UNIVERSITY OF SOUTHERN PHILIPPINES FOUNDATION

Salinas Drive, Lahug, Cebu City

College of Health Sciences

Department of Nursing

Perioperative Care of a Client with Chronic Calculous Cholecystitis

NGCM116L
Care of Clients w/ Problems in Nutrition, Gastrointestinal, Metabolism & Endocrine, Perception
& Coordination (Acute and Chronic)

Submitted by:
JIESSA TANO
BSN-III

Submitted to:
MR. VICTOR DEGAMO, RN, MN, LPT
Clinical instructor

FEBRUARY 2023
 INTRODUCTION

Cholecystitis is inflammation of the gallbladder. The gallbladder is a small, pear-shaped

organ on the right side of the abdomen, beneath the liver. The gallbladder holds a digestive fluid

(bile) that's released into the small intestine. In most cases, gallstones blocking the tube leading

out of the gallbladder cause cholecystitis. This results in a bile build-up that can cause

inflammation. Other causes of cholecystitis include bile duct problems, tumors, serious illness

and certain infections.

Gallstone disease is very common. About 10-20% of the world population will develop

gallstones at some point in their life and about 80% of them are asymptomatic. There are

approximately 500,000 cholecystectomies done yearly in the United Stated for gallbladder

disease. The incidence of gallstone formation increases yearly with age. Over one-quarter of

women older than the age of 60 will have gallstones. In the United States, approximately 14

million women and 6 million men with an age range of 20 to 74 have gallstones.

In developed countries, more than 85% of gallstones are cholesterol stones. About 20

million people in the USA have gallstones. The Third National Health and Nutrition

Examination Survey (NHANES III) indicated a higher prevalence in Mexican-Americans than in

non-Hispanic whites, and a lower prevalence in non-Hispanic blacks. An extraordinarily high

prevalence was found in American Indians. In Europe, ultrasound studies revealed a prevalence

of 9 - 21% and an incidence of 0.63/100 persons/year. A trend for increasing gallstone

prevalence has been identified in Europe and North America by necroptic and ultrasound studies

(Acalovschi & Lammert, 2012).

 Calculous cholecystitis is the cause of more than 90% cases of acute cholecystitis (

Cushieri, steele, Moossa 2002). In calculous cholecystitis, a gallbladder stone obstructs bile

outflow. Bile remaining in the gallbladder initiates a chemical reaction; autolysis and edema

occur; and the blood vessels in the gallbladder are compressed, compromising its vascular

supply. Gangrene of the gallbladder with perforation may result.

Patient M., C.L. , is a 60 year old male diagnosed with Chronic Calculous Cholecystitis.

This case study will provide ways to practice the nursing process which is the core of nursing

profession and it gives acquaintance to the condition known as cholecystitis. It allows us students

to acquire specific information on the said condition and be able to obtain knowledge on the

proper medical interventions that should be done and the rationales for such procedures.
 PATIENT’S PROFILE

Patient’s Name: M., C. L.

Age: 60 year old

Sex: Male

Marital Status: Married

Citizenship: Filipino

Religion: Roman Catholic

Address: Sitio Kanan-as Singson, Guadalupe, Cebu City

Hospital: Cebu City Medical Center

Case Number: 510665

Date and Time of Admission: January 10, 2023 at 12:00nn

Chief Complaints: Epigastric Pain

Medical Dx: 1. Obstructive Jaundice secondary to Mirizzi Syndrome

2. Chronic Calculous Cholecystitis

 PATIENT’S HISTORY

History of Present Illness

2 months prior to admission, noted onset of on/off epigastric pain, no consult due to took

Kremil-S at relief.

2 weeks prior to admission, patient had onset of RUQ pain radiating to the upper back,

had consult and managed medically at work-up lab tests done.

1 week prior to admission, patient noted reoccurrence of abdominal pain radiating to

upper back associated with icteric sclera non decreasing thus opted consult.

Past Medical History

The patient has maintenance drug Losartan 50mg, for his hypertension.
 GENOGRAM

I.

II.

III
. PATIENT

IV
.

LEGEND:

Square- male

Circle -Female

Blue- Diabetes

Orange – Gallstones

Yellow - PATIENT
 DEVELOPMENTAL TASK

Generativity vs. stagnation is the seventh stage of Erik Erikson’s theory of psychosocial
development. This stage takes place during middle adulthood, between the approximate ages of
40 and 65. It comes before the eighth and final stage of development in Erikson's theory, which is
integrity vs. despair (Cherry, 2020)

During this stage, middle-aged adults strive to create or nurture things that will outlast
them, often by parenting children or fostering positive changes that benefit others. Contributing to
society and doing things to promote future generations are important needs at the generativity vs.
stagnation stage of development.

Adults need to create or nurture things that will outlast them, often by having children or
creating a positive change that benefits other people. Success leads to feelings of usefulness and
accomplishment, while failure results in shallow involvement in the world.

During adulthood, they continue to build their lives, focusing on their career and family.
Those who are successful during this phase will feel that they are contributing to the world by
being active in their home and community. Those who fail to attain this skill will feel unproductive
and uninvolved in the world.

It's important to note that life events at this stage tend to be less age-specific than they are
during early- and late-stage life. The major events that contribute to this stage (such as marriage,
work, and child-rearing) can occur at any point during the broad span of middle adulthood.
 GORDON’S FUNCTIONAL HEALTH PATTERNS
Functional Health Pattern Before Hospitalization During hospitalization
1. Health Perception and The patient viewed his health “sakit kaayu dapit sa ako
Health maintenance as fine. “aktibo kaayu ko sa kuto2 mo inom rakug Kremil-
mga buluhaton sabalay. Kung S sauna para mawala ang
hilantan inom rakug biogesic. kasakit. Karn pag human sa
Ug magsakit ako tiyan mo opera kay sakit pa akung tahi.
inom raman kug Kremil-S” as Nalipay ko kay nakuha
verbalized by the patient. nagyud ang bato” as
verbalized by the patient.
2. Nutritional - Metabolic “hilig kaayu ko mga tambok “mo kaon raman ko bisan unsa
ug panit sa manok. Mo kaon ihatud nga rasyun ari” as
sad ko mga utan pero usahay verbalized by the patient.
ra kay mahal na kaayu mga
utanon. ” as verbalized by the
patient.
3. Elimination The client stated that usually “gi tauran kug catheter katung
he defecate 1 - 2 times a day wala pako operahi hangtud
with a color of brown and karn mana ako opera naa
well-formed stool. He voids 8 gihapon ako catheter” as
- 10 times a day yellow or verbalized by the patient.
clear colored urine.
“Maka ihi ug maka libang
raman kog tarong ug dali “as
verbalized by the patient.

4. Activity and Exercises “dli man ko mag exercise “sige rako higda pag human sa
kaayu. Hilig pud kog inom ug ako opera kay sakit akung
beer.” as verbalized by the tahi” as verbalized by the
patient. patient
 5. Sleep and Rest “sayu ko mo mata mga 4am “usahay mag putol2 akung
kay mag andam sa mga katulog kay mag sakit ako tahi
lutoonon dayun 9pm akung pero katung wala pako na
ting katulog kay mag ” as operahi kay sige ko mata2 sa
verbalized by the patient. kasakit sa ako tiyan" as
verbalized by the patient.
6. Cognition and “basta masakit ko sauna kay “kahibalo ko karn sa ako
perception mo inom raman ko tambal na kahimtang pag admit nako
mapalit ra sa botika” as dri” as verbalized by the
verbalized by the patient patient. The patient is oriented
to time, place and person.
Also, he stated that he is
sometimes bored in the
hospital.
7. Self-perception and self- Patient regarded his children “magpaayu jud ko maam kay
concept to be of more concern than lisud kaayu kung magsakit-
himself. He put his family at
sakit or mawala ko, louy
greater priority.
kaayu akung pamilya” as
verbalized by the patient.
8. Sexuality and Patient expressed satisfaction “Kontento nami sa akong
Reproduction and content in her sexual asawa sa among mga anak”.
relations.
9. Roles and Relationship Patient identified himself as a “kuyog akung asawa, siya
husband and a father. He man ga bantay nako dri sa
regarded his relationship with hospital” as verbalized by the
his family with the greatest patient.
concern.
10. Stress and tolerance “malipayun raman ko “positive kaayu ko huna2
coping pagkatao pero usahay magool maam kay kahibaw jud ko dali
tungod sa mga problema pero rako maayu. Kabalo sad ko
mawala raman kung masulbad nga naa ra ako asawa, ,mga
 na” as verbalized by the anak ug apo nag gabay sa
patient. akoa” as verbalized by the
patient.
11. Values and Belief Patient reported to have a “sige lang ko ampo nga ma
strong relationship with the okay na akung kahimtang" as
Almighty. verbalized by the patient.
 PHYSICAL ASSESSMENT

General Survey
Received patient lying on bed, awake and coherent with a GCS score of 15 (E4 V5 M6),
with IVF #2 PLR 1L @ 500 cc level infusing well at left metacarpal; yellow skin noted, height of
164 cm and weight of 54 kg, with the following vital signs as follows, temperature of 36.7° C
Heart rate of 84 bpm, respiratory rate of 24 cpm, blood pressure of 140/90 mmHg and O2
saturation of 97%. With epigastric pain radiating to upper back with the pain score of 7/10.
 System Normal Findings Abnormal Patient Findings
Findings

Skin, Hair, and Warm to touch, with Pallor, Dry, Scaly No presence of
Nails good turgor, smooth and lesions and
soft. Yellowish skin noted.
Skin Dry skin noted.

Unevenly
Evenly distributed. distributed, signs Black hairs are evenly
of alopecia distributed with no
Hair lesions noted

Nails are clean, pink

tones, 160-degree angle Nails are smooth and
between the nail base Dirty, broken,
Nails firm
and the skin, immobile, Spoon nails,
Nails are smooth and Thickened nails.
firm.
Face
Symmetrical. No Symmetrical. No
involuntary movements. Asymmetrical, involuntary
No abnormal lesions presence of movements. No
noted involuntary abnormal lesions
movements. lump, noted
crack, ulcer or
abnormal
discolouration of
the skin that is not
normally present
Eyes
Both have even colors Greyish, uneven Both have even colors
1. Iris colors
Cloudy white
Yellowish, red

White Red
Yellowish noted
2. Sclera

moist
Moist Dry
3. Cornea

Equally round and Equally round and

Unequal, non
4. Pupils reactive to light
reactive to light reactive to light
accommodation

Unevenly Evenly distributed,

distributed, curls curls outward
Evenly distributed, curls
5. Eyelashes outward inward

No lesions, non tender

No lesions, non tender (+) lesions,
6. Eyelids tenderness

Pink palpebral Pale conjunctiva

conjunctiva Abnormal tissue
growth, yellowing
7. Conjunctiva
Ears (+) earwax, aligned, no Presence of (+) earwax, aligned,
palpable mass, non palpable mass no palpable mass, non
tender tender
(+) tenderness

Nose External nose is (+)lesions, External nose is

symmetrical with no swelling and symmetrical with no
discoloration, swelling tenderness discoloration,
or malformations. Nasal swelling or
mucosa is pinkish red malformations. Nasal
with no mucosa is pinkish red
discharge/bleeding, with no
swelling, malformations discharge/bleeding,
or foreign bodies swelling,
malformations or
foreign bodies
Mouth
No Presence of
1. Teeth No plaque and caries Presence of plaque
plaque and dental
noted and dental caries,
caries
tooth loss

(+) lesions, dry

2. Oral mucosa Pink and moist, no (+)lesions, No lesions noted
lesions noted bleeding, swelling

Epulis nodes
3. Gingiva Hypertrophy of gingival
tissue is common. No abnormalities
noted

Dry, cracked lips

Hydrated, not dry,
symmetrical Lips are symmetric.
4. Lips

Lesions
Pinkish, no lesions noted

5. Tongue
Pink and moist, No
Positioned in the lesions noted
midline, no swelling and Misaligned, lesions
lesions noted.
6. Uvula Positioned in the
midline
Head & Neck

Head Skull is generally round. (+) tenderness

No tenderness upon (+) lesions
palpation. Skull is generally
round. No tenderness
upon palpation.
Neck (+) lesions
No lesions, masses
(+) masses
present. Able to move
neck freely Unable to move No lesions, masses
neck freely present. Able to move
the neck freely. No
lesions, masses
present. Able to move
neck freely

Lungs and Symmetrical chest (+) adventitious Symmetrical chest

Thoracic Region expansion, scapula are sounds expansion, scapula are
symmetrical and (+) Labored symmetrical and
prominent. Produces a breathing prominent. Produces a
resonant sound when resonant sound when
Respiratory rate is
percussed. percussed.
not within normal
No adventitious sound. limits. No adventitious
sound.

Breast and
Lymphatic

Symmetrical, nontender Nipple inversion. Symmetrical,

1. Breast
Localized redness, nontender
pain, and warmth.
Tender. Lesions.
Cardiovascular
Neck vessels
1. Jugular (-) distention
Pulse is not visible Bounding, visible
veins
(-) distention pulse
(-) protrusion at > 45 (+) distention
degrees (+) protrusion at
>45 degree

No blowing and (+) Blowing and

2. Carotid swishing sounds swishing sounds
arteries 2+ pulse
No blowing and
Irregular rhythm. swishing sounds
Progressive
Normal Sinus rhythm.
dyspnea,
Heart Soft systolic murmurs
palpitations, and
are audible.
markedly
decreased activity Regular rhythm noted
tolerance indicate
cardiovascular
disease.

Abdomen Tender, abnormal Bulging abdomen noted

Soft, symmetric, and masses palpable
non-tender without
distention

Musculoskeletal Both upper

Both upper extremities Extremities are extremities are equal
are equal in size. unequal in size in size.

Swollen and
(-) tenderness enlarged joints
(-) muscle spasms (+) tenderness
(+) muscle spasms
Neurologic
Level of Movements are smooth Movements are . Able to talk
Consciousness and coordinated. Alert uncoordinated. spontaneously but
and respond to voice and Disoriented or with notable slurring.
pain. lethargic.

Responds to light touch,

position sense, and No corresponding
Sensory Nerve
vibration. Demonstrates reaction to light,
Assessment Responds to light
discriminative touch, and
sensations. Alertness vibrations. touch, position sense,
responds to vocal stimuli and vibration.
Demonstrates
No fasciculations, tics, discriminative
or tremors are noted. sensations. Alertness
responds to vocal
stimuli
 LABORATORY AND DIAGNOSTIC STUDIES

Date Test Result Reference

01/25/23 CBC
WBC 7.9 4.0-15.0 10^g/L
RBC L 4.3 3.8-5.9 10^12/L
Hemoglobin 145 113-139 g/L
Hematocrit 0.43 0.35-0.40 %
MCV 100.0 80.0-100.0 fL
MCH H 33.9 27.0-31.0 pg
MCHC 33.6 31.0-36.0 g/dL
RDW 0.125 0.115-0.150
Platelet 328 150-450 10^g/L
Segmenters H 0.66 0.40-0.48 %
Lymphocytes 0.27 0.40-0.48 %
Monocytes 0.06 0.05-0.10 %
Eosinophils L 0.01 0.02-0.05%
Basophils 0.00 0.00-0.01%

Date Test Result Reference

01/25/23 Immunology
Procalcitonin (PCT) H 1.12 0-0.5 ng/mL
 Date Test Result
01/15/23 Urinalysis
Color Dark Yellow
Transparency Clear
pH 6.0
Specific Gravity 1.010
Protein Negative
Glucose +3
RBC 0-1/hpf
WBC 0-1/hpf
Epithelial Cells FEW/hpf
Bacteria FEW/hpf
Mucus Thread RARE/hpf

Date Test Result

01/10/23 Urinalysis
Color Yellow
Transparency Hazy
pH 6.0
Specific Gravity 1.015
Protein Negative
Glucose 3+
RBC 0-2/hpf
WBC 2-3/hpf
Epithelial Cells MODERATE/hpf
Bacteria FEW/hpf
Mucus Thread MODERATE/hpf
 Date Test Result Reference
01/15/23 Clinical Chemistry
Sodium L 134.70 135.0-148.0 mmol/L
Potassium L 3.32 3.5-5.0 mmol/L
Creatinine L 0.53 0.7-1.3 mg/dL
SGPT (ALT) H 315.9 <45 U/L
SGOT (AST) H 152.7 <35.0 U/L

Date Test Impression

01/17/23 Ultrasound
Whole Abdomen Normal sized liver with subtitle
heterogeneity of echotexture
which may be consistent with
aging liver or early non specific
hepatic parenchymal disease.
Cholelithiases probably with
recent episode of cholecystitis.
Unremarkable CBD and
intrahepatic biliary radicles.
Essentially normal pancreas and
spleen.
Relative increase in renal
parenchymal echogenicity which
may relate to normal variance
(40%) or early, non specific
medical renal disease (60%).
Borderline sized prostate gland
approximately 29.30grams
Structurally unremarkable urinary
bladder
Atheromatous abdominal aorta;
No evidence of aneurysm or
dissection noted.
 Date Test Result Reference
01/18/23 Clinical Chemistry
Alkaline Phosphatase H 428.00 U/L
Total Bilirubin H 177.33 0.7-1.3 umol/L
Direct Bilirubin H 156.81 0.0-0.2 umol/L
Indirect Bilirubin H 20.52 0.1-1.2 umol/L

Date Test Result Reference

01/25/23 Clinical Chemistry
Indirect Bilirubin 1.6 mg/dL
Creatinine 0.81 0.7-1.3 mg/dL
Direct Bilirubin H 2.97 0.0-0.2 mg/dL
Total Bilirubin H 4.55 0.1-1.2 mg/dL

Date Test Result Reference

01/15/23 Clinical Chemistry
Sodium L 129.20 135.0-148.0 mmol/L
Potassium 4.40 3.5-5.0 mmol/L
 Date Test Result Reference
01/15/23 CBC
WBC 4.0-15.0 10^g/L
RBC L 4.3 3.8-5.9 10^12/L
Hemoglobin 145 113-139 g/L
Hematocrit 0.43 0.35-0.40 %
MCV 100.0 80.0-100.0 fL
MCH H 33.9 27.0-31.0 pg
MCHC 33.6 31.0-36.0 g/dL
RDW 0.125 0.115-0.150
Platelet 328 150-450 10^g/L
Segmenters H 0.66 0.40-0.48 %
Lymphoctyes 0.27 0.40-0.48 %
Monocytes 0.06 0.05-0.10 %
Eosinophils L 0.01 0.02-0.05%
Basophils 0.00 0.00-0.01%
 SUMMARY OF SIGNIFICANT FINDINGS

Table . Summary of Significant Findings

Gordon’s Functional Health Assessment / Laboratory & Therapeutic Key Nursing Problems
Health Pattern Physical Findings Diagnostic Findings Management
Pre-Operative Period
“sakit kaayu ako tiyan Pain score – 7/10 -Provide pharmacologic Acute pain r/t epigastric
sa may kuto2 dapit” as Bulging abdomen noted pain management as pain
verbalized by the patient Sweats are noted ordered.
Facial grimace - Provide comfort
Guarding behaviour measure such as slow
Increased sweating rhythmic breathing,
repositioning and other
diversional activities
such as music
“ma putol ako katulog Yawning noted -Provide pharmacologic Disturbed sleep pattern
basta mo sool ako sakit Restlessness noted pain management as r/t impaired comfort as
sa tiyan, ug dugay ordered. evidenced by difficulty
napud ko katug balik” -Do as much care as initiating sleep
as verbalized by the possible without waking
patient up the client.
-Encourage to increase
fluid intake
Intra-Operative Period
sedation Provided strict Risk for injury r/t
temporary muscular continuous monitoring sedation and loss of
paralysis after the procedure until motor function
anesthesia completely
wears off.
Open wound incision at Adhere to facility Risk for infection r/t
abdominal area infection control, surgical procedure
 sterilization, and aseptic
policies and procedures.
Post-Operative Period
“sakit pa kaayu ako Facial grimace noted Administered pain Acute pain r/t post-
tahi” as verbalized by discomfort noted reliever as prescribed. surgical incision as
the patient positioning to ease pain evidenced by pain score
Pale skin is noted of 6/10
PS: 6/10
“dako dako diay ako Presence of Surgical Taught the client to Impaired skin integrity
tahi sa tiyan” as Wound in the RUQ of keep the wound clean r/t surgical incision site
verbalized by the patient the abdominal area and to support incision
covered with dressing. Encouraged client to
inspect skin on daily
basis and to describe
wound characteristics
and changes observed.
 ANATOMY AND PHYSIOLOGY

The gallbladder is a pear-shaped, green-colored sac located in a depression on the inferior

surface of the liver, which is mainly a storage organ for bile. A rounded fundus protrudes from
the fossa in which it resides. It is connected to the cystic duct, which joins the common hepatic
duct. The gallbladder has a thin epithelial lining and strong muscles in its wall and is about 10
cm or 4 inches long. It stores bile not immediately needed for digestion, reabsorbs water, and
contracts to release bile into the small intestine. The gallbladder concentrates bile by absorbing
certain amounts of its water and ions.

The common bile duct is formed by the joining of the common hepatic and cystic ducts.
It leads to the duodenum via a chamber called the duodenal ampulla, where the hepatopancreatic
sphincter is normally contracted. The duodenal ampulla opens into the duodenum at a small
mound called the duo-denal papilla. As bile collects in the common bile duct, it backs up into the
cystic duct and flows into the gall-bladder for storage. This occurs because of contraction of the
gallbladder’s muscular walls.
 PATHOPHYSIOLOGY

Predisposing factors: Precipitating Factors:

Age: 60 y/o Diet: -high-fat and high-cholesterol

diet
Gender: Male
-alcohol intake
Genetic: Gallstones
(Grandmother) and diabetes
(Mother and father)
Supersaturation of cholesterol in the bile

Gallstone formation in the gallbladder

Pressure obstruction

Bile stasis

-Decrease fat
emulsificatio
Accumulation of Irritation of gallbladder n:
bile in liver lining mucosal surface
fat
intolerance

Mucus hyper secretion

-
inflammation
:
Cholecystitis
Pain (RUQ)
Signs and symptoms
PROGNOSIS -Pain(RUQ)
-Leukocytosis
-(+)Murphy’s sign
-Leukocytosis
If treated: If not treated:

-Laparascopic -empyema and hydrops -Fever

cholecystectomy -gangrene and perforation -nausea and vomiting
-diet management -fistula formation and
-Antibiotic and pain gallstone ileus -yellowing of skin and
management therapy -Limey (milk of calcium) bile eyes (jaundice)
and porcelain gallbladder
 MANAGEMENT

Medical:

-Ciprofloxacin (Antiobiotic)
-Metronidazole (Antibiotic)
Nursing:
-Observe and document location, severity (0-10 scale), and character of pain.
-Promote bedrest, allowing the patient to assume a position of comfort.
-Encourage use of relaxation techniques, and provide diversional activities.
-Provide a pleasant atmosphere at mealtime and remove noxious stimuli.
-consume a low-fat diet rich in HDL sources (seafood, nuts, olive oil)
-Monitor laboratory studies: BUN, pre-albumin, albumin, total protein,
transferrin levels.
-Ambulate patient as tolerated with doctor’s order three times daily.
-Monitor BP, Pulse, temperature, and respirations
-Monitor intake and output
-Encourage exercise
 NURSING CARE PLAN

Pre-operative period
Nursing Dx 1: Acute pain related to epigastric pain as evidenced by pain score of 7/10.
ASSESSMENT SCIENTIFIC PLANNING INTERVENTIONS RATIONALE EVALUATION
BASIS
Subjective data: Inflammation of Short-term SAFE & QUALITY SAFE & QUALITY Short-term goal:
the gallbladder goal: NURSINGCARE NURSINGCARE
“sakit kaayu ako often causes • Obtain and monitor • To provide baseline After 8 hours of
tiyan sa may severe pain in the After 8 hours of VS every 4 hrs and data nursing
kuto2 dapit” as mid or right nursing endorse for any interventions the
verbalized by the upper abdomen. interventions the abnormalities. patient was able to
patient Pain can also patient will appear calm and
spread between appear calm and • Note for the • To determine the relaxed with vital
Objective data: the shoulder relaxed with location, scale, nursing care to be signs within
blades. In severe vital signs intensity and onset given to the patient. normal limits and
• Bulging cases, the within normal of pain will report a pain
abdomen gallbladder may limits and will score of 2 or less
noted tear or burst and report a pain • Maintain a calm and • To minimize out of 10
• Sweats are release bile into score of 2 or less quiet environment. stimulus that could
noted the abdomen, out of 10 aggravate the Long-term goal:
• Facial grimace causing severe condition of the
• Guarding pain. Long-term patient After 3 days of
behavior goal: nursing
• Increased • Use relaxation • To promote comfort
interventions the
sweating technique such as: and relaxation.
After 3 days of patient was able to
• Pain score – deep breathing
nursing exercise state two methods
7/10 interventions the to control their
patient will state stress and worry.
two methods to There will be
control their • Provide a dim and • To add comfort to diminished or
stress and worry. light but providing the patient absent nonverbal
There will be good ventilation indicators.
diminished or
absent nonverbal • Provide comfort • They serve as non-
indicators. measure such as pharmacological
slow rhythmic methods for
breathing, reducing
repositioning and pain/promoting
other diversional comfort
activities such as
music

MANAGEMENT OF MANAGEMENT OF
RESOURCES & RESOURCES &
ENVIRONMENT ENVIRONMENT
• Raised side rails. • To promote comfort
and safety and
prevent falls.

LEGAL LEGAL
RESPONSIBILITY RESPONSIBILITY
• Informed client and • To adhere practices
S/O about any on accordance with
procedures nursing law and
performed & other relevant
obtained informed legislation.
consent.

ETHICO-MORAL ETHICO-MORAL
RESPONSIBILITY RESPONSIBILITY
• Provided patient’s • To respect patient’s
privacy rights.
• Provided • To respect the rights
confidentiality to of the patient
patient’s data and
records.

QUALITY
IMPROVEMENT QUALITY
• Solicits feedback IMPROVEMENT
from client and • To help identify
significant others improvements in the
regarding care delivery of
rendered healthcare

RECORD
MANAGEMENT RECORD
• Maintained MANAGEMENT
integrity, safety, • Makes record
access and security readily accessible to
of records facilitate client care
and ensures safety
of patient’s records.

COLLABORATION&
TEAM WORK COLLABORATION&
• Regulated and TEAM WORK
monitored IVF as • To keep electrolytes
prescribed by the balanced and route
physician. for possible
medication
administration
Nursing Dx 2: Disturbed sleep pattern r/t impaired comfort as evidenced by difficulty initiating sleep
ASSESSMENT SCIENTIFIC PLANNING INTERVENTIONS RATIONALE EVALUATION
BASIS
Subjective data: Sleep Short-term SAFE & QUALITY SAFE & QUALITY Short-term goal:
disturbances goal: NURSINGCARE NURSINGCARE
“ma putol ako encompass • Obtain and monitor • To provide baseline After 2-3 hours of
katulog basta mo disorders of After 2-3hours VS every 4 hrs and data nursing
sool ako sakit sa initiating and of nursing endorse for any interventions,
tiyan, ug dugay maintaining interventions, abnormalities. Patient was able
napud ko katug sleep (DIMS, Patient will be to identify
balik” as insomnias), able to identify • Assess past patterns • Sleep patterns are individually
verbalized by the disorders of individually of sleep in normal unique to each appropriate
patient excessive appropriate environment: individual. interventions to
somnolence interventions to amount, bedtime promote sleep.
rituals, depth, length
Objective data: (DOES), promote sleep.
disorders of
• Assess patient's • Knowing the
• Yawning sleep–wake
specific etiologic
Long-term goal:
perception of cause
noted schedule, and Long-term factor will guide
of sleep difficulty
• Restlessness dysfunctions goal: appropriate therapy. After 8hrs of
noted associated with nursing
• Dry skin sleep, sleep After 8hrs of • interventions, the
• Maintain a calm and To minimize
noted stages, or partial nursing stimulus that could patient was able
quiet environment.
• With the arousals. Short- interventions, aggravate the to achieves
following vital term the patient will condition of the optimal amounts
signs of: consequences of be able to patient of sleep as
T-37.1 sleep disruption achieves optimal evidenced by:
PR- 115 include increased amounts of sleep • To promote comfort rested appearance,
RR- 21 • Use relaxation
stress as evidenced by: technique such as: and relaxation. verbalization of
BP- 130/80 responsivity, rested feeling rested and
deep breathing
O2sat-97% somatic pain, appearance, improvement in
exercise
reduced quality verbalization of sleep pattern.
of life, emotional feeling rested • Provide a dim and • To add comfort to
distress and and light but providing the patient
mood disorders, improvement in good ventilation
and cognitive, sleep pattern.
memory, and • Provide comfort • They serve as non-
performance measure such as pharmacological
deficits. slow rhythmic methods for
breathing, reducing
repositioning and pain/promoting
other diversional comfort
activities such as
music

MANAGEMENT OF MANAGEMENT OF
RESOURCES & RESOURCES &
ENVIRONMENT ENVIRONMENT
• Raised side rails. • To promote comfort
and safety and
prevent falls.

LEGAL LEGAL
RESPONSIBILITY RESPONSIBILITY
• Informed client and • To adhere practices
S/O about any on accordance with
procedures nursing law and
performed & other relevant
obtained informed legislation.
consent.

ETHICO-MORAL ETHICO-MORAL
RESPONSIBILITY RESPONSIBILITY
• Provided patient’s • To respect patient’s
privacy rights.
• Provided • To respect the rights
confidentiality to of the patient
patient’s data and
records.

QUALITY
IMPROVEMENT QUALITY
• Solicits feedback IMPROVEMENT
from client and • To help identify
significant others improvements in the
regarding care delivery of
rendered healthcare

RECORD
MANAGEMENT RECORD
• Maintained MANAGEMENT
integrity, safety, • Makes record
access and security readily accessible to
of records facilitate client care
and ensures safety
of patient’s records.

COLLABORATION&
TEAM WORK COLLABORATION&
• Regulated and TEAM WORK
monitored IVF as • To keep electrolytes
prescribed by the balanced and route
physician. for possible
medication
administration
Intra-Operative Period
Nursing Dx 3: Risk for injury r/t sedation and loss of motor function
ASSESSMENT SCIENTIFIC PLANNING INTERVENTIONS RATIONALE EVALUATION
BASIS
Subjective data: state of sedation Short-term SAFE & QUALITY SAFE & QUALITY Short-term goal:
puts an goal: NURSINGCARE NURSINGCARE
N/A individual at risk • Verify patient • Assures correct After 3-4 hours of
for injuries such After 3-4 hours identity and patient, procedure, nursing
as fall, as the of nursing procedure and appropriate interventions, the
Objective data: inhibitory interventions, extremity or side. patient was able to
function against the patient will remain free from
• Sedation physical injury remain free from injury throughout
• temporary are temporarily injury • Give simple and • Impairment of the longevity of
muscular blocked. throughout the concise directions to thought process the surgical
paralysis longevity of the the sedated patient. makes it difficult for procedure.
surgical patient to
procedure. understand lengthy Long-term goal:
directions.
Long-term After 24 hours of
• Document allergies, • Reduces risk for
goal: nursing
including risk for allergic responses
interventions, the
adverse reaction to that may impair skin
After 24 hours integrity or lead to patient was able to
latex, tape, and prep
of nursing life-threatening remain free from
solutions.
interventions, systemic reactions. injury throughout
the patient will the longevity of
remain free from
• Verify that patient is • To lessen the risk the effect of
injury for fall anesthesia.
securely placed on
throughout the the table through
longevity of the use of safety belts
effect of • Verify that • To establish a state
anesthesia. anesthesia is of sedation before
effectively induced surgical procedure
before starting the
procedure

• Provide strict • allows patient to

continuous concentrate more
monitoring after the completely.
procedure until
anesthesia
completely wears
off.

• Provide an • To prevent injuries

atmosphere of related to the effects
respect, openness, of anesthesia
trust, and
collaboration.

LEGAL
LEGAL
RESPONSIBILITY
RESPONSIBILITY
• Informed client and
• To adhere practices
S/O about any
on accordance with
procedures
nursing law and
performed &
other relevant
obtained informed
legislation.
consent.

ETHICO-MORAL
ETHICO-MORAL
RESPONSIBILITY
RESPONSIBILITY
• Provided patient’s • To respect patient’s
privacy rights.
• Provided • To respect the rights
confidentiality to of the patient
patient’s data and
records.

RECORD RECORD
MANAGEMENT MANAGEMENT
• Maintained • Makes record
integrity, safety, readily accessible to
access and security facilitate client care
of records and ensures safety
of patient’s records.

COLLABORATION& COLLABORATION&
TEAM WORK TEAM WORK
• Confirm and • Foreign bodies
document correct remaining in body
sponge, instrument, cavities at closure
needle, and blade not only cause
counts. inflammation,
infection,
perforation, and
abscess formation,
disastrous
complications that
lead to death.
Nursing Diagnosis 4: Risk for infection r/t surgical procedure
ASSESSMENT SCIENTIFIC PLANNING INTERVENTIONS RATIONALE EVALUATION
BASIS
Subjective data: Exogenous Short-term goal: SAFE & QUALITY SAFE & QUALITY Short-term
infection occurs NURSINGCARE NURSINGCARE goal:
N/A when external After 3-4 hours of • Adhere to facility • To establish
microorganisms nursing infection control, mechanisms After 3-4 hours
Objective data: contaminate the interventions, the sterilization, and designed to prevent of nursing
operative site patient will aseptic policies and infection. interventions, the
• Open wound during the maintain safe procedures. patient was able
incision at procedure. aseptic maintain safe
abdominal Infections environment and • Verify sterility of all • Package sterilization aseptic
area caused by able to prevent manufacturers’ and expiration dates, environment and
exogenous crosscontamination items. lot/serial numbers prevent cross
bacteria occurs throughout the must be documented contamination
when microbes longevity of the on implant items for throughout the
further follow-up if
that are non- surgical procedure. longevity of the
necessary.
commensal enter surgical
a host. Sources Long-term goal: procedure.
• Disruptions of skin
include surgical
integrity at or near
instruments, the After 24 hours of the operative site are Long-term goal:
theatre nursing • Examine skin for
breaks or irritation, sources of
environment and interventions, the contamination to the After 24 hours of
signs of infection.
the air. patient will remain wound. nursing
free from infection interventions, the
throughout the • Contamination by patient remained
longevity of the environmental or free from
surgical procedure. personnel contact infection
• Identify breaks in
renders the sterile throughout the
aseptic technique
 and resolve field unsterile, longevity of the
immediately on thereby increasing surgical
occurrence. the risk of infection. procedure.

LEGAL
RESPONSIBILITY
LEGAL • To adhere practices
RESPONSIBILITY on accordance with
• Informed client and nursing law and
S/O about any other relevant
procedures legislation.
performed &
obtained informed
consent. ETHICO-MORAL
RESPONSIBILITY
ETHICO-MORAL • To respect patient’s
RESPONSIBILITY rights.
• Provided patient’s • To respect the rights
privacy of the patient
• Provided
confidentiality to
patient’s data and
records.
QUALITY
QUALITY IMPROVEMENT
IMPROVEMENT • To help identify
• Solicits feedback improvements in the
from client and delivery of
significant others healthcare
regarding care
rendered
 RECORD
RECORD MANAGEMENT
MANAGEMENT • Makes record
• Maintained readily accessible to
integrity, safety, facilitate client care
access and security and ensures safety
of records of patient’s records.

COLLABORATION&
TEAM WORK
COLLABORATION& • presence of systemic
TEAM WORK or organ infection,
• Review laboratory which may
studies for contraindicate or
possibility of impact surgical
systemic infections. procedure and/or
anesthesia
Post-Operative Period
Nursing Diagnosis 5: Acute pain r/t post-surgical incision as evidenced by pain score of 6/10
ASSESSMENT SCIENTIFIC PLANNING INTERVENTIONS RATIONALE EVALUATION
BASIS
Subjective data: Complex Short-term SAFE & QUALITY SAFE & QUALITY Short-term goal:
responses of goal: NURSINGCARE NURSINGCARE
“sakit pa kaayu tissue and nerve • Obtain and monitor • To provide baseline After 8 hours of
ako tahi sa ako endings due to After 8 hours of VS every 4 hrs and data nursing
tiyan” as trauma from nursing endorse for any interventions, the
verbalized by the surgery (incision) interventions, abnormalities. patient was able
patient and cause the patient will to experience
hypersensitivity be able to • Note for the • To determine the lesser pain and
to the central experience location, scale, nursing care to be above a tolerable
Objective data: nervous system lesser pain and intensity and onset given to the patient. level as
that causes above a of pain manifested by
• facial grimace unpleasant tolerable level pain scale of
noted physical and as manifested by • Assess and record • Utilize pain 2/10, no facial
• discomfort the patient’s level of intensity rating scale grimace and calm
emotional pain scale of at
noted pain.
reactions and least 2/10, no and cooperative
• positioning to responses. facial grimace
ease pain • Maintain a calm and • To minimize
and slight
• Pale skin is quiet environment. stimulus that could
irritability
noted aggravate the Long-term goal:
• With the Long-term
condition of the
following vital patient
goal: After 3 days of
signs of: nursing
T-36.9C • Use relaxation • To promote comfort
Within 3 days of technique such as: interventions, the
PR-84bpm and relaxation.
nursing deep breathing patient was able
RR-22cpm interventions, to effectively
BP- exercise
the patient will demonstrate use
130/80mmHg
O2sat-98% effectively • Provide a dim and • To add comfort to of relaxation
Pain score: demonstrate use light but providing the patient skills and
6/10 of relaxation good ventilation diversional
skills and activities.
diversional • Provide comfort • They serve as non-
activities. measure such as pharmacological
slow rhythmic methods for
breathing, reducing
repositioning and pain/promoting
other diversional comfort
activities such as
music

• Maintain • Immobilization
immobilization of relieves pain and
affected part using prevents bone
bed rest displacement and
extension of tissue
injury.

• Elevate bed covers; • Maintains body

keep linens off toes. warmth without
discomfort due to
the pressure of
bedclothes on
affected parts.

MANAGEMENT OF MANAGEMENT OF
RESOURCES & RESOURCES &
ENVIRONMENT ENVIRONMENT
 • To promote comfort
• Raised side rails. and safety and
prevent falls.

LEGAL
LEGAL RESPONSIBILITY
RESPONSIBILITY • To adhere practices
• Informed client and on accordance with
S/O about any nursing law and
procedures other relevant
performed & legislation.
obtained informed
consent.
ETHICO-MORAL
ETHICO-MORAL RESPONSIBILITY
RESPONSIBILITY • To respect patient’s
• Provided patient’s rights.
privacy • To respect the rights
• Provided of the patient
confidentiality to
patient’s data and
records.

QUALITY
QUALITY IMPROVEMENT
IMPROVEMENT • To help identify
• Solicits feedback improvements in the
from client and delivery of
significant others healthcare
regarding care
rendered
RECORD RECORD
MANAGEMENT MANAGEMENT
• Maintained • Makes record
integrity, safety, readily accessible to
access and security facilitate client care
of records and ensures safety
of patient’s records.

COLLABORATION& COLLABORATION&
TEAM WORK TEAM WORK
• Regulated and • To keep electrolytes
monitored IVF as balanced and route
prescribed by the for possible
physician. medication
administration
Nursing Diagnosis 6: Impaired skin integrity r/t surgical incision site
ASSESSMENT SCIENTIFIC PLANNING INTERVENTIONS RATIONALE EVALUATION
BASIS
Subjective data: Impaired skin Short-term SAFE & QUALITY SAFE & QUALITY Short-term goal:
integrity defined goal: NURSINGCARE NURSINGCARE
“dako dako diay as an "altered • Obtain and monitor • To provide baseline After 8 hours of
ako tahi sa tiyan” epidermis and or After 8 hours of VS every 4 hrs and data nursing
as verbalized by dermis nursing endorse for any interventions, the
the patient destruction of interventions, the abnormalities. patient’s wound
skin layers patient’s wound will remain free
Objective data: (dermis), and will remain free • Inspect the • To determine from any signs of
disruption of from any signs surrounding skin for presence of wound infections
• Presence of skin surface of wound erythema, complication
Surgical (epidermis)". infections induration,
Wound in the maceration
RUQ in the Long-term Long-term goal:
abdominal • Encourage the • To monitor progress
goal:
area covered patient to inspect of wound healing After 1 week of
with dressing. skin on daily basis
After 1 week of nursing
• Pale skin is and to describe
nursing wound interventions, the
noted interventions, the patient will be
• With the characteristics and
patient will be changes observed. able to display
following vital
able to display timely healing of
signs of:
timely healing of wound without
T-36.9C
wound without MANAGEMENT OF complications.
PR-84bpm MANAGEMENT OF
complications. RESOURCES &
RR-22cpm RESOURCES &
BP- ENVIRONMENT
ENVIRONMENT
130/80mmHg • Raised side rails.
O2sat-98%
 • To promote comfort
and safety and
LEGAL prevent falls.
RESPONSIBILITY
• Informed client and LEGAL
S/O about any RESPONSIBILITY
procedures • To adhere practices
performed & on accordance with
obtained informed nursing law and
consent. other relevant
legislation.
ETHICO-MORAL
RESPONSIBILITY
• Provided patient’s ETHICO-MORAL
privacy RESPONSIBILITY
• Provided • To respect patient’s
confidentiality to rights.
patient’s data and • To respect the rights
records. of the patient

QUALITY
IMPROVEMENT
• Solicits feedback QUALITY
from client and IMPROVEMENT
significant others • To help identify
regarding care improvements in the
rendered delivery of
healthcare
RECORD
MANAGEMENT
• Maintained RECORD
integrity, safety, MANAGEMENT
access and security • Makes record
of records readily accessible to
facilitate client care
and ensures safety
of patient’s records.

COLLABORATION&
TEAM WORK COLLABORATION&
• Regulated and TEAM WORK
monitored IVF as • To keep electrolytes
prescribed by the balanced and route
physician. for possible
medication
administration
 DRUG STUDY

Name of Drug Classificatio Mechanism of Indication Contraindication Adverse Nursing

n Action Effects Responsibilities
Generic Name: General Inhibits proton • Symptomatic • Contraindicated CNS: asthenia, Before:
classificatio pump activity GERD in patients dizziness, • Check
Omeprazole n: by binding to Without hypersensitive to headache patient’s
Proton Pump hydrogen esophageal drug or Its name, right
Trade Name: Inhibitors potassium Lesions components GI: abdominal drug, right
adenosine • Erosive • Use cautiously in pain, constipation, route and drug
Prilosec triphosphate, Esophagitis patients with diarrhea, dosage
located at the • Zollinger- hypokalemia and flatulence, nausea, • Assess for
Patient dose: secretory Ellison respiratory and vomiting hypersensitivi
Functional
40mg IVTT surface of Syndrome alkalosis in ty.
classificatio
Q24h
n:
gastric parietal • Duodenal patients on a low- Musculoskeletal: • Instruct
cells, to Ulcer sodium diet back pain patient to take
Anti- Ulcer
suppress gastric • treatment for the drug at
drugs
acid secretion. active benign Respiratory: least 1 hour
gastric ulcer cough, upper before meals
• Frequent respiratory tract,
heartburn infection During:
• Stress ulcer • Assess
Skin: rash
• Prophylaxis dizziness that
might affect
Patient’s gait, balance,
indication: and other
Prevention of functional
ulcer activities
• Monitor other
CNS side
effects
 (drowsiness,
fatigue,
weakness,
headache).
• Monitor any
chest pain and
attempt to
determine if
the pain is
drug-induced
or caused by
cardiovascular
dysfunction

After:
• Assess for
clinical
improvement
record
• Monitor client
response and
document
drug effect.
Name of Drug Classificatio Mechanism of Indication Contraindication Adverse Nursing
n Action Effects Responsibilities
Generic Name: General diffuses into the • to treat skin • Contraindicated Appetite loss Before:
classificatio organism, infections, in patients Yeast infection • Check
Metronidazole n: inhibits protein rosacea and hypersensitive to (candidiasis) patient’s
Nitroimidazo synthesis by mouth drug or Its Diarrhea name, right
Trade Name: les interacting with infections, components Dizziness drug, right
DNA, and including • Use cautiously in Headache route and drug
Flagyl causes a loss of infected gums patients with Nausea dosage
Functional helical DNA and dental hypokalemia and Vomiting • Assess for
Patient dose: classificatio structure and abscesses. respiratory Loss of control of hypersensitivi
500mg IVTT n: strand breakage. • It's also used alkalosis in bodily movements ty.
Q8h Antibiotic Therefore, it to treat patients on a low- Dark urine • Instruct
causes cell conditions sodium diet Disulfiram-type patient to take
death in such as reaction with the drug at
susceptible bacterial ethanol least 1 hour
organisms. vaginosis and Furry tongue Low before meals
pelvic white blood cell
inflammatory count During:
disease. (neutropenia) • Assess
Metallic taste dizziness that
Patient’s Neuropathy might affect
indication: Pancreatitis gait, balance,
Infections Seizures Blood and other
clot functional
(thrombophlebitis) activities
Dry mouth Brain • Monitor other
disease CNS side
(encephalopathy) effects
Aseptic meningitis (drowsiness,
Optic neuropathy fatigue,
Stevens-Johnson weakness,
syndrome Toxic headache).
epidermal • Monitor any
necrolysis chest pain and
Decreased libido attempt to
determine if
the pain is
drug-induced
or caused by
cardiovascular
dysfunction

After:
• Assess for
clinical
improvement
record
• Monitor client
response and
document
drug effect.
Name of Drug Classificatio Mechanism of Indication Contraindication Adverse Nursing
n Action Effects Responsibilities
Generic Name: General acts on bacterial • to treat • Contraindicated nausea Before:
classificatio topoisomerase infections of in patients vomiting • Check
Ciprofloxacin n: II (DNA the skin, hypersensitive to stomach pain patient’s
fluoroquinol gyrase) and lungs, drug or Its heartburn name, right
Trade Name: ones topoisomerase airways, components diarrhea drug, right
Ciproxin IV. bones, and • Use cautiously in vaginal itching route and drug
Ciprofloxacin's joints caused underlying CNS and/or discharge dosage
Functional targeting of the by susceptible pathology, renal pale skin • Assess for
Patient dose: classificatio alpha subunits bacteria. impairment, unusual hypersensitivi
400mg IVTT n: of DNA gyrase • It is also cirrhosis. tiredness ty.
Q12h Antibiotic prevents it from frequently sleepiness • Instruct
supercoiling the used to treat fluttering in your patient to take
bacterial DNA urinary chest, the drug at
which prevents infections shortness of least 1 hour
DNA caused breath, before meals
replication. bybacteria lightheadedness,
such as E. rash, breathing During:
Coli problems, little or • Assess
• It is effective no urination, dizziness that
in treating yellowing of the might affect
infectious skin or eyes, gait, balance,
diarrheas severe headache, and other
caused byE. ringing in your functional
coli, ears, vision activities
Campylobacte problems, and pain • Monitor other
r jejuni , and behind your eyes CNS side
Shigella effects
bacteria . (drowsiness,
fatigue,
Patient’s weakness,
indication: headache).
Infections • Monitor any
chest pain and
attempt to
determine if
the pain is
drug-induced
or caused by
cardiovascular
dysfunction

After:
• Assess for
clinical
improvement
record
• Monitor client
response and
document
drug effect.
Name of Drug Classificatio Mechanism of Indication Contraindication Adverse Nursing
n Action Effects Responsibilities
Generic Name: General acts by • Symptomatic • Contraindicated CNS: asthenia, Before:
classificatio inhibiting both GERD in patients dizziness, • Check
Ketorolac n: COX-1 and Without hypersensitive to headache patient’s
NSAIDs COX-2 esophageal drug or Its name, right
Trade Name: enzymes which Lesions components GI: constipation, drug, right
Functional are normally • Erosive • Use cautiously in diarrhea, route and drug
Toradol classificatio responsible for Esophagitis patients with GI flatulence, nausea, dosage
n: converting • Zollinger- bleeding, renal and vomiting • Assess for
Patient dose: arachidonic acid Ellison impairment, hypersensitivi
30mg IVTT Analgesics to Syndrome cardiovascular ty.
Q8h PRN prostaglandins. • Duodenal disease Respiratory: • Instruct
The COX-1 Ulcer cough, upper patient to take
enzyme is • treatment for respiratory tract, the drug at
constitutively active benign infection least 1 hour
active and can gastric ulcer before meals
be found in • Frequent Skin: pallor,
platelets, gastric heartburn edema During:
mucosa, and
• Stress ulcer • Assess
vascular
• Prophylaxis dizziness that
endothelium. might affect
Patient’s gait, balance,
indication: and other
Pain functional
activities
• Monitor other
CNS side
effects
(drowsiness,
fatigue,
 weakness,
headache).
• Monitor any
chest pain and
attempt to
determine if
the pain is
drug-induced
or caused by
cardiovascular
dysfunction

After:
• Assess for
clinical
improvement
record
• Monitor client
response and
document
drug effect.
 DISCHARGE PLANNING
● Advised to complete the whole course of the medication treatment.
Medications ● Advised not to stop taking prescription medication without talking to
the doctor.
● Advised not to share prescription medication.
● Advised S.O to ensure patient to stay hydrated all the time.
Environment ● Advised S.O to let the patient be in well-ventilated places
● Advised patient to rest as directed.

Treatment ● Remind the S.O to follow the schedule for patient’s follow check-up.
● Advice to comply with the treatment.
Contact your doctor if the ff occurs:
● Severe pain in your upper right or center abdomen.
● Pain that spreads to your right shoulder or back.
Observable Signs and ● Tenderness over your abdomen when it's touched.
Symptoms ● Nausea.
● Vomiting.
● Fever
● You have questions or concerns about your condition or care.

● Encourage the patient to eat nutritious food such as eggs, fish, potato,
and fruits such as bananas, apple, avocado, oranges.
● Increase fluid intake at least 6-8 glasses of water in a day.
● Avoid caffeinated drinks
Diet ● Avoid high-fat foods, such as: fried foods, canned fish, processed
meats, full-fat dairy products, processed baked goods, fast food, and
most packaged snack foods.
● Avoid drinking alcohol
● Avoid smoking
● Avoid gas-forming foods (beans, cabbage, cauliflower, broccoli)
● Allow client to express positive feelings of spirituality
Spirituality ● Always have faith in God and ask for help and guidance
● Encouraged the patient and family outlook prior and during recovery
 HEALTH TEACHING PLAN

Topic: Health promotion and disease prevention of cholecystitis

Goal: After 35 minutes of nurse-client interaction, the patient will recognize the importance of health promotion and to know the
cholecystitis prevention.

Learning
Learning Content Learning Activity Time Allotment Teaching Style Evaluation
Objectives
After 35 minutes of I. Introduction 5 minutes After 35 minutes,
health teaching, the Introduce oneself, the patient was able
patient will be able establish rapport to identify the
to: and inform pt what terms discussed, the
Definition of terms: will be happening causes of present
condition and its
1. Define what • Cholecystitis is II. Lecture 30 minutes Conversational managements.
cholecystitis is a redness and Proper (one on one
swelling • Definition of discussion)
(inflammation) terms
of the • Causes of
gallbladder. It Cholecystitis
happens when a • Health
digestive juice promotion and
called bile gets prevetion of
trapped in your cholecystitis
gallbladder.

2. Discover the
causes of • Gallstones
cholecystitis blocking the
tube leading out
 of the
gallbladder
cause
cholecystitis.
This results in a
bile buildup that
can cause
inflammation.
Other causes of
cholecystitis
include bile duct
problems,
tumors, serious
illness and
certain
3. Identify ways of infections.
health promotion
and prevention. Eating a healthy
diet:
-Eat a variety of
vegetables and
fruits. These are
high in nutrition and
low in fat.

-Whole grains
(whole-wheat
bread, brown rice,
oats, bran cereal)

-Lean meat, poultry,

and fish
-Low-fat dairy
products

-consumes a low fat

diet rich in HDL
sources such as
seafood, nuts, olive
oil)

-take fat-soluble
vitamins or bile
salts as prescribed
to enhance
absorption and aid
with digestion.

Avoid high-fat
foods, such as:
-Chocolate, whole
milk, ice cream,
processed cheese,
and egg yolks.

-Fried, deep fried,

or buttered foods.

-Sausage, salami,
and bacon.

-Cinnamon rolls,
cakes, pies, cookies,
and other pastries.
-Prepared snack
foods, such as
potato chips, nut
and granola bars,
and mixed nuts.

-Coconut and
avocado.

-Fast food and

convenience food
meals that have lots
of fat.

-avoid gas-forming
foods such as beans,
cabbage,
cauliflower and
broccoli)

Exercise:
Exercise reduces
cholesterol, and the
lower the
cholesterol level.

Such as:
Walking, jogging,
and etc.

-avoid low-calorie,
rapid weight loss
diets. There's
evidence they can
disrupt your bile
chemistry and
increase your risk of
developing
gallstones.

Avoid smoking:
Smoking can
elevate the LDL, or
“bad,” cholesterol
in your blood and
decrease HDL, or
“healthy,”
cholesterol.

Avoid drinking
alcohol:
drinking alcohol
raises the
triglycerides and
cholesterol in your
blood.