COLLEGE OF NURSING

RELATED-LEARNING EXPERIENCE (RLE)

DE VERA MEDICAL CENTER (DVMC)

A CASE STUDY
ON
CHOLELITHIASIS

Presented by: BSN 4A-GROUP 1

Submitted by:

CATAINA, ANGEL JOY R OLIDAN, NOVELYN

CONCEPCION, HENSON L. ORPILLA, ERICA B.

ENCARNACION, MERRIN M. SALVADOR, KAYLA ZHAINE T.

JANDOC, AILA TRICIA S TASSIE, RUTH M.

Presented to:
Level 4 Clinical Instructors + Other Panelists

MARCH 2023
GOALS AND OBJECTIVES

General Objectives

BSN 4A Group 1 students will have a better grasp of Cholelithiasis by the end of this
course and will be able to produce synthesis based on real-life scenarios.

In this case study, we'll look at ways to better manage Cholelithiasis patients and
improve any nurse interventions that may be required in their treatment.

After completing this case analysis, the BSN 4A Group 1 will be able to define the
following. In order to achieve the General Goals, the following actions are designed:

Specific Objectives

• Study the potential causes of cholelithiasis to better comprehend the illness.

• To ascertain the patient's medical history and how it might impact the condition
they now have
• To comprehend how the current sickness is physio pathologically portrayed.
• Explain the normal outcomes of a physical exam for cholelithiasis, go over
diagnostic testing, patient signs and symptoms, and discuss nursing care for
cholelithiasis patients;
• To carry out a drug study to understand the function, side effects, and
contraindications of the medication administered to the patient.
• Construct a planned home care and health promotion plan.
Overview of the Disease
Definition
Gallstones, also known as cholelithiasis, are hardened deposits of digestive

fluid that develop in the gallbladder. The bile produced by the liver is stored in the

gallbladder, a little, pear-shaped organ that lies beneath the liver. Bile, a digestive fluid

that helps with fat digestion and is released into the small intestine by the cystic and

common bile ducts, is composed of cholesterol, bile salts, and bilirubin. Gallstones

can vary in size, and an individual may experience the development of multiple small

stones, one large stone, or a combination of stones of various sizes. Cholelithiasis

affects around 6% of men and 9% of women in the US, with the majority of cases

being asymptomatic.

Signs and Symptoms

Cholelithiasis is typically not characterized by any signs or symptoms, unless

there is an obstruction of the cystic duct, bile ducts, or both. Additionally, the signs and

symptoms of cholelithiasis can vary depending on the size and location of the

gallstone. Small gallstones are more likely to exit the gallbladder and block the cystic

or bile ducts, while large gallstones are more likely to stay in the gallbladder and not

cause any symptoms. Gallbladder attacks, or biliary colic, are the most common

signs and symptoms of cholelithiasis and are characterized by severe, rapidly

intensifying abdominal pain in the upper right or central abdomen. It usually occurs at

night after a fatty meal. Biliary colic can cause abdominal pain that radiates to the

upper back, between the shoulder blades, and to the right shoulder, and can last

anywhere from 15 minutes to several hours. Other abdominal symptoms that may

occur include clay-colored stools, bloating, indigestion, belching, and gas

Diagnostics

Cholelithiasis is usually diagnosed using imaging techniques such as abdominal

ultrasound, endoscopic ultrasound, and other imaging tests.

Abdominal Ultrasound - most often completed as it is painless and the least invasive.

However, it may not visualize all biliary ducts in detail.

Endoscopic retrograde cholangiopancreatography (ERCP) - a diagnostic and

potential treatment procedure involving the insertion of a long, thin, and flexible tube

with a camera attached through the mouth, down toward the small intestine

Magnetic resonance cholangiopancreatography (MRCP) - a diagnostic procedure

in which the bile ducts are examined with magnetic resonance imaging. This

procedure provides a detailed image, is less invasive, and is a safer alternative for

most individuals.

Other imaging tests that may be used to diagnose cholelithiasis include oral

cholecystography, a hepatobiliary iminodiacetic acid (HIDA) scan, and CT scan.

Treatment

Treatment options for cholelithiasis depend on the age of the individual; overall

health; medical history; severity of symptoms; as well as the size, location, and

quantity of gallstones. It can be treated through certain diagnostic procedures; or

through gallbladder removal surgery, also known as a cholecystectomy. It is commonly

performed when the gallstones are located inside the gallbladder A cholecystectomy

eliminates the risk for recurrent cholelithiasis and subsequently allows for bile to flow

directly from the liver into the small intestine

Prevention

Being overweight or diabetic increases your chances of developing gallstones.

However, in general, a healthy diet is the best way to avoid them. High-fiber, low-fat

diet helps in the preservation of bile cholesterol in liquid form. However, don't cut out

fats abruptly or eliminate them altogether, as too little fat can also lead to gallstone

formation.
Patient’s Profile

o Name: Mrs. L

o Age: 48 years old

o Gender: Female

o Birth date: March 02, 1975

o Address: P3- Villamarzo Cordon, Isabela

o Occupation: Business Owner

o Date of Admission: March 08, 2023

o Time of Admission: 6:00 pm

o Chief Complaint: Abdominal Pain and vomiting

o Admitting Diagnosis: Cholelithiasis

Past Medical History

According to the patient, she had pain in her epigastric region all the way up to her
right hypochondria for two years prior to admission. The patient self- diagnosed herself
2 years ago for ulcer and take Maalox plus to relieve the pain that she brought over
the counter. Also, she has hypertension and was prescribed Metropolol for
maintenance, but occasionally she forgot to take it for a week. Her mother massage
her epigastric area whenever she felt pain. When she experienced pain from an ulcer,
she would also drink boiled avocado leaves to ease the discomfort. The patient takes
cetirizine anytime she experiences seafood allergies. She seeks admission at Quirino
Provincial Medical Center, however the hospital only administered butylscopolamine
by intramuscular injection to relieve her pain. Immunization of the patient was
completed and got her covid-19 vaccine for 1st and 2nd dose.

Present Medical History

The patient reported radiating discomfort from her epigastric region to her right
hypochondriac region, and she rated it an 8 out of 10. She also vomited and was given
Maalox as a pain medication. The patient’s siblings convinced her to have a
consultation at DVMC and upon check-up the patient was weak in appearance and
can’t tolerate her pain due to her epigastric pain. On March 10, 2023, she had a
cholecystectomy at DVMC.
OB History

The patient had her first menstrual period when she was 16 years old .After using Lady
Pills as her contraceptive for a long time, she attempted injectable contraceptives for
two years, and she is now using an implant as her birth control. The patient had three
children via normal spontaneous delivery. Patient gravida is 3, parity is 0, term is 3,
abortion is 0, living 3

Social/Psychological History

According to the patient, she owned Pansiteria restaurant in Cordon, Isabela. She
woke up at 4 AM to clean their house before go to the restaurant. She usually cooked
and manage the shop. She slept at 10 in the evening after her children fall asleep.

Family History

Father Mother
Diabetes - +
Ulcer - +
HTN + -
Allergies - -
Asthma + -
Cholelithiasis - +
PHYSICAL ASSESMENT (HEAD TO TOE)

GENERAL SURVEY: The 48 year’s old is on Semi- Fowler's position in bed, she is
conscious and coherent.
Date of Physical Assessment: March 16, 2023
Post-Operative Surgery: March 10,2023
Time: 10:00 am
Body built: Endomorph
Weight: 50 kg
Height: 4’7
VITAL SIGN
BP: 120/80 mm/hg
TEMP: 36.7 C
RR: 20 cpm
PR: 93 bpm
SPO2: 97%

Head
AREAS TECHNIQUE FINDINGS INTERPRETATION
Generally Round, with
Skull Inspection prominence in the NORMAL
frontal and occipital
area. (Normocephalic)

Palpation No tenderness upon

palpation.
Lighter in color than the
Scalp Inspection complexion, moist, no NORMAL
scars noted, free from
lice, nits, and dandruff.

Palpation No lesions, no
tenderness or masses
on palpation.
Re-bonded black
Hair Inspection colored hair with no NORMAL
artificial color and evenly
distributed hair no
evidence of alopecia,
thick and smooth
Face
AREA TECHNIQUE FINDINGS INTERPRETATION
Face is
Face Inspection symmetrical, oval NORMAL
shape, no
involuntary
movements, can
move facial
muscles at will, no
drooping down of
face

Eyes
AREA TECHNIQUE FINDINGS INTERPRETATION
Eyebrows Inspection Symmetrical and
in line with each Normal
other, color black
and evenly
distributed.
Eyes Inspection Evenly placed and
in line with each Normal
other, none
protruding and
equal palpebral
fissure, no
complaining of
pain, no tearing,
swelling or
discharge
Eyelashes Inspection Color black,
evenly distributed Normal
and turned
outward.
No PTOSIS noted.
Eyelids Inspection Meets completely Normal
when eyes are
closed,
Symmetrical
Sclera is white
Sclerae Inspection (anicteric sclerae), Normal
no yellowish
discoloration
(icteric sclerae)
some capillaries
are visible.
Lacrimal Non palpable, no
apparatus Palpation tenderness on Normal
palpation
Cornea Inspection No irregularities in Normal
surface, looks
smooth, clear and
transparent, iris is
visible through the
cornea and
positive corneal
reflex.

Iris Inspection Color of iris is Normal

black, appear flat
from side view, no
crescent shadow
casted on the
other side when
illuminated from
one side

Pupil Inspection Pupil are equal in Normal

size of 3mm,
equally round,
constrict briskly
when light is
directed to the
eye, pupils dilate
when looking at
distant objects and
constrict when
looking at nearer
objects.

Ears
AREA TECHNIQUE FINDINGS INTERPRETATION
Earlobes are
bean-shaped,
parallel, and
symmetrical; the
skin is the same
Ears Inspection/Palpation color as the Normal
complexion; there
are no lesions; the
auricles have firm
cartilage; the
pinna recoils when
folded; there is no
discomfort upon
touch; and the ear
canal has some
cerumen but no
 discharge and
proportional

Nose
AREA TECHNIQUE FINDINGS INTERPRETATION
No discharges, no
Nose Inspection flaring, both nares Normal
are patent,
symmetrical and in
midline Normal
Palpation
No tenderness
upon palpation.

Mouth
AREA TECHNIQUE FINDINGS INTERPRETATION
Lips Inspection Pinkish in color, Normal
symmetrical
movement, no
lesions, no
inflammation
Pinkish in color,
Gums Inspection no bleeding, no Normal
receding gums.
Two teeth are
Teeth Inspection extracted with four Abnormal
jacket teeth in due to artificial teeth
front with braces and poor oral
at the lower teeth hygiene
and no dental
cavities but with
yellowish
discoloration
Pinkish, no lesion,
Tongue Inspection/Palpation Gag reflex is Normal
present, tongue is
in midline and
able to move the
tongue freely and
with strength, no
oral thrush.
Position in the
midline, pinkish in
Uvula Inspection color, no swelling Normal
or lesion noted,
moves upward
and backward
when asked to
say “ah”
Neck
AREA TECHNIQUE FINDINGS INTERPRETATION
Neck is straight,
symmetrical with
Neck Inspection head in central Normal
position no visible
mass or lumps,
symmetrical, no
Jugular Vein, able
to move head
without discomfort

Palpation Distension,
trachea is Normal
palpable, lymph
nodes are
palpated, no
palpable masses

Thorax (Cardiovascular System)

AREA TECHNIQUE FINDINGS INTERPRETATION
Inspection No lift or heaves. Normal

Palpation Apical pulsation Normal

Heart can be felt upon
palpation, no
abnormal heaves.

Auscultation S1 & S2 can be Normal

heard, no
abnormal heart
sounds are heard.
Heart rate: 80 bpm

Lungs
AREA TECHNIQUE FINDINGS INTERPRETATION
Lungs
Inspection Chest expansion Normal
is symmetrical
Auscultation
Resonant sounds Normal
Respiratory rate of
20 cpm

Quiet, rhythmic
Palpation and effortless Normal
breathing
Abdomen
AREA TECHNIQUE FINDINGS INTERPRETATION
Abdomen Inspection Skin color is
uniform, no
lesions, not Normal
distended,
presence of
stretch marks as a
result of past
delivery.

4.5 cm of incision
on the right upper
quadrant Abnormal due to
Dry and intact presence of stitches
dressing, no
presence of
discharge.

Abnormal
Auscultation Hypoactive bowel due to constipation
sounds

Percussion Tympany, Normal

predominant
sound heard

Extremities
AREA TECHNIQUE FINDINGS INTERPRETATION
Both extremities
are equal in size,
Extremities Inspection no involuntary Normal
movement, no
edema, can
perform complete
Range of Motion.
Patient has a
contraceptive
implant on her left
arm

Palpation With minimal Normal

scars, no lesions
Integument
AREA TECHNIQUE FINDINGS INTERPRETATION
Brown complexion
and Uniform in
Skin Inspection/Palpation color, No foul Normal
odor, No masses,
lesions, no
wound, no
laceration, no
rashes, warm and
uniform to touch,
good skin turgor.
skin sprung back
rapidly when
pinched, edema is
not present
Smooth and has
an intact
Nail Inspection/Palpation epidermis with a Normal
short and clean
pink tone
fingernails and
painted toenails
Convex and with
a good capillary
refill time of 2
seconds
 GORDON’S 11 FUNCTIONAL HEALTH PATTERN

DATE OF INTERVIEW: March 16 ,2023

TIME OF INTERVIEW: 10:00 am

Days of Confinement: 4 days

LOC: Conscious and coherent

FUNCTIONAL BEFORE DURING

HEALTH HOSPITALIZATION HOSPITALIZATION
PATTERN

The patient stated that health is very She emphasized that

HEALTH vital to her, she claimed that being sick she should pay more
PERCEPTION keep her from working or doing her attention to her health
AND daily activities. The patient stated that and keep her
MANAGEMENT she never saw herself being admitted medications up to date,
in the hospital since she claimed that as well as consider
she has a strong immunity system and taking food supplements
and vitamins to keep her
rarely get sick. Patient claimed that if
immunity stronger than
she suffered from pain in her abdomen
before and also stated
she would boil avocado leaves and that she would do her
drink it, patient don’t have any vitamins utmost to consult a
or supplemental foods, or sometimes medical practitioner
she would ask her neighbor what to do anytime she felt sick.
or what pain management to be done
if her pain occur, or sometimes she will
let her mother massage her abdomen.
Patients claimed that’s she has an
allergy on seafoods and would take
cetirizine for management and no
history of consultation of health
professional or quarterly check-up.

Patient is not particular about her food,
NUTRITIONAL/ but she claims she enjoys eating salty
METABOLIC and fatty foods, as well as junk food
PATTERN and can consume 12 ounces of
carbonated drinks each day. The
patient claims that she can only drink
4-5 glasses of water each day and
occasionally only 2 glasses. Patient
Meals are provided, and
fruits and drinks are also
available. Because she
does not engage in
strenuous activity, the
patient can drink 2-3
glasses of water per day.
 mentioned that in her younger ages
she drink alcoholic beverages, she
never smoke.
The patient stated that she defecates
ELIMINATION well twice a day, has no urinary
PATTERN resistance or incontinence, and has no
history of hospitalization due to a
urinary condition. However, a week
before admission, the patient stated
that she was having difficulty urinating.
she felt her urine was hot but not
stingy, and her urine color is dark
yellow as claimed by the patient
The patient stated that she used to
EXERCISE AND actively participate in outdoor
ACTIVITY activities, particularly volleyball, but
PATTERN that now that she is married and have
children, she does not have time to
participate in outside games or sports
because she needs to work early in her
"pancitan," and doing household
chores serves as her exercise,
according to her.
Due to the nature of her job, she must
SLEEP/REST rise at the early hour of 4 or 5 am and
PATTERN typically goes to bed at 10 pm. She
occasionally naps in the afternoon
because she needs to accommodate a
customer, but she claims she can't
sleep when her abdomen hurts,
especially one week before admission.
She tried to focus on something else
but had trouble doing so.
The patient stated that she speaks
COGNITIVE Tagalog, Ilocano, and English, that she
PERCEPTION has no hearing or vision problems, and
PATTERN that she wears glasses for about two
years. She cooperates and
Patient was not wearing
any diaper or foley
catheter. She urines well
but according to her, two
days after her surgery,
she did not defecate at
all, and on 3/15/2023,
she defecated but just
slightly and with wet
feces.
Patients reported that
she remains in bed for
the majority of the time
and seldom ever gets
out of bed.
The patient claimed that
although she frequently
lies down to sleep, she
occasionally finds it
difficult to do so because
of the noise in the room
and the slight discomfort
emanating from her
incision.
The patient is delightful
to be around and
responds to all of the
healthcare personnel'
inquiries about her.
 communicates efficiently, and she has
a long attention span.

Patient bathe once a day and shower The patient is unable to

SELF in the afternoon, no history of plastic take a regular shower
PERCEPTION surgeries or semi-permanent make-
AND SELF but she has her son to
up, Patient claims she is attractive on provide TSB
CONCEPT
her own
PATTERN

ROLE The patient stated that she gets along The patient's had her
RELATIONSHIP well with her neighbors and family son to take care of her
PATTERN members.

SEXUALITY AND The patient reported that while she There is no evidence of
REPRODUCTIVE occasionally had irregular periods and a reproductive system
PATTERN
dysmenorrhea, she otherwise had no dysfunction.
issues with her reproductive system.
She also remarked that she and her
husband no longer sexually active
together because he works in a distant
construction location. They have
sexual intercourse only once a month,
and sometimes none at all.

If a patient has a difficulty or is stressed She spends the most of

COPING AND out at work or in her home, she will just her time resting, lying
STRESS seek the guidance of the almighty down, and using her
TOLERANCE father, or she will go out and do some phone to watch videos.
PATTERN fun stuff, do some diversional activities
like watching movies or listening to
music especially Christian songs

The patient is a devoted Baptist who The patient

VALUE-BELIEF defies superstitions and accepted acknowledged that
PATTERN norms. She claimed that life would've challenges come with life
been meaningless and misery without and that she must
God. She and her children will attend maintain his optimism
bible study each Sunday.
while dealing with them.
Course in the Ward

Date/Time Doctor’s progress Note Doctor’s Order Interpretation

March 8, - Secure consent - For legal basis
2023 for admission and purposes
6:00 pm and
management
- Monitor VS Q4 - For baseline
data and
comparison

- WF: PNSS 1L x - For IV access

16

Dx:
- CBC - It is used to
make sure that
your blood
platelet is
adequate
before the
operation

- CREA - To assess
kidney function
- SGPT/ SGOT - To assess liver
function
Tx:
- Omeprazole - Inhibit the
40mg IV now production of
then OD the acids in the
(omepron) stomach
+ epigastric region to - Unit whole - For diagnostic
6:29 PM right hypochondriac abdomen + purposes
region TVS
 -paracetamol 1amp IV - For fever
Q4 PRN for temp
>37.8C

- To prevent the
-Ceftriaxone 1 gram IV
growth of
OD monitor and stable
bacterial
Q2
infections

- Preparation for
-NPO temporarily
whole
abdomen UTZ

10:30 PM (-) Fever - NPO temporarily - Preparation for

(-) Jaundice whole
(+) RUQ pain abdomen UTZ
(+) epigastric pain
(+) bloater - Facilitate whole
abdomen
- Suggest to give - For pain
ketorolac 30mg management
TIV now then
PRN every 8
hours for severe
pain

- Acute
Cholecystitis
Probably see to
cholecystolithiasis
March 9, - Urinalysis & - To assess
2023 transvaginal urinary
7:40 AM UTZ abnormalities
 - Facilitate whole
abdomen utz
and tvz

- Ketorolac 1amp - For pain

Q8 ANST management
- May have low
salt, non-fat diet
- Suggest
lap/open
cholecystectomy
5:30 pm OB Note:
- Pt. hx received &
lab result seen.
- Presenting
implant since
2021
G3P3 3003
- Removal of
implant
- Yearly pap - Regularly done
smear for prevention
of cervical
cancer
March 10, - MRA: - To determine
2023 Intermediate the patient’s
3:37 pm Risk for OR ability to
contemplated withstand the
operation

7:19 pm - Post-op orders

- To RR then to
ROC
 - O2 inhalation till
fully awake 2-3
LMP
- VS Q15 min x2 - For baseline
then Q4 if stable data and
comparison
- NPO - To avoid or to
lower the risk
of aspiration of
gastric
Contents

- Regulate IVF:
D5LRS 1L x Q8

Tf:
- D5LRS 1L x Q8 - For
- D5NM 1L x Q8 maintenance to
- PLRS 1L x Q10 prevent
hypoglycemia

Meds:
- Continue - To prevent the
ceftriaxone (for growth of
gram) 1 gm TID bacterial
infections

- Continue - Inhibit the

omeprazole IV production of
OD the acids in the
stomach
- Paracetamol 1 - For pain
gm IV Q6 x 8 management
doses
 - Continue - For pain
ketorolac 30mg management
slow IV Q8
- Tramadol 50 mg - For pain
slow IV Q8 x 2 management
doses then PRN
- Nalbophic 10 mg - For pain
slow IV Q6 RN management
for severe pain
with BP
10:00 pm precaution
- Flat on bed for 8 - To prevent
hours decompression
of the
abdomen
- Please insert - To help the
IFC patient drain
the bladder
prior to surgery
- Drain residual - To prevent
urine urine overload
- Monitor I&O - For monitoring
x4hours then 6 of fluid status
hours if I&O
>30ml/hr
- Please remove
IFC tomorrow at
8 am if adequate
I&O
- Encourage deep - Deep breathing
breathing exercise for
exercise pain
management
- Please give one - To relieve
more dosage of abdominal pain
 hyoscine 1 amp
IV given at 7 pm

March 11, - For gen. Liquid -

2023 - May have soft -
6:27 PM diet
- May ambulate -
- Secure dressing
kit
-repeat CBC - To check if
there are other
complication

March 12, - DAT

2023 - May go home
8:00 am Home Medications:
- Ceftriaxone 500
mg 1 Tab TID x
6 days
- Celecoxib 200
mg 1 cap 2x a
day x 3 days
then PRN for
pain
- Omeprazole 60
mg OD x 7 days

- Daily wound - To prevent

care infections
- May apply - It helps to
abdominal reduce
binder postoperative
pain

10:50 am - Avoid fat in diet

LABORATORIES AND DIAGNOSTICS
Patient Name: L (HEMATOLOGY)
Age: 48 Sex: Female
Study Date: March 8, 2023 Time: 6:45 am

Parameters Result Unit. Ref. Ranges Interpretation

Hemoglobin 14.6 12.000-16.000 Normal
g/dL
Hematocrit 43.0 36.000-47.000 % Normal

WBC 16.70 5.000- Abnormal due to

10.000x10^9 inflammation
cells/L
Segmenters 75.50 50.000-80.000 % Normal

Lymphocyte 11.70 (L)25.000-50.000 Infection

%
Eosinophils 0.50 0.000-5.000 % Normal
Monocytes 11.90 (M) 2.000-10.000 High due to fever
% and inflammation
Basophils 0.40 0.000-2.000 % Normal
Platelet Count 405.00 150.00-450.00 Normal
mm^3

BLOOD TYPE
Parameters Result Unit. Ref. Ranges Interpretation
MVC 92.7 80.000-97.000 Normal
um^3
MCH 31.5 26.000-32.000 pg Normal
MCHC 34.0 31.000-36.000 Normal
g/dL
RDW-CV 11.80 10.000-16.000 % Normal

Study Date: March 8, 2023 Time: 7:41 am

Parameters Result Unit. Ref. Ranges Interpretation
ALT (SGPT) 23.97 F :<= 32 : M:<41 Normal
U/L
Serum Creatinine 60.72 44.000-80.000 Normal
umol/L
Patient Name: L (HEMATOLOGY)
Age: 48 Sex: Female
Study Date: March 9, 2023 Time: 7:20 am
Parameters Result Unit. Ref. Ranges Interpretation
Hemoglobin 12.0 12.000-16.000 g/dL Normal

Hematocrit 39.5 36.000-47.000 % Normal

WBC 10.24 5.000-10.000x10^9 Normal
cells/L

Segmenters 80.00 50.000-80.000 % Normal

Lymphocyte 6.30 (L)25.000-50.000 %

Eosinophils 0.40 0.000-5.000 % Normal

Monocytes 6.00 (M) 2.000-10.000 % Normal

Basophils 0.30 0.000-2.000 % Normal

Platelet Count 411.00 150.00-450.00 Normal
mm^3

BLOOD TYPE
Parameters Result Unit. Ref. Ranges Interpretation
MVC 94.8 80.000-97.000 Normal
um^3
MCH 31.2 26.000-32.000 pg Normal
MCHC 32.9 31.000-36.000 Normal
g/dL
RDW-CV 11.80 10.000-16.000 % Normal

Patient Name: L (URINALYSIS)

Age: 48 Sex: Female
Study Date: March 9, 2023 Time: 8:39 am
ROUTINE URINALYSIS
Physical Examination Interpretation
Color DARK YELLOW Normal
Transparency Slightly cloudy Presence of alkaline
Specific Gravity 1.020 Normal
pH 6.0 Slightly acidic
Chemical Examination
Protein TRACE
Glucose NEGATIVE
Microscopic
Pus cells 2-3
Red blood cells 0/1

Microscopic Examination
White Blood Cells 2-3 /HPF
Red Blood Cells 0-1 /HPF
Amorphous FEW
PO4/Urates
Epithelial Cells FEW
Bacteria FEW
Mucus Threads MANY

Patient Name: L (HEMATOLOGY)

Age: 48 Sex: Female
Study Date: March 10, 2023 Time: 3:00 am
Parameters Result Unit. Ref. Ranges Interpretation
Hemoglobin 12.8 12.000-16.000 g/dL Normal

Hematocrit 39.0 36.000-47.000 % Normal

WBC 9.89 5.000-10.000x10^9 Normal

cells/L
Segmenters 64.30 50.000-80.000 % Normal
Lymphocyte 19.90 (L)25.000-50.000 % Mild infection

Eosinophils 3.00 0.000-5.000 % Normal

Monocytes 9.20 (M) 2.000-10.000 % Normal

Basophils 0.6 0.000-2.000 % Normal

Platelet Count 375.00 150.00-450.00 Normal
mm^3
PT Patient 12.7 10.000-15.000 secs Normal

PT Control 14.5 11.700-18.800 Normal

PT Activity 109.0 70.000-120.000 % Normal

INR 0.94 <1.2 Normal

PTT 27.000-42.000 secs

BLOOD TYPE
Parameters Result Unit. Ref. Ranges Interpretation
MVC 93.5 80.000-97.000 um^3 Normal
MCH 30.7 26.000-32.000 pg Normal
MCHC 32.8 31.000-36.000 g/dL Normal
RDW-CV 11.60 10.000-16.000 % Normal

Study Date: March 10, 2023 Time: 3:38 am

Parameters Result Unit. Ref. Ranges Interpretation
Blood Sugar (FBS) 106.34 P: 60-100 : A: 70- Normal
115 mg/dL

Study Date: March 10, 2023 Time: 10:01 am

Parameters Result Unit. Ref. Ranges Interpretation
Hemoglobin A1c 5.40 4.800-5.900 % Normal
Patient Name: L
Age: 48 Sex: Female
Study Date: March 10, 2023
CHEST X-RAY
March 10, 2023 Impression:
➢ No significant chest findings.

Patient Name: L
Age: 48 Sex: Female
Study Date: March 9, 2023
WHOLE ABDOMINAL ULTRASOUND
March 10, 2023 Impressions:
➢ Gallbladder stone and sludge with
signs of cholecystitis.
➢ Minimal ascites.
➢ Normal ultrasound of the liver,
pancreas, spleen, aorta/paraaortic
areas, kidneys, and urinary
bladder.
➢ Normal retroverted uterus with
intact endometrium.
➢ Clear adnexae.
Anatomy and physiology
Gallbladder

Gallstones form in Gallbladder

Cholelithiasis or gallstones are hardened deposits of digestive fluid that can form
in your gallbladder. The gallbladder is a small organ located just beneath the liver. The
gallbladder holds a digestive fluid known as bile that is released into your small
intestine, gallbladder stores and releases bile, a fluid made in your liver, to help in
digestion. Bile also carries wastes like cholesterol and bilirubin, which your body
makes when it breaks down red blood cells. These things can form gallstones.
Gallstones can range in size from a grain of sand to a golf ball. You might not know
that you have them until they block a bile duct, causing pain that needs treatment right
away.
Gallbladder is part of biliary system. It belongs to a network of organs that pass bile
between each other. These organs are connected by a series of pipelines called bile
ducts. Bile travels through the bile ducts from your liver to your gallbladder, and from
your gallbladder to your small intestine. Your pancreas also uses the bile ducts to
deliver its own digestive juices. A gallstone that travels to the mouth of your gallbladder
can obstruct the flow of bile in or out. A gallstone that makes its way out of your
gallbladder and into the bile ducts could block the flow of bile through the ducts. This
will cause bile to back up into the nearby organs. When bile backs up, it builds pressure
and pain in your organs and bile ducts and causes inflammation.
 PATHOPHYSIOLOGY

Predisposing Factors: Precipitating Factors:

Sex: Female Obesity

Age: 48 Diet

Ethnicity Pregnancy

Diabetes Mellitus Fasting

Rapid weight loss from (54 to 50kl)

Use of Oral contraceptives (Lady)

Bile stagnates in the

gallbladder

Pigment solute precipitate as

solid crystals

Crystals clump together and

forms stones

Gallstones

Gallbladder contracts after

intake of fat to release bile

A stone is moved and

becomes impacted on the
cystic duct upon contraction

CHOLELITHIASIS

Bile stasis

Lumen is obstructed by
stones
Chemical reaction inside
gallbladder triggers the release
of inflammatory enzymes
 Fluid leaks into Inflammation of the
gallbladder gallbladder

Edema

Increased
intraluminal pressure
Biliary Colic
and distention of the
gallbladder RUQ pain

Constriction of
blood vessels Murphy’s Sign

Surgical Management:
Diagnostic Tests:
Open Cholecystectomy Medical Management:
Cholecystography
Laparoscopic Cholecystectomy Anticholinergics
Blood Test
Mini Cholecystectomy Antibiotics
MRI
Choledochotomy UDCA
CT Scan
Surgical Cholecystectomy Dissolving agents
ERCP
Percutaneous Cholecystostomy

Nursing Management: (After Surgery)

Maintain patency of IFC and assess and measure drainage in every shift.

Monitor intake and output.

Check IV site for phlebitis and operation site for soakage.

Keep patient in a comfortable position.

Encourage patient for deep breathing and coughing exercise.

Evaluate for complications for example hemorrhage, post-operative jaundice, sub-hepatic

abscess, pancreatitis, and disruption of the ducts.
 NURSING CARE PLAN

ASSESMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective: Constipation Short term goal: ➢ Review daily ➢ Inadequate Short term goal:
“Agtallo aldaw ti related to dietary dietary fiber
napalabas diay abdominal muscle Within 6 hours of regimen, contributed to After 6 hours of
last nga panag cr weakness nursing intervention noting if diet poor intestinal nursing intervention
ko,inggana tatta secondary to the patient will is deficient in function the patient were able
awan pay ,kala post-operative establish or return to fiber to establish or return
takki kalding tay surgery normal patterns of ➢ Provides to normal patterns of
takkik idi “ as bowel functioning ➢ Noted color, baseline of bowel functioning
verbalized by the amount, odor comparison
patient Long term goal: and Long term goal:
consistency
Objective: After 2 days of and frequency After 2 days of
Nursing intervention of stool Nursing intervention
As witnessed and patient will: patient
claimed by her - Verbalize ➢ Reviewed the ➢ To determine - Verbalized
SO, the patient understanding client’s the drugs understanding
was consistently of etiology current contributing to of etiology
lying down and medication constipation and
throughout the appropriate regime appropriate
interview and the interventions interventions
previous few days. - Demonstrate ➢ Auscultated ➢ Reflecting - Demonstrate
behavior abdomen for bowel sounds behavior
Limited movement changes to presence, changes to
as seen prevent location and prevent
recurrence of characteristics recurrence of
Borborygmi problem of bowel problem
sounds of 4 sounds
As evidenced by
Distended ➢ Encouraged ➢ To help assist Bristol type 3
abdomen fluid intake of in improving
 1-2 liters a stool
day within consistency
cardiac
tolerance
➢ Stimulate
➢ Encouraged peristalsis and
patient to do increase tone
minimal of
ambulation gastrointestinal
tract and
abdominal wall

➢ Help decrease
➢ Advised abdominal
patient to distention
avoid gas
forming foods
➢ To provide
➢ Assisted and predictable
instructed and effective
patient with elimination
other means
triggering
defecation
like
abdominal
massage or
suppositories
 ASSESMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective: Acute pain Within 2 hours of ➢ Noted ➢ This can After 2 hours of
“Madi ak unay related to Post nursing intervention, location of influence the nursing intervention,
makagaraw gamin operative the patient will be able surgical, amount of post- the patient were able
agsaki-sakit atuy surgical incision to: Evaluate pain operative pain to:
sugat ko nukwa at RUQ characteristics experienced
“as verbalized by - Verbalize and and intensity - Verbalize and
the patient while demonstrate demonstrate
arm rubbing the relief and ➢ Performed ➢ To demonstrate relief and
right upper control of pain pain improvement in control of pain
quadrant and discomfort assessment status and discomfort
each time
Repeated pain - Follow pain occurs - Follow
with scale of 5/10 prescribed prescribed
pharmacological ➢ Administered ➢ To maintain pharmacological
Objective: regimen analgesic acceptable level regimen
celecoxib as of pain
➢ Guarding indicated to - Demonstrate
behavior of - Demonstrate maximum use of
putting her use of dosage as relaxation skill
arm on her relaxation skill needed. and diversional
abdomen and diversional activities for
➢ Abdominal activities for ➢ Provided ➢ Provide and individual
binder is individual comfort promote non- situation
seen situation measures of pharmacological
➢ Positioning back rub, pain As evidenced by relief
to ease pain change of management pain from scale of 5/10
➢ Facial position, to 3/10 and stable vital
grimace diversional sign and complied in
➢ 4.5 cm activities and taking medication on
Kocher use of time
incision with relaxation
dry and exercises.
 intact
dressing ➢ Encouraged ➢ To prevent
adequate rest fatigue that can
Vital sign: periods impair ability to
BP- 130/100 manage pain.
RR- 24
O2 -95%
 ASSESMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
Following a 1 day • Assess • High After a 1 day of
“Paputol putol tulog Disturbed sleeping of nursing sleep pattern percentage of nursing
ko kasi mayat- pattern related to intervention, the disturbances sleep intervention, the
maya may mga interruptions for patient will achieve that are disturbances patient was able to
pumapasok na mga therapeutics, optimal amount of associated can affect the display
nars para monitoring and sleep as evidenced with the recovery of improvement in
magbigay gamot other generated by; environment the patient sleeping pattern as
tapos maingay awakening and • Observe and • To determine evidenced by;
paligid” as excessive • Verbalization obtain usual
verbalized by the stimulation (noise of feeling feedbacks sleeping • The patient
patient and lightning) rested regarding on pattern and to verbalized;
• Decrease the usual compare if “medyo
the presence sleeping there are any nakatulog at
Objective: of dark pattern, improvements nakapagpahinga
circles under bedtime on the na ako nang
Presence of dark the eyes routine and sleeping maayos
circles under the • Improvement the usual pattern of the kumpara sa
eyes of sleeping number of patient dati”
pattern hours of
Yawning • Absence of sleep and • The patient
restlessness rest. does not
Restlessness • Do as much look weak
care as • To avoid and
possible disturbances restlessness
without during sleep, compare to
waking up and also to the past
the client maximize the • The
and do as sleep and rest presence of
much care of the client. eyebags
as possible have been
while the minimized or
client is still have gone.
awake
• Explain • Decrease of
necessity of • For the the usual
disturbances patient to yawning.
for have an
monitoring understanding
vital signs of the
and care importance of
when care being
hospitalized done to her
and to
minimize the
complaints.
 DRUG STUDY

DRUG NAME MECHANISM OF INDICATION & SIDE EFFECT AND NURSING

ACTION CONTRAINDICATION ADVERSE REACTION RESPONSIBILITIES
Generic Name: ➢ Is a bactericidal Indication: Side Effects: Before:
➢ Cefuroxime agent that ➢ For the treatment of GV: ➢ Advice patient to
exerts its many different types ➢ Phlebitis take Cefuroxime
Brand Name: mechanism of of bacterial infections ➢ Thrombophlebi with food to
➢ Zoltax action by such as bronchitis, tis increase
binding sinusitis, tonsillitis, ear absorption and
Classification: penicillin- infections, skin Skin: reduce stomach
➢ Antibiotics binding proteins infection, gonorrhea ➢ Jaundice/yellowi ache.
(PBPs) via beta- and urinary tract sh Skin During:
Dosage: lactam rings. infections. ➢ Rash ➢ Monitor patient
➢ 500mg ➢ Temperature for any signs of
elevation allergic reaction
Route: ➢ Urticaria and anaphylaxis.
➢ Oral After:
GI: ➢ Advice patient to
Frequency: ➢ Diarrhea report any signs
➢ BID Contraindication: ➢ Nausea of rash, loose
➢ Cefuroxime should ➢ Vomiting stools, diarrhea
Timing: be used cautiously ➢ Anorexia
➢ 8 am – 8 in patients with ➢ Stomach pain and evidence of
pm hypersensitivity to ➢ Dizziness/drows superinfections.
penicillin. The iness ➢ Monitor signs of
structural similarity blood
between cefuroxime Adverse Reaction: dyscrasias,
and penicillin means Nausea, vomiting, including
that cross-reactivity diarrhea and stomach eosinophilia
can occurs. pain may occur, (fatigue,
dizziness and weakness,
drowsiness may occur myalgia)
frequently, especially
with higher doses.
 DRUG NAME MECHANISM OF INDICATION & SIDE EFFECT AND NURSING
ACTION CONTRAINDICATION ADVERSE REACTION RESPONSIBILITIES
Generic Name: ➢ Celecoxib is a Indication: Side Effects: Before:
➢ Celecoxib selective ➢ Celecoxib is not a CNS: ➢ Assess patient
noncompetitive substitute for aspirin ➢ Headache for allergy to
Brand Name: inhibitor of for cardiovascular ➢ Dizziness sulfonamides,
➢ Celebrex cyclooxygenase-2 event prophylaxis. ➢ Insomnia aspirin or
enzyme that CV: NSAIDs. Patient
Classification: expressed heavily ➢ It may be also be ➢ HTN with these
➢ NSAIDs in inflamed used to treat acute ➢ Peripheral Edema allergies should
Dosage: tissues where it is pain from various EENT: not receive
➢ 200mg induced by sources, juvenile ➢ Rhinitis celecoxib.
inflammatory rheumatoid arthritis ➢ Sinusitis
Route: mediators in children over 2, GI: During:
➢ Oral ankylosing ➢ Abdominal Pain ➢ Monitor patient
spondylitis, and ➢ GI Reflux for any signs of
Frequency: primary ➢ Nausea allergic reaction
➢ BID dysmenorrhea. Musculoskeletal: and anaphylaxis
➢ Back Pain ➢ Assess patient
Timing: for skin rash
➢ 8 am – 8 Adverse Reaction: frequently during
pm medication.
 an adverse reaction of
celecoxib is (hives, After:
Contraindication: difficult breathing, Advice patient to
➢ Due to its swelling in your face or report any signs
cardiovascular throat) or a severe skin and symptoms of
risk, celecoxib is reaction (fever, sore shortness of
contraindicated for throat, burning eyes, breath or trouble
the treatment of skin pain, red or purple breathing, chest
perioperative pain skin rash with blistering pain weakness in
in the setting of and peeling). one side of the
coronary artery body, slurred
bypass graph speech, swelling
(CABG) surgery. of the face or
throat occurs.
 DRUG NAME MECHANISM OF INDICATION & SIDE EFFECT AND NURSING
ACTION CONTRAINDICATION ADVERSE REACTION RESPONSIBILITIES
Generic Name: ➢ Used to reduce Indication: Side Effects: Before:
Omeprazole the risk of stroke ➢ Indicated for short CNS: ➢ Assess patient’s
Brand Name: in patients who term treatment of ➢ Headache magnesium level
➢ Losec are risk in active benign gastric ➢ Dizziness and reduce sign
developing a ulcer and symptoms.
GI:
Classification: stomach ulcer.
➢ Abdominal Pain
➢ Antiulcer During:
➢ Constipation
Drug Contraindication: ➢ Monitor patient
➢ Diarrhea
Dosage: ➢ Contraindicated in for any signs of
➢ Nausea
➢ 40mg patient allergic reaction
➢ Vomiting
hypersensitive to and anaphylaxis
➢ Acid
Route: drugs or its ➢ Assess patient
regurgitation
➢ Oral components and in for skin rash
Musculoskeletal:
patients receiving frequently during
➢ Back pain
Frequency: rilpivirine medication.
➢ Weakness
➢ OD containing
products.
Adverse Reaction: After:
Timing:
It can decrease ➢ Report any
➢ 12 pm
absorption in Iron, changes in

calcium, magnesium, urinary

vitamin B12 and elimination such
increased risk of as pain or
clostridioides difficile discomfort
infection pneumonia. associated with
urination, or
blood urine.
➢ Advice patient to
avoid hazardous
activities if
dizziness
➢ occurs.
 DRUG NAME MECHANISM OF INDICATION & SIDE EFFECT AND NURSING
ACTION CONTRAINDICATION ADVERSE REACTION RESPONSIBILITIES
Generic Name: ➢ Binds the 50S Indication: Side Effects: Before:
➢ Clarithromycin subunit of ➢ Clarithromycin may CNS: ➢ Assess patient
Brand Name: bacterial also decrease the ➢ Headache for any signs of
➢ Klaricid ribosomes, incidence of ➢ Insomnia low level of
blocking protein cryptosporidiosis, GI: magnesium.
Classification: synthesis; prevent the ➢ Abdominal Pain ➢
➢ Antibiotics bacteriostatic or occurrence of α- ➢ Nausea
Dosage: bactericidal, hemolytic (viridans ➢ Taste During:
➢ 500mg depending on group) streptococcal Perversion ➢ Monitor patient
concentration. endocarditis, as well ➢ Dyspepsia for any signs of
Route: as serve as a ➢ Flatulence allergic reaction
➢ Oral primary prevention and anaphylaxis
for Mycobacterium Adverse Reaction: ➢ Assess patient
Frequency: avium complex ➢ Serious skin for skin rash
➢ OD (MAC) bacteremia reactions can frequently during
or disseminated occur with this medication.
Timing: infections (in adults, medicine like
➢ 7 am adolescents, and blistering, peeling, After:
children with or loosening of Advice patient to
the skin, red skin report any signs
 advanced HIV lesions, severe and symptoms of
infection) acne or skin rash, shortness of
sores or ulcers on breath or trouble
the skin, or fever breathing, chest
or chills while you pain weakness in
or your child are one side of the
using this body, slurred
medicine speech, swelling
Contraindication: of the face or
➢ Due to its throat occurs.
cardiovascular
risk, celecoxib is
contraindicated for
the treatment of
perioperative pain
in the setting of
coronary artery
bypass graph
(CABG) surgery.
 DRUG NAME MECHANISM OF INDICATION & SIDE EFFECT AND NURSING
ACTION CONTRAINDICATION ADVERSE REACTION RESPONSIBILITIES
Generic Name: ➢ Used to treat Indication: Side Effects: Before:
Ceftriaxone certain infections ➢ To prevent the ➢ Headache ➢ Do not mix
Brand Name: caused by growth of bacterial ➢ Fever ceftriaxone with
➢ Chills
➢ Rocephin bacteria. infections. other
➢ Diarrhea
antimicrobial
➢ Nausea and
Classification: drug.
vomiting
➢ Antibiotic
➢ Rash
Dosage: During:
➢ 500 mg Contraindication: ➢ Use a separate
Adverse Reaction:
➢ Hypersensitivity to syringe when
Infection site
Route: cephalosporins giving this drug.
inflammation, rash,
➢ Oral and related
pruritus, fever,
antibiotics. After:
eosinophilia, diarrhea,
Frequency: ➢ Discontinue if
nausea and vomiting,
➢ TID hypersensitivity
may result from altered
occurs.
bacterial balance in GI
Timing: ➢ Monitor patient’s
tract.
➢ 8am,1pm, blood level.
6pm
➢ Instruct patient to
notify prescriber
about rash, loose
stools, diarrhea
or evidence of
super infection.
 DISCHARGE PLAN

MEDICINE OR TREATMENT ➢ Instructed to take medications at home at the proper dose, time, frequency, and route.
➢ Encouraged to comply with medications to prevent further complications.
➢ Emphasized the importance of regular follow-up check-ups and as instructed by
physician.

ENVIRONMENT AND EXERCISE ➢ Maintain a quiet, pleasant, environment to promote relaxation.

➢ Provide clean and comfortable environment.
➢ Encourage daily walking to promote adequate circulation and help return of normal
bowel function.
➢ Avoid any strenuous activity such as lifting, pushing or pulling objects that weight more
than 10 pounds.
TREATMENT ➢ Continue home medications
➢ Teach the patient about proper wound care
➢ Check for signs of infection each day. Check the area for swelling, red streaks or pus.
➢ Wash the incision area with gentle soap and water, do not vigorously rub the incision
area, pat it dry with a clean towel.
➢ Avoid allowing the water spray directly on your incision, it may damage the healing skin
and increase infection.
➢ Do not apply any lotion, powder or cream on your incision until it has completely healed.
➢ Encourage patient to take multivitamins to enhance her immunity
HEALTH TEACHING ➢ Provide verbal and written advice on how to take medications, how to exercise, how to
eat right, how to take care of wounds, and how to schedule follow-up appointments.
 ➢ After release, advise the patient to minimize her activity for the following 24 to 48 hours.
➢ Suggested to the patient to exercise by walking for at least 10 minutes each day in the
morning.
➢ Hug a pillow against the surgery area before sneezing or coughing. This will prevent
pain and protect the surgery area.
➢ Told to make dietary, pharmaceutical, and exercise changes.
➢ To prevent damaging the area where invasive procedures are conducted or opening
surgeries are performed, avoid hard work or vigorous activities. Encouraged to stick to
the monitoring protocol prescribed by the doctor.
➢ Tell the patient to clean the area surrounding the wound so that an infection won't
develop.
➢ Instruct the patient to maintain a clean environment as much as possible to prevent the
buildup of disease or infection that could impact the incision.
➢ Told the patient to take their medication as directed.
➢ The client received instruction on how to maintain proper hygiene.
➢ For dry skin, use lubricant such as lanolin.
➢ It is advised to get medical attention right away if you have a fever, chills, difficulty
breathing (dyspnea), body aches, shortness of breath, sputum, severe exhaustion, or
any other strange symptoms.

OUT PATIENT FOLLOW-UP ➢ After discharge, the patient will be advised to return to the hospital on a specific date
for a follow-up check-up to check on healing progress and assess if there are any
further complications after surgery.
 ➢ Encouraged to call physician, ambulance, family member or friends to take you to
hospital if severe pain is felt.
➢ For any problems or complications, consult a doctor.
DIET ➢ Instruct patients to never skip meals.
➢ Consume a variety of foods, as advised by your doctor, to acquire a balanced diet of the
vitamins, minerals, proteins, carbs, and fats your body requires.
➢ Eat less fat by avoiding foods high in fat and using less fat when cooking.
➢ Consume at least 5 servings of fruits and vegetables each day to increase your fiber
intake.
➢ Eat fewer sugary foods, such as sodas, fruit-flavored drinks, and sugar-sweetened tea
or coffee. Drink more fluids to help your body flush out waste.
➢ Lessen your use of salt when cooking and eating. Consume fewer processed meats,
canned and boxed soups, pickles, and other high-sodium items. Limit your intake of junk
food.
➢ Avoid eating rich greasy or spicy foods
➢ If nauseated take liquids and light meals
➢ Eat high fiber foods such as beans, broccoli, avocados, apples and other green leafy
vegetable.
➢ Drink atleast 8 glasses of water daily.

SPIRITUAL/ SEXUAL ➢ Encouraged to keep seeking God's guidance and understanding.

➢ Emphasized the significance of prayer in healing
➢ Encouraged to seek heavenly assistance in all situations
➢ Encouraged to maintain a cheerful attitude in life.
➢ Encouraged to pursue interests and hobbies for enjoyment in the future as an
alternative to sexual desire.