeks (gastric ulcer).
Maintenance: 10-20 mg once daily, may
increase up to 40 mg according to
response.
For GERD:
PO
Adult: 20 mg once daily for 4-8 weeks.
For severe cases: 40 mg once daily for 8
weeks. Maintenance: 10 mg once daily,
may increase to 20-40 mg once daily if
necessary.
Child: ≥1 year weighing 10-20 kg: 10 mg
once daily, increased to 20 mg once daily
if necessary. ≥2 years weighing >20 kg: 20
mg once daily, increased to 40 mg once
daily if necessary. Treatment duration: 4-
8 weeks.
81
For Zollinger-Ellison syndrome

PO
Adult: Initially, 60 mg daily, adjust as
required. Usual dose: 20-120 mg daily.
Dose >80 mg should be given in 2 divided
doses.
MODE OF ACTION The proton pump 10's H(+)/K(+)-ATPase

is primarily responsible for controlling the
release of hydrochloric acid (HCl) into the
gastric lumen. This enzyme is highly
expressed by the parietal cells of the
stomach. The parietal cell membrane
contains an enzyme called ATPase that
aids in hydrogen and potassium
exchange within the cell, which typically
leads to potassium extrusion and the
production of HCl (gastric acid).
The substituted benzimidazoles, of which

omeprazole is a part, are a class of
antisecretory substances that prevent
gastric acid secretion by specifically
inhibiting the H+/K+ ATPase enzyme
system. Omeprazole, a proton-pump
inhibitor, binds covalently to cysteine
residues on the H+/K+ ATPase pump's
alpha subunit via disulfide bridges,
preventing stomach acid output for up to
36 hours. Regardless of the stimulus, this
antisecretory effect is dose-related and
82
results in the inhibition of both basal and

stimulated acid secretion.
INDICATION • Treatment of active duodenal ulcer in

adults
• Eradication of Helicobacter pylori to
reduce the risk of duodenal ulcer
recurrence in adults
• Treatment of active benign gastric ulcer
in adults
• Treatment of symptomatic GERD in
patients 1 year of age and older
• Treatment of erosive esophagitis (EE)
due to acid-mediated GERD in patients 1
month of age and older
• Maintenance of healing of EE due to
acid-mediated GERD in patients 1 year of
age and older
• Pathologic hypersecretory conditions in
adults
CONTRAINDICATION • Patients with a known history of

hypersensitivity to the drug
• diarrhea from an infection with

Clostridium difficile bacteria
• inadequate vitamin B12
• low amount of magnesium in the blood
• liver problems
83
• interstitial nephritis
• systemic lupus erythematosus
• osteoporosis
• CYP2C19 poor metabolizer
SIDE EFFECTS • Headaches

• Nausea
• Vomiting
• Diarrhea
• Stomach pain
• Constipation
• Flatulence
ADVERSE EFFECTS • low magnesium blood level

• muscle spasms
• irregular heartbeat
• seizures
• lupus
• serious allergic reaction with symptoms
of fever, swollen lymph nodes, rash,
itching/swelling, severe dizziness, trouble
breathing, kidney problems
• black tarry stool
DRUG INTERACTION omeprazole + warfarin = abnormal

bleeding
omeprazole + methotrexate = toxic levels
of methotrexate in the body
omeprazole + clopidogrel = decrease
84
effectiveness of clopidogrel
omeprazole + tacrolimus = increase
levels of tacrolimus in the body
omeprazole + antibiotics = cause life-
threatening reactions
omeprazole + antiretrovirals = decrease
effectiveness of antiretrovirals
NURSING RESPONSIBILITIES 1. Assess for possible contraindications

and cautions to reduce the risk of
hypersensitivity.
2. Perform physical assessment to
establish baseline data to compare the
before and after of drug administration.
3. Inspect the skin for lesions, rash, and
pruritus to identify possible adverse
effects.
4. Instruct patient to take omeprazole
before eating and to take omeprazole
tablets as a whole to ensure the
effectiveness of the drug.
5. Monitor patient response to the drug
6. Provide appropriate safety measures if
CNS effects occur to prevent injury.
7. Provide patient support to help patients
cope with the disease.
8. Educate the patient about the
importance of taking the drug with the
right dose.
9. Educate the patient about the possible
side effects and the measures to prevent
85
or minimize them.
10. Evaluate the patient’s understanding
of the health teachings being rendered to
ensure safety in taking the drug.
GENERIC NAME Ursodeoxycholic acid (UCDA)
BRAND NAME Udcacid, URSO Forte
CLASSIFICATION ● Cholagogues, Cholelitholytics &

Hepatic Protectors
● Gallsone-solubilizing drug
ORDERED DOSE 300mg T.I.D.
SUGGESTED DOSE (By Manufacturer) ● Solubilization of gallstones

○ 8–10 mg/kg/day PO given in
two to three divided doses.
● Treatment of biliary cirrhosis
○ 13–15 mg/kg/day PO
administered in two to four
divided doses with food
● Prevention of gallstones
○ 300 mg PO B.I.D. or 8–10
mg/kg/day PO in two to
three divided doses
● Udcacid: 300mg T.I.D. with meals
86
MODE OF ACTION Ursodeoxycholic acid (UDCA), also

known as ursodiol, is a secondary bile
acid having cytoprotective,
immunomodulating, and choleretic
properties. The digestive system absorbs
UCDA, which then goes through
enterohepatic recycling. Before being
eliminated in the bile, it is partially
conjugated in the liver. The free and
conjugated forms undergo 7α-
dehydroxylation to lithocholic acid by
intestinal bacteria, with part of this acid
being expelled directly in the feces and
the remainder being absorbed and mostly
conjugated and sulfated by the liver
before excretion. However, UCDA is
subject to less bacterial degradation than
chenodeoxycholic acid. By preventing
cholesterol from being absorbed in the
gut and from being secreted into the bile,
UDCA lowers biliary cholesterol
saturation, and it enhances bile acid
secretion as well as increases bile acid
flow.
INDICATION ● Dissolution of cholesterol-rich

gallstones in patients with
functioning gall bladders
● Used in primary biliary cirrhosis
● Short-term treatment of
radiolucent, noncalcified
87
gallbladder stones in patients

selected for elective
cholecystectomy
● Prevent gallstone formation in
obese patients experiencing rapid
weight loss
CONTRAINDICATION ● Patients with hypersensitivity or

intolerance to its components
● Patients with complete obstruction
of biliary tract
● Patients with fulminant hepatitis
● Patients with radiopaque calcifying
cholelithiasis
● Patients with non-functioning gall
bladder or acute cholecystitis
● Patients with renal disease
● Patients with acute gastroduodenal
ulcers
● Patients with colitis or enteritis
SIDE EFFECTS ● Diarrhea

● Vomiting
● Nausea
● Dizziness
● Abdominal pain
● Constipation
● Heartburn
● Epigastric discomfort
● Itchiness
88
● Rashes
● Fever
● Cough
● Dyspnea
● Dark urine
● Clay-colored stools
ADVERSE EFFECTS ● General malaise

● Calcification of cholelithiasis
● Increase in ALT, ALP, AST, y-GT
● Decrease in leukocyte
● Increase in serum bilirubin
● Increase in hepatic enzyme
● Jaundice
● Gastrointestinal disorders
● Myalgia
DRUG INTERACTION ● Oral hypoglycemic agents

combined with UDCA may
increase the effects of oral
hypoglycemic agents
● UDCA combined with ciclosporin
may increase absorption and
serum concentration of ciclosporin
● May increase serum concentration
of rosuvastatin
● Increases hepatic cholesterol
secretion and reduces efficacy
when combined with estrogen
hormones, oral contraceptives, or
blood cholesterol-lowering agents
● May reduce absorption of
89
ciprofloxacin, nitrendipine when

combined with UCDA
● The following may reduce the
absorption and efficacy of UCDA:
○ Cholestyramine
○ Cholestipol
○ Charcoal
○ Aluminum hydroxide
○ Magnesium-based antacids
NURSING RESPONSIBILITIES 1. Obtain patient health history and

assess patient’s suitability of drug
therapy.
2. Perform physical assessment such
as liver evaluation, abdominal
examination, orientation, lesions,
and biliary ultrasound to establish
baseline data.
3. Assess patient's response to
medication by scheduling oral
cholecystograms or
ultrasonograms every six months
until the patient's symptoms have
resolved, then every three months
to monitor stone formation.
Perform a follow-up ultrasound
after three months of therapy if the
gallstones seem to have
disappeared.
4. Do not combine medication with
antacids that are aluminum-based.
90
If such medications are required,

administer 2-3 hours after ursodiol.
5. Note that this medication should
not be given to patients with peptic
ulcer disease, inflammatory bowel
disease, or chronic liver disease.
6. Perform liver function tests
periodically to monitor patient’s
level of liver enzymes.
7. Carefully assess patient if any
change in liver function occurs.
8. Inform patient of the side effects of
the medication. Instruct patient to
report any severe or prolonged
adverse reactions.
9. Advise patient to take medication
with food or as directed by the
physician, and take the drug as
long as prescribed. Do not
discontinue drug unless otherwise
stated.
10. Inform the patient that while this
medication may remove
gallstones, it does not treat the
underlying cause of the stones,
and the stones frequently reoccur.
Medical follow-up care is
important.
VIII. NURSING MANAGEMENT

91
92
Name of the Client: M.G.C Age/Sex: 43/F Ward: St. Mary Room#: 250 Bed #: 1
Chief Complaint: Right upper quadrant pain radiating to the back Attending Physician: Dr.
Madayag
Admitting Diagnosis or Impression: Acute Cholecystolithiasis
DATE CUES N NURSING PATIENT NURSING IMP EVALUATION

/ E DIAGNOSIS OUTCOME INTERVENTIONS LEM
TIME E ENT
D ATI
ON
F Subjective: N Acute Pain related to Within 8 hours of 1. Establish 1 FEBRUARY 4, 20203

inflammation of the nursing rapport and
E · “Ang U gallbladder as intervention, the provide client’s @ 11:00 PM
sakit ng evidenced by right patient will be privacy
B tagiliran T upper quadrant able to: “GOAL PARTIALLY
ko sir” as abdominal pain, pain R: Creates a MET”
U verbalize R scale of 10/10 ● Alleviate trusting
d by the guarding sign on the the site of relationship that
A patient I pain promotes
abdomen, rebound
cooperation and Within 8 hours of
R · Pain T tenderness, and
nursing intervention,
restlessness comfort
Scale of the patient was able
Y I to:
10/10 Rationale: 2. Monitor & record
O patient’s vital signs 2
Objective: Cholelithiasis is the · Progressively
alleviate the site
4 N formation of R: To assess
of pain
VS @ 4PM: gallstones, which are general well-being,
composed of detect signs of
· Temp: cholesterol, calcium medical disorders,
93
and provide
2 36.9°C & salts, and bile appropriate health
pigments. When care.
0 · PR: gallstones block the
81 bpm flow of bile, the 3. Position the
2 M gallbladder becomes head of the bed
· CR: swollen, leading to and in Semi
3 85 bpm E the possibility of
Fowler’s
pain, inflammation, 3
@ · RR: T
or infection. The R: To increase
25 cpm
A signs and symptoms oxygen level thus
of cholelithiasis often creating optimal
· BP:
3 120/80 B do not begin until the lung expansion
gallstone causes
mmHg
P O blockage in the
VS @ 8PM: biliary system. They 4. Encourage
M L may include, patient to have a
· Temp: abdominal pain, low-fat diet and
36.3°C I usually in the upper general liquid diet
right quadrant of the 4
· PR: C abdomen, jaundice, R: To give time of
83 bpm fever. the gallbladder to
rest thus results in
· CR: healing.
P
86 bpm
Romero, B. W., RN,
A &
· RR: MSN. (n.d.). 5. Administer
T Nursing Care Plan –
20 cpm prescribed
Cholelithiasis. medications
· BP: T Nursing Crib.
120/80 https://nursingcrib.co R: To alleviate the
5
mmHg E m/nursing-care- symptoms of
plan/nursing-care- abdominal pain
94
· Urine: R plan-cholelithiasis/ 6. Administer IV as

Foley ordered by the
Catheter N Doctor.
(1000 cc
level) R: To maintain an 6
appropriate
· hydration level.
Defecate 7. Encourage
d: 0 adequate bed rest
· (+) R: To reduce
rebound gastrointestinal
7
tendernes stimulations thus
s on the decreasing GI
RUQ activity.
· 8. Perform
relaxation
Anicteric techniques such
sclera as deep breathing
exercise and
· provision of 8
distractions such
Slightly as TV or
pale Cellphone
conjunctiv
a R: To provide
optimal comfort to
· (-) the patient
murphy
sign 9. Apply warm
95
· compress on the
abdomen
Present
Guarding R: To calm 9
Behavior spasms and
relieve pressure
· from bile buildup
Restlessn 10. Educate

ess patient on bladder
training.
· On a
NPO diet R: To increase the
10
then amount of time in
shifted to between emptying
Low Fat and intaking of
Diet and fluids in your
General bladder.
Liquids
11. Monitor intake
· and output.
Administe
red PLR R: To monitor
1L @ patient’s fluid
volume accurately 11
80cc/hr
and effectiveness
· of actions
VDCA
300mg
t.i.d
·
96
Finofibrat
e 100mg
1cap o.d
·
Nalbuphin
e 5mg
IVq6 PRN
for severe
pain
·
Ketorolac
30mg
IVTT q8
PRN for
severe
pain
·
HNBB
20mg
IVTT q8
·
Ampicillin
Sulbacta
m 1.5g
IVq8
·
97
Celecoxib
200mg
tabs, b.i.d
PO
98
99
100
DISCHARGE PLANNING (METHOD)
METHOD HEALTH TEACHINGS RATIONALE
Medication 1. Inform the patient of the a.) Analgesics are pain

use and side effects of the medication used to alleviate
following prescribed pain. Pain medications are
medications: needed for this patient
since she recently
a.) Analgesics underwent laparoscopic
b.) Antibiotics cholecystectomy, which can
cause pain after surgery
and during recovery.
Analgesics, especially
NSAIDs, should be taken
with food. Common side
effects of analgesics are
the following: stomach
upset, constipation,
dizziness, dry mouth, and
drowsiness.
b.) Antibiotics are

medications used to kill or
stop bacterial growth. The
patient underwent
laparoscopic
cholecystectomy. In order
to prevent subsequent
infections, antibiotics are
prescribed. Antibiotics
101
should be taken after meals

and they should be taken at
the right time to avoid
antibiotic resistance.
Common side effects of
antibiotics are the following:
rash, dizziness, nausea,
and diarrhea.
Exercise 1. Discuss with the patient Walking can strengthen the

the importance of walking muscle and promote wound
exercises after a week of healing. Walking can keep
discharge to be able to the patient’s body active
restore health. The while recovering.
following precautions
should be followed: a.) Performing strenuous
exercises during the
a.) Avoid strenuous activity healing of surgical wounds
for 4-6 weeks can interrupt with the
b.) Avoid lifting heavy healing process of the
objects for 2-4 weeks wound and can result in
c.) Rest whenever you feel infection, excessive
tired scarring, and bleeding.
b.) Lifting heavy objects
immediately after surgery
can cause physical stress
that could raise blood
pressure and cause the
surgical wound to break
open and bleed.
c.) Resting is essential to
102
boost wound healing.
Treatment 1. Introduce to the patient a.) Pharmacological

the different types of therapy is the use of
treatment for her condition. medicines to treat common
The different types of discomforts after
treatment appropriate for laparoscopic
the patient are as follows: cholecystectomy. Pain
medications are used to
a.) Pharmacological therapy alleviate pain from the pain
such as, pain medications, brought about by the
antibiotic treatment, and GI surgery. Antibiotics are
meds. used to prevent or eliminate
infection causing bacterias.
Gastrointestinal
medications are used to
alleviate discomfort of the
gastrointestinal tract. The
gallbladder is a part of the
digestive system, alongside
the gastrointestinal tract.
Since the gallbladder is
removed during
cholecystectomy, the
normal function of the
digestive system is
interrupted.
Hygiene 1. Emphasize the a.) Having a wound care

importance of wound care. routine can help in
preventing the occurence of
2. Instruct the patient to infection.
103
avoid bathing for a few days

until wound is healed. b.) Surgical wounds should
not be soaked in water until
2. Instruct the patient to it’s healed because it can
shower carefully once the soften the skin and reopen
wound is healed. the wound.
c.) Showering carefully will

avoid putting injury to the
surgical wound area.
Outpatient 1. Inform the patient of the Follow-up checkups are

importance of follow-up important in order for the
checkups. physician to check the
healing progress of the
2. Instruct the patient to patient.
report to the physician any
unusual symptoms such as: The patient should report
immediately to the
a.) Severe right upper physician any unusual
abdominal pain within 48 symptoms because it will
hours after discharge help the physician act on
b.) Right upper abdominal these symptoms and
pain increasing over time prevent further
c.) Jaundice after several complications.
weeks
d.) Fever within two weeks
Diet 1. Educate the patient about a.) A well balanced diet has
the importance of a healthy a vital role in the speedy
diet in achieving optimum recovery from laparoscopic
health. cholecystectomy. When
104
you are recovering, a

2. Instruct the patient to healthy diet can help your
have a diet that is made up body to repair properly and
of clear liquids, broth, and give it the energy it needs
gelatin. to carry out the rest of the
recovery process.
3. Instruct the patient to
gradually introduce solid b.) Eating a soft, liquid diet
foods after a week after after cholecystectomy will
surgery. The patient should prevent nausea, vomiting,
have a low fat diet and a and constipation.
high fiber diet which
consists of: c.) Patients recovering from
cholecystectomy should
a.) whole grains avoid eating high fat foods
b.) fruits because the patient will
c.) green leafy vegetables have a hard time digesting
fat. Food that contain
4. Instruct the patient to saturated fat and trans fat
avoid food that cause such as processed food
constipation or diarrhea, and fast food should be
such as: especially avoided. Eating
high fiber foods can help in
a.) spicy food normalizing bowel
b.) dairy products movement.
c.) processed food
d.) Eating food that can
cause diarrhea and
constipation can cause
discomfort in the patient
and can disrupt the healing
105
process from
cholecystectomy.
VIII. NURSING THEORY
NURSING NEED THEORY
VIRGINIA HENDERSON
Virginia Henderson was an American

nurse best known for her development of the
Nursing Need Theory. The theory places a strong
emphasis on boosting patient independence to
ensure that recovery from hospitalization doesn't
take longer than necessary. Her emphasis on
fundamental human needs as the center of nursing
practice has sparked more theoretical growth
regarding patient needs and how nursing might help to address those needs. There are
four major concepts in the nursing need theory: the individual, the environment, health,
and nursing. Henderson contends that all individuals have needs that are fundamental to
their health. They might need help getting healthy and independent or getting help dying
peacefully. Instead of viewing the patient as a specific customer or consumer, this idea
sees them as a composite with physiological needs. The environment consists of the
circumstances under which a person learns their particular ways of living. all
environmental factors and influences that have an impact on development and life. In
addition to families, individuals are also part of the environment. The following fourteen
tasks can be performed independently in order to provide basic nursing care to the
patient: breathe normally; eat and drink adequately; eliminate bodyK wastes; move and
maintain desirable postures; sleep and rest; select appropriate clothing; dress and
undress appropriately; maintain body temperature within a normal range by adjusting
106
clothing and modifying the environment; keep the body clean and well groomed; protect
the integument; avoid dangers.
Virginia Henderson’s theory can help the patient suffering from acute
cholecystolithiasis learn how she can manage her condition independently. The nurse
guides and cares for the patient suffering from acute cholecystolithiasis throughout her
healing process. While caring for the patient, the nurse incorporates appropriate health
teachings that can help the patient recover independently. Acute cholecystolithiasis is a
condition that affects the gallbladder and causes it to become inflamed and have
gallstones. The leading cause of gallstones is the formation of stones from the excess
cholesterol in the body. The nurse can assist the patient by rendering health teachings
that the patient can apply to herself independently, such as teaching the patient about the
fourteen tasks of the nursing need theory: eating a low-fat diet, drinking plenty of fluids
unless contraindicated, taking pain medications as prescribed by the doctor, avoiding
strenuous activity for two weeks, and keeping the surgical area clean and dry.
SELF-CARE NURSING THEORY
DOROTHEA E. OREM
The self-care theory, created by Dorothea Orem,

focuses on a person's capacity to care for themselves.
This may entail managing general well-being or leading
a healthy lifestyle. This idea may be used to evaluate
patients and help decide whether they have totally
healed or still require treatment. This theory's core
principle is that patients who need aid taking care of
themselves frequently require ongoing nursing care, but
patients who are able to take care of themselves may no longer require a nurse's
services. An acute cholecystolithiasis patient who has undergone surgery may need care
from nurses in all aspects. Taking this into account, it is crucial for nurses in deciding
which areas of patient care to concentrate on in a particular circumstance. With this,
107
nurses could determine how to aid patients towards full recovery, wherein the patients are
also able to retain control over their self-care processes, leading them towards
independence. Conforming to the self-care theory, everyone has a need to take care of
oneself. Although this assumption may be correct, it raises challenging issues for the
nurse who must step in when a patient refuses to reach their highest level of autonomy.
Some patients may choose to become the ones receiving care whenever a disease
process affects self-image. For this reason, they may temporarily feel in control of their
hapless position. Thus, the process of self-care and healing can start when nursing
intervention is geared on giving the patient back control of the circumstance. In the
instance of rendering health teachings, patients going through the post-operative phase
may learn how to take care of their own behalf, therefore letting them gain control over
their wellbeing. Hence, it could imply that they are aware of the situation they’re in and
are willing to fend themselves in order to reach maximum health.
There are three interconnected theories that make up the Self-Care: the theory of
self-care, self-care deficit, and nursing systems. Self-care theory, as mentioned,
emphasizes on the practice of actions that people take on their own initiative to preserve
their own health, well-being, and quality of life. In contrast, self-care deficit theory
identifies the appropriate times for nursing care. Finally, the nursing systems theory is the
result of several relationships between the two people: a legitimate patient and a
legitimate nurse. Since this case study is dealing with a post-operative patient, the
movements she can do are limited, thereby constricting her ability to continuously provide
good self-care. When a client's need for therapeutic self-care demand is beyond the
capacity of the individual to care for oneself, the nursing system is triggered, necessitating
nursing care. In aiding a patient or rendering nursing interventions, Orem identified 5
methods: Acting for and doing for others, Guiding others, Supporting another, Providing
an environment promoting personal development about meet future demands, and
Teaching another.
IX. REVIEW OF RELATED LITERATURE

Management of cholelithiasis with choledocholithiasis: Endoscopic and surgical
approaches.
108
Most people get gallstones (Shaffer,2021). Biliary discomfort, obstructive jaundice,

chollangitis, and acute biliary pancreatitis are the most common complications of CBD
stones (Dasari et al.,2019) Preoperative serological and instrumental diagnostics are
crucial.The first is Serology.According to ASGE Standards of Practice Committee (2022),
total and direct bilirubin are the best ways to tell if someone has choledocholithiasis.
Second, radiological exams. Radiological tests include ultrasound (US) which is often
best for identifying high-risk patients (Abboud et al.,2020). According to Einstein et al.
(2019), Radiological examinations include Computed Tomography (CT).According to
Mitchell and Clark (2023), it is carried out in an emergency and to evaluate stomach
pain.Compared to magnetic resonance cholangiography, it is less accurate but better at
diagnosing CBDSs (Soto et al.,2019). There is also MRC, which is now regarded as the
most accurate non-invasive method for the identification of CBDS (Lammert et al.,2020).
Percutaneous transhepatic cholangiography is the last (commonly referred to as
PTC).Fluoroscopy monitors contrast administration while percutaneously cannulating the
intrahepatic biliary tract.Modern radiographic and endoscopic imaging methods have
replaced PTC for choledocholithiasis diagnosis (Cianci & Restini,2023). Third are
endoscopic examinations.Today, ERCP is rarely used to diagnose CBDS, especially in
low-risk patients(Swanstrom et al.2021). Sain (2023) states that two-session and single-
session LC is the gold standard for treating symptomatic cholelithiasis.Two-session
method is safe and effective, according to studies (Bansal et al., 2023).Another option is
one-session. Cuschieri et al. (2019) believe they are efficient, safe, convenient, and well-
accepted by patients.Like other procedures, open surgery remains crucial but Clayton et
al.(2022) claim that open surgery is no longer effective.Stone fragmentation has been
described using a variety of methods, including mechanical, electrohydraulic, laser, and
extracorporeal shock wave (Siegel et al.,2020).A failed endoscopic sphincterotomy for
CBDS is usually followed by endoscopic mechanical lithotripsy. In between 80% and 90%
of cases, CBD clearance is achieved (Van Dam et al.,2021). The second method is
endoscopic electrohydraulic lithotripsy. In circumstances where CBDS is challenging, this
may be used.Third, because of the possibility of heat-induced biliary injury, endoscopic
laser lithotripsy has been utilized to shatter big stones while being visualized
fluoroscopically (Neuhaus et al.,2022). And lastly, in cases of challenging CBDS under
109
US or fluoroscopic guidance, extracorporeal shock-wave lithotripsy is also

performed.Extracorporeal shock-wave lithotripsy is currently not regarded as the first-line
treatment for tough bile duct stones (Chang et al.,2023).
Risk Factors for Cholelithiasis
Cholelithiasis is the process of gallstone formation (Venes & Taber, 2013). Cholecystitis is
an acute or chronic infection of the gallbladder (Kimura et al., 2007) and can occur in
association with gallstones. Most gallstones are silent, but symptomatic gallstones cause
biliary colic. It is a stable, sudden, severe pain in the right upper quadrant lasting more
than 30 minutes (Venes & Taber, 2013). Associated symptoms include nausea, vomiting,
and pain that radiates to the back (Gracie & Ransohoff, 1982) beginning at night and
lasting 1 to 4 hours. Common complications associated with gallstones include infection,
perforation, or gangrene (Gracie & Ransohoff, 1982). Clinical treatment of cholelithiasis
mostly ends with cholecystectomy and endoscopic or drug treatment of complications. In
general, circulating cholesterol is transported by lipoproteins, taken up by the liver,
metabolized, and finally excreted into bile (Zanlungo & Rigotti, 2009). Biliary cholesterol
overload is an important predisposing factor for cholesterol gallstone deposition
(Acalovschi, 2001; Portincasa, Moschetta & Palasciano, 2006; Zanlungo & Rigotti, 2009).
Although cholesterol makes up only 5% of bile, cholesterol or cholesterol mixtures cause
75% of gallstones in the United States (Portincasa et al., 2006). Other types of gallstones
include black pigment gallstones (15%–20%) and brown pigment gallstones (0%–5%).
The traditional risk factors for cholelithiasis are the 4 "F's". Female, obese, 40 years of
age, of childbearing potential”, and many studies support the known risk factors for
cholelithiasis. 1963), studies have shown a high prevalence of gallstones and gallstone-
related diseases in Pima Indian and Mexican populations. However, Obesity is
considered a major risk factor for diseases caused by cholesterol gallstones. Stone
formation occurs as a result of a complex interplay of genetic, environmental, metabolic,
and related conditions, although factors such as age and gender are invariant. Diet and
physical activity are modifiable can be a risk factor. Many studies have linked cholesterol
gallstones with obesity, the 'Western diet' (Acalovschi, 2001; Di Ciaula, Wang, Wang,
110
Leonilde & Portincasa, 2010), hyperinsulinemia, and dyslipidemia (Andreotti et al., 2008).
It has been observed to be associated with a number of predisposing factors, including
type 2 diabetes and metabolic syndrome (Di Ciaula et al., 2010; Portincase et al., 2006).
In addition, older age, female gender, pregnancy history, rapid weight loss, estrogen
replacement therapy, oral estrogen contraceptives, total parenteral nutrition, genetic
factors, and ethnicity have been associated with increased incidence of gallstones.
The Need for Standardizing Diagnosis, Treatment and Clinical Care of Cholecystitis
and Biliary Colic in Gallbladder Disease
Cholelithiasis (gallstone development, presenting symptomatically as biliary colic) is a

serious public health issue in industrialized nations, and its symptoms and consequences
can impose a significant economic and social cost. Gallstones are gallbladder or biliary
tract lumps caused by excessive amounts of cholesterol or bilirubin in bile. Acute
cholecystitis is the most common consequence of symptomatic gallstone disease, and it
is caused in 90% of instances by obstruction of the cystic duct, however the gallbladder
neck may also be blocked (Ahmed et al., 2011). Obstruction is generally accompanied by
inflammation, which can be bacterial in some situations, notably with H. pylori (Wang et
al., 2021). Over-eating, low levels of physical activity, obesity, a low-fibre diet, prolonged
fasting, rapid weight loss, metabolic syndrome and insulin resistance have all been
recognised as risk factors for gallstone formation (Lammert et al., 2015). Between 1980
and 2013, the proportion of persons with a BMI more than 25 kg/m2 increased from 29%
to 37% in men and from 30% to 38% in women, indicating that the number of people at
risk is expected to increase further (Ng et al., 2014). It is recommended that individuals
with AC undergo an early cholecystectomy at the first admission if the pain lasts less than
five days, or choose for conservative care six weeks after the acute episode (Health
Information and Quality Authority, 2014). Laparoscopic Cholecystectomy for TG18-
defined Grade I Acute Cholecystitis should be performed only if the Charlson comorbidity
index and American Society of Anesthesiologists Physical Status scores indicate an
ability to withstand surgery; otherwise, surgery should be postponed and conservative
management should be used. If the CCI and ASA-PS scores demonstrate the potential to
endure surgery and the patient is in an advanced surgical center, LC should be explored
111
shortly after commencement; otherwise, conservative therapy and biliary drainage should
be considered. Normalizing organ dysfunction should be explored for Grade III.
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A Case Study on

In Partial Fulfillment of the

February 15, 2023

I. Introduction and Objectives………………………………………………………….3-6

I. INTRODUCTION AND OBJECTIVES

The case analysis outlines the significance of comprehending how acute

II. DATA BASE

Family Health History

Past Health History

History of Present Illness

III. PHYSICAL ASSESSMENT

IV. DEFINITION OF DIAGNOSIS

V. ANATOMY AND PHYSIOLOGY

PREDISPOSING PRESENT RATIONALE

Age over 40 years old / According to Cleveland

even children, but they

Fertile / Fertile women were

Ethnicity/Race (Hispanic, x According to Zagaria(2021)

Family history of x Gallstones run in families.

causes a rise in bilirubin

Multiple pregnancy / According to Hossain,G.A.

Use of oral contraceptives x It appears that birth control

Estrogen x According to Wang, H. H.

which increases bile

Table 1.2: Precipitating Factors of Acute Cholecystolithiasis

PRECIPITATING PRESENT RATIONALE

Obesity x Particularly in women,

Metabolic syndrome x A risk factor for GS is

Excessive weight loss x Gallstone disease may also

tissue, which results in

Certain medications x The risk of gallstones is

High fat diet / Bile can build up and result

Cirrhosis x Your liver can produce

SYMPTOMS PRESENT RATIONALE

Presence of Stones in tha / For individuals with

Right Upper Quadrant / For individuals with

exceeds the bile's capacity

Elevated White Blood Cell / Studies have shown that

Nausea and Vomiting / Biliary colic is usually

McGowan et al. (n.d.), a

Increased Cholesterol / According to Cleveland

chemicals (lecithin and bile

Increased Gas / A mechanical intestinal

Fever x Gallbladder inflammation

Jaundice x In a study conducted by

Steatorrhea x Chronic steatorrhea is

Furthermore, the treatment of cholelithiasis is determined by the symptomatology

VII. MEDICAL MANAGEMENT

DEFINITION NURSING RESPONSIBILITIES

Complete blood count (CBC) is a test that a. Explain test procedure.

c. Explain that fasting is not necessary.

d. Monitor the puncture site for oozing or

2. Bilirubin Blood Test

DEFINITION NURSING RESPONSIBILITIES

c. Clean the puncture site with an alcohol

Assess the puncture site for hematoma

formation, if hematoma forms apply direct

DEFINITION NURSING RESPONSIBILITIES

A creatinine test is done in order to a. Explain the procedure to the patient.

4. Capillary Blood Glucose (CBG) Test

DEFINITION NURSING RESPONSIBILITIES

usually from a fingertip prick. These tests antidiabetic medications.

b. Gather equipment needed ahead of