Pines City Colleges

(Owned and operated by THORNTONS INTERNATIONAL STUDIES, Inc.)

COLLEGE OF NURSING
Magsaysay Ave. Baguio City 2600

A CASE STUDY PRESENTED TO THE

FACULTY OF THE COLLEGE OF NURSING
ON
Choledocholithiasis

In Partial Fulfillment of the Requirement in NCM 112 Related Learning

Experience (RLE)

Submitted by:

Area of Rotation: Medical Surgical Ward

Date of Rotation: September 11-13, 2023
Date Submitted: September 16, 2023

Submitted to:
Marjorie Ilonen BSN, RN

Clinical Instructor

A. PATIENT PROFILE
Name: Patient AB

Age: 67 years old

Sex: Female

Address: 29 Modesta ST. Mines View, Baguio City, Benguet

Civil Status: Single

Birthdate: December 15, 1995

Weight: 57 kg

Height: 152.4 cm

Race /Culture: Asian

Occupation: Self-employed (Retired Nurse)

Educational level: College Graduate

Significant others: Daughter

Religion: Roman Catholic

Nationality: Filipino

Ethnicity: Tagalog

CHIEF COMPLAINT: Abdominal pain in RUQ

Admission Date: February 15, 2023

ADMITTING DIAGNOSIS: Small bowel thickening right hemiabdomen choledocholithiasis

rectosigmoid adenocarcinoma

FINAL DIAGNOSIS: Upon admission for surgery (choledocholithiasis)

MEDICAL HISTORY

a. HISTORY OF PAST ILLNESS

The patient's medical history includes several significant events. In the year 2000, she underwent
a hysterectomy. In 2005, she received a diagnosis of breast cancer, leading to a mastectomy where her
right breast was removed. Subsequently, she underwent a rigorous six-month course of chemotherapy. In
June 2022, the patient experienced issues related to a rectosigmoid colon blockage, which necessitated a
colostomy procedure to alleviate the passage of stool. From June to November 2022, she underwent
chemotherapy to manage her condition. On November 28, 2022, a major operation was performed,
resulting in the removal of a large portion of her intestine. In April 2021, the patient initiated
chemotherapy once again. However, in August 2023, she presented with severe upper abdominal pain in
the right quadrant and sought hospitalization at SLU. During her hospitalization, procedures such as
ERCP (Endoscopic Retrograde Cholangiopancreatography) and colonoscopy were performed, but no
abnormalities were observed. Specimens were sent for histopathological analysis, which also did not
reveal any significant findings.

b. HISTORY OF PRESENT ILLNESS

The patient was readmitted to Pines City Doctors Hospital on September 8 due to severe and
intolerable abdominal pain localized in the upper right quadrant of her abdomen. Following a thorough
evaluation by the medical team, it was determined that the severity and nature of her pain warranted
another exploratory laparotomy procedure. This decision was made in consultation with the attending
 physicians, aiming to investigate the underlying cause of her distressing symptoms and to provide
appropriate medical intervention.

c. FAMILY HISTORY

Upon interview, the patient mentioned that her sister died in the year 1980’s because of luekemia.
Both of her parents has no history of hypertension and diabetes as claimed by the patient, “Wala
malalakas yung mga magulangko yung nanay ko namatay dahil sa matanda na, yung tatay ko naman
nabunggo ng truck.” But her brother has tuberculosis.

B. DEVELOPMENTAL DATA

HAVIGHURST’S THEORY OF DEVELOPMENTAL DATA

According to Havighursts, learning is fundamental to life and in order to have a deeper insight on
growth and development, one must understand and recognize the premise that the human being continues
to learn throughout life. Happiness is being achieved when a particular task of a certain age is achieved by
the person successfully but if not, failure occurs which is a feeling of unhappiness and disapproval from
people surrounding the client.

The patient is 67 years old and she is categorized under elderly wherein her developmental tasks are:

Below are the met/unmet tasks for this view:

Task Met/Unmet Justification

Achieving adult civic
and social responsibility
Met Patient AB achieves adult civic and social responsibility as she was
an active member of the Roman Catholic. The patient verbalized
that, “lagi kaming nagsisimbang pamilya simba, bahay, trabaho
kami madalas.” She enjoys being with neighbors so whenever
there’s a harvesting of onion they set together and clean it.

Establishing and Met The patient works as a farmer and they have business that supports
maintaining an economic their daily needs, and bills.
standard of living

Assisting teenage Met Assisting adolescent children is where she was able to care for her
children to become child, who is 23 years of age. The patient also assists the family
responsible and happy members since she is a retired nurse.
adults

Relating oneself to one’s Unmet Relating oneself to one's spouse is unmet as she is single but she
spouse as a person has adopted child and has a strong relationship with her family.
Her significant other is providing for their needs during her
hospitalization.

Accepting and adjusting Met The patient verbalize that, “ganito talaga kapag tumatanda na may
to the physiologic mga bagay na hindi magawa, mabilis mapagod pero malakas pa
changes of middle age. naman ako.”

The patient almost achieved all the tasks. She still involves herself in civic and social responsibility.
She assists her child to become responsible and happy adults by taking care of the family members.
During leisure time, she watches television and socializes with his family and relatives. She also relates
her old self to other nurses and respects them as they are. She accepts and adjusts to the physiologic
changes happening to her and, she gives back the love and care she had when she was still young.

ERIKSON’S STAGES OF DEVELOPMENT

According to Erikson, development depends primarily upon what a person does. While he was
influenced by Freud’s ideas, Erikson’s theory differed in a number of important ways. He believed that
 personality develops in a series of predetermined stages and that, the impact of social experience across
the whole lifespan.

Central task: Adulthood = Generativity versus Stagnation

This central task emphasizes that a person might have a virtue of caring whereas she nurtures
others and contributes to society.

Below are the met/unmet tasks for this view:

TASK MET/ JUSTIFICATION

UNMET

Generativity vs. Stagnation
At this stage of life, individuals
are pulled in all directions with
parenting, family obligations,
community participation and
children.
Met The patient achieved generativity as evidenced by being a
committed and a loving mother to her child, and family
member. She likes to share her blessings to her neighbors.
Since they live in a compound together with their relatives.
She still works and participates in the activities conducted by
their barangay like free medical checkup.

C. 13 AREAS OF ASSESSMENT

PSYCHOSOCIAL STATUS

Patient AB, female, and belongs to the Ilocano ethnic group. Her educational attainment is
college graduate and now self-employed as a retired nurse. She actively participates in community
activities such as working in the barangay and is also a registered voter. She felt delighted and grateful for
having her adopted daughter take care of her during her stay at the hospital.

MENTAL AND EMOTIONAL STATUS

Upon assessment, the patient can converse properly. She is aware that she is in the hospital,
admitted for severe abdomen pain and has undergone colostomy and mastectomy operation. She was also
able to state the date, and day. The client also stated her past experiences of work abroad.

ENVIRONMENTAL STATUS

Patient lives in a compound together with her relatives and it was along the road. Their house is a
cement type with good lighting and ventilation.

SENSORY STATUS

 Visual

Upon observation, the patient was not wearing any eyeglasses or contact lenses. She was
instructed to look straight at the notebook with 1 foot to observe the general appearance of her eyes.
However, upon letting her read a small size letter it was a little bit difficult with her eyes slightly closed
but able to read what is written. But when let her read a bigger letter size she immediately read what was
written and pronounced the word even its letters. No colorblindness was noted after answering
appropriately to what color the green isolation gown, blue notebook, and a red blanket are.
 Auditory

Upon performing the whisper test, covering one side of her ears alternately and whispered
“kumusta po,” then she was able to repeat the words being whispered.
 Olfactory

During the assessment, she was tested if she is able to distinguish the item upon smelling it
with closed eyes, particularly the smell of orange, and vicks and she was able to distinguish the
items. .
  Gustatory

The patient had no difficulty swallowing. The patient can distinguish between sweet, sour,
salty, and bitter flavors. As she verbalized, “Mapait ang gamot, matamis yung papaya at orange,
at sakto lang yung lasa ng pagkain hindi maalat, hindi rin kulang sa asin.”
 Tactile

Regarding the patient's tactile status, the patient is capable of differentiating between sharp
and dull, light and firm touch, as well as heat, cold, and pain in relation to stimulus. As I touched
her, she stated that “ang lamig ng kamay mo.”

MOTOR STATUS

Her movements are limited and feels weak during the hospital stay. With it, she needs minimal
assistance whenever she get up from bed. She was able to walk but with assistance from her daughter.
The patient also can lift spoon as she eats, and she can drink on her own.

NUTRITIONAL STATUS

The patient claims that she often eats vegetables 3x a day and rare on meat. Since, they live near
the field and they have lots of vegetables on their backyard. But the patient drinks less than 8 glasses of
water for about 4-5 glasses of water. She often drinks herbal tea such as green barley, ginseng, oregano,
avocado and sambong.

ELIMINATION STATUS

 STOOL: Did not defecate during the hospital stay.

 URINE: The patient has a urine color of yellowish urine.

DATE TIME AMOUN

T

09/11/2023 7am-3pm shift 100 ml

09/11/2023 7am-3pm shift 50 ml

Implication: Patient’s elimination states that she does not have a regular bowel elimination pattern.

FLUID AND ELECTROLYTE STATUS

Date Shift/Time IVF Amount Consumed OFI

09/11/2023 7-3 shift

3 7:0am - 3:00 pm PNSS 1L x KVO N/A
120 mL

09/11/2023 7-3 shift 500 mL N/A

7:0am - 3:00 pm TPN 1400 kcal x 24
09/11/2023 7-3 shift KCL 20 mEqs in 70 mL N/A
7:0am - 3:00 pm 100ml PNSS x 4
TOTAL 690mL

CIRCULATORY STATUS
Date Shift BP PR SPO2
09/11/2023
7-3 shift 8:00 am 120/80 mm/Hg 70 95% @ RA
7:0am - 3:00 pm
10:00 am 120/80 mm/Hg 84 95% @ RA
 12:00 pm 130/80 mm/Hg 77 95% @ RA

2:00 pm 120/80 mm/Hg 79 96% @ RA

*** Patient AB has a normal blood pressure ranging 120/80-130/80.

The patient pulse rate, blood pressure, oxygen saturation, are normal.

RESPIRATORY STATUS
Date Shift RR
09/11/2023
7-3 shift 8:00 am 16 bpm
7:0am - 3:00 pm
10:00 am 17 bpm

12:00 pm 16 bpm

2:00 pm 18 bpm

*** Patient AB respiratory status were all normal. It ranges from 16 bpm to 18 bpm this patient does not
experience any difficulty during inhalation and exhalation.

TEMPERATURE STATUS
Date Shift Temp
09/11/2023
7-3 shift 8:00 am 36.5 ° C
7:0am - 3:00 pm
10:00 am 36.6 ° C

12:00 pm 36.7 ° C

2:00 pm 36.5 ° C

*** Temperature of patient AB ranges from 36.5-36.7° C which means patient X doesn’t experience any
fever during 7-3 shift.

INTEGUMENTARY STATUS

Skin is light brown with no wounds /lesions noted upon inspection. Hair is well kept by the
patient with a hair color of black with few gray hairs and well-distributed hair with no infestations of lice
or dandruff. Nails are white, well-trimmed with no observed wounds nor dirt, with a noted capillary refill
of 1 second. The scalp is tender and shows no presence of oiliness and dryness, scars, lesions, and lice.

REST, SLEEP, AND COMFORT STATUS

Patient claimed she was able to sleep properly for at least 6 to 8 hours at night and woke up
during medication and if an assessment needed to be done. She takes a nap in the daytime. However,
sometimes she can’t sleep well due to the pain she experienced.

D. PATHOPHYSIOLOGY
E. LABORATORY RESULTS AND FINDINGS
BLOOD TEST
NAME: Pt. AB
AGE: 67
SEX: Female
DATE: 09/09/2023

Results:

ABO typing and RH typing: “O” Rh Positive

COAGULATION
Examination Desired: Prothrombin Time (PTPA), Activated Partial Thromboplastin Time (APTT)
Specimen: Citrated Plasma
Method: Mechanical (STAGO COMPACT MAX)
Results:

PTPA Normal Value

13.1 seconds 11.7-15.3 seconds

APTT Normal Value

21.5 seconds (Repeated) 24-25 seconds

CLINICAL CHEMESTRY
NAME: Pt. AB
AGE: 67
SEX: Female
DATE: 09/10/2023

TEST NAME RESULT/S NORMAL VALUE

Sodium 141.0 mmol/L 133-148 mmol/L

Potassium 2.88 mmol/L (Repeated) 3.5-5.3 mmol/L

CBC RESULT

Result Normal Value Result Normal Value

RBC COUNT: 3.87 3.8-6.5 10^6/mm^3 WBC COUNT: 5.80 5.0-10.0 10^3/mm^3

Hemoglobin: 13.8 11.5-17.0 G/dl Neutrophils%: 62.0 50-70

Hematocrit%: 39.1 37.0-54.0 Lymphocytes%: 30.9 22-40

MCV: 101.0 78-100 um^3 Monocytes%: 6.4 2-9

MC Hgb: 35.6 27-32 pg Eosinophils%: 0.7 0-4

MC Hgb Co: 35.3 32-36 G/dl Basophils%: 0.0 0-1

RDW%: 15.4 11-16 Neutrophil#: 3.60 2-8

PLATELET: 314 150-400 10^3/mm^3 Lympohocytes#: 1.79 1-5

MPV: 8.4 6.0-11.0 um^3 Monocytes#: 0.37 0.1-1.0

Eosinophils#: 0.04 0-0.4

Basophils#: 0.00 0-0.2

NURSING PRIORITIZATION

PRIORITIZATIO ACTUAL/ JUSTIFICATION

N POTENTI
AL

1 Risk for infection Potential The body has localized infections considering that she
undergone major operation.

Acute pain Actual This nursing problem is classified as physiological needs. It is

2 considered a real problem that requires as much immediate
attention and intervention as possible because it was verbalized
by the patient.

3 Anxiety Actual If addressed it will promote rest and comfort.

4 Sleep pattern Actual This nursing problem is classified as physiological needs.

disturbance

RADIOGRAPHIC REPORT
EXAM REQUESTED: ABDOMEN SUPINE & UPRIGHT(FPA)
DATE: 09/08/2023
FINDINGS: In the supine image there are dilated gas filled small bowl loops are seen while in the erect
image there are horizontally oriented row of small gas bubbles. No evidence of free air, gross
organomegaly or abnormal calcification is appreciated. Flank stripes and psoas shadows are intact.
Degenerative Osseous changes are seen.
IMPRESSION: SMALL BOWEL OBSTRUCTION

EXAM REQUESTED: CHEST PA

DATE: 09/08/2023
FINDINGS: No active lung infiltrates, heart is not enlarged. The aorta is tortuous and calcific pulmonary
vascularity is within normal. Diaphragm and costophrenic sulci are intact. Bones are unremarkable.
IMPRESSION: CLEAR LIUNGS, ATHEROMATOUS AORTA

EXAM REQUESTED: BARRIUM ENEMA KIT

SMALL INTESTINAL SERIES (SIS) X-RAY
DATE: 09/10/2023
HISTORY: Known case of Sigmoid Cancer Status post subtotal Colectomy
COMPARISON: None
TECHNIQUE: Small intestinal series
FINDINGS: Scout film shows segmental dilation of the small bowel with undifferentiated air fluid levels.
No evidence of free air, gross organomegaly or abnormal calcification is appreciated. Flank stripes and
psoas shadows are intact. Introduction of barium contrast material per orem (1:3 dilution), of
approximately 180cc shows opacification of the stomach. The stomach appears well opacified with a
normal mucosal pattern. The mucosal fold pattern of the small bowel maintains its normal feathery
appearance. The duodenal-jejunal junction is in its normal location excluding malrotation. On the 30-
minute study a suspicious area of transition from undilated to dilated small bowl, still in the area of the
proximal jejunum. There is no delay in the transit of contrast material from jejunum down to the ileocecal
area. There is an increase in caliber of a part of the proximal jejunum, distal jejunum, and ileum. Spot
films of the ileocecal region show no abnormal findings. On 24 hours delay there is significant contrast
retention of the dilated small bowel loops.
IMPRESSION: CONSIDER PARTIAL SMALL INTESTINAL BOWEL OBSTRUCTION WITH THE
AREA OF TRANSITION IN THE PROXIMAL JEJUNUM, CORRELATE WITH PREVIOUS CT
SCAN STUDY.