Final Grand Case-Generalao

A Case Study on
CHOLEDOCHAL CYST TYPE I
Authors:
Lugatiman, Lovely Hope J.
Ilajas, Riz Strawberry G.
Jubane, Monica Marie T.
Juntilla, Joanna Paola S.
Lacbain, Aprille Dawn N.
Looking, Clara Julia S.
Maaño, Francine Kaye Angela D.
Manliguez, Cyrill John B.
Mondoñedo, Tazha Camille D.
June 2023
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A Case Study on Choledochal Cyst Type I
Lovely Hope J. Lugatiman; Riz Strawberry G. Ilajas; Monica Marie T. Jubane; Joanna Paola S. Juntilla; Aprille
Dawn N. Lacbain; Clara Julia S. Loking; Francine Kaye Angela D. Maaño; Cyrill John B. Manliguez; Tazha
Camille D. Mondoñedo
Abstract:
This is a case of Patient X, a 15-year-old boy who was diagnosed with Choledochal
Cyst Type I and was admitted at Northern Mindanao Medical Center. Type I cysts are
fusiform dilatation of hepatic and common bile ducts. This is a rare medical condition
with an incidence of 1 in 100,000 to 150,000 live births in the western populations and 1
in 1,000 in Asian populations. This study aims to establish appropriate nursing
interventions and management in patient care and add to the limited existing studies
that are currently accessible regarding this disease. Patient X was noted to have a
palpable mass at the right upper quadrant, abdominal pain, jaundice, nausea, vomiting,
and generalized weakness. He had a Magnetic resonance cholangiopancreatography
(MRCP) with contrast Magnetic Resonance IMaging (MRI) and was found to have a
cystic lesion involving the hepatic and common bile ducts measuring approximately 11.6
x 13.1 x 17.3 centimeters. He then underwent a surgery for the excision of his
choledochal cyst and hepaticojejunostomy. His condition after the surgery improved, his
jaundice gradually subsided and there were no reports of abdominal pain, nausea, and
vomiting anymore. He was then discharged after the seventh postoperative day. Caring
for this patient enabled the researchers to institute Lydia Halls’ 3Cs; with the core or
center of care being the patient, the cure involves the medical and nursing interventions
instituted to the patient, and the care is the nurturing provided by nurses.
Keywords: Pediatrics, Choledochal cyst, Jaundice, hepaticoduodenostomy, excision

of cyst
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ACKNOWLEDGEMENT
The researchers would like to express their deepest appreciation for the
generous support given to the participants of this study, our patient and his parents, who
were very forthcoming and gracious in accepting to participate in this case. If it were not
for their support and contributions, the following case would not have come to fruition.
To Ms. Lovely Terry Z. Caballes, LPT, RN, MN, the researchers would like to
extend their gratitude for the guidance and support during the times in which the
researchers conducted this study.
To Mr. Rey D. Pinalba, RN, MAN, the researchers would like to express their
thanks for the teachings, tough love, and patience. The growth and experience will be
put to good use in the future as nurses and supervisors.
To Ms. Emman M. Parangue, RN, MN,USRN, Level I Coordinator, the

researchers would also like to express their gratitude for the guidance and teachings
that you passed onto us. The task in making this case study was arduous and difficult
but if it were not for your support, this research would not have come to a conclusion.
To Ms. Daryl Mae A. Casirayan, RN, MN, the researchers would like to extend
our deepest thanks for guiding us throughout our consultations with you about this case
study. The work of creating this case study was rigorous and demanding, but without
your assistance, this research would not have been accomplished.
To Dr. Fidela B. Ansale, RN, MN, the researcher would like to express our
deepest gratitude for encouraging us to become a safe and better nurse when handling
our patients, for imparting to us the type of nurse that we should become in our future
endeavors.
The researchers would also like to extend their warmest thanks to each other
and their efforts put forth. It was worth it in the end.
To our beloved families, friends and classmates for the love, moral support and
guidance.
Above all, to the Heavenly Father, for the blessings, guidance, enlightenment and
protection, which made the researchers’ stronger amidst all the problems they
encountered along the way.
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INTRODUCTION
Background of the Study
Choledochal cysts (CC) are congenital anomalies of the bile ducts and are
defined as abnormal, disproportionate, cystic dilatation of the biliary duct that involves
either extrahepatic duct, intrahepatic duct, or both (Khandelwal et al., 2013).
Substances normally excreted into the bile will accumulate in the vascular system owing
to obstruction of the biliary tree and the inability to excrete bile into the intestine (Wang
& Yu, 2014). Böyük et al. (2015) explained that CCs are classified into five types: Type I
cysts are fusiform dilatation of hepatic and common bile ducts; Type II involves
diverticular dilation anywhere along the extrahepatic duct; Type III cysts, involves
Intraduodenal cystic dilation of the distal common bile duct; Type IV cysts involves
multiple dilations affecting both the intrahepatic and extrahepatic biliary or may also
involve multiple dilations confined to the extrahepatic biliary tree; and Type V cysts
involves multiple dilations confined to the intrahepatic biliary tree. Choledochal cysts are
a rare anomaly and may sometimes be considered a premalignant condition, posing a
diagnostic dilemma (Khandelwal et al., 2013).
The typical clinical presentation of CCs include abdominal pain, jaundice, nausea
and vomiting, and a palpable mass in the right upper quadrant (Albuquerque et al.,
2020). Jaundice continues to serve as a warning indication for biliary tract abnormalities
in CC (Hadikusumah & Diposarosa, 2020). If left untreated, they can cause morbidity
and mortality from recurrent cholangitis, pancreatitis, sepsis, liver abscesses and
cholangiocarcinoma (Singham et al., 2019). Currently, worldwide, increasing access to
more accurate medical imaging enables early diagnosis, contributing to the use of
therapeutic methods in appropriate time, avoiding development of complications
(Albuquerque et al., 2020). However, the management of choledochal cyst and the
operative conduct will depend upon the patient comorbidities and choledochal cyst
subtype (Kelly et al., 2016).
Numerous explanations have been proposed as a result of the fact that the
precise etiology of CC is still unknown. The most widely accepted theory holds that the
cyst arises from an abnormal pancreaticobiliary junction (APBJ). APBJ occurs when the
pancreatic and biliary ducts converge 1 to 2 cm from the Oddi sphincter and as a result,
the long channel that is created is not blocked by the sphincter, allowing pancreatic and
biliary fluids to combine and flow backward, activating pancreatic enzymes. As a result,
the pressure increases, leading to the biliary tree's dilatation, inflammation, epithelial
damage, dysplasia, and cancer (Hoilat & Savio, 2022). However, some views contend
that this condition's genesis is solely congenital. According to Kusunoki et al. (2018),
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patients with CCs had fewer ganglionic cells than controls in the distal common bile duct
(CBD) which causes the proximal portion of the CBD to enlarge.
Choledochal cyst is a rare medical condition with an incidence of 1 in 100,000 to

150,000 live births in the western population and is remarkably higher in Asian
populations with a reported incidence of 1 in 1,000 (Böyük et al., 2015). The specific
incidence of this condition in the United States and Australia was reported to be 1 in
13,500 and 1 in 15,000 live births, respectively (Agrawal et al., 2021). Additionally, CCs
exhibit an unexplained 3:1 or 4:1 female to male ratio (Bhavsar et al., 2015). Although
choledochal cysts are present at birth and around 80% of cases are diagnosed in
childhood, they are increasingly diagnosed in adults and now comprise 20% of all new
cases (Pandit et al., 2020).
Sacher et al. (2013) reported that the preferred diagnostic test for a number of
biliary and pancreatic disorders during the past ten years has begun to shift from
Endoscopic retrograde cholangiopancreatography (ERCP) to Magnetic resonance
cholangiopancreatography (MRCP). MRCP is non-invasive, unlike ERCP procedure,
and involves a simple process of scanning the patient using magnetic and radio
frequencies from an MRI. The most effective methods of treatment for the typical kinds
of CC include precise imaging of the pancreatic and bile ducts, as well as any
accompanying pathology, radical excision of the extrahepatic bile ducts, and
reconstruction by wide hilar hepaticoenterostomy (Stringer, 2018).
Objectives of the Study
The purpose of this case study is to explore and analyze the physiological
process of the disease, its medical-surgical management, and appropriate nursing care
for Obstructive Jaundice Secondary to Choledochal Cyst Type I.
At the end of this case study, the researchers will be able to outline the
physiological process of the disease, apply its medical management in the clinical
setting, and provide the optimum nursing management of patients with Choledochal
Cyst Type I to deliver the most efficient care for the patient.
Significance of the Study
This case study may have implications for nursing practice, more notably for
Nursing practice. The study’s prospective findings could assist nurses in managing
patient’s existing condition, providing appropriate medical management, educating
patients and their families about their condition and
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treatment. Collaborating with the health care team to ensure comprehensive patient
care can also assist them in ensuring holistic care and ensure positive patient
outcomes. Additionally, it can assist them in coordinating and managing the continuity of
care of the patient.
This case study may also potentially contribute to the field of Nursing research.
The study’s data and findings will provide additional data since only limited information
and studies are available regarding Choledochal Cyst Type I. Moreover, it will also
provide new data specifically for male pediatric population in the Philippines since
studies and this health condition is mostly focused on female pediatric populations in
Asia and in the U.S. More case studies similar to this case study can be conducted
which will cover the pediatric male population.
Nursing education can also benefit from this study. The result of this study
contributes to the understanding and knowledge of the nursing educators which allows
them to impart adequate information and equip students with the necessary theoretical
knowledge, practical skills, and clinical experiences needed to provide quality patient
care and make informed decisions in healthcare settings.
Scope and Limitation
This case study discusses Choledocal Cyst Type I. It contains fundamental

concepts associated with the condition such as the patient’s profile and health history,
nursing assessment and clinical manifestations, drug study and diagnostic exams done.
The anatomy and physiology are also included as well as the pathophysiology of its
corresponding factors. The nursing and medical management along with the discharge
plan and other important data are also being included.
The scope of the study only covers for a week during the course of duty last May
22 - May 29, 2023 because the group was scheduled last for this rotation which enabled
us to assess the patient only for a short span of time.
Definition of Terms
Magnetic resonance cholangiopancreatography (MRCP) - it is a non-invasive

imaging technique that uses magnetic resonance imaging (MRI) to visualize the bile
ducts, pancreatic duct, and gallbladder. MRCP provides detailed images of the biliary
and pancreatic systems, helping to diagnose various conditions and abnormalities. The
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MRI machine uses a strong magnetic field and radio waves to create detailed images of
the bile ducts and pancreatic duct. MRCP can help diagnose bile duct abnormalities,
pancreatic disorders, gallbladder conditions, and biliary and pancreatic tumors. This
case study talks about Choledochal Cyst Type I where there is dilation or enlargement
of the common bile duct.
Hepaticoduodenostomy - a surgical procedure that involves creating a direct

connection between the common bile duct of the liver and the duodenum. It is
performed to restore the flow of bile from the liver into the digestive system when the
normal passage is obstructed or compromised. The hepaticoduodenostomy procedure
bypasses the site of obstruction or injury in the bile duct, allowing bile to flow directly
into the digestive system. This helps restore proper digestion and prevents
complications associated with biliary obstruction, such as jaundice, infection, or liver
damage. In Obstructive Jaundice Secondary to Choledochal Cyst Type I there is
accumulation of bilirubin in the bloodstream and subsequent jaundice.
Excision of Choledochal cyst - Complete removal of a choledochal cyst from the bile
duct system. It is a surgical procedure performed to remove the abnormal cystic dilation
of the common bile duct (choledochal cyst). This procedure is considered the standard
treatment for choledochal cysts as it helps to alleviate symptoms, prevent
complications, and reduce the risk of long-term complications, including recurrent
infections, bile duct obstruction, and the development of cancer. In Obstructive Jaundice
Secondary to Choledochal Cyst Type I, there is presence of an abnormal sac or pouch
in the bile ducts.
Hepaticojejunostomy reconstruction - A surgical procedure performed to restore the

flow of bile from the liver into the small intestine (jejunum) when the normal passage is
blocked or compromised. This procedure involves creating a new connection between
the bile ducts and the jejunum to bypass the site of obstruction or injury. In Obstructive
Jaundice Secondary to Choledochal Cyst Type I, it causes a backup of bile in the liver,
leading to obstructive jaundice. Obstructive jaundice occurs when the flow of bile is
impeded, resulting in the yellowing of the skin, eyes, and mucous membranes due to
the buildup of bilirubin.
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PATIENT’S PROFILE
Demographic Profile
Patient X is a 15-year-old male from Kalilangan, Bukidnon. He was born in 2007

to Filipino parents. His mother is a housewife while his father is a farmer and he has
three younger siblings. He is in grade 10 level in the K-12 curriculum and a diligent
student in their school. Roman Catholicism is their family’s religion.
Nursing Health History
Chief of Complaint: Patient received at the Northern Mindanao Medical Center’s

Emergency Room for his scheduled elective surgery.
History of Present Illness
In 2009, patient X was admitted for 5 days at Kalilangan Provincial Hospital due
to persistent vomiting for 2 days. He was only given intravenous fluids and was
observed and discharged after a day.
Three months prior to admission, patient X noticed a growing mass on his right
upper abdomen and experienced intense pain but tolerated it because he was worried
about his family’s finances.
Two months prior to admission, patient X had an episode of nausea and

vomiting. He was fetching water from a nearby spring and lifted a gallon of water and
walked home for approximately 1 kilometer. When he arrived at home, he suddenly had
a sudden onset of abdominal pain and then had several episodes of vomiting. He was
temporarily relieved by applying a hot compress on his abdomen but was vomiting
again after eating food. He was then brought to Kalilangan Health Center for check up
on the next day, and was assumed to be a case of ulcer and was only given
Omeprazole tab but with temporary relief of symptoms. After 2 days of taking
medications, he continued vomiting, and so the patient was then referred to Bukidnon
Provincial Hospital – Maramag and was admitted. After 2 days of admission, he was
noted to develop jaundice. He then underwent a computerized tomography (CT) scan
and results showed that he had a huge cystic mass in the right to mid upper abdomen
measuring 9.8 cm and his intrahepatic ducts and common bile duct were dilated. He
was advised to find a specialized doctor in another hospital to take on his case since
there was no specialized doctor available to manage his case. His parents then decided
to bring him to Cagayan de Oro City but it was postponed due to financial constraints.
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One month prior to admission, patient X was rushed to the Emergency Room of
Northern Mindanao Medical Center (NMMC) because of generalized weakness,
vomiting, fever and jaundice. Patient X was then admitted for one week for
management of present symptoms and relief of symptoms noted but his jaundice
persisted. He was then advised for re-admission on April 17, 2023 for scheduled
Magnetic Resonance Cholangiopancreatography (MRCP) with Contrast MRI and results
showed a well-defined cystic lesion involving the common hepatic and common bile
ducts measuring approximately 11.6 x 13.1 x 17.3 cm. Patient was then admitted for 5
days and was discharged thereafter because no surgeon was available to take on his
case.
Three days prior to admission, patient X’s family was called by NMMC for a
scheduled elective surgery on May 19, 2023. He was advised for admission two days
prior to the scheduled surgery.
On the day of admission, the institution informed patient X and his family that the
scheduled elective date of surgery was postponed and rescheduled to May 23,2023.
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Vital Signs
Vital Signs Intake Output

Hospital Assessment Day and Date
Day BP PR RR Temp O2 Sat Pain Scale Parenteral Oral Urine Drains Stool
(mmHg) (bpm) (cpm) (ºC) (%)
1 ADMISSION (May 17,2023) 110/70 102 20 38.0 99 8/10 —- 700 900 — 0
6 Day 1 (May 22, 2023); 6:00 PM 110/70 110 22 38.5 98 7/10 2400 900 1700 — 0
7 Day 2 (May 23, 2023); 7:30 PM 100/70 97 30 36.5 99 under anesthesia 2840 NPO 220 0 0
8 Day 3 (May 24, 2023); 5:00 PM 100/70 121 24 38.0 97 10/10 2400 NPO 400 NGT: 300cc, JP: 10cc 0
9 Day 4 (May 25, 2023); 5:00 PM 130/90 106 26 36.2 96 10/10 2400 NPO 800 JP: 150 cc 0
10 Day 5 (May 26, 2023); 5:00 PM 120/80 102 23 36.2 98 8/10 2240 NPO 1100 JP: 150cc 0
11 Day 6 (May 27, 2023); 5:00 PM 120/80 61 18 36.4 99 4/10 1920 500 1000 JP: 120 cc 0
12 Day 7(May 28, 2023); 5:00 PM 120/90 52 20 36.2 99 4/10 1920 480 1300 JP: 110 cc 0
13 Day 8 (May 29, 2023); 5:00 PM 110/80 63 20 36.5 99 4/10 1920 760 1200 JP- 100cc 0
14 May 30, 2023 PATIENT WAS DISCHARGED AT 10:23 A.M
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Day 1: May 22, 2023 Physical Assessment
Health Perception/Health Management Pattern:
First day of assessment, the patient appeared worried and nervous for the
upcoming surgery. When questioned, the patient looked away avoiding being asked.
Nutritional/Metabolic Pattern
Upon admission the patient was advised to be on a Low Fat Diet. Patient X has
poor appetite, weight loss noted from 41 kls to 38kls and is experiencing nausea and
vomiting. Furthermore, patients’ nutritional state is underweight. Assessment in the
mouth reveals yellowish oral mucosa, tongue is pinkish and the patient has missing
teeth. There are no wounds, drains, or dressings. Intravenous fluid-1L 0.9% Normal
Saline Solution regulated @30 gtts/min.
Pre-operative Management: The patient is on NPO prior to operation.
Elimination Pattern
Upon assessment, the patient can void independently and needs assistance with
a person in ambulating. The patient’s urine is orange-yellow in color and there were no
reports of defecation on the day of assessment. Last bowel movement was May 21,
2023 and it was a pale stool and soft in appearance.
Activity and Exercise Pattern
Upon assessment, the patient can perform Range of Motion Movements but
limited with movement to the extremities. Patient can’t tolerate moving his truncal body
and needs assistance when transferring.
Activities of Daily Living/ Mobility Status
Feeding 2 Meal Preparation 4 Bed Mobility 2
Bathing 2 Cleaning 4 Chair / Toilet Transfer 2
Dressing 2 Laundry 4 Ambulation 2
Grooming 2 Toileting 2 R.O.M. 2
Legend: 0 - Total Independence

1 - Assist with Device
2 - Assist with Person
3 - Assist with Device and Person
4 - Total Dependence
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Sleep and Rest Pattern
During assessment, Patient X had an interval of sleeping pattern due to

stimulation of the environment, giving medication, taking vital signs and had 4-5 hours
of uninterrupted sleep during night time.
Cognitive and Perceptual Pattern
During assessment, Patient X is oriented to time, person, and place. Patient X

does converse lightly but in a low voice, patient is weak and irritable. The patient's
primary language is Cebuano and has no speech deficit prior to admission.
Self-Perception and Self-Concept Pattern
During assessment, Patient X is conversing when asked and is irritable upon

questioning and describes his feelings towards his present health issues.
Roles and Relationships Pattern
During assessment, Patient X is the eldest of the 4 siblings of his parents. Prior
to Admission, his parents are the one who helped him to be treated and admitted in the
hospital.
Sexuality and Reproduction Patterns
During assessment, The patient had no urinary problem but MRCP with Contrast
MRI shows bilateral renal cortical cysts with the largest one in the right likely containing
hemosiderin deposits and/or calcification. The patient does not have any prostate
problems and voids 3 to 4 times a day.
Coping and Stress Tolerance Pattern
During assessment, Patient X is avoiding questions related to his illness. He is

still processing the illness he had experienced.He appeared drowsy, weak and irritable
at the days of assessment. The patient is communicating the problems he is
experiencing and letting his primary provider know the things he needs for assistance.
Value- Belief Pattern
Patient X and his family are Roman Catholics. Their religious practices include
going to church and praying for good health and bounty.
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Second day of Assessment, patient is received at Medical Surgical Ward awake,

conscious and lethargic with presence of NGT Left Nostril for lavage, Cherney’s Incision
with wound dressing notes, Jackson Pratt Drain at RLQ noted. A yellow sclera,
conjunctiva, and oral mucosa was noted and documented.
Upon assessment, Patient X was advised for NPO until doctor’s order.
Elimination Pattern
Upon assessment, the patient had a Foley Bag Catheter attached with dark
orange-yellow output. There were no reports of defecation on the day of assessment.
Last bowel movement was May 21, 2023 and it was a pale stool and soft in
appearance.



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During assessment, Patient X is assisted by his mother and father during hospital stay.
During assessment,The patient does not have any prostate problems and voids
through the catheter attached.

still processing the illness he had experienced. He appeared drowsy, weak and irritable
at the days of assessment.
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On the third day of assessment, the patient appeared weak given that it is the
second postoperative day. When asked about his feelings, he would respond in a
single word and would nod his head in agreement with our statement. An NGT was still
present in the left nostril for gavage. Wound dressing was performed at the incision site.
Jackson Pratt drain was still attached at the RLQ with output of 600cc. A yellow sclera,
conjunctiva, and oral mucosa was noted and documented.
Elimination Pattern
orange output. There were no reports of defecation on the day of assessment. Last
bowel movement was May 21, 2023 and it was a yellowish-colored stool and soft in
appearance.


During assessment, Patient X had an interval of sleeping pattern due to giving

medication, taking vital signs and had a good amount of rest since being transferred in
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an air conditioned endoscopy ward where there were only 2 patients inside including
him.


questioning and describes his feelings towards his present health issues as sad and
unfortunate.
During assessment, Patient X is assisted by his mother and father during hospital
stay.
through the foley bag catheter attached.
During assessment, Patient X is avoiding questions related to his illness but he

responds in a single word manner. He appeared drowsy, weak and irritable at the days
of assessment.
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On th fourth day of assessment, Patient is transferred from Medical Surgical

Ward to Endoscopy Ward. Patient is awake, conscious and weak in appearance with
presence of NGT Left Nostril for lavage , Cherney’s Incision with wound dressing notes,
Jackson Pratt Drain at RLQ noted. A yellow sclera, conjunctiva, and oral mucosa was
noted and documented.Patient’s skin was light yellow in color and noted a pitting edema
at Right and Left Extremities 2+ and 1+ consecutively.
Elimination Pattern
orange-yellow output. There were no reports of defecation on the day of assessment.
No bowel movement postoperative day 3 but noted flatus 3x



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During assessment, Patient X is assisted by his mother and father during hospital
stay.
through the catheter attached.

still processing the illness he had experienced. He appeared drowsy, weak and irritable
going to church and praying for good health and bounty
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On the fifth day of assessment, the patient is received at Endoscopy Ward

awake, conscious, weak in appearance, yellowish in color with the presence of NGT
Left Nostril for Drain, Cherney’s incision with wound dressing noted, JP Drain at RLQ
noted, Edema was noted bilaterally (R2+, L1+).
Upon assessment, Patient X was still on NPO as per doctor’s order.
Elimination Pattern
Upon assessment, the patient still had Foley Bag Catheter attached with dark
orange output. There were still no reports of defecation but had flatus 4 times already.
Last bowel movement was May 21, 2023 and it was a pale-colored stool and soft
appearance.
Upon assessment, the patient can perform Range of Motion Movements but with
limited movement to the extremities. Patient still cannot tolerate moving his truncal body


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hospital.
The patient does not have any prostate problems and voids 3 to 4 times a day.

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On the sixth day of assessment, the patient is received at Endoscopy Ward

awake, conscious, weak in appearance, yellowish in color. NGT Left Nostril for Drain
was removed, Cherney’s incision with wound dressing noted, JP Drain at RLQ noted,
Edema was noted bilaterally (R2+, L1+).
Upon assessment, Patient X was on Liquid Diet as per doctor’s order.
Elimination Pattern
Upon assessment, the patient’s Foley Bag Catheter was removed. Patient
urinated 4x with amber in color. There were still no reports of defecation but had flatus 5
times already. Last bowel movement was May 21, 2023 and it was a yellowish-colored
stool and soft appearance.
and needs assistance when transferring


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hospital.

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On the 7th day of assessment, the patient was received lying in bed supine.
Patient was conscious and awake with yellowish sclera, conjunctiva, oral mucosa, and
light-yellow skin. Was able to eliminate gas from the stomach 5x. Edema was noted
bilaterally (R2+, L1+). NGT and FBC were removed, and were able to void 5x.
Nutritional/Metabolic Pattern:
Upon assessment, the patient was still on a liquid diet as per doctor’s order.
Elimination Pattern:
Upon assessment, the patient was able to void 4x and is amber in color. Patient
X was able to flatus 5x but still there were no reports of defecation.
Activity and Exercise Pattern:

Sleep and Rest Pattern:

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does converse lightly but in a low voice, patient is weak. The patient's primary language
is Cebuano and has no speech deficit prior to admission.
During assessment, Patient X is conversing comfortably when asked with no

irritability noted upon questioning and describes his feelings towards his present health
issues.
hospital.

still processing the illness he had experienced.He appeared drowsy and weak at the 7th
day of assessment.
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On the 8th day of assessment, the patient was received lying in bed supine
awake. Patient was conscious with yellowish sclera, conjunctiva, oral mucosa, and light
yellow skin. The patient is in pain and Was able to eliminate gas from the stomach 5x.
Edema was noted (R2+). NGT was removed, was able to void 3x. And patient X was
able to eliminate gas from the stomach 5x.
Nutritional/Metabolic Pattern:
Upon the assessment patient X is on a soft diet then diet as tolerated as per
doctor’s order.
Elimination Pattern:
Upon the assessment patient X was able to void 3x with yellowish colored urine.
The patient was able to pass flatus 5 times. And there were still no reports of
defecation.
Activity and Exercise Pattern:


Sleep and Rest Pattern:

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does converse lightly but in a low voice, the patient is weak. Patient X is cooperative
and responsive to questions and instructions. The patient's primary language is
Cebuano and has no speech deficit prior to admission.
During assessment, Patient X is conversing comfortably when asked with no

irritability noted upon questioning and describes his feelings towards his present health
issues.
hospital.
Patient X avoids questions about his ailment during the evaluation. He is still
adjusting to the illness he experienced. On the eighth day of the examination, he
showed signs of weakness.
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Anatomical Model
Day 1 of Assessment: May 22, 2023

Hospital Day: 6
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Day 2 of Assessment: May 23 , 2023
Hospital Day: 7
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Hospital Day: 8
27
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Hospital Day: 9
29
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Hospital Day: 10
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Hospital Day: 11
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Hospital Day: 12
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Hospital Day: 13
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Patient’s Developmental Stage
A. Psychosexual Development
Sigmund Freud
Genital Stage (13-18 years old)
This stage occurs during puberty and extending into adulthood, plays a pivotal
role in shaping individuals’ sexual desires, relationships and overall psychological
well-being and it marks a significant milestone in human development (Mcleod, 2023).
Understanding the complexities and significance of the genital stage empowers
individuals to embrace their sexual desires and fulfill personal growth (Mcleod, 2023).
Patient X is in the stage of becoming more aware of his body and attractions
towards other gender. The mother stated that his son has a lot of friends, also he has a
crush at his school but he gives more importance to his education and to help his
parents than entering a relationship at an early age. Patient X does not disclose any
relationship because he felt embarrassed and shy.
B. Psychosocial Theory
Erik Erikson
Identity vs. Role Confusion (12 to 18 or 20 years old)
This stage is a critical period of adolescence in seeking to develop a strong and

coherent identity (Cherry, 2022). Individuals face the task of developing a sense of
identity and figuring out who they are and what they want to become in life (Cherry,
2022).
Patient X is in the stage of developing a sense of identity and figuring out what
he wants to become in life. Patient X mentioned that he wants to finish college and
become a police officer. He wants to help his parents and other people who need help.
Patient X shows a sense of identity and has a clear view about the future, interest and
self-confidence. His mother said that he is an independent person and a good role
model to his siblings, as a typical kid he loves teasing and goofing around above all of
that he takes good care of his younger siblings.
C. Cognitive Development Theory
Jean Piaget
Formal Operational Stage (12 to 20 years old)
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This stage opens up new avenues for intellectual growth, creativity, and the
exploration of diverse possibilities represents a significant leap in cognitive
development, enabling individuals to transcend concrete thinking and embrace abstract
reasoning, hypothetical thinking, logical deduction, metacognition, and complex
problem-solving (Lynch, 2021).
The mother said that patient X is smart and hard working. He aced in his class
and always got a good grade. Even though their financial situation is uneasy it’s not a
burden to him and he still wants to go to school, he also helps his siblings doing their
homework and helps them in terms of numbers. The mother stated his son is a logical
thinker and able to solve a problem without help from them.
D. Moral Development
Lawrence Kohlberg
Conventional (ages 10 to 13 or beyond)
During this stage it plays a crucial role in shaping individuals' understanding of

social norms, seeking approval and maintaining positive relationships (Koblin, 2022).
Moral judgments are influenced by a sense of duty and maintain social order and
stability (Koblin, 2022).
Patient X mentioned that he wants to help his parents. As a eldest child, he

strives hard to reach his goal to finish college and to help not only to his parents but
also to the people surrounding him. Patient X is willing to extend his help and has
shows of what good people should be. He is also aware about what is right and wrong
and its consequences and he shows respect. Also, patient X shows independence
towards helping his father in farming and house chores without any hesitation.
37
THEORETICAL AND CONCEPTUAL FRAMEWORK
Dorothea Orem: Self-care deficit
Orem's theory of self-care states that everyone has the capacity and
responsibility to engage in self-care activities in order to preserve their health and
well-being (Hartweg, 2015). Self-care deficiencies happen when people struggle with or
are unable to accomplish certain self-care tasks. Deficits in self-care can occur for a
number of reasons, including disease, injury, disability, ignorance of available services,
and lack of knowledge (Hartweg, 2015). Nursing interventions are put in place when a
self-care gap is found to assist people in meeting their requirements (Hartweg, 2015).
The ability of the patient to complete self-care tasks is evaluated by nurses, which
additionally provide information, support, and assistance as needed (Hartweg, 2015).
We choose Dorothea Orem because of our patient's condition, which makes him
unable to care for himself or perform basic personal hygiene tasks. The responsibility of
self-care cannot be reached due to inability to perform the normal hygienic tasks.
Nurses' responsibilities include supporting the patient, imparting knowledge, and
assisting in goal-setting. Addressing self-care deficits is crucial for promoting overall
health and preventing complications. By assisting individuals in meeting their self-care
needs, healthcare professionals aim to enhance their independence, improve their
quality of life, and facilitate their recovery and well-being.
Albert Bandura: Self Care Efficacy Theory
Self-efficacy theory emphasizes empowering patients to take an active role in

their own care (Vaughan & Jacobson, 2020). When patients believe in their ability to
manage their health and participate in decision-making, they are more likely to engage
in self-care behaviors, adhere to treatment plans, and effectively communicate their
needs and concerns to healthcare providers (Vaughan & Jacobson, 2020).
Self-efficacy theory emphasizes the role of self-belief in effectively coping with

challenges and setbacks (Vaughan & Jacobson, 2020). Patients with higher self-efficacy
are better equipped to handle stress, manage pain, and navigate the emotional aspects
of their illness or hospitalization Vaughan & Jacobson, 2020). They are more likely to
persist in their efforts and find adaptive strategies to overcome obstacles. When
patients feel empowered, involved, and confident in their care, they are more likely to be
satisfied with their healthcare experience (Vaughan & Jacobson, 2020). Self-efficacy
theory promotes patient-centered care, where healthcare providers collaborate with
patients, respect their autonomy, and support their active participation (Vaughan &
38
Jacobson, 2020). This approach fosters trust, improves communication, and
strengthens the therapeutic relationship (Vaughan & Jacobson, 2020).
We chose the self-efficacy theory because, in the case of patient X, he is

conscious in regard to his gallbladder removal, which led him to cry when it was brought
up in a conversation. Nurses can provide emotional support and create a supportive
environment for patients. Encouragement, praise, and positive reinforcement can boost
patients' self-efficacy by acknowledging their efforts and progress. Active listening,
empathy, and validation of the patient's concerns can help reduce anxiety and enhance
the patient's belief in their ability to cope with challenges. And by offering
comprehensive education, nurses can empower patients with the knowledge and skills
necessary to make informed decisions and take an active role in their care. Clear
instructions and explanations can enhance patients' self-efficacy by increasing their
confidence in understanding and implementing their care plan.
39
ANATOMY AND PHYSIOLOGY
ABDOMEN
The abdomen (commonly called the belly) is the body space between the thorax
(chest) and pelvis (Park & Singh, 2017). The diaphragm forms the upper surface of the
abdomen. At the level of the pelvic bones, the abdomen ends and the pelvis begins
(Park & Singh, 2017).The abdomen contains all the digestive organs, including the
stomach, small and large intestines, pancreas, liver, and gallbladder (Park & Singh,
2017). These organs are held together loosely by connecting tissues (mesentery) that
allow them to expand and to slide against each other. The abdomen also contains the
kidneys and spleen (Park & Singh, 2017).
Many important blood vessels travel through the abdomen, including the aorta,
inferior vena cava, and dozens of their smaller branches (Hoffman, 2020). In the front,
the abdomen is protected by a thin, tough layer of tissue called fascia (Hoffman, 2020).
In front of the fascia are the abdominal muscles and skin and in the rear of the
abdomen are the back muscles and spine (Hoffman, 2020).
STOMACH
The stomach is a sac-like organ that's an important part of the digestive system
(Rad, 2022). After food is chewed and swallowed, it enters the esophagus, a tube that
carries food through the throat and chest to the stomach (Rad, 2022).
SPLEEN
The spleen is an organ in the upper far left part of the abdomen, to the left of the
stomach (Kapila et al., 2022). The spleen varies in size and shape between people,
40
but it’s commonly fist- shaped, purple, and about 4 inches long (Kapila et al., 2022).
Because the spleen is protected by the rib cage, you can’t easily feel it unless it’s
abnormally enlarged (Kapila et al., 2022).
LIVER
The liver is the largest solid organ in the body (Kalra et al., 2021). It removes
toxins from the body's blood supply, maintains healthy blood sugar levels, regulates
blood clotting, and performs hundreds of other vital functions (Kalra et al., 2021). It is
located beneath the rib cage in the right upper abdomen (Kalra et al., 2021).
GALLBLADDER
Its main function is to store bile, which helps your digestive system break down
fats. Bile is a mixture of mainly cholesterol, bilirubin and bile salts Basit et al., 2022).
SMALL INTESTINE
The small intestine or small bowel is an organ in the gastrointestinal tract where
most of the absorption of nutrients from food takes place (Rad, 2022). It lies between
the stomach and large intestine, and receives bile and pancreatic juice through the
pancreatic duct to aid in digestion (Rad, 2022).
LARGE INTESTINE
The large intestine, also known as the large bowel, is the last part of the
gastrointestinal tract and of the digestive system in vertebrates (Hoffman, 2020).. Water
is absorbed here and the remaining waste material is stored in the rectum as feces
before being removed by defecation (Hoffman, 2020).
DIGESTIVE ENZYMES
Maltose
Maltose is produced by the enzymatic breakdown of starch, a

homopolysaccharide, which is facilitated by the enzyme amylase. Maltase further
hydrolyzes maltose to create two molecules of d-glucose. The hemiacetal of the
-d-glucopyranosyl unit is the monosaccharide unit on the left.
Exopeptidase
An enzyme that triggers the cleavage of the terminal (last) or next-to-last peptide
bond from a polypeptide or protein, releasing a single amino acid or dipeptide (Stöppler,
41
2021). An endopeptidase, on the other hand, catalyzes the breakage of internal peptide
bonds inside a polypeptide or protein (Stöppler, 2021).
Nucleases
Enzymes called nucleases break down nucleic acids (Yang, 2016). These are
divided into deoxyribonucleases (DNases), which attack DNA, and ribonucleases
(RNases), which target RNA, although the level of specificity varies widely, the majority
of nucleases are specific (Yang, 2016).
Peptidase
Enzymes are able to cleave small peptides, frequently rendering them inactive in
the process (Hulsmann, & Velden, 2017). The catalytic site is only visible at the external
surface, and they are extensively dispersed on the surface of several distinct cell types
(Hulsmann, & Velden, 2017).
Lactase
The group of enzymes known as lactases hydrolyzes the disaccharide lactose

(Ouellette & Rawn, 2015). As a result of their catalytic activity, lactose is broken into its
component monomers, glucose and galactose. Mammals' tiny intestines, kidneys, and
livers all secrete lactases. (Ouellette & Rawn, 2015) They are mostly present in humans
at the enterocytes' brush boundary membrane, which lines the villi of the small intestine
(Ouellette & Rawn, 2015).
Sucrase
Located on the outer surface of intestinal epithelial cells, which are the cells that
line the intestine's walls (Amiri et al, 2017). These cells feature fingerlike extensions
known as microvilli that absorb nutrients from food as it travels through the intestine
(Amiri et al, 2017).
Lipase
When triglycerides' ester linkages are hydrolyzed, an enzyme called lipase

converts them into free fatty acids and glycerol (Pirahanchi, 2022). Lipases are found in
pancreatic secretions and are involved in the digestion and metabolism of fat
(Pirahanchi, 2022). They perform distinct tasks in a variety of organs, including the liver,
adipocytes, endothelial cells, hepatic lipase, pancreatic lipase, and small intestine. They
all play a crucial part in the transport of lipids (Pirahanchi, 2022).
Amylase
42
The enzyme or particular protein that aids in the breakdown of carbohydrates (Ali
& Nater, 2020). Pancreas and salivary glands produce the majority of the amylase that
is found in your body. It's normal to have a tiny quantity of amylase in your blood and
urine (Ali & Nater, 2020).
Phospholipase
Enzymes known as lipolytics that break down certain ester bonds in phospholipid
substrates (Pirahanchi, 2022). Phospholipases are widely distributed in nature and have
a wide range of functions, from producing lipid mediators, signal transmission, and the
digestion of metabolites in humans to causing aggressiveness in snake venom
(Pirahanchi, 2022). The structure, purpose, control, and mechanism of action of
phospholipases vary widely (Pirahanchi, 2022).
Endopeptidase
A protein or polypeptide-containing enzyme that catalyzes the breaking of

peptide bonds (Hulsmann, & Velden, 2017). Since it works on peptide bonds, it is known
as a peptidase, and since these bonds are internal, it is known as an endopeptidase
(Hulsmann, & Velden, 2017).
43
DIAGNOSTIC AND LABORATORY TESTS
IDEAL DIAGNOSTIC AND LABORATORY TESTS
Complete Blood Count
A total blood cell count is a common hematology test used in medicine to

differentiate between anemia and other medical disorders. Because a significant
proportion of CBC results are reported as abnormal, it is in every clinician's best interest
to have a basic grasp of the specific test as well as a planned response plan when
presented with aberrant results (Jacob, 2016)
It is a set of tests used to assess the composition and concentration of the

cellular components of blood, which includes red blood cell (RBC) counts, red cell
indices, hematocrit, hemoglobin concentration, white blood cell (WBC) count, white
blood cell classification (WBC differential), and platelet count.
An increase of white blood cell count (WBC) and neutrophil count are the first
signs of inflammation in acute appendicitis; however, the sensitivity and diagnostic value
vary widely, depending on the study population, the severity of symptoms, and
laboratory results. A complete blood count (CBC) is a very common blood test
performed in laboratories and is performed in emergency room surgeons as part of a
preoperative evaluation to determine inflammatory lesions. Other factors, such as the
neutrophils-to-lymphocytes ratio (NLR), platelet count (PLT), mean platelet volume
(MPV), platelet distribution width (PDW), and red cell distribution width (RDW), are
investigated to improve the accuracy of the preoperative diagnosis of appendicitis
(Maghsoudi et al, 2021).
WHOLE ABDOMEN ULTRASOUND
Ultrasound is frequently the first modality used to evaluate a patient because

there is no radiation exposure, it is suitable for pediatric patients. This can be repeated
at the bedside. Several issues may develop during pediatric patient follow-up correction
of post-choledochal cysts, some of which require immediate attention. Surgical
intervention is required. As a result, sonographers and radiologists must be familiar with
the imaging features of these complexities (Takahiro et al, 2021)
Sonography is typically used to evaluate individuals with abdominal discomfort.

On an abdominal radiograph in a gasless abdomen, sonography or computed
tomography can show dilated fluid-filled bowel loops, indicating blockage and its cause.
44
Ascites inside the small bowel mesenteric leaves and gut wall thickening are signs of
colon ischemia alterations caused by blockage (Takahirto et al, 2021)
COMPUTED TOMOGRAPHY SCAN (CT Scan)
X-ray computed tomography (CT) may give unequaled information on the interior
structure of materials non-destructively from the meters down to the tens of nanometer
length scales. It makes use of the penetrating X-ray power to generate a succession of
two-dimensional images (2D) radiography of the item taken from various angles. This
procedure is also known as a CT scan.Then, a calculated reconstruction procedure is
applied to construct a stack of cross-sectional slices from these 2D sections. (Philip J et
al, 2021)
One of the primary benefits of X-ray CT imaging, its advantage over other procedures,
is that it is non-destructive. This is essential for analyzing sensitive materials that cannot
be handled when the structural integrity can be readily compromised before an
engineering component may be used (Philip J et al, 2021)
URINALYSIS
Urinalysis is a useful tool for clinicians. It is most likely widely used in the
evaluation of the genitourinary system; also, it can help in the identification of certain
diseases. Diabetes mellitus and pregnant hypertension are examples of systemic
illnesses. The physical, chemical, and microscopic examination of a urine specimen is
included in a complete urinalysis. The physical examination describes the visual
appearance and measured concentration of the urine. Chemical analysis, which is
mostly conducted via dipstick technology, is used to uncover and quantify important
urine components. The third main component of urinalysis is microscopic assessment; it
is the most time-consuming component, but it is essential. Urinary tract infections and
kidney damage continue to be important diagnosis (Shu Ling, 2020)
Specific gravity is a density measurement. More specifically, it is the mass of a

solution divided by the mass of an equivalent amount of water. Urea, sodium chloride,
sulfate, and phosphate are the major contributions to specific gravity in normal urine.
Specific gravity may be measured using a variety of approaches. The strip method is a
colorimetric approach that uses a reagent strip containing an electrolyte dye
combination that causes a pH shift dependent on the ionic content (pKa) of the urine
(Shu Ling, 2020)
45
PROTHROMBIN TIME
The prothrombin time (PT) is the most often used co-agulation test, and it was
developed by Dr. Armand Quick and colleagues in 1935. The PT is a single-stage
screening test used to evaluate tissue factor (TF) and common coagulation pathways,
and is thus impacted by coagulation factor and fibrinogen activity.
In clinical laboratories, the prothrombin time (PT) is the most often used
coagulation test. To offer test findings that are adjusted for thromboplastin and
instrument used, the PT is mathematically transformed to the international normalized
ratio (INR) for use in monitoring anticoagulant treatment with vitamin K antagonists such
as warfarin (Dorgalaleh et al, 2020).
C-REACTIVE PROTEIN
A c-reactive protein test measures the level of c-reactive protein (CRP) in a

sample of your blood. CRP is a protein that your liver makes. Normally, you have low
levels of c-reactive protein in your blood. Your liver releases more CRP into your
bloodstream if you have inflammation in your body. High levels of CRP may mean you
have a serious health condition that causes inflammation.
Inflammation is your body's way of protecting your tissues and helping them heal
from an injury, infection, or other disease. Inflammation can be acute (sudden) and
temporary. This type of inflammation is usually helpful. For example, if you cut your skin,
it may turn red, swell, and hurt for a few days. Those are signs of inflammation.
Inflammation can also happen inside your body.
As an understanding of distinctive CRP structural isoforms is evolving, its role not

only as a biomarker but as regulator of both physiologic and pathophysiologic
processes of inflammation may be relevant in the understanding of and treatment
approaches for gallbladder-associated disease. (Rajab et al, 2020)
LIVER FUNCTION TEST
The term "liver function tests" pinpoint the source of the damage. Elevated ALT
and AST levels that are out of proportion to ALP and bilirubin indicate hepatic illness.
Most liver diseases generate very minor symptoms at first, but they must be diagnosed
as soon as possible. Hepatic involvement in various disorders can be critical. This
testing is done on a blood sample from a patient. Some tests are connected with
46
functioning, some with cellular integrity, and yet others with bile tract problems
(Iluz-Freundlich D et al. 2020).
A cholestatic pattern would be defined by an increase in ALP and bilirubin in

relation to ALT and AST. A mixed injury pattern is characterized by an increase in
alkaline phosphatase and AST/ALT levels. Isolated hyperbilirubinemia is characterized
as an increase in bilirubin with normal levels of alkaline phosphatase and AST/ALT.
These tests can be used to detect the existence of liver illness, differentiate between
different types of liver problems, assess the amount of known damage, and monitor
therapy response. Some or all of these measures are also performed on people who
are taking particular drugs to verify that they are not harming their liver.
MAGNETIC RESONANCE CHOLANGIOPANCREATOGRAPHY
Magnetic resonance cholangiopancreatography (MRCP), which employs strongly

T2-weighted MR sequences to emphasize fluid-filled biliary structures, can examine the
biliary channels to the same quality as ERCP. MRCP is now used in diagnosis and
monitoring since it is noninvasive and provides no danger to patients (Goldfinger et al,
2020).
In numerous biliary diseases, magnetic resonance cholangiopancreatography (MRCP)

is employed as the primary diagnostic technique. This is the first review of published
research on MRCP as a diagnostic tool for choledochal cysts. This paper also
discusses how modern imaging methods have increased MRCP diagnostic accuracy in
detecting choledochal cysts and their anatomic variations. The benefits, drawbacks, and
contraindications of MRCP in comparison to endoscopic retrograde
cholangiopancreatography are also highlighted (Sacher, 2013)
ACTUAL DIAGNOSTIC AND LABORATORY TESTS
On admission to surgical ward, the doctor ordered laboratory testing which

includes Computed Tomography (CT) Scan, Magnetic Resonance
Cholangiopancreatography (MRCP) with Contrast Magnetic Resonance Imaging (MRI),
Urinalysis, complete blood count (CBC), Activated partial thromboplastin time,
Prothrombin time and INR, Liver function test and blood chemistry. Below are the results
of the laboratory tests conducted.
Computed Tomography (CT) Scan (March 14, 2023)
There is a huge, well-defined cystic mass in the right to mid upper abdomen measuring
14.4 x 11.5 x 9.78 cms (850 mL). The cyst is contiguous to the pancreatic head and
displaces the common bile duct superiorly.
47
The intrahepatic ducts are dilated and also the common bile duct with the widest
diameter measuring 1.49 cm. There is dilation of the pancreatic duct as well.
There are cortical cysts in both kidneys; in the right measures 1.67 cms located in the
superior pole and 1.88 cms in the left mid cortex.
IMPRESSION:
● Huge, well-defined cystic mass in the right to mid upper abdomen - large
choledochal cyst versus a pancreatic head cyst, for clinical correlation.
● Intra and extrahepatic biliary ectasia and pancreatic duct ectasia - secondary
● Renal cortical cysts, bilateral
Interpretation
The clinical impression suggests the presence of a large, well-defined cystic

mass in the upper abdomen, specifically in the right to mid portion. The healthcare
provider who reviewed the CT scan is considering two possible diagnoses based on the
appearance of the mass: a choledochal cyst or a pancreatic head cyst. However, further
clinical correlation is needed to determine the exact nature of the findings and to
establish an accurate diagnosis.
Since the patient is diagnosed with Choledochal cyst type I, the presence of
intrahepatic and extrahepatic biliary ectasia suggests the involvement of both the bile
ducts within and outside the liver. Additionally, the pancreatic duct ectasia indicates the
dilation of the pancreatic duct, which can occur as a secondary effect, probably a mass
effect of the choledochal cyst.
Bilateral renal cortical cysts refer to the presence of cysts in both kidneys within
the renal cortex, these cysts are common and often benign. The cyst typically develops
as a result of fluid accumulation in the kidney tissue, leading to the formation of a
sac-like structure. Most renal cortical cysts are considered simple cysts, which means
they have a thin wall and contain clear fluid. Simple cysts do not typically require
treatment unless they cause symptoms or complications, such as pain, infection, or
obstruction of the urinary tract.
Magnetic Resonance Cholangiopancreatography (MRCP) with Contrast Magnetic

Resonance Imaging (MRI) (April 17, 2023)
MRCP shows a well-defined T1 cystic lesion involving the common hepatic and
common bile ducts measuring approximately 11.6 x 13.1 x 17.3 cm. Minimal layering T1
48
hyperintense- T2 isointense foci are noted within the dependent portion relating to bile
sludge. There is a mass effect onto the adjacent pancreatic head, duodenum and
kidney. There is evidence of dilatation involving the central intrahepatic duct-biliary
radicals.
The gallbladder is normal in size without intraluminal calculus. The wall is not thickened.
Both kidneys show symmetric nephrogram. Several well-defined non-enhancing round

structures are noted relating to cysts with the larger ones located in the upper third
segments, with the one in the right measuring 1.4 x 0.7 cm, and in the left measuring
1.4 x 1.6 cm.
IMPRESSION:
● Large cystic lesion involving the common hepatic and common bile ducts with
associated central intrahepatic duct-biliary radical dilatation likely from mass
effect. Consider a large choledochal cyst (Type 1) with minimal layering
intraluminal bile sludge exerting mass effect onto the adjacent structures.
● Bilateral renal cortical cysts, with the largest one in the right likely containing
hemosiderin deposits and/or calcification.
● Minimal perihepatic and perisplenic ascites.
●
Interpretation
Magnetic Resonance Imaging (MRI) is a medical imaging technique that uses a

strong magnetic field and radio waves to generate detailed images of the body's internal
structures. MRI is used to visualize and assess various diseases and conditions
affecting different organs and systems of the body (Vlaardingerbroek & Boer, 2013).
The first clinical impression suggests that the large cystic lesion is likely a
choledochal cyst, specifically a Type 1 choledochal cyst. There is a suspicion of a large
choledochal cyst (Type 1) that is causing dilation of the central intrahepatic bile ducts
and exerting a mass effect on adjacent structures. The presence of intraluminal bile
sludge within the cyst is further contributing to the mass effect. The second impression
suggests the presence of multiple renal cortical cysts in both kidneys, with the largest
cyst located in the right kidney. The presence of hemosiderin deposits and/or
calcification within the largest cyst indicates past bleeding within or around the cortical
cyst and potential mineral deposition. The presence of minimal perihepatic and
49
perisplenic ascites suggests that there is a small amount of fluid accumulation around
the liver and spleen.
URINALYSIS
Item Name Result Unit Reference Implication

of Values
Measurement
April 19, April 15, April 24,
2023 2023 2023
RBC 2-5 (H) 0-2 1-3 (H) HPF 0 - 2 HPF Presence of

bleeding within or
around the cortical
cyst.
WBC 0-3 (H) 0-2 5-10 (H) HPF 0 - 2 HPF Presence of

inflammation.
Squamous Rare Rare Few HPF 0 - 20 Normal number of

Epithelial Cells HPF squamous epithelial
cells. The sample is
not contaminated
Non–Squamou None HPF 0 - 20 Normal number of

s Epithelial HPF non-squamous
Cells epithelial cells. The
sample is not
contaminated
Epithelial Cells None HPF 0 - 20 Normal number of

HPF epithelial cells in
the urine. The
sample is not
contaminated
Hyaline Casts None HPF 0 - 5 LPF No hyaline casts in

the urine
Pathological None HPF 0 - 5 LPF No pathological

Cast cast in the urine
Bacillus Rare Few Few HPF 0-0 HPF Presence of few

suspected bacillus in the urine.
Within normal
range
Coccus Many HPF 0-0 HPF Active bacterial

Inflammation
Pseudohyphae None HPF 0-0 HPF No presence of

Pseudohyphae in
the urine.
Yeast Cells None HPF 0-0 HPF No presence of

yeast cells in the
urine.
Calcium Many HPF 0 - 2 HPF Presence of

Crystals bilateral renal
Cortical cyst
containing
calcification
Mucous Many HPF 0 - 0 HPF Presence of

Strands Bilateral Renal
Cortical Cyst.
50
Color Amber Amber Dark The urine color is
Yellow normal
Transparency Hazy Clear Slightly The urine

Hazy transparency is
normal
Specific 1.030(H) 1.025 1.025 1.005 - Presence of high

Gravity 1.025 urine concentration
due to dehydration
pH 6.0 6.0 6.5 4.5 - 8 The level of acidity

in the urine is
normal.
Protein Negative Negative Trace Negative The level of protein

is normal
Glucose +1 Negative Negative 130 The level of glucose

mg/dL or in the urine is
less normal
Urobilinogen 0.20 0.2 - 2 The urobilinogen in

urine is within
normal levels.
Bilirubin ≥ 6 (H) Negative Presence of biliary

obstruction. bilirubin
accumulates and
excreted in the
urine
Creatinine 300.00 10 - 300 Normal range
Microalbumin 80.00 (H) mg/L 10 mg/L Presence of

or less bilateral renal
cortical cyst.
Nitrite 0.13 (H) Negative Presence of

inflammation..
Leukocyte 15.00 (H) Negative Presence of

bacterial infection.
Interpretation
Urinalysis is a commonly used diagnostic test that examines the physical,

chemical, and microscopic properties of urine. It provides valuable information about the
health and function of the urinary system and can help in the diagnosis and monitoring
of various medical conditions (Bates, 2013)
There is a presence of RBC in the urine of our patient, which is caused by the
presence of bleeding within or around the cortical cyst. RBCs may be released into the
urine, resulting in hematuria. Over time, the breakdown of RBCs can lead to the
accumulation of hemosiderin deposits. Hemosiderin deposits in the kidneys, along with
hematuria, may indicate chronic or recurrent bleeding associated with the renal cortical
cysts. The presence of hemosiderin deposits does not directly cause hematuria but
rather indicates previous episodes of bleeding. Based on the urinalysis, there is a
presence of WBC and coccus in the urine, which indicates an inflammation or infection.
51
Based on the MRI and CT scans of the patient, there is the presence of bilateral
renal cortical cysts, with the largest one on the right likely containing hemosiderin
deposits and/or calcification. In the case of a cyst with calcification, there may be
leakage or rupture of the cyst, leading to the release of calcified material into the urinary
system. This can result in the presence of calcium crystals in the urine. The presence of
mucus strands in the urine is caused by renal cortical cysts, causing obstruction in the
urinary tract. This obstruction may trigger the production of mucus strands in response
to irritation or injury. In the month of March, the patient experienced dehydration, which
caused him to have an increased urine specific gravity.
Measuring bilirubin in the urine is a valuable diagnostic tool that helps assess the
function of the liver and the biliary system. In the case of patient X, he had a biliary
obstruction that resulted in the accumulation of bilirubin in the bloodstream and its
subsequent excretion in the urine.
There is an increase in microalbumin in the urine since the patient has bilateral
renal cortical cysts, which can interfere with the normal function of the kidneys. This can
lead to leakage of the blood and albumin into the urine.
Nitrate is a chemical compound that is normally not present in the urine. The
presence of nitrite in the urine is a result of bacterial activity, specifically the conversion
of nitrates by bacteria, and since there is an elevated level of nitrate in the urine of the
patient, this indicates an inflammation or infection.
Leukocytes play a crucial role in the body's immune response to infection and
inflammation. An increased amount of leukocytes in the urine suggests that there is
inflammation or infection in the urinary tract.
52
COMPLETE BLOOD COUNT (CBC)
March- April 2023
Results
Test Unit of Reference Implications
March 18, March 22, March 25, March 28, April 4, April 15, April 23, April 28, Measurement Values
2023 2023 2023 2023 2023 2023 2023 2023
WBC 11.90 (H) 10.23 (H) 11.98 (H) 10.74 (H) 9.91 9.55 9.77 11.09 (H) x103 uL 5.0 - 10.0 Presence of inflammation.
RBC 4.78 4.18 (L) 4.35 3.98 (L) 3.62 (L) 3.87 (L) 4.57 4.27 x106 uL 4.2 - 5.4 Decreased amount of RBC circulating in
blood. Caused by impaired liver function.
Hgb 13.30 11.70 (L) 12.00 10.80 (L) 9.80 (L) 10.50 (L) 12.20 11.90 (L) g/dL 12.0 - 16.0 Less concentration of oxygen carrying
proteins in blood. Caused by impaired
liver function.
Hct 40.50 35.40 (L) 35.70 33.30 (L) 29.90 32.10 (L) 38.40 35.20 (L) % 37.0 - 47.0 Decreased percentage of RBC per
(L) volume.Caused by impaired liver function.
MCV 84.70 84.70 82.10 83.70 82.60 82.90 84.00 82.40 fL 82.0 - 98.0 Normal red blood cell size.
MCH 27.80 28.00 27.60 27.10 27.10 27.10 26.70 (L) 27.90 pg 27.0 - 31.0 Decrease the amount of oxygen carrying
protein per cell of RBC. Caused by
impaired liver function.
MCHC 32.80 33.10 33.60 32.40 32.80 32.70 31.80 33.80 g/dL 31.5 - 35.0 Normal amount of oxygen carrying protein
per cell of RBC.
RDW 17.10 (H) 16.50 16.50 16.90 16.60 17.70 (H) 17.00 16.30 % 12.0 - 17.0 Increased values of variability shaped and
sized red blood cells.Caused by
inflammation in the bile duct secondary to
biliary obstruction.
PDW 9.90 11.00 9.70 10.20 10.40 10.70 12.90 10.50 fL 9.0 - 16.0 Normal platelet size
MPV 9.60 10.00 9.30 9.80 10.40 10.20 10.60 10.00 fL 8.0 - 12.0 Average size of platelets found in blood.
53
DIFFERENTIAL COUNT
Results Unit of Reference Implications

Test Measurement Values
March 18, March 22, March 25, March April 4, April 15, April 23, April 28,
2023 2023 2023 28, 2023 2023 2023 2023 2023
Neutrophil 75.70 62.70 61.50 61.20 64.90 77.40 (H) 64.80 67.10 % 43.4 - 76.2 Presence of Inflammation
Lymphocyte 13.70 (L) 20.90 24.40 21.50 20.10 8.40 (L) 22.80 17.20 (L) % 17.4 - 48.2 Presence of Inflammation
Monocyte 7.50 10.10 8.70 10.10 8.60 10.60 (H) 6.40 10.10 % 4.5 - 10.5 Presence of Inflammation .
Eosinophil 2.00 4.70 (H) 4.20 (H) 5.70 (H) 5.00 (H) 2.30 5.00 (H) 4.60 (H) % 1.0 - 3.0 Increased number of eosinophils
circulating in peripheral blood
due to Presence of iInflammation
Basophil 1.10 1.60 1.20 1.50 1.40 1.30 1.00 1.00 % 0.0 - 2.0 Normal Range
Platelet 588 (H) 388 440 (H) 435 (H) 409 (H) 442 (H) 181 346 x103 uL 150 - 400 Increased clotting
Count factors/Coagulators. Caused by
possible inflammation on the bile
duct secondary to biliary
obstruction.
54
Interpretation:
During the course of our assessment from March 18 to 28 and April 28 the
patient had an increase in white blood cells which showed that there was an
inflammation. One way to determine if there is an infection in the WBC count of the
patient. This supports the diagnosis of the patient with Choledochal cyst which is a
biliary obstruction that can cause the liver to have accumulation of bile and subsequent
hepatocellular injury which triggers an immune response, leading to the release of
inflammatory mediators and the recruitment of white blood cells to the liver. This
immune response can cause an increase in WBC count.
RBC, Hemoglobin count as well as the hematocrit was low. Since hemoglobin is
a protein in red blood cells that carries oxygen throughout the body and the hematocrit
blood test determines the percentage of red blood cells (RBC’s) in the blood, a low
RBC, hemoglobin and hematocrit indicate that the patient had a choledochal cyst which
results to Obstructive jaundice, caused by the obstruction of the bile ducts, leads to the
accumulation of bilirubin in the bloodstream. If there is prolonged obstruction and the
bilirubin levels become high, it can lead to an indirect effect on red blood cells. The
excess bilirubin can be deposited in the bone marrow, where red blood cells are
produced, potentially affecting their production. This disruption in red blood cell
production may contribute to anemia.
In the differential counts there was an increase in the number of neutrophils on

our 6th day of assessment as shown above. Neutrophils are a type of white blood cell
that plays a crucial role in the body's immune response to Inflammation. An increased
neutrophil count, known as neutrophilia, in patients with choledochal cysts may indicate
the presence of an inflammation.
Lymphocytopenia (decreased amount of lymphocytes) reduces the body’s ability

to fight off bacterial infections. Since lymphocytes help the body to eliminate the
bacteria which causes the infection a decrease in number indicates that the body has a
weakened response to fight off infections.
There was an increased level of monocyte as well as the eosinophils which

signifies that the body is responding to an inflammation since monocytes are typically
present in relatively low numbers in the bloodstream compared to other white blood
cells. However, their levels can increase in response to certain inflammation.
The platelet count is high since the choledochal cysts can lead to inflammation
and damage to the bile ducts and surrounding tissues. This inflammatory response can
55
stimulate the production of platelets in the bone marrow, leading to an increase in
platelet count. While the basophil is normal during the course of assessment.
56
BLOOD CHEMISTRY
March - April 2023
Creatinine/BUN
Results
Test Unit of Reference Value Implications
March 18, March 22, March 28, April 4, April 15, April 24, April 28, Measurement
2023 2023 2023 2023 2023 2023 2023
Creatinine 0.63 0.80 0.84 0.58 (L) 0.72 0.52 (L) 0.70 mg/dL 0.6 - 1.8 mg/dL Impaired kidney function
BUN 11 mg/dL 8.4 - 25.7 mg/dL Normal Range
Albumin
Results
Test Unit of Measurement Reference Value Implications
March 18, March 25, April 4,
2023 2023 2023
Albumin 3.64 (L) 3.04 (L) 3.4 (L) g/dL 3.8 - 5.1 g/dL Impaired liver function. Losses from Albuminuria.
Bilirubin
Results
March 18, March 30, April 4, April 15, April 28, Measurement
2023 2023 2023 2023 2023
Direct Bilirubin 7.41 (H) 2.75 (H) 5.87 (H) mg/dL 0.00 - 0.25 mg/dL Presence of choledochal cyst
Indirect Bilirubin 1.5 (H) 1.16 (H) 1.2 (H) mg/dL 0 - 1.0 mg/dL Presence of impaired liver function
Total Bilirubin 8.40 (H) 8.86 (H) 8.70 (H) 3.91 (H) 7.04 (H) mg/dL 0.2 - 1.3 mg/dL Presence of impaired liver function
57
Amylase
Results
March 18, March 26,
2023 2023
Amylase 166 (H) 134 (H) U/L 30 -110 U/L Presence of pancreatic duct ectasia
Electrolytes
Results
March 18, March 22, March 25, March 28, April 4, April 24, April 28, Measurement Value
2023 2023 2023 2023 2023 2023 2023
Potassium 4.10 3.57 3.80 3.60 3.19 (L) 4.97 3.94 mmol/L 3.5 - 5.3 Presence of impaired liver function.
mmol/L
Sodium 144.03 144.2 143.04 141.09 139.3 143.9 141.61 mmol/L 135 - 148 Normal Range
mmol/L
Phosphorus 4.63 (H) mg/dL 2.5 - 4.5 Presence of Bilateral Renal Cortical
mg/dL cyst.
Liver Profile
Results
March 18, March 22, March 25, April 4, April 15, Measurement Value
2023 2023 2023 2023 2023
S.G.O.T/AST 135.4 (H) 89.0 (H) 96.8 (H) 77 (H) 114 (H) U/L 17 - 59 U/L Liver injury secondary Bile duct obstruction.
S.G.P.T/ALT 60.20 (H) 45.4 (H) 44 (H) 46 (H) 42 U/L 0 - 42 U/L Presence of Biliary obstruction
Alk. Phosphate 1143.0 (H) 1027 (H) 646 (H) U/L 80 - 306 U/L Presence of Billiary obstruction
58
59
Interpretation:
One way to determine the renal function of the patient is to determine its BUN
and creatinine levels in the blood. Since the patient was diagnosed with a choledochal
cyst that can lead to complications caused by the biliary obstruction which can directly
affect the kidney function (Arihan et al., 2018).
Upon our assessment There was a decreased level of creatinine in the blood
which signifies that the patient has an impaired kidney function related to his Bilateral
Renal Cortical cyst. While the Blood Urea Nitrogen (BUN) is within normal range during
our assessment on April 14th.
Albumin is a protein made by the liver. Albumin keeps the fluid from leaking out
of blood vessels; nourishes tissues and transports hormones, vitamins, drugs, and
substances like calcium throughout the body. Low levels of albumin indicates that there
is Inflammation or infections taking place, and low levels may be due impaired function
of the liver to create albumin and due to renal losses.
Indirect bilirubin is the initial form produced by the breakdown of red blood cells,
while direct bilirubin is the water-soluble form that is conjugated in the liver and excreted
in bile. Total bilirubin represents the sum of both indirect and direct bilirubin and is used
as a measure of overall bilirubin levels in the body; it is measured as a diagnostic
marker to assess liver function. During our assessment patient X has an impaired liver
function caused by biliary obstruction which resulted in Hyperbilirubinemia. Normally,
the liver conjugates bilirubin, converting it from its unconjugated (indirect) form to its
conjugated (direct) form for excretion into the bile. In the case of biliary obstruction, the
liver's ability to process bilirubin is impaired, leading to elevated levels of unconjugated
bilirubin in the blood.
There was an increased amylase noted above. amylase is an important digestive

enzyme involved in the breakdown of carbohydrates, starting from the mouth through
the small intestine. Amylase is an enzyme produced primarily by the pancreas and
salivary glands. Since the patient has a Pancreatic duct ectasia the dilation and
distortion of the pancreatic ducts in pancreatic duct ectasia can impair the normal flow
and drainage of pancreatic enzymes, including amylase. This disruption can result in
the accumulation of enzymes within the pancreas, leading to increased amylase levels
in the blood.
The liver plays a vital role in the regulation of potassium levels in the body. It
actively takes up potassium from the bloodstream and stores it within liver cells.The
patient had a normal potassium levels during the assessment days, but on the April 4th
60
of assessment, there was sudden decrease of potassium level which indicates that the
patient has a liver dysfunction, which is the liver's ability to uptake and store potassium
is impaired, leading to decreased potassium levels in the bloodstream. And the level of
sodium within the course of our assessment is within normal levels.
Normally, Phosphorus is regulated by the kidneys, which help maintain its

balance in the body. Healthy kidneys filter and excrete excess phosphorus, preventing
its buildup in the blood. An increased amount of phosphorus was noted during May 22,
2023 of our assessment. In the case of our patient he had bilateral renal cortical cysts
that can cause renal dysfunction which can disrupt the normal urine flow and impair the
kidneys' ability to properly filter and excrete waste products, resulting in renal
dysfunction which is an indication of an increased amount of phosphorus in the blood.
During the course of our assessment there is an increased level of

glutamic-oxaloacetic transaminase (S.G.O.T), also known as aspartate
aminotransferase (AST). AST is commonly measured through blood tests to evaluate
liver function and assess potential liver damage or injury. The liver is the main source of
circulating AST, and an elevation in AST levels can indicate liver cell damage or
dysfunction.
S.G.P.T, also known as alanine aminotransferase (ALT), is an enzyme found

primarily in the liver. In clinical practice, ALT is commonly measured through blood tests
to assess liver function and evaluate potential liver damage or injury. An increased level
of S.G.P.T/ALT indicates that there is a presence of liver injury caused by biliary
obstruction. There was an increase of Alkaline Phosphatase which indicates that the
patient has a decline in his liver function and a presence of injury and inflammation in
the bile duct which causes a leakage of Alkaline Phosphatase that results to high
Alkaline Phosphatase in the blood.
61
ACTIVATED PARTIAL THROMBOPLASTIN TIME
Unit of Normal Range Implications

Test Date Result Control Measurement
APTT April 23, 2023 51.8 (H) 34.1 seconds 23.4 - 38.5 seconds Increased duration APTT caused by liver dysfunction
PROTHROMBIN TIME
Unit of Normal I.N.R. Implications

Test Date Result Control Measurement Range
March 18, 2023 21.6 (H) 13.9 1.55 Increased duration of prothrombin
Prothrombin seconds 11.0 - 16.0 time caused by liver dysfunction.
Time seconds
March 22, 2023 30.1 (H) 13.3 2.26 Increased duration of prothrombin
time caused by liver dysfunction.
March 27, 2023 15.0 13.7 1.09 Normal range
March 28, 2023 14.0 15 0.93 Normal range
April 4, 2023 16.0 12.4 1.29 Normal range
April 24, 2023 19.5 (H) 13.9 1.40 Increased duration of prothrombin
April 26, 2023 19.0 (H) 14.1 1.34 Increased duration of prothrombin
62
Interpretation
Activated partial thromboplastin time measures how long it takes your blood to
form a clot, and a prothrombin time test measures how quickly your blood clots, and this
uses a sample of your blood. Prothrombin is a protein produced by your liver. Normally,
when one of the blood vessels is damaged, proteins in your blood called clotting factors
come together in a certain order to form blood clots and quickly stop bleeding. During
the course of our assessment, there was a longer duration of activated partial
thromboplastin time, and the duration of prothrombin time was beyond normal.
Normally, the liver is responsible for synthesizing clotting factors. These factors are
essential for the normal clotting process. In the context of choledochal cysts, since the
patient has impaired liver functioning caused by the biliary obstruction, this affects the
synthesis of clotting factors, leading to abnormal aPTT and prothrombin time results.
The patient has to take vitamin K supplements because of the increased duration of
aPTT, and PTT also indicates a vitamin K deficiency. Vitamin K is essential for the
synthesis of several clotting factors, and its deficiency can result in abnormal
coagulation tests, including prolonged APTT and PTT.
63
COMPLETE BLOOD COUNT (CBC)
May 2023
Results
May 17, May 22, May 23, May 24, May 25, May 28, May 29, Measurement Values
2023 2023 2023 2023 2023 2023 2023
WBC 12.44 (H) 9.43 12.18 (H) 9.41 8.81 6.84 8.17 x103 uL 5.0 - 10.0 Presence of inflammation.
RBC 4.30 3.65 (L) 3.88 (L) 3.45 (L) 3.94 (L) 4.27 4.13 (L) x106 uL 4.2 - 5.4 Decreased amount of RBC circulating in blood. Caused
by impaired Liver function.
Hgb 11.30 (L) 9.70 (L) 10.60 (L) 9.40 (L) 10.80 (L) 12.20 11.70 (L) g/dL 12.0 - 16.0 Less concentration of oxygen carrying proteins in
blood. Caused by impaired Liver function.
Hct 34.60 (L) 29.60 (L) 32.70 (L) 28.30 (L) 33.30 (L) 36.40 (L) 35.50 (L) % 37.0 - 47.0 Decreased percentage of RBC per volume. Caused by
impaired Liver function.
MCV 80.50 (L) 81.10 (L) 84.30 82.00 84.50 85.20 86.00 fL 82.0 - 98.0 Decreased red blood cell size. Caused by impaired
Liver function.
MCH 26.30 (L) 26.60 (L) 27.30 27.20 27.40 28.60 28.30 pg 27.0 - 31.0 Decreased amount of oxygen. Caused by impaired
Liver function.
MCHC 32.70 32.80 32.40 33.20 32.40 33.50 33.00 g/dL 31.5 - 35.0 Normal amount of oxygen carrying protein per cell of
RBC
RDW 16.60 16.60 16.60 16.20 16.10 15.70 16.10 % 12.0 - 17.0 Normal values of variability shaped and sized red blood
cells
PDW 11.40 9.50 9.30 9.20 10.20 10.20 11.10 fL 9.0 - 16.0 Normal platelet size
MPV 10.10 9.20 9.60 9.70 10.20 10.00 10.30 fL 8.0 - 12.0 Average size of platelets found in blood
64
DIFFERENTIAL COUNT
Results Unit of Reference Implications

Test Measurement Values
May 17, May 22, May 23, May 24, May 25, May 28,
2023 2023 2023 2023 2023 2023
Neutrophil 66.20 61.50 81.20 (H) 71.30 69.60 60.70 % 43.4 - 76.2 Presence of inflammation.
Lymphocyte 20.30 23.50 10.30 (L) 16.50 (L) 15.80 (L) 23.20 % 17.4 - 48.2 Presence of inflammation.
Monocyte 7.80 8.80 7.30 9.60 9.00 7.90 % 4.5 - 10.5 Normal Range
Eosinophil 4.30 (H) 4.70 (H) 0.30 (L) 1.50 4.10 (H) 6.60 (H) % 1.0 - 3.0 May 17, 22, 25, 28, 2023 there is an
increased level of eosinophils circulating in
the peripheral blood. Due to the presence of
inflammation.
May 23, 2023 there is a decreased level of

eosinophils circulating in the peripheral blood.
Due to post surgical procedure.
Basophil 1.40 1.50 0.90 1.10 1.50 1.60 % 0.0 - 2.0 Normal Range
Platelet Count 305 377 363 342 347 364 x103 uL 150 - 400 Normal Range
65
Interpretation:
During our assessment on May 17 to 29, the patient had a significant increase in
white blood cells on the 17th of May and the 23rd of May which showed that the body is
fighting off infection. There was a drop in RBC, which indicates that there was
inadequate oxygen circulating in the body. RBCs carry hemoglobin, which transports
oxygen to our tissues. The amount of oxygen delivered to your tissues can be affected
by the quantity of RBCs you have. This manifestation is the result of his condition's
pathophysiological repercussions on his body.
Hemoglobin and hematocrit count was low, given that hemoglobin is a protein
found within red blood cells that ships oxygen throughout the body, and the hematocrit
blood test determines the percentage of red blood cells (RBCs) in the blood, low levels
of both indicate that the patient had a choledochal cyst, which leads to liver dysfunction
or damage, impairing RBC and hemoglobin production.
Mean corpuscular volume (MCV) and mean corpuscular hemoglobin (MCH) go

hand-in-hand when diagnosing blood disorders and underlying physiological conditions.
To have low MCV and MCH means your hemoglobin production is less than normal. As
a result, the number of healthy red blood cells also decreases
66
BLOOD CHEMISTRY
May 2023
Creatinine
Results
May 17, May 22, May 23, May 24, May 28, May 29, Measurement
2023 2023 2023 2023 2023 2023
Creatinine 0.70 0.50 (L) 0.47 (L) 0.64 0.60 0.70 mg/dL 0.6 - 1.8 mg/dL Impaired kidney function.
Albumin
Results
May 17, May 22, May 24, May 29,
2023 2023 2023 2023
Albumin 3.77 (L) 2.54 (L) 3.82 3.14 (L) g/dL 3.8 - 5.1 g/dL Impaired liver function. Losses from
albuminuria.
Bilirubin
Results
May 17, May 24, May 28, May 29,
2023 2023 2023 2023
Direct 7.2 (H) 4.75 (H) 4.2 (H) 3.38 (H) mg/dL 0.00 - 0.25 mg/dL Presence of biliary obstruction
Bilirubin
Indirect 1.40 (H) 1.1 (H) 1 0.82 mg/dL 0 - 1.0 mg/dL Presence of liver dysfunction
Bilirubin
Total Bilirubin 8.6 (H) 5.80 (H) 5.20 (H) 4.20 (H) mg/dL 0.2 - 1.3 mg/dL Presence of biliary obstruction
67
Amylase
Results
May 17, 2023 May 24, 2023 Measurement
Amylase 90.00 33 U/L 30 -110 U/L Normal Range Amylase circulating in the blood
Electrolytes
Results
May 17, May 18, May 22, May 23, May 24, May 28, May 29, Measurement
2023 2023 2023 2023 2023 2023 2023
Potassium 3.94 3.80 3.83 4.8 4.09 3.90 3.96 mmol/L 3.5 - 5.3 mmol/L Normal Range
Sodium 126.42 (L) 140.0 135.7 141.4 140.0 137.9 138.4 mmol/L 135 - 148 mmol/L Low sodium in blood circulation caused by
liver dysfunction.
Ionized Calcium 1.3 mmol/L 1.12 - 1.23 mmol/L Normal Range
Lipid Profile
Result
May 20, 2023 Measurement
Cholesterol 108.00 mg/dL < 200 mg/dL Normal Range
Triglycerides 127.00 mg/dL < 150 mg/dL Normal Range
HDL-Cholesterol 15.00 (L) mg/dL 40 - 60 mg/dL Presence of high HDL- cholesterol caused by liver dysfunction
LDL-CHolesterol 67.6 mg/dL 0 - 150 mg/dL Normal Range
68
Liver Profile
Results
Test Reference Value Implications
May 17, 2023 May 24, 2023 May 29, 2023 Unit of
Measurement
S.G.O.T/AST 149.00 (H) 50.9 (H) 112.00 (H) U/L 17 - 59 U/L Liver Injury secondary to bile duct obstruction.
S.G.P.T/ALT 43 (H) 14 24.00 U/L 0 - 42 U/L Presence of biliary obstruction.
Alk. Phosphate 621.00 (H) 269.5 567 (H) U/L 80 - 306 U/L Presence of Biliary duct obstruction.
69
Interpretation:
Creatinine is a normal waste product that builds up in your blood from using your
muscles. Your body makes creatinine at a constant rate all the time, and healthy
kidneys remove almost all of this creatinine. By comparing the amount of creatinine in
your blood with a standard normal amount. A liver disease. Poor liver function interferes
with creatine production, which can cause low creatinine. Symptoms include jaundice,
abdominal pain and swelling which the patient manifested.
Low level of albumin happens when your body doesn’t produce enough of the
albumin protein, or when you lose too much albumin in your urine or stool. Your liver
makes albumin, which prevents fluid from leaking out of blood vessels into your tissues.
Albumin makes up 50% of the proteins found in your plasma. When your albumin levels
are low, hormones and other important compounds aren’t able to get to where they
need to go in your body to fulfill their duties. Low levels of albumin indicates that there
are infection or inflammation taking place that can signify our patient to have an
infection caused by his condition.
During our assessment patient X has an impaired liver function caused by biliary
obstruction which resulted in Hyperbilirubinemia. Higher levels of direct bilirubin in your
blood may indicate your liver isn't clearing bilirubin properly which indicates liver
damage. Higher levels of indirect bilirubin is manifested in our patient causing him to be
jaundiced.
Hyponatremia means that the sodium level in the blood is below normal. Your
body needs sodium for fluid balance, blood pressure control, as well as the nerves and
muscles. When the sodium level in your blood is too low, extra water goes into your
cells and makes them swell. On the 17th of May the patient's sodium level decreased
because of liver dysfunction.
There was an increase in glutamic-oxaloacetic transaminase (S.G.O.T),

commonly known as aspartate aminotransferase (AST), during our evaluation. AST is
widely evaluated in blood tests to monitor liver function and potential liver damage or
injury. The liver is the primary source of circulating AST, and an increase in AST levels
might suggest injury or malfunction of liver cells.
S.G.P.T, commonly known as alanine aminotransferase (ALT), is a liver-specific

enzyme. ALT is widely tested in clinical practice via blood tests to determine liver
function and identify potential liver damage or injury. An elevated S.G.P.T/ALT level
shows the existence of liver damage induced by biliary blockage. There was a rise in
Alkaline Phosphatase, indicating that the patient's liver function has declined and that
70
there is damage or inflammation in the bile duct, which causes a leakage of Alkaline
Phosphatase, resulting in elevated Alkaline Phosphatase in the blood.
71
IMMUNOLOGY
Results Reference Implications
Test Values
May 17, 2023 May 22, 2023 May 29, 2023
C-Reactive Protein 199.0 (H) 93.7 (H) 14.6 (H) 1-3 Presence of high C-reactive protein caused by liver dysfunction.
Anti-HAV Non Reactive Normal Range
HBsAg Non Reactive Normal Range
HCV Non Reactive Normal Range
ACTIVATED PARTIAL THROMBOPLASTIN TIME
Unit of Normal Range Implications

APTT May 17, 2023 99.8 (H) 31.9 Increased APTT caused by liver dysfunction
seconds 23.4 - 38.5 seconds
May 20, 2023 48 (H) 36.8 Increased APTT caused by liver dysfunction
May 22, 2023 38.0 26.2 Normal Range
PROTHROMBIN TIME
Unit of Normal Range I.N.R. Implications
Prothrombin Time May 18, 2023 35.9 (H) 14.2 seconds 11.0 - 16.0 2.5 Increased prothrombin time caused by liver dysfunction.
seconds
May 20, 2023 13.8 13.2 1.05 Normal Range
May 22, 2023 15.6 14.6 1.1 Normal Range
72
Interpretation:
A C-reactive protein (CRP) test determines the level of C-reactive protein in your
blood, which is a protein produced by your liver. In reaction to inflammation, your liver
secretes CRP into your circulation. These cells initiate an inflammatory response in
order to capture bacteria and other pathogens or to begin mending wounded tissue. As
a result, the patient had discomfort, swelling, bruising, or redness. However,
inflammation may also impact bodily systems that you cannot see, such as your joints.
There was a greater duration of activated partial thromboplastin time throughout

our testing, and the duration of prothrombin time was above normal. Generally, the liver
is in charge of clotting factor synthesis. These elements are required for the proper
clotting process. In the case of choledochal cysts, the patient's reduced liver function
due to biliary blockage impairs clotting factor production, resulting in aberrant aPTT and
prothrombin time values. The patient has to take vitamin K supplements because of the
increased duration of aPTT, and PTT also indicates a vitamin K deficiency. Vitamin K is
essential for the synthesis of several clotting factors, and its deficiency can result in
abnormal coagulation tests, including prolonged APTT and PTT.
73
PATHOPHYSIOLOGY
74
Choledochal cyst is a congenital cystic dilation of bile duct. The disease pathway
starts with two factors. Predisposing and Precipitating. Predisposing factors are due to
the patient’s race, age, gender, immune etiologies and congenital factors. According to
Alverson (2019), choledochal cyst is a congenital abnormality that causes abnormal
enlargement of bile duct. What precipitates his condition is his environment as he is
exposed to toxins or chemicals such as fertilizers and his hard labor lifestyle because
he helps his parents with hard work on their farm. His diet is also detrimental to his
condition consisting of coffee 3-4 times a day, cobra energy drink, softdrinks, junk foods,
high-fat cholesterol, fried,dried,salty and spicy foods and drinking untreated water with
scarcity of fruits and vegetables. Viral infection also precipitates the condition because
we do not know that the patient has been exposed to viral infection before that
contributes to his condition now. These factors mentioned contributed to the injury of the
lining of the bile duct that activates the inflammatory and immunologic response which
leads to the proliferation of biliary epithelial cells. When the biliary epithelial cells
proliferate, this increases the number of cell growth and cell division which then results
in the formation of cystic mass in the bile duct. In this case, a Computed Tomography
(CT) Scan was ordered and it was found that the mass measures 14.4x11.5x9.78cm
(April 17, 2023). The patient also underwent Magnetic Resonance
Cholangiopancreatography (MRCP) with contrast Magnetic Resonance Imaging (MRI)
that resulted with the measurement of approximately 11.6x13.1x17.3 cm (April 17,
2023). The mass is palpable at RUQ. The mass continues to enlarge which then
resulted to complete obstruction of lumen of the hepatic biliary tree that increases the
Alkaline Phosphatase (ALP) of 1143 U/L (N:80-306 U/L).
The hepatic biliary tree obstruction contributes to fibro-inflammatory obstruction

that resulted in resorption of bilirubin which increases the bilirubin in the blood that
manifested jaundice of the skin and eyes, and acholic (pale) stool. Due to the
fibro-inflammatory obstruction, the bilirubin is not reabsorbed to the intestines so then
the kidneys excrete bilirubin that manifests dark/amber urine by the patient.
Fibro-inflammatory obstruction is also the cause why progressive sclerosis occurs that
obliterates the hepatic biliary duct that resulted in the development of atresia and
hepatocellular injury. Hepatocellular injury causes inflammation of the hepatocytes and
collagen/fibrin depositions. This results in subsequent hyperactive growing fibrin
scars/scar tissue formation that shows an increase in WBC of 11.90 (N: 5.0-10.0), and
abnormally high Platelet count of 588 (N:150-400). In line with this, the patient was
given Piperacillin-tazobactam 1.5gm IV q8 to initiate prophylaxis and to prevent growth
of bacteria pre and postoperatively.
75
The formation of subsequent hyperactive growing fibrin scars results in damage
of the hepatocytes. Hepatocytes damage decreases the synthetic function that leads to
derangement in coagulation. In this case, this will then decreases the clotting factors
which shows abnormality in the lab results of: above normal Partial Thromboplastin
Time (PTT) of 35.9 (N:11.0-16.0) and Activated Partial Thromboplastin Time (APTT) of
99.8 (N:23.4-38.5). The result also shows below than normal: Red Blood Cells (RBC) of
4.13 (N:4.2-5.4), Hemoglobin (Hgb) of 9.80 g/dL (N:12-16 g/dL), Hematocrit (Hct) of
29.90% (N:37-47%), and Mean Corpuscular Hemoglobin (MCH) of 36.70 pg
(N:27-31pg). In this case, the patient was given Vitamin K 1 amp/10mL because this is
essential for the synthesis of several clotting factors. Due to these abnormal laboratory
results, the patient was given 2 Fresh Frozen Plasma (FFP) transfused on May 19,
2023 and 2 Packed Red Blood Cells (PRBC) transfused on days May 22 and 24, 2023.
Due to the blood transfusion, tha patient manifested fever with at temperature of 38.5C
and because of this, the patient was given Paracetamol 300mg IV q6 x4. Hepatocytes
damage also results to decrease in Albumin of 2.54 mg/dL (N: 3.8-5.1 mg/dL).
Abnormally high results of liver function tests also manifests due to hepatocytes
damage such as Aspartate Aminotransferase (AST) of 135.4 U/L (N:17-59), Alanine
Aminotransferase (ALT) of 60.20 U/L (N:0-42), and C-reactive protein of 199.0 (N:1-3).
The CT Scan and MRCP with contrast MRI mentioned above that showed
palpable mass at RUQ shows manifestation of indigestion, dyspepsia, restlessness,
diaphoresis, and nausea. These resulted in abdominal pain tenderness at RUQ that the
patient reported 8 out of 10 of pain scale. In line with this, the patient was given
Paracetamol 300 mg IV q6 x4. Due to the palpable mass at RUQ, the patient was
ordered to be NPO that contributed to his low BMI of 13.6 (N: <16.5). The NPO was
ordered for the preparation of the surgery on May 23, 2023 with the surgical procedure
of Excision of Choledochal Cyst Hepaticoduodenostomy, Drain, from 7:25AM-3:00PM.
The surgery was done and the cyst was successfully excised with a measurement of
approximately 19 cm in size. The final diagnosis of the patient is Choledochal Cyst Type
I.
76
IDEAL MEDICAL AND SURGICAL MANAGEMENT
MEDICAL MANAGEMENT
If the infection is brought on by gallstone disease, the doctor may initially advise painkillers
and antibiotics to treat the infection depending on the underlying reason. The numerous
causes of jaundice may usually be distinguished using diagnostic imaging and blood tests.
The etiology of the jaundice will determine the final course of action. The surgical procedure
of hepatocutaneous jejunostomy is simple, but it is imperative to construct a relatively straight
and short loop from the skin to the biliary-enteric anastomosis; choledochoscopy through a
redundant loop of small bowel is difficult, and access to the intrahepatic branches may be
impossible.
SURGICAL MANAGEMENT
Hepaticojejunostomy
The common bile duct, which drains bile into the duodenum, is often formed when the hepatic
duct joins the cystic duct, which transports bile from the gallbladder. Digestion becomes
difficult when a disease or injury to the biliary system prevents bile from flowing freely. To
guarantee that the bile from the liver readily drains into the intestine, a hepaticojejunostomy is
performed. Treatment options for ailments including benign strictures in the common bile duct
brought on by cysts, inflammation, and stones include a hepaticojejunostomy.
Hepaticoduodenostomy
The most commonly performed operations for biliary reconstruction after complete
surgical resection of choledochal cyst are Roux-en-Y hepaticojejunostomy or
hepaticoduodenostomy. The technique of hepaticoduodenostomy consisted of transection of
the common hepatic duct at the hilum with an incision extending approximately 5 mm along
the lateral wall of both the hepatic ducts to permit a wide anastomotic stoma.
77
Hepaticoduodenostomy is preferred by surgeons since it is a more physiological
procedure, is simpler to perform, and is associated with fewer complications such as adhesive
bowel obstruction, anastomotic leakage, and peptic ulcer as compared with Roux-en-Y
hepaticojejunostomy. Hepaticoduodenostomy requires less operative time, allows faster
recovery of bowel function, and produces fewer complications requiring reoperation.
Laparoscopic Cholecystectomy
Laparoscopic cystectomy has become a common procedure for choledochal cysts. The cyst
should be removed completely just above the confluence of the common biliopancreatic
channel at the distal end and approximately 5 mm from the confluence of the right and left
hepatic ducts at the proximal end to avoid complications of the cystic remnant. The operation
is feasible and safe. The rate of conversion to open surgery is low. The rate of complication
under skilled laparoscopic surgeons is also low, even lower than in open surgery.
Laparoscopic cholecystectomy takes about an hour or two. A surgeon will make a few small
incisions in your abdomen. The surgeon will insert thin, hollow tubes into those incisions. The
surgical team will then place a laparoscope and other surgical tools into the tubes. Your team
may pump carbon dioxide into your abdomen. This step inflates the surgical area and makes
it easier to see inside. Using the special tools, the surgeon will detach the gallbladder from the
78
rest of the body and remove it. The team will then close the incisions with stitches, surgical
clips or surgical glue.
ACTUAL SURGICAL MANAGEMENT
Patient was brought to Northern Mindanao Medical Center for the Excision of
Choledochal Cyst last May 17, 2023. PNSS1L @ 25 gtts/min was started. Excision of
Choledochal Cyst, Hepaticojejunostomy was the requested surgery plan; however, it was later
altered to Excision of Choledochal Cyst, Hepaticoduodenostomy, Drain and was rescheduled
on May 23, 2023.
PRE-OPERATIVE
Condition of patient on departure to operating room, patient’s sensorium is awake GCS
is 15, reflexes are intact and pupils are reactive. Cardiovascular function rhythm is sinus.
Respiration is spontaneous, airway is patent, auscultatory is clear … Urine output is
adequate, blood replacement 1 unit PRBC. Neuromascular function is intact. Vital signs taken
as follows: BP 108/76 mmHg, PR 96 bpm, RR 20 cpm, Temp 36.8 C, sPO2 100%. Special
instructions is Morphine precaution.
INTRA-OPERATIVE
Secured consent signed by the Mother. Sign in time is 6:20 am, patient’s general status
is awake; conscious and coherent. With IVF lines PNSS 700cc level at Right arm regulated at
25 gtts/min. D5LR 300 cc level at the Left arm regulated at 20 gtts/min. Vital signs were: BP
110/70 mmHg, HR 118 bpm, RR 24 cpm, sPO2 99% with O2 4 lpm via mask. Induction of
anesthesia is general anesthesia, time started at 6:55 am and intubation time is 6:58 am. With
14 french foley catheter with return flow description of yellowish urine. Skin is prepped with
7.5% betadine cleanser site is Abdomen. Pre-Op counting is done and draping is also done.
Time out at exactly 7:20 am. Operation started at 7:25 am. C—arm is used and PNSS is used
for irrigation. Dressing is subcuticular and operation ended at exactly 3:00 pm. Extubation
time is 3:25 pm. Skin condition after removal had no signs of burns; dry and intact. Airway is
spontaneous. Patient is sedated but responsive to direct stimulus. IV lines are PNSS1L at 10
gtts/min and PLR at 30 gtts/min. Urine output is 200 ml, yellowish. Patients contraption are
FBC and JP Drain. Post-Op vital signs are as follows: BP 140/80 mmHg, PR 100 bpm, RR 18
cpm, sPO2 100%. Patient is then transferred by a stretcher at exactly 3:50 at the PACU .
Special endorsements: maintain patient on NPO, placed on MHBR with FBC attached to
Urobag.
On May 23, 2023 at 6:20 am, the patient was brought to the operating room. The
following were the actual step-by-step procedures that were performed to the patient:
1. The patient was placed in a supine position under general anesthesia.
2. Asepsis was antisepsis.
79
3. Drapes were placed.
4. At exactly 7:25 am, the surgery started. Cherney Incision was performed first.
5. Approximately 19 cm of choledochal cyst and a distended gallbladder were
found.
6. During the operation blood was transfused at around 12:00 PM. No passage to
duodenum.
7. Isolation of cyst (circumferential dissection and separation from Portal Vein and
Hepatic Artery).
8. Distal CBD dilated & united above pancreas level.
9. Proximal hepatic duct ligated.
10. Hepaticoduodenostomy was done and Jackson-Pratt drain was inserted.
11. Surgery ended at exactly 3:00 PM.
POST-OPERATIVE
Patient’s vital signs BP: 129/70, PR 97 bpm, RR 20 cpm, sPO2 100% Temp 36.0 C.
Patient is drowsy, Patients position at PACU is semi fowler with side rails up. IVF 1 is PLR1L
at Right arm and IVF 2 is PNSS1L at the Left arm. Oxygen support 4-6 lpm via face mask.
Monitoring devices are Pulse Oximeter, BP apparatus. Post op site at the abdomen dry and
intact. PostOp drain is JP, Urine FBC 100mL. Patient is transferred to ward at exactly 7:45
pm.The following medications were given to the patient: Morphine 2 mg IV q6; Paracetamol
300 mg IV q6 x4 ; Keterolac 15 mg IV q6 x 4 ; Piperacillin-Tazobactan 1.5 gm IV q8 ;
Metronidazole 300 mg IV q6.
After the operation the patient was still on NPO.The following medications were given to
the patient: Morphine 2 mg IV q6; Paracetamol 300 mg IV q6 x4 ; Keterolac 15 mg IV q6 x 4 ;
Piperacillin-Tazobactan 1.5 gm IV q8 ; Metronidazole 300 mg IV q6.
80
DRUG STUDY #1
DRUG ORDER MECHANISM OF INDICATION CONTRAINDICATION ADVERSE EFFECTS OF THE DRUG NURSING RESPONSIBILITIES/
(Generic Name, ACTION PRECAUTIONS
Brand Name,
Classification,
Dosage, Route,
Frequency)
Generic Name: Paracetamol has a To relieve pain Hypersensitivity to its 1.It is important to note that pain assessment
paracetamol central analgesic effect components; liver CNS: agitation, anxiety, headache, should be performed regularly
that is mediated problems; kidney fatigue, insomnia. 2. Monitor the patient’s response to the
Brand Name: through activation of problems medication throughout the course of
Febrinil descending Resp: atelectasis, dyspnea. treatment to ensure that the
serotonergic pathways. medication is effectively managing the
Classification: To exert central actions patient’s pain and to make any
Analgesic which ultimately lead to CV: hypertension, hypotension. necessary adjustments to the dosage
the alleviation of pain or treatment plan.
Dosage: symptoms. GI: constipation, nausea (IV), 3. Advise patient to consult a health
300mg vomiting. care professional if discomfort or fever
is not relieved by routine doses of this
Timing: F and E: hypokalemia. drug or if fever is greater than 39.5 C
6am, 12nn, 6pm, or lasts longer than 3 days.
12mn GU: renal failure (high doses/chronic 4. Caution parents not to let the patient take other
medication containing paracetamol and they
use). should read the label of all other medication
Route:
Intravenous carefully to ensure that it does not contain
Hemat: neutropenia, pancytopenia. paracetamol.
5. Make sure the parent and the patient are aware
Frequency: that they must not exceed the recommended
q6 MS: muscle spasms, trismus.
dose to avoid overdose and further complications.
Derm: rash, urticaria.
81
DRUG STUDY #2
DRUG ORDER MECHANISM OF INDICATION CONTRAINDICATION ADVERSE EFFECTS OF THE DRUG NURSING RESPONSIBILITIES/
(Generic Name, ACTION PRECAUTIONS
Brand Name,
Classification,
Dosage, Route,
Frequency)
Generic Name: Piperacillin binds Perioperative Hypersensitivity to 1.Observe patient for signs and
piperacillin and to bacterial cell prophylactic agent penicillin’s, beta-lactams, CNS: SEIZURES (higher doses), symptoms of hypersensitivity (rash,
tazobactam wall membrane, cephalosporins, or pruritus, laryngeal edema, wheezing).
confusion, dizziness, headache,
causing cell tazobactam (cross Discontinue the drug and notify health
Brand Name: sensitivity may occur) insomnia, lethargy. care professional immediately if these
death. Spectrum
Pipcin occur.
is extended
Classification: compared with GI: diarrhea, constipation, 2. Monitor bowel function. Diarrhea,
penicillin antibiotic other penicillins. drug-induced hepatitis, nausea, abdominal cramping, fever, and bloody
Tazobactam is an stools should be reported to health care
Dosage: antibiotic of the vomiting. professional promptly.
1.5gms beta-lactamase
inhibitor class that GU: interstitial nephritis. 3. Instruct patient and significant other to
Timing: prevents the report rash, itching, or other signs of
4am, 12nn, 8pm breakdown of hypersensitivity immediately and report
Derm: rashes, urticaria. loose stools or diarrhea.
other antibiotics
Route:
Intravenous by 4. Inform parents that before they have any
Hemat: bleeding, leukopenia,
beta-lactamase medical tests, tell the doctor in charge
Frequency: enzyme neutropenia, thrombocytopenia. that your child is receiving this medicine.
q8 producing The results of some tests may be
organisms Local: pain, phlebitis at IV site. affected by this medicine.
5. Administer piperacillin-tazobactam via a

Misc: hypersensitivity reactions, peripheral or central venous line to
including ANAPHYLAXIS and fever. ensure optimal absorption and
therapeutic action, as well as reduce
possible side effects.
82
83
DRUG STUDY #3
DRUG ORDER MECHANISM OF INDICATION CONTRAINDICATION ADVERSE EFFECTS OF THE NURSING RESPONSIBILITIES/
(Generic Name, ACTION DRUG PRECAUTIONS
Brand Name,
Classification,
Dosage, Route,
Frequency)
Generic Name: Disrupts DNA and Perioperative Prior history of hypersensitivity to CNS: SEIZURES, dizziness, 1. Monitor neurologic status during
metronidazole protein synthesis in prophylactic metronidazole or other headache, aseptic meningitis, and after IV infusions. Inform health
susceptible agent nitroimidazole derivatives. Use encephalopathy. care professional if numbness,
Brand Name: organism. with caution and reduce dose in paresthesia, weakness, ataxia, or
Antizoal therapeutic effect severe hepatic impairment. EENT: optic neuropathy seizures occur.
is bactericidal.
Classification: GI: abdominal pain, anorexia, 2. Monitor intake and output and daily
nitroimidazole nausea, diarrhea, dry mouth, furry weight, especially for patients on
antimicrobials tongue, glossitis, unpleasant taste, sodium restriction. Each 500mg of
vomiting. premixed injection for dilution
Dosage: contains 14 mEq of sodium.
300mg Derm: rash, urticaria; burning, mild
dryness, skin irritation, transient 3. If patient reports dry mouth,
Timing: redness. suggest ice chips or sugarless hard
6am, 12nn, 6pm, candy or gum; suggest a dental visit if
12mn Hemat: leukopenia. dryness lasts longer than 2 weeks.
Route: Local: phlebitis at IV site.

Intravenous
Neuro: peripheral neuropathy.
Frequency:
q6 Misc: superinfection.
84
DRUG STUDY #4
Brand Name,
Classification,
Dosage, Route,
Frequency)
Generic Name: It works by stopping the For the management of Hypersensitivity; CV: Edema, fluid retention, 1. Assess pain (note type,
ketorolac body’s production of a pain Cross-sensitivity with other hypertension location, and intensity) prior to
substance that causes EENT: Laryngeal edema, and 1–2 hr following
NSAIDs may exist; stomatitis ENDO: Hyperglycemia
Brand Name: pain, fever, and Cerebrovascular bleeding; administration.
Pentolac inflammation. GI: Abdominal pain; acute
Advanced renal impairment pancreatitis; bloating; constipation;
diarrhea; diverticulitis; flatulence;
2. Frequently asses blood
Classification: or at risk for renal failure pressure (BP) during and after
due to volume depletion. GI bleeding, perforation, or
NSAID ulceration; hepatitis; hepatic administration and compare to
failure; jaundice; indigestion; normal values. because drug
Dosage: nausea; perforation of stomach or can lead to onset of
15mg intestines; vomiting; worsening of hypertension or worsen
inflammatory bowel disease existing hypertension.
Timing: GU: Interstitial nephritis, renal
4am, 12nn, 8pm failure, urine retention 3. Advise patient to report if
HEME: Agranulocytosis, anemia,
aplastic or hemolytic anemia,
rash, itching, visual
Route: Intravenous eosinophilia, leukopenia, disturbances, tinnitus,
pancytopenia, thrombocytopenia persistent headache, or fever
Frequency: RESP: Bronchospasm, pneumonia, occurs.
q8 x 3 cycle respiratory depression
SKIN: Diaphoresis, erythema

multiforme, exfoliative dermatitis,
photosensitivity, pruritus, rash,
toxic epidermal necrolysis, urticaria
85
DRUG STUDY #5
Brand Name,
Classification,
Dosage, Route,
Frequency)
Generic Name: Binds to opiate For the management of Hypersensitivity; CNS: confusion, sedation, 1. Assess type, location, and
morphine receptors in the CNS. severe pain Acute or severe bronchial dizziness, dysphoria, euphoria, intensity of pain prior to and 1
Alters the perception asthma. Head trauma; floating feeling, hallucinations, hr following PO, subcut, IM,
Brand Name: of and response to increased intracranial headache, unusual dreams. and 20 min (peak) following IV
painful stimuli while pressure; administration.
Classification: producing generalized Severe renal, hepatic, or EENT: blurred vision, diplopia,
narcotic CNS depression. pulmonary disease. 2. Monitor blood pressure prior
miosis.
Therapeutic effect is to Hypothyroidism; Seizure to administration. Hold if
Dosage: decrease the severity disorder. systolic BP < 100 mm Hg or
2mg of pain. Resp: respiratory depression. 30 mm Hg below baseline.
Monitor for respiratory
Timing: depression and hypotension
6am, 12nn, 6pm, CV: hypotension, bradycardia. frequently up to 24 hours after
12mn administration of morphine.
GI: constipation, nausea,
Route: 33. May cause drowsiness or
Intravenous vomiting. dizziness. Caution patient to
call for assistance when
Frequency: GU: urinary retention. ambulating.
q6
4. Advise patient to change positions
Derm: flushing, itching, slowly to minimize orthostatic
sweating. hypotension.
5. Advise patient that good oral

hygiene, frequent mouth rinses, and
sugarless gum or candy may decrease
dry mouth
86
DRUG STUDY #6
Brand Name,
Classification,
Dosage, Route,
Frequency)
Generic Name: Require for hepatic The treatment of Impaired liver function, patients GI: gastric upset, unusual 1. Monitor pulse and BP
Vitamin K synthesis of blood coagulation disorders with hereditary taste. frequently; notify health care
coagulation factors. due to faulty formation of hypoprothrombinemia, renal professional immediately if
Brand Name: Therapeutic coagulation factors impairment, cases of over Derm: flushing, rash, urticaria. symptoms of internal bleeding
effectsare prevention caused by interference in anticoagulation due to heparins, or hypovolemic shock
Classification: of bleeding. Vitamin the activity of vitamin K. and hypersensitivity to vitamin develop.
fat soluble vitamin K helps to make K. Hemat: hemolytic anemia.
various proteins that 2. Monitor therapeutic
Dosage: are needed for blood Local: erythema, pain at effectiveness which is
1amp/10ml clotting and the indicated by shortened PT,
building of bones. injection site, swelling. INR, bleeding, and clotting
Timing: times, as well as decreased
4am, 12nn, 8pm Misc: allergic reactions, hemorrhagic tendencies.
3. Educate patient to
Route: hyperbilirubinemia (large maintain consistency in diet
Intravenous doses in very and avoid significant
increases in daily intake of
Frequency: vitamin K–rich foods when
q8 x 3 cycle premature infants), drug regimen is stabilized.
kernicterus. Know sources rich in vitamin
K: Asparagus, broccoli,
cabbage,
4. assist patient when
ambulating because dizziness
may occur.
5. do not give aspirin for pain

medication.
87
NURSING MANAGEMENT
Preoperative Nursing Care Plans
Priority Problem #1: Impaired tissue perfusion related to blockage of bile duct as evidenced by low hemoglobin level
ASSESSMENT DATA NURSING DIAGNOSIS GOALS AND OBJECTIVES NURSING INTERVENTIONS AND RATIONALE EVALUATION
May 22, 2023 Impaired tissue perfusion related Short-term Goal: Independent: Goals are met.The patient was
to blockage of bile duct as ● After 2 hours of nursing ● Assess skin color, temperature, moisture, and able to identify individual risk
Subjective: evidenced by low hemoglobin intervention, the patient will whether changes are widespread or localized. factors affecting the condition.
● None level be able to identify individual Rationale: Helps in determining location and type The patient and family were able
risk factors affecting the of perfusion problem. to participate in prevention
Objective: condition. ● Measure capillary refill. measures and treatment
● Hgb 9.70 g/dL Long-term Goal: Rationale: To determine adequacy of systemic programs.
(N:12.0-16.0) ● After 6 hours of nursing circulation.
● MCH 26.60 pg intervention, the patient and ● Explain all procedures and treatments.
(N:27-31) family will be able to Rationale: Understanding expected events and
● WBC 12.44x10^3/uL participate in prevention sensations can help eliminate anxiety, associated
(N:5-10) measures and treatment with the unknown.
● Pallor programs. ● Provide knowledge on normal tissue perfusion
● Skin cool to touch and possible causes of impairment.
● Pale nail beds Rationale: Knowledge of causative factors provides
● Bipedal edema a rationale for treatments.
● Determine nutritional status and potential for
delayed healing or tissue injury exacerbated by
malnutrition.
Rationale: Proper nutrition aids in healing.
● Encourage early ambulation or mobilization as
tolerated.
Rationale: Promotes circulation and reduces risk
associated with mobility.
● Emphasize the need for regular medical and
laboratory follow-up.
Rationale: To evaluate disease status and
response to therapies.
Dependent:
● Administer fluids, electrolytes, and nutrients as
indicated.
Rationale: To promote optimal blood flow, organ
perfusion and function.
88
Priority Problem #2: Acute pain related to palpable mass at RUQ as evidenced by guarding behavior
May 22, 2023 Acute pain related to Short-term Goal: Independent:

palpable mass at RUQ as ● After 30 minutes of nursing
Subjective: evidenced by guarding intervention, the patient will 1. Monitor pain intensity using a tool Goals met. After 30 minutes of
● “Pag hawiran akong behavior be able to: appropriate to the client's age/ nursing interventions, the patient
tiyan, sakit kaayo”, as ● promote safety by developmental level and condition. promoted safety and demonstrated
verbalized by the ● demonstrable use of Rationale: The pain experience is an relaxation skills and diversional
patient. relaxation skills and individualized one composed of both physical activities and the patient verbalized
● Pain scale: 7 out of 10; diversional activities. and emotional responses. decreased pain from the rate of
sharp stabbing pain felt 2. Provide non-pharmacological comfort 7/10 to 3/10 in pain rating scale
at the right upper Long-term Goal: measures and relaxation techniques such
quadrant of the ● After 8 hours of nursing as deep breathing exercises and guided
abdomen intervention, the patient will imagery, diversional activities such as using
be able to verbalize decrease of mobile phone.
pain from the rate of 7/10 to Rationale: Promotes relaxation and helps
Objective: 3/10 in pain rating scale. refocus attention.
● Protuberant abdomen 3. Monitor vital signs.
with hard palpable mass Rationale: Monitoring of vital signs helps
on RUQ determine patient status/condition.
● Elevated vital signs: PR 4. Instruct the watcher to be at the patient’s
110bpm and Temp side at all times
38.5C Rationale: To promote safety and avoid injury.
● facial grimacing noted 5. Encourage patient to verbalize feelings.
● positioning to ease pain Actively listen and provide support by
noted acceptance, remaining with the client, and
● guarding behavior noted giving appropriate information.
Rationale: Reduction of anxiety and fear can
promote relaxation and comfort.
6. Promote uninterrupted sleep periods.
Rationale: Sleep deprivation can increase
perception of pain and reduce coping abilities.
Dependent:
1. Administer prescribed pain medications:
Rationale: To provide pain relief.
● paracetamol (Febrinil) 300 mg IVTT every 4
hours (4am-8am-12nn-4pm-8pm-12mn)
89
Priority Problem #3: Anxiety related to threat to change in health as evidenced by fear of complications of the outcome of the operation
Subjective: Anxiety related to threat to Short-term Goals: Independent:

change in health as After 4 hours of nursing intervention, the 1. Acknowledge reality of patient’s fears and Goals are met. The patient
N/a evidenced by fear of patient will be able to: concerns and encourage expression of acknowledged and discussed fears
complications of the ● acknowledge and discuss fears feelings. and concerns and verbalized
outcome of the operation and concerns. Rationale: Support may enable client to accurate knowledge of information.
● verbalize accurate knowledge begin exploring and dealing with the reality of The patient demonstrated an
of information cyst and its treatment. Client may need time appropriate range of feelings and
to identify feelings and even more time to appeared relaxed and rested
Objective: begin expressing them. appropriately.
● fear of complications of Long-term Goals: 2. Acknowledge the anxiety and fear of the
the outcome of the After 8 hours of nursing intervention, the situation. Avoid meaningless reassurance
operation noted patient will be able to demonstrate that everything will be alright.
● poor eye contact appropriate range of feelings and appear Rationale: Validates the reality of the
● apprehensive relaxed and resting appropriately situation without minimizing the emotional
● worriness noted impact. Provides opportunity for client and
● restlessness noted family to accept and begin to deal with what
● irritability has happened, reducing anxiety.
3. Answer all questions factually. Provide
consistent information; repeat as
indicated.
Rationale: Accurate information about the
situation reduces fear, strengthens
nurse-patient relationship, and assists patient
and family to deal realistically with the
situation. Attention span may be short, and
repetition of information helps with retention.
4. Provide for patient’s physical comfort.
Rationale: It is difficult to deal with emotional
issues when experiencing extreme or
persistent physical discomfort.
5. Provide a calm, restful environment.
Rationale: Removing client from outside
stressors promotes relaxation and may
enhance coping skills.
6. Provide comfort measures: family
presence, quiet environment, and
therapeutic touch.
Rationale: Promotes relaxation and
enhances ability to deal with situations.
90
Postoperative Nursing Care Plans
Priority Problem #1: Acute Pain related to surgical incision secondary to Excision of Choledochal Cyst and Hepaticoduodenostomy and
insertion of Jackson-Pratt (JP) drain (May 24 to 26, 2023)
ASSESSMENT DATA NURSING GOALS AND OBJECTIVES NURSING INTERVENTIONS AND RATIONALE EVALUATION
DIAGNOSIS
Acute Pain
Subjective: related to surgical Short-term Goals: Independent: Goals partially met:
incision
May 24, 2023 secondary to After 8 hours of nursing 1. Note type and location of incision and drainage. After 8 hours of nursing
● “Sakit kaayo ang kaning dapit sa gi Excision of interventions, the patient will: interventions the patient:
opera sa ako, mura ko og gidunggab Choledochal Cyst Rationale: Severe pain in either area should be
sa kasakit. Nag sige ko og mata
gabii, dili ko katulog og tarong tungod and ● verbalize pain within manageable investigated further for possible complications ● reported that pain was slightly
sa ka sakit,” as verbalized by the Hepaticoduodeno level and will report a decrease in relieved from a pain scale of
patient on the first postoperative day stomy and pain scale rating from 10/10 to 8/10 2.Perform and document a comprehensive 10/10 to 9/10(May 24, 2023)
● Pain scale 10/10; sharp stabbing pain insertion of ● participate in actions to decrease continuous pain assessment. Instruct patient in ● participated in actions to
felt at the right upper and lower Jackson-Pratt pain regular use of a (0–10 or similar) pain-rating scale. decrease pain and demonstrated
quadrants of the abdomen (JP) drain (May ● demonstrate proper use of adjunct Monitor pain scale rating at regular intervals. proper use of non-pharmacologic
24 to 26, 2023: comfort measures comfort measures such as
May 25, 2023
Postoperative Rationale: Assists in differentiating cause of pain and comfortable positioning and
Days 1 to 3) Long-term Goals: provides information about disease progression or splinting when moving and
● “Sakit pa gihapon akong tahi og kini
pud dapit sa drain nga nakasabit sa resolution, development of complications, and performing deep breathing
akong tiyan, wala pa gihapon ko’y After 3 days of nursing interventions, effectiveness of interventions.A standardized tool for exercises
tarong nga tulog,” as verbalized by the patient will: rating pain helps in assessment and management of
the patient on the second pain
postoperative day ● report that pain is decreased or After 3 days of nursing
● Pain scale 10/10; sharp pain felt at controlled through a decrease in 3. Regularly monitor and investigate if there are interventions, the patient:
the at the right upper and lower
pain scale rating from greater than reports of increased incisional pain and changes in
quadrants of the abdomen
5/10 to less than 5/10. characteristics of pain. ● reported that pain was
May 26, 2023 ● appear relaxed and able to rest controlled from a pain scale of
and sleep appropriately. Rationale: Deep, dull, aching pain in the operative area 10/10 to 4/10 (May 26, 2023)
● “Dili na kaayo sakit akong tahi pero ● demonstrate age-appropriate may indicate developing infection. ● appeared relaxed and got
sakit pa gihapon ni ang dapit sa drain blood pressure (BP), pulse, and uninterrupted longer sleep at
nga nakasabit sa akong tiyan,” as respiratory rates. 4. Position JP drain accordingly for optimal night
verbalized by the patient on the third ● manifest decreased or absence of function; making sure tubing is not kinked and is ●demonstrated normal vital signs:
postoperative day
91
guarding behaviors, restlessness, free from clots or any obstructions. Secure the BP: 120/80 mmHg; PR: 62
● Pain scale 8/10; gnawing pain felt at and irritability. bulb to keep it from pulling on the skin or bpm; RR: 18 cpm
the at the right upper and lower ● demonstrate use of relaxation skills becoming dislodged. Drain accumulated fluid as ● did not manifest guarding
quadrants of the abdomen and diversional activities and on necessary. behaviors, was not restless,
● non-pharmacologic methods to control Rationale: Improper position, kinking, or accumulation was smiling and was not
● May 26, 2023 pain. of clots and fluid in the tubing changes the desired irritable anymore
● ● “Dili na kaayo sakit akong tahi ● participate in usual activities of daily negative pressure and impedes air or fluid evacuation ● demonstrated proper use of
pero sakit pa gihapon ni ang living (ADLs) within the level of ability
dapit sa drain nga nakasabit sa non-pharmacologic comfort
akong tiyan,” as verbalized by 5. Promote bedrest, allowing client to assume
measures such as comfortable
the patient on the third position of comfort
positioning and splinting and
postoperative day performing deep breathing
Rationale: Bedrest in low-Fowler’s position reduces exercises patient participating
intra-abdominal pressure; however, client will naturally in usual activities of daily living
assume the least painful position. (ADLs) such as ambulating,
brushing his teeth, and
6. Identify and provide essential adjuncts as combing his hair.
necessary.
Rationale: Pillows or blanket rolls are useful in

supporting extremities, maintaining body alignment,
and splinting incisions to reduce muscle tension and
promote comfort.
7. Teach and demonstrate the use of splinting the

abdomen with pillows during deep breathing,
sneezing, coughing or movement.
Rationale: Reduces incisional tension, promotes

maximal lung expansion
8. Provide comfort measures, such as back rubs

and position changes, assist with self-care
activities, and encourage diversional activities, as
indicated.
Rationale: May promote relaxation, redirect attention,

and reduce analgesic dosage or frequency.
92
9.Teach and encourage use of behaviors such as
guided imagery, distractions, visualizations, and
deep breathing
Rationale: Relaxation techniques aid in management of

stress, promote sense of well-being, may reduce
analgesic needs, enhance coping abilities, and
promote healing.
10. Teach and assist in performing

range-of-motion exercises and encourage early
ambulation. Avoid prolonged sitting position.
Rationale: Reduces muscle and joint stiffness.

Ambulation returns organs to normal position and
promotes return to the usual level of functioning.
11. Schedule care activities to balance with

adequate periods of sleep and rest.
Rationale: Rest and sleep are vital for healing and can
enhance coping with stress and discomfort.
12. Review and promote client’s own comfort

interventions— position and physical activity or
inactivity.
Rationale: Successful management of pain requires

client involvement. Use of effective techniques provides
positive reinforcement, promotes sense of control, and
prepares clients for interventions to be used after
discharge.
93
Collaborative:
13. Keep NPO and maintain NG suction as

indicated.
Rationale: Decreases discomfort of early intestinal

peristalsis and gastric irritation or vomiting.
14. Administer prescribed analgesics
Rationale: To treat severe pain.

● paracetamol 300 mg IV every 6 hours (6
am-12 nn- 6 pm - 12 mn)
● morphine 2 mg IV every 6 hours (6 am-12 nn-
6 pm - 12 mn)
● ketorolac 15 mg IV every 8 hours for 3 cycles
( 4 am, 12 nn, 8 pm)
94
Priority Problem #2: Imbalanced nutrition less than body requirements related to medically restricted intake
Subjective: “Dili pa siya pakaonon sa Imbalanced nutrition less Short-term Goal: Independent: Goals were met:
doctor kay obserbahan pa siya kung than body requirements
pwede na tanggalon ang NGT drain related to medically After 8 hours of nursing 1. Evaluate abdomen, noting presence and character After 8 hours of nursing interventions,
sa iyahang ilong og basin mo suka restricted intake and interventions, the patient and of bowel sounds, abdominal distention, and reports the patient and SO:
pa,” as verbalized by the patient’s hypermetabolic state SO will: of nausea.
mother. (March 24, 2023)
Rationale: Gastric distention and intestinal atony are
● identify individual nutritional ● identified client’s individual
frequently present, resulting in reduced or absent bowel
Objective: needs. sounds. Return of bowel sounds and relief nutritional needs such as need for
● Oral restriction (nothing per ● verbalize understanding of adequate vitamins and minerals,
orem): May 23, 2023to May 27, nutritional needs. 2. Note passage of flatus. increased protein and caloric intake.
2023 ● plan a diet to meet nutritional ● verbalized understanding of
● With NGT for drainage needs and limit Rationale: Indicates reestablishment of bowel function. nutritional needs as evidenced by
attached gastrointestinal (GI) Lack of return of bowel sounds and function within 72 SO saying, “Dapat jud nako
● Mid-upper Arm Circumference disturbances. hours may indicate presence of complications. bantayan iyahang mga kinaon,
(MUAC): 21 cm luto-an permi og gulay,
● Weight- 36 kg , Height-163 cm Long-term Goal: 3. Monitor NG tube output. Note the presence of maningkamot makapalit og vitamins
vomiting and diarrhea.
, BMI- 13.6 kg/m2 (underweight) para niya, og bawalan na nako siya
● Pale and dry skin, cracked After 1 week of nursing mag sige og kaon og parat og
Rationale: Large amounts of gastric aspirant, or severe
lips, brittle and dry hair interventions, the patient will: vomiting and diarrhea, suggest bowel obstruction, halang.”
● Pale mucous membranes requiring further evaluation. ● participated in planning a diet to
● Sluggish and fatigued ● initiate behaviors and lifestyle meet nutritional needs and limit
● Poor muscle tone changes to regain and to 4. Evaluate client’s appetite. gastrointestinal (GI) disturbances by
● Weight loss of 5 kgs from 41 maintain appropriate weight identifying foods and nutrients that
kg (May 17, 2023) to 36 kg (May 27, ● ingest nutritionally adequate Rationale: Appetite may be suppressed because of are ideal for the patient's diet.
2023). diet for age, activity level, and altered taste, early satiety, meal-related cramping, or
metabolic demands. medications, or a combination of these factors. After 1 week of nursing interventions,
● report improved energy level the patient:
5. Determine client’s current nutritional status using
● demonstrate progress in
age-appropriate measurements, including weight and
tissue healing free of infection body build, strength, activity level, and sleep and rest ● exhibited good appetite and
● demonstrate progressive cycles. consumed full share of his meal
weight gain toward goal and when diet was shifted to soft diet
improve MUAC Rationale: Identifies individual nutritional needs and ● exhibited improved energy level,
95
● experience no further signs of provides a comparative baseline. can tolerate walking and changing
malnutrition, with laboratory positions easier
values within normal range 6. Monitor client’s weight regularly. Evaluate weight ● demonstrated progress in tissue
in terms of premorbid weight. Compare serial weights healing, surgical incision and wound
and anthropometric measurements. remained dry and intact, free of
infection
Rationale: Indicator of nutritional needs and adequacy of ● did not gain weight but
intake. maintained his weight of 32 kgs.
MUAC remained at 21 cm. Note: He
7. Review client’s nutritional history, including food was still on his first day of being on
preferences and evaluate knowledge of nutrition. a soft diet
Rationale: Identifies deficiencies and suggests possible

interventions. Helps plan for individual nutritional need
8.Teach client and SO the importance of

well-balanced meals. Provide information regarding
individual nutritional needs and ways to meet these
needs within financial constraints.
Rationale: Providing age-appropriate guidelines to

children as well as to parents or care provider may help
them in making healthy choices.
9. Teach client and SO about nutritionally dense

high-calorie, high-protein, high-vitamin, and
high-mineral foods.
Rationale: Having this information helps client and SO

understand the importance of a well-balanced diet.
10. Plan diet with client and SO, incorporating foods

client likes or food from home. Assist client in
selecting food and fluids that meet nutritional needs
and restrictions when diet is resumed. Limit food(s)
that induce nausea or vomiting or are poorly
tolerated by client.
96
Rationale: Including client in planning gives a sense of
control of the environment and may enhance intake.
Fulfilling cravings for desired food may also improve
intake.Previous dietary habits may be unsatisfactory in
meeting current needs for tissue regeneration and
healing.
11. Encourage client to eat high-calorie, nutrient-rich

diet, with adequate fluid intake. Encourage use of
supplements and frequent, smaller meals spaced
throughout the day.
Rationale: Hypermetabolic state and treatment requires

increased nutrients and fluids to promote healing and
elimination of toxins. Supplements can play an important
role in maintaining adequate caloric and protein intake.
12. Ascertain current financial status and recent

and/or anticipated changes in economic status.
Explore related costs of a variety of foods.
Rationale: Helps in planning for meeting nutritional needs,

such as purchasing low-cost foods that are nutritionally
rich.
Collaborative:
13. Refer to nutritionist or dietitian to develop diet

appropriate to client’s needs
Rationale: Provides assistance in planning nutritionally

sound diet and identifying nutritional supplements to meet
individual needs
14. Maintain nothing by mouth (NPO) status when

and maintain nasogastric (NG) tube, as indicated.
97
Rationale: May be needed to reduce nausea or vomiting.
15. Provide IV fluids as indicated.
Rationale: Given for general hydration.
16. Resume or advance diet as indicated—clear

liquids progressing to bland, low-residue, and then
high-protein, high-calorie, caffeine-free, non spicy,
and low-fiber, as indicated.
Rationale: Allows the intestinal tract to readjust to the

digestive process. Protein is necessary for tissue healing
integrity. Low bulk decreases peristaltic response to
meals.
98
Priority Problem #3: Impaired skin integrity related to postsurgical procedure and presence of Jackson-Pratt drain
Subjective: none Impaired skin integrity Short-term Goal: Independent: Goals were met:
related to postsurgical After 8 hours of nursing 1. Inspect incision and dressings. Note
Objective: procedure and presence interventions, the patient and SO characteristics of drainage from JP drain. Observe After 8 hours of nursing interventions,
● surgical incision at RUQ of Jackson-Pratt drain will: incision and drainage periodically, noting the patient and SO:
● JP drain at RLQ approximation of wound edges, hematoma
● Wound drainage: ● learn and demonstrate proper formation and resolution, and presence of redness, ● learned and demonstrated proper
Postop days 1-2: sanguineous techniques of wound/incision care. bleeding, and drainage. techniques of wound/incision care
Postop days 3-5: serosanguineous ● demonstrate behaviors that Rationale: Verifies status of healing, provides for early and the proper way to drain the
Postop day 6: serous reduce tension on suture line. detection of developing complications requiring prompt contents of the JP drain.
● identify and participate in evaluation and influencing choice of interventions. ● demonstrated behaviors that reduce
interventions to prevent and reduce tension on suture line such as
risk of infection. 2. Teach and promote proper hand hygiene such as splinting when moving.
proper handwashing. Maintain strict hand hygiene ● identified and participated in
Long-term Goal: measures, using soap and water or antibacterial interventions to prevent and reduce
After 1 week of nursing soaps, before and after client care. Institute infection risk of infection such as knowing the
interventions, the patient will: precaution. signs and symptoms to watch out for
● achieve timely wound healing Rationale: Hand hygiene remains the cornerstone of and report that may indicate infection
without complications infection prevention. and ways to prevent infection such as
● be free of signs of infection and handwashing and wound/incision
inflammation such as purulent 3. Provide routine incisional care, being careful to care.
drainage, erythema, and fever keep dressing dry and sterile.
Rationale: To promote wound healing and reduce After 1 week of nursing interventions
bacterial contamination and avoid infections. the patient’s incision and drainage site
remained dry, intact and free of signs of
4. Teach client and SO proper wound care and infection and inflammation as
dressing change. manifested by normal vital signs,
Rationale: Promotes competent self-care and serosanguineous/serous drainage,
independence in self-care, reducing risk of absence of erythema and fever.
complications.
5. Educate client and SO of signs of infection to

watch out for and report such as redness, swelling,
increased pain or burning sensation, foul odor, or
purulent drainage.
Rationale: To detect early identification of onset of
infection and institute prompt intervention. Early
recognition and treatment of developing complications
may prevent more serious illness or injuries.
99
6. Emphasize to the client and SO not to touch the
incision and drain site.
Rationale: May cause infection.
7. Provide and encourage meticulous skin care and

frequent repositioning.
Rationale:Maintains skin integrity.
8. Keep skin surfaces dry and clean and linens dry

and wrinkle free.
Rationale: Moist, contaminated areas provide excellent
media for growth of pathogenic organisms.
9. Assess and maintain patency of JP drain.

Routinely empty drainage device.
Rationale: Jackson-Pratt drains facilitate removal of
drainage, promoting wound healing and reducing risk of
infection.
10. Monitor vital signs, noting onset of fever.

Rationale: A rise in pulse and temperature may provide
warning of infectious processes.
100
DISCHARGE PLAN
Goals:
1.Instruct patients to follow the entire course of prescribed medications according to the
doctor's order. Discontinuation of treatment may result potential complications
2.Instruct the patient on the importance of following the right dosage and timing of the
medications as prescribed.
3.Explain to the patient the purpose, indications and side/adverse effects of the
prescribed medications.Take pain medicine exactly as directed
Medications
1.) Take pain medicines exactly as directed., If the doctor gave you a prescription for
pain, take it as prescribed.
2.) If your doctor prescribed antibiotics, take them as directed. Do not stop taking
them just because you feel better. You need to take the full course of antibiotics.
Take Cefixime 500 mg/tab, 2x/day for 7 days; Metronidazole 500mg/tab, 3x/day
for 7 days; Celecoxib 200mg/cap, 2x/day for 7 days.
Environment
Make sure to practice proper aseptic technique in wound dressing.
Treatments and Therapy
1. To reduce swelling and pain, put ice or a cold pack on your belly for 10 to 20 minutes
at a time. Do this every 1 to 2 hours. Put a thin cloth between the ice and your skin.
2. Keep the area clean and dry. You may cover it with a gauze bandage if it weeps or
rubs against clothing. Change the bandage every day.
Health Teachings
1. Health Teachings about daily wound dressing with emphasis of proper aseptic
technique on wound care and daily bath for hygienic purposes. Do not remove the
paper strips or cut any of the visible sutures.
2..Take your medicines exactly as directed. Use pain medicine as needed for easy
ambulation.
Outpatient Follow up and Consultations
1. Follow up Check-up on June 7, 2023 as an OPD direct at the Surgery Department.
2. Provide the patient with the name and telephone number of the physician to call if a
question arises.
101
3.Instructed the patient about the importance of regular check-up and for any follow up
visit to any health care provider to continuously assess the patient’s condition.
4.Instructed patient to write down any questions to remember during visit
Diet
Emphasize to the patient to try the Dietary Patterns with Choledocal Cyst Diet including
Soft Food Diet with no colored food. Eat fewer refined carbohydrates and less sugar.
Eat healthy fats, like fish oil and olive oil, to help your gallbladder contract and empty on
a regular basis. Avoid unhealthy fats, like those often found in desserts and fried foods
Spirituality
Encouraged the client to attend mass if able. To thank God for all the things He provided
and pray to almighty God for guidance and healing.
102
RESULTS AND DISCUSSION
Patient was last assessed on May 29, 2023, the patient was still admitted at the
hospital ready to be discharged. On May 30, 2023, the patient was discharged at 10:23
AM. There are significant changes in his condition. His vital signs on the last day of
assessment were the following: T- 36.5⁰C; P- 63 bpm; R- 20 cpm, BP- 110/80 mmHg,
Oxygen Saturation of 99% with tolerable abdominal pain with a pains cale rating of
4/10. Patient was ambulating and JP Drain was attached to the surgical site with
purulent discharges. Patient was eventually discharged from the hospital on May
30,2023 and was scheduled for a follow-up check up on June 7, 2023.
The authors were able to compare the actual and ideal nursing and medical
interventions. Based on the author’s study, there are various ideal medical management
that can be done to facilitate his complete recovery. Also, the researcher learned the
vital role of proper nutrition, diet and healthy lifestyle where this can prevent the
occurrence of Choledochal Cyst. Therefore, health teachings are of utmost
importance to prevent these complications.
103
CONCLUSION
Choledochal cyst is a congenital type of illness in which there is a rare cystic

mutation of the pancreatic juice and the bile juice in which creates a force between two
enzymes that proliferates the inner lining of the gallbladder resulting in thinning of the
walls. This phenomenon happens usually in children and infants and it progresses in
adolescence where the cyst enlarges in a progressive manner. In the case of the
patient, the growth of the cyst grows rapidly in a short manner of time. This led to
admission of the current symptoms and diagnosing the symptoms present. This type of
condition is aided through surgical management such as Laparoscopic
Cholecystectomy, Hepaticojejunostomy and Hepaticoduodenostomy reconstruction.
Appropriate nursing diagnosis and interventions were given based on the persistent
symptoms such as Ineffective tissue perfusion related to obstruction of bile duct as
evidenced by low hemoglobin; Acute pain related to palpable mass at Right Upper
Quadrant as evidenced by Guarding behavior; Anxiety related to threat to change in
health as evidenced by fear of dying; Infection related to elevated white blood cell count
and decreased hemoglobin and hematocrit; Imbalanced nutrition; Less than Body
requirements related to medically restricted intake and Impaired Skin integrity related to
post-surgical procedure and presence of Jackson- Pratt Drain
At the end of this case study, the researchers were able to outline the
physiological process of the disease, apply its medical management in the clinical
setting, and provide the optimum nursing management of patients with Choledochal
Cyst Type I to deliver the most efficient care for the patient.
104
REFERENCES
Journals:
Agrawal, V., Liem, N., & Aison, D. (2021). Laparoscopic management of choledochal cyst in
children: Lessons learnt from low-middle income countries. Journal of Minimal
Access Surgery, 17(3), 279. https://doi.org/10.4103/jmas.jmas_114_20
Albuquerque, V.M., De Mercado, F.P., Costa, K., Nunes, Z.R., & Silva, R. (2020).
Choledochal cyst – Unusual Presentation in the Adult Phase: Case Report.
International Journal of Surgery, 70, 33–36.
Ali, N., & Nater, U. M. (2020). Salivary alpha-amylase as a biomarker of stress in behavioral
medicine. International journal of behavioral medicine, 27, 337-342
Amiri, M., Naim, H. Y., & Schecker, N., (2017). Structure-function analysis of human
sucrase-isomaltase identifies key residues required for catalytic activity. Journal of
Biological Chemistry, 292(26), 11070–11078.
https://doi.org/10.1074/jbc.m117.791939
Arihan, O., Wernly, B., Lichtenauer, M., Franz, M., Kabisch, B., Muessig, J., ... & Jung, C.
(2018). Blood Urea Nitrogen (BUN) is independently associated with mortality in
critically ill patients admitted to ICU. PloS one, 13(1), e0191697.
Bates, B. N. (2013). Interpretation of urinalysis and urine culture for UTI treatment. US
Pharm, 38(11), 65-68.
Basit, H., Hundt, M., & John, S. (2022). Physiology, bile secretion - statpearls - NCBI
bookshelf. Physiology, Bile Secretion.
https://www.ncbi.nlm.nih.gov/books/NBK47020
Bhavsar, M., Vora, H., & Giriyappa, V. (2015). Choledochal Cysts: A Review of Literature,
18(4), 230-236.
Böyük, A., Kırkıl, C., Karabulut, K., Sözen, S., & Demirelli, S. (2015). A Choledochal Cyst
Resulting in Obstructive Jaundice in a Case with Gallbladder Agenesis: Report of a
Case and Review of the Literature. Balkan Medical Journal, 29, 106-106.
Chalya, P., Kanumba, E.S., & McHembe, M. (2016). Etiological spectrum and treatment
outcome of Obstructive jaundice at a University teaching Hospital in northwestern
Tanzania: A diagnostic and therapeutic challenges. BMC Res Notes, 23(4),147.
https://doi.org/10.1186/1756-0500-4-147
Chan et al.,(2018). Laparoscopic management of choledochal cyst in infants and children:
A review of current practice. Surgical Practice, doi:10.1111/1744-1633.12310. 9/
Cherry, k. (2022). How people develop an identity or cope with role confusion. Verywell
well. retrieved from:
https://www.verywellmind.com/identity-versus-confusion-2795735
Erlichman, J., Loomes, K.M. (2021). Biliary atresia. UpToDate. Retrieved December 15, 2021, from
https://www.uptodate.com/contents/biliary-atresia
Erlichman, J., Loomes, K.M. (2021). Causes of cholestasis in neonates and young infants. UpToDate.
Retrieved December 15, 2021, from
https://www.uptodate.com/contents/causes-of-cholestasis-in-neonates-and-young-infants
Evrimler, S. et al(2020). Wirsungocele: Evaluation by MRCP and clinical significance.
Abdominal Radiology, 46(2), 616–622. https://doi.org/10.1007/s00261-020-02675-4
Fan, Shu-Ling (2020). Contemporary Practice in Clinical Chemistry || Urinalysis. , (),
665–680. doi:10.1016/B978-0-12-815499-1.00038-7
Goldfinger et al. (2020). Quantitative MRCP imaging: Accuracy, repeatability,
reproducibility, and cohort‐derived normative ranges. Journal of Magnetic
Resonance Imaging, 52(3), 807–820. https://doi.org/10.1002/jmri.27113
Hartweg, D. L. (2015). Dorothea Orem’s self-care deficit nursing theory. Nursing theories
and nursing practice, 105-132.
https://nurseslabs.com/ida-jean-orlandos-deliberative-nursing-process-theory/
Hoilat, G. J., & Savio, J. (2022, August 29). Choledochal cyst - statpearls - NCBI bookshelf.
National Library of Medicine. https://www.ncbi.nlm.nih.gov/books/NBK557762/
Hoffman, M. (2020). The abdomen (human anatomy) - picture, function, parts, definition,
and more. WebMD.
https://www.webmd.com/digestive-disorders/picture-of-the-abdomen
105
Hosokawa, T., et al(2021). Role of ultrasound in follow-up after choledochal cyst surgery.
Journal of Medical Ultrasonics, 48(1), 21–29.
https://doi.org/10.1007/s10396-020-01073-z
Hulsmann, A. R., & Velden, V. (2017). Peptidases: Structure, function and modulation of
peptide-mediated effects in the human lung. Clinical & Experimental Allergy, 29(4),
445–456. https://doi.org/10.1046/j.1365-2222.1999.00462.x
Hundt, M., Wu, C.Y., Young, M. (2021) Anatomy, abdomen and pelvis, biliary ducts. StatPearls.
Retrieved December 21, 2021, from https://www.ncbi.nlm.nih.gov/books/NBK459246/
Iluz-Freundlich D et al., (2020). The relative expression of hepatocellular and cholestatic
liver enzymes in adult patients with liver disease.
Jacob E. (2016). Complete Blood Cell Count and Peripheral Blood Film, Its Significant in
Laboratory Medicine: A Review Study. American Journal of Laboratory Medicine.
Vol. 1, No. 3, 2016, pp. 34-57. doi: 10.11648/j.ajlm.20160103.12
Kalra, A., Tuma, F., Wehrle, C., & Yetiskul, E. (2021). Physiology, liver - statpearls - NCBI
bookshelf. Physiology, Liver. https://www.ncbi.nlm.nih.gov/books/NBK535438/
Kamath, B.M., Ye, W., et al. (2020). Outcomes of childhood cholestasis in Alagille syndrome: results of a
multicenter observational study. Hepatology Commun 4:387–398. DOI: 10.1002/hep4.1468
Kapila, V., Tuma, F., & Wehrle, C. (2022). Physiology, spleen - statpearls - NCBI bookshelf.
Physiology, Spleen. https://www.ncbi.nlm.nih.gov/books/NBK537307/.
Katrich, A.N., Polshikov, S.V., & Kurilskaya, A.M. (2020). Value of Radiology Techniques
for Diagnosis of Obstructive Jaundice in the Admission Department. Innovative
Medicine of Kuban, 12(6), 9-11.
https://doi.org/10.35401/2500-0268-2020-19-3-68-76
Kelly, S., Soares, K., Alsma, E., & Pawlik, T. (2016). Management of Choledochal Cysts.
Current Opinion in Gastroenterology 32(3), 225-231.
Khandelwal, C., Anand, U., Kumar, B., & Priyadarshi, R. (2013). Diagnosis and
management of choledochal cysts. Indian Journal of Surgery, 74(1), 29-34.
https://doi.org/10.1007/s12262-011-0388-1
Koblin, J. (2022). Kohlberg’s 6 stages of moral development. Sprouts Learning Videos
Social Sciences.
https://sproutsschools.com/kohlbergs-6-stages-of-moral-development/
Kusunoki, Y.T., Takahashi,K.M., Ishikawa, Y., & Utsunomiya, J. (2018). Choledochal cyst:
Its possible autonomic involvement in the bile duct. The Archives of Surgery,
122(9):997-1000.
Lia, E., Hadikusumah, R. N., & Diposarosa, R. (2020). Characteristics of Choledocal Cyst
Patients in Bandung, Indonesia: Single Centre Experience. Imaging, 13(40.0), 20-0.
Lecturion Medical. (2019). Brian Alverson: Pediatric choledochal cyst [Video].
https://www.youtube.com/watch?v=O9kQWCcW5f8
Lynch, M. (2021). Piaget’s theory of cognitive development: The formal operational stage.
The Edvocate.
https://www.theedadvocate.org/piagets-theory-of-cognitive-development-the-formal-
operational-stage/
Mcleod, S. (2023). Freud’s psychosexual theory and 5 stages of human development.
Simply Psychology. https://www.simplypsychology.org/psychosexual.html
Nguyen Thanh Liem (2013). Laparoscopic surgery for choledochal cysts. , 20(5), 487–491.
doi:10.1007/s00534-013-0608-0
Ouellette, R. J., & Rawn, J. D. (2015). Carbohydrates. Principles of Organic Chemistry,
343–370. https://doi.org/10.1016/b978-0-12-802444-7.00013-6
Pandit, N., Deo, K.B., Yadav, T., Gautam, S., Dhakal, Y., Awale, L., & Adhikary, S. (2020).
Choledochal Cyst: A Retrospective Study of 30 Cases from Nepal. Cureus, 12(11).
https://doi.org/10.7759/cureus.11414
Park, S., & Singh, P. (2017). Vessels, lymphatic system and nerves, abdominal. Imaging
Anatomy: Chest, Abdomen, Pelvis, 550–591.
https://doi.org/10.1016/b978-0-323-47781-9.50028-3
106
Pirahanchi Y. (2022). Sharma S. Biochemistry, Lipase. In: StatPearls [Internet]. Treasure
Island (FL): StatPearls Publishing; 2023 Jan-. Available from:
https://www.ncbi.nlm.nih.gov/books/NBK537346/
Rad, A. (2022). Stomach. https://www.kenhub.com/en/library/anatomy/the-stomach
Rajab, I.M., et al (2020).C-reactive protein in gallbladder diseases: diagnostic and
therapeutic insights. Biophys Rep 6, 49–67
https://doi.org/10.1007/s41048-020-00108-9
Sacher, Vikas Y (2013). Role of magnetic resonance cholangiopancreatography in
diagnosing choledochal cysts: Case series and review. World Journal of Radiology,
5(8), 304–. doi:10.4329/wjr.v5.i8.304
Simon, J. A., & Hudes, E. S. (2000). Serum ascorbic acid and gallbladder disease
prevalence among US adults: the Third National Health and Nutrition Examination
Survey (NHANES III). Archives of internal medicine, 160(7), 931-936.
Singham, J., Yoshida, E., & Scudamore, C. (2019). Choledochal Cysts. Canadian Journal
of Surgery, 53 (1), 51-56.
Soares, K. C., et al (2014). Choledochal cysts: presentation, clinical differentiation, and
management. Journal of the American College of Surgeons, 219(6), 1167.
Stringer, M. D. (2018). Choledochal cysts. Surgical Diseases of the Pancreas and Biliary
Tree, 121-147.
Stöppler, M. (2021). Medical definition of exopeptidase. RxList.
https://www.rxlist.com/exopeptidase/definition.htm
Tokoro, H., et al (2020). Usefulness of breath-hold compressed sensing accelerated
three-dimensional magnetic resonance cholangiopancreatography (MRCP) added to
respiratory-gating conventional MRCP. European Journal of Radiology, 122, 108765.
https://doi.org/10.1016/j.ejrad.2019.108765
Topazian, M. (2021). Biliary cysts. UpToDate. Retrieved December 15, 2021, from
https://www.uptodate.com/contents/biliary-cysts
Vaughan‐Johnston, T. I., & Jacobson, J. A. (2020). Self‐efficacy theory. The Wiley
Encyclopedia of Personality and Individual Differences: Models and Theories,
375-379.
Vlaardingerbroek, M. T., & Boer, J. A. (2013). Magnetic resonance imaging: theory and
practice. Springer Science & Business Media.
Wang, L., & Yu, W.F. (2014). Obstructive Jaundice and Perioperative Management. Acta
Anaesthesiologica Taiwanica, 52(1), 22-29. https://doi.org/10.1016/j.aat.2014.03.002
Withers, P. J. et al. (2021). X-ray computed tomography. Nature Reviews Methods Primers,
1(1). https://doi.org/10.1038/s43586-021-00015-4
Xiao J, et al(2022). Surgical management and prognosis of congenital choledochal cysts in
adults: a single Asian center cohort of 69 cases. J Oncol.. 2022:9930710.
Yang, W. (2016). Nucleases: Diversity of structure, function and mechanism. Quarterly
Reviews of Biophysics, 44(1), 1–93. https://doi.org/10.1017/s0033583510000181
Books:
Hinkle, J., & Cheever, K. (2018). Brunner & Suddarth’s Textbook of Medical Surgical
Nursing (14th ed.). Lippincott Williams & WIlkins.
Doenges, M., Moorhouse, M., Murr, A. (2013). Nurses’ Pocket Guide (13th ed.).
Philadelphia: F.A. Davis Company.
Marieb, E. N. (2015). Essentials of Human Anatomy & Physiology (11th ed.). Pearson
Education.
Vallerand, A. H., & Sanoski, C. A. (2021). Davis's drug guide for nurses (17th ed.). F. A.
Davis Company.
Wildhaber, B.E. (2012). Biliary atresia: 50 years after the first Kasai. ISRN Surg. DOI:
10.5402/2012/132089
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A Case Study on

CHOLEDOCHAL CYST TYPE I

Lugatiman, Lovely Hope J.

Ilajas, Riz Strawberry G.

Jubane, Monica Marie T.

Juntilla, Joanna Paola S.

Lacbain, Aprille Dawn N.

Looking, Clara Julia S.

Maaño, Francine Kaye Angela D.

Manliguez, Cyrill John B.

Mondoñedo, Tazha Camille D.

Keywords: Pediatrics, Choledochal cyst, Jaundice, hepaticoduodenostomy, excision

To Ms. Emman M. Parangue, RN, MN,USRN, Level I Coordinator, the

Background of the Study

Choledochal cyst is a rare medical condition with an incidence of 1 in 100,000 to

Objectives of the Study

Significance of the Study

Scope and Limitation

This case study discusses Choledocal Cyst Type I. It contains fundamental

Magnetic resonance cholangiopancreatography (MRCP) - it is a non-invasive

Hepaticoduodenostomy - a surgical procedure that involves creating a direct

Hepaticojejunostomy reconstruction - A surgical procedure performed to restore the

Patient X is a 15-year-old male from Kalilangan, Bukidnon. He was born in 2007

Nursing Health History

Chief of Complaint: Patient received at the Northern Mindanao Medical Center’s

History of Present Illness

Two months prior to admission, patient X had an episode of nausea and

Vital Signs Intake Output

1 ADMISSION (May 17,2023) 110/70 102 20 38.0 99 8/10 —- 700 900 — 0

14 May 30, 2023 PATIENT WAS DISCHARGED AT 10:23 A.M

Health Perception/Health Management Pattern:

Pre-operative Management: The patient is on NPO prior to operation.

Activity and Exercise Pattern

Activities of Daily Living/ Mobility Status

Feeding 2 Meal Preparation 4 Bed Mobility 2

Bathing 2 Cleaning 4 Chair / Toilet Transfer 2

Dressing 2 Laundry 4 Ambulation 2

Grooming 2 Toileting 2 R.O.M. 2

Legend: 0 - Total Independence

During assessment, Patient X had an interval of sleeping pattern due to

Cognitive and Perceptual Pattern

During assessment, Patient X is oriented to time, person, and place. Patient X

Self-Perception and Self-Concept Pattern

During assessment, Patient X is conversing when asked and is irritable upon

Roles and Relationships Pattern

Sexuality and Reproduction Patterns

Coping and Stress Tolerance Pattern

During assessment, Patient X is avoiding questions related to his illness. He is

Value- Belief Pattern

Health Perception/Health Management Pattern:

Second day of Assessment, patient is received at Medical Surgical Ward awake,

Activity and Exercise Pattern

Activities of Daily Living/ Mobility Status

Feeding 2 Meal Preparation 4 Bed Mobility 2

Legend: 0 - Total Independence

Sleep and Rest Pattern

During assessment, Patient X had an interval of sleeping pattern due to

Cognitive and Perceptual Pattern

Self-Perception and Self-Concept Pattern

During assessment, Patient X is conversing when asked and is irritable upon

Roles and Relationships Pattern

Sexuality and Reproduction Patterns