PERPETUAL HELP COLLEGE OF MANILA 1240 V. Concepcion St.

, Sampaloc, Manila

College of Nursing

In partial fulfillment of the requirements for NCM 204 RLE Grand Case Presentation on CHRONIC CALCULOUS CHOLECYSTITIS

Submitted by: Nacis, Michiko Grace D. Pascual, Garnet D Sagun, Star M. Sanuco, Janine Vittoria M. Sison Elizabeth C. Soller, Glychelle Maia M. Supan, Richard Nixon Y. Tumolva Dante M. Vergel, Kaycee G. Villasanta, Nuclie Lee B. Yongco, Jenifher A.

I.CLIENTS DATA PATIENT: PS AGE: 40 years old GENDER: Male BIRTHDATE: August/7/1971 ADDRESS: 118 Barangay Sta. Cruz A.D Sapang Palay, Bulacan CIVIL STATUS: Married SPOUSE: AS (Housewife) Children: PS (18 y/o) Third Year College ES (17 y/o) Second Year College DS (14 y/o) Second Year High School OS (12 y/o) Grade VI RS (8 y/o) Grade III EDUCATIONAL ATTAINMENT: High School Graduate RELIGION: Catholic NATIONALITY: Filipino OCCUPATION: Jeepney Driver ADMISSION DATA DATE OF ADMISSION: July 5, 2011 INITIAL DIAGNOSIS Cholelithiasis DIAGNOSIS: Chronic Calculous Cholecystitis CHIEF COMPLAINT: Abdominal Pain, Right Upper Quadrant DATE OF ASSESSMENT: July 8, 2011

A2. PRESENT HEALTH HISTORY Seven months prior to his admission, patient drinks 2-3 bottles of San Miguel a week and smokes 4-5 sticks of cigarette/day.( Dec, 28 2010) patient had his check up in Roquero General Hospital, Sapang Palay, San Jose Del Monte, Bulacan for having experienced of jaundice and sudden onset of pain in the right upper quadrant of the abdomen with nausea and vomiting. Jaundice may also be seen as yellowing of the skin, sclera (Icterus). He had an increased level of pain so he took Mefenamic acid as a pain reliever prescribed by the doctor. He experienced the pain until 1-2 hours especially during after meal. He encouraged his self to socialize to others like neighborhood because it helps to reduce or control pain. Six months prior to his admission, he was still suffering from pain with the level of 6 out of 10. He also had insidious symptoms of clay colored stool and dark yellow urine result from obstetric process without fever. He experienced mild to moderate pain with loss of appetite. Low fat diet to prevent further pain of biliary colic. He experienced pruritus or burning sensation especially during bed time. July 2, 2011 he was confined in Roquero General Hospital. The patient was still suffering with the level of 8 out of 10 severe pain and he cant tolerate the pain. Duration of pain is 30 minutes -1 hour. 3 days PTA patient experienced severe pain on right upper quadrant so he consulted in Roquero General Hospital. He was suffering a severe pain with a level of 8/10. On July 5, 2011, he was then transferred to East Avenue Memorial Medical Center for further examination.

A1. PAST MEDICAL HISTORY SP is fond of eating meats, salt cured foods, likes condiments (especially fish sauce), chicharon, oily foods. He drinks 2-3 bottles of San Miguel beer per week and smokes 4-5 cigerettes per day. SP experienced common illness such as colds, cough, chicken pox, and fever during his childhood and had completed his immunization. However he could not recall at what age he got the disease. He has an allergy on sea foods but no allergy on drugs. The patient does not participate in any sports, exercises and routine. SP goes to Roquero General Hospital for his check-ups.

A3. FAMILY HEALTH HISTORY The patients father is hypertensive which he inherited together with his youngest brother. He has 5 children (3 boys, 2 girls). His first and fourth child has asthma which they inherited from their grandmother (mothers side). The patient is the only one in the family who had a chronic calculous cholecystitis. A4. SOCIAL HISTORY Patient P.S is a High school graduate from Marcelo H. Del Pilar National High school. His occupation is a jeepney driver. Hes the bread winner of his family. He drinks 2-3 bottles of San Miguel a week and smokes 4-5 sticks of cigarette per day. The patient does not participate in any sports, exercises or routine. Patient is a Roman Catholic who usually goes to church every Sunday or whenever possible to attend the mass or even just to offer a prayer. He have 5 children and they are all close to each other. They all live in Bulacan. Patient is a very active and friendly person. He loves to socialize with his friends in their neighborhood during his free time. He considered his self as a holistic human being as long as hes complete, healthy and his family is always there for him. Patient puts his self to sleep by watching primetime television programs. He does not have usual time of sleep. He sleeps for a long period of time.

GENOGRAM

Wifes side

Patients side

Father

Mother Asthma

Father hypertension

Mother

v Brother Sister Brother Asthma hypertension Wife Sister Patient hypertension Chronic Calculos Cholecystitis 39 yrs old Sister Sister Brother Sister

Asthma

Asthma

Asthma

The patient, his father and his youngest brother is hypertensive The patient is married to Ms. AN on June 8 1995. He is a high school graduate from Marcelo H. Del Pilar Natinal High Shool, Bulacan. They live in the same household together with his parents. They have five children. He is the only one in his family who got Chronic Calculous Cholecystitis.

Two of his children got asthma from their mother side.

B.Risk Factors Associated with Disease B1. Non- modifiable Age B2. Modifiable Risk Factors lifestyle high- fat diet (chicharon, meat specially pork) Drinking liquor Smoking Fond of eating salty foods

III. PHYSICAL ASSESSMENT

GENERAL SURVEY: The patient was admitted at East Avenue Memorial Medical Center Male Surgical Ward Room4019D.The patientt appeared weak with yellowish skin color. His hair is well groomed and no body odor being noted during assessment. He is cooperative and responds to questions appropriately with weak voice and low tone.

Initial Assessment: Taking of Vital Signs DATE OF ADMISSION: July 5, 2011 (Tuesday) DATE OF ASSESSMENT: July 8, 2011 (Friday) DIET: NPO

PRE OPERATIVE

Vital Sign Temp

Technique Digital Thermometer via Axilla

Normal Findings 35.8-37.0C

Actual findings 37.2C

Analysis Normal

Interpretation The normal axillary temperature is between 35.8 to 37.0C (Udan, 2009, p.249).

In other literature, the usual range of normal is 36.0 to 37.8 [without routes indicated]. (Kozier, 2008, p.528) Pulse Rate Taken in radial artery (thumb side of the inner aspect of the wrist) 60-100bpm 80bpm, regular rhythm, normal strength, bilaterally equal on radial pulses Normal The normal pulse rate for adults is between 60 to 100 beats per minute.

(Udan, 2009, p.251)

Respiratory Rate

Inspection of the rise and fall of chest cavity over 1 minute

12-20 cpm

32cpm

Elevated RR

Tachypnea is rapid respiration above 20 breaths per minute in an adult. (Udan, 2009, p. 253) Due to abdominal pain

B/P Rate

Auscultation and BP apparatus, left arm

Systolic: 90-120 mmHg Diastolic 60-80mm Hg

150/90mm Hg

Hypertensiv e

Factors associated with hypertension include thickening of the arterial walls, which reduces the size of the arterial lumen, and inelasticity of the arteries as well as such lifestyle factors cigarette smoking, heavy alcohol consumption, lack of physical

exercise,high blood cholesterol level and continued exposure to stress

Ref. Fundamental by Kozier 8th edition, p. 552

Appearance and mental status

Assessment Body built, height and weight Posture Gait, standing, seating and walking Over all hygiene and grooming body and breath odor

Techniques Inspection

Normal findings Proportionate BMI= 18.5-24.9 Relaxed, erect posture; coordinated movement No body order or minor body odor relative to work or exercise; no breath odor No distress noted

Actual findings Proportionate BMI= 24.5 Patient is lying on bed in a fetal position No presence of body or breath odor noted; patient is well groomed and neat appearance With facial grimace

Analysis Within Normal Range

Inspection

Due to RUQ pain

Inspection

Normal

Signs of distress in posture or facial

Inspection

Due to RUQ pain

expression Quantity of speech; quality and organization Inspection Understandable, moderate phase, clear tone and inflection; exhibits thoughts association Healthy appearance With weak voice and low tone. Patient cant speak clearly because he was disturbed by the pain he felt Jaundice or icterus, is the yellow pigmentation of the sclerae, skin, and deeper tissues caused by excessive accumulation of bile pigments in the blood. It is a common manifestation of a variety of liver and biliary diseases and serves as a starting point for evaluating many of these disorders

Obvious signs of health or illnesses

Patient is jaundice and exhibited signs of weakness; there are no visible lessions noted

Integumentary (skin) Body part Color Technique used Inspection Normal findings Actual findings Analysis Jaundice appears when there is an obstruction in the common bile duct. It results from the impaired bilirubin transport and excretion in the biliary system. In this case, the problem arises from obstruction of an extra hepatic bile duct by gallstones. Ref. Medical- Surgical Nursing 6th Edition Vol.2, by Joyce M. Black Normal

Varies from light to deep Yellowish brown, from ruddy pink to light pink, from yellow overtones to olive

Uniformity of color

Inspection

Generally uniform except Yellowish for those areas exposed to sun, pigmentation. Moisture in the skin folds Moisture skin and axillae.

Skin moisture

Inspection Palpation

Skin temperature

Inspection Palpation

Uniform within the normal Skin temperature is range. uniform throughout the body. When the skin is pinched, Poor skin turgor brings back to previous state.

Normal

Skin turgor

Inspection Palpation

This indicate that the person is dehydrated (+) vomiting Ref. Fundamental by Kozier p. 580

Skin Itching

Inspection

(+) Pruritus

Pruritus is the most common skin symptoms; occurs with dry skin, aging, drug reactions, allergy, obstructive jaundice, uremia. Presence or absence of pruritus may be significant for diagnosis. Scratching may cause excoriation of primary lesion. Ref. Physical Examination and Health Assessment 3rd Edition by Carolyn Jarvis,

p.218)

Integumentary (nails) Body part Fingernail plate shape and curvature Technique used Inspection Normal findings Convex structure and 160 Actual findings Convex structure and 160 Analysis Normal

Fingernail and toenail texture and color

Inspection Palpation

Smooth Texture and color

Smooth in texture, and Due to low hematocrit value slowly returns to pink or usually indicates the person usual color upon has anemia performing blanch test (fundamental by Kozier,

of capillary refill.

p.800) Arterial insufficiency (fundamental by Kozier, p.800)

Head

Body part Skull

Technique used Inspection Palpation

Normal findings Smooth, no lumps, Absence of nodules or masses, No area of tenderness,Symmetrical with protrusions on the lateral part of parietal forehead and occipital bone.Rounded, and normocephalic and symmetrical.

Actual findings Smooth, no lumps, absence of nodules or masses, no area of tenderness, symmetrical, rounded, and normocephalic

Analysis Normal

Scalp

Inspection Palpation

Lighter in color than complexion, no scars, no lesions, no masses, no depression upon palpation.

Lighter in color than complexion, no scars is noted, no lesions, no masses, no depression upon palpation. No nits, no lice and no dandruff

Normal

Hair

Inspection

Evenly distributed hair Black or Brown in color, hair is evenly distributed, No area of baldness, thick, fine.Curly/kinky/straight, Dry/oily/shiny hair

Black in color, straight hair and evenly distributed

Normal

Face

Inspection

Appearance, symmetrical Facial Grimace. facial expressions and well jaundice. coordinated facial movements.

Facial grimace due to his pain at right upper abdominal quadrant. Jaundice appearance is cause by excessive accumulation of bile pigment in the blood. It is common manifestation of a variety of liver and biliary diseases and serve as a starting point for evaluating many of this disorder (Medsurg black, p.1135)

Eyes

Body part Eyebrows

Technique used Inspection

Normal findings Hair evenly distributed; skin intact

Actual findings Hair evenly distributed, aligned, color black and well-coordinated movement Evenly distributed and slightly curved outward. -Skin is intact and lids close symmetrically. The eyelids blink within the normal range

Analysis Normal

Normal

Eyelashes

Inspection

Equally distributed, curled slightly outward Skin intact, no discharge, no discoloration. Lids close symmetrically. Approximately 15 to 20 involuntary blinks per minute; bilateral blinking Shiny, smooth, moist, pinky, shiny, with visible blood vessels and no discharge

Eyelids

Inspection

Normal

Conjunctiva

Inspection

Yellowish

Resulting from the increased levels of bilirubin in the blood (hyperbilirubinemia) Reference (Virginia L. Cassmeyer p.1496)

Body part Sclera

Technique used Inspection

Normal findings Appears white,clear and vascular

Actual findings yellowish

Analysis Deviationfrom normal due to effect of bilirubin in the blood stream. Reference (Virginia L. Cassmeyer p.1496) With yellowing of the sclera of the eyes resulting from the accumulation of the bile pigments in those tissues. (essentials of anatomy and physiology by seely page 474) Sclera of the eye, which contains considerable elastic

fiber in which jaundice can be affected because bilirubin has a special affinity for elastic tissue. (Pathophysiology by Lipincott, Page 850, Fourth Edition) Cornea Inspection Transparent, shiny and smooth; details of the iris are visible Transparent, shiny and smooth. Normal

Iris

Inspection

No shadows of light, brown and no cloudiness. Symmetrical, round, transparent/ shiny

No shadows of light, brown and no cloudiness. Symmetrical round, transparent and shiny

Normal

Pupil

Inspection

3mm-7mm in diameter. The technique used is Black in color, equal in size, Direct and Consensual round, smooth border. reaction to light. 3mm7mm in diameter. Black in color, equal in size, round, smooth border. illuminated pupil constricts Illuminated pupil while non constricts while

Normal

normal

illuminated dilates Pupil constricts when looking near object while when looking distant objects, it dilates.

non illuminated dilates Pupil constricts when looking near object while when looking distant objects, it dilates Both eyes are coordinated, move in unison with parallel alignment When looking straight ahead, client can partially see objects periphery. 20/20 both eyes Normal

Extra ocular Muscles

Inspection

Both eyes are coordinated, move in unison with parallel alignment When looking straight ahead, client can see objects periphery.

Visual Fields

Inspection

Ears Body part Auricles Technique used Inspection Palpation Normal findings Color same as in facial skin Actual findings Ear lobes are bean shaped, parallel and symmetrical. The upper connection is parallel with the outer canthus of the eye same in color as complexion, no lesions. Analysis normal

Auricle is aligned in with the outer canthus of eye

Mobile, firm, and not tender; pinna recoils back after it is folded External ear canal and Tympanic membrane Inspection Contains hair follicles, moist waxy cerumen and no foreign body

Has a firm cartilage. Pinna recoils when folded. No pain or tenderness. Presence of wet cerumen in both ear, no skin lesions, no pus and no blood and have presence of hair follicles Normal

Nose Body part Nose Technique used Inspection Palpation Normal findings Symmetric, straight, uniform in color, No discharge or flaring, no tenderness, no lesions, presence of cilia Actual findings Uniform in color in facial skin, straight, presence of cilia and no discharge Analysis normal

Nasal Cavities

Not tender, no lesions, mucosa is pink, clear and no lesions

No swelling, no presence of discharges. No lesions and pink mucosal layer

Normal

Normal Nasal Septum Intact and in midline Intact between the nasal chambers Normal

Patency

Air moves freely when breathing

Patency shallow breathing

Due to abdominal pain

Sinuses

No tenderness on maxillary No tenderness on and frontal sinuses maxillary and frontal sinuses

Normal

Mouth

Body part Lips

Technique used Inspection

Normal findings

Actual findings

Analysis Abnormal findings due to poor oral hygiene, smoking caused by nicotine. - Fundamentals of Nursing by Taylor,Lillis,LeMone, Copyright 2005, (p.583)

Uniform pink in symmetrical, dark in color, soft, color moist, smooth texture, symmetry of contour, ability to purse lips and no tenderness

Buccal Mucosa

Inspection Palpation

Pinkish in color, Moist, smooth, and elastic structure, no lesions 32 adult teeth, smooth and white

Pinkish in color, Moist, smooth, and elastic structure, no lesions Has incomplete adult teeth 18 (10 teeth at the upper area of the mouth and 8 teeth at the lower part) with yellow discoloration of teeth. Presence of tartar

Normal

Teeth

Inspection

Dark in discoloration of teeth due to cigarette smoking. Nicotine plays a part in discoloration of teeth. - Fundamentals of Nursing by Taylor,Lillis,LeMone, Copyright 2005, (p.583)

Gums

Inspection

No retraction of gums and No retraction of gum, Dark discoloration due to bleeding, pinkish in color. bleeding and moist. Dark smoking, nicotine plays a discoloration part in discoloration of the gums.

Tongue / Floor of the mouth

Inspection Palpation

Central position, pinkish in color, no lesions and raised Central position, whitish A white coating on the papillae. It has prominent in color, no lesions and tongue from poor oral

veins

raised papillae. It has prominent veins.

hygiene, irritation and smoking. - Fundamentals of Nursing by Taylor, Lillis, LeMone, Copyright 2005, (p.583)

Moves freely and no tenderness, smooth with no palpable nodules Palates Uvula Inspection Light pink, smooth palate. Lighter pink in hard palate than soft palate Positioned in the midline of soft palate.

Moves freely and no tenderness, smooth with no palpable nodules Palate: Yellowish soft and hard palate Uvula: moist, moist, smooth texture

Jaundice is first noted in the junction in the hard and soft palate in the mouth and sclera. It is due to rising amounts of bilirubin in the blood. Ref. Physical Examination and health Assessment 3rd Edition by Carolyn Jarvis p.225

Pharynx and Tonsils

Inspection Palpation

Tonsils, no discharge, pink, Tonsils, no discharge, smooth. pink, smooth.

Normal

Neck and Lymph nodes Body part Neck Muscles Technique used Inspection Normal findings Actual findings Analysis This determines the function of the sternocleidomastoid muscle.

Muscles equal in size; head Muscles equal in size; centered. head centered.

Move the chin to the chest

Inspection

Head flexes 45 Head flexes 45 This determines the function of the trapezius muscle. This determines the function of the sternocleidomastoid muscle. This determines the function of the sternocleidomastoid muscle. - Fundamentals of Nursing

Move the head back so that the chin points upward.

Inspection

Head laterally 60 Head laterally 60

Move the head so that Inspection the ear is moved toward the shoulder on each side. Turn the head to the right and to the left Inspection

Head laterally flexes 40

Head laterally flexes 40

Head laterally flexes 70

Head laterally

flexes 70

8th edition vol. I by Kozier & Erbs, Copyright 2008 (p.607)

Body part Muscle Activity

Technique used Inspection

Normal findings Equal strength In both sides

Actual findings Decrease of strength and tone

Analysis Due to lack of activities

Range of Motion

Inspection

Can perform freely

Cant perform freely

Due to his presence condition and pain felt by the client

Lymph Nodes

Inspection Palpation

All lymph nodes are not palpable

No palpable lymph nodes. Lymph nodes are small oval clumps of lymphatic tissue located at intervals along the vessels. Most nodes are arranged in groups, both deep and superficial in the body. Ref. Physical Examination and Health Assessment 2nd Edition by Carolyn Jarvis, p. 574

Trachea

Palpation

Central placement in midline of the neck

Central placement in midline of the neck

A tube-like portion of the breathing or "respiratory" tract that connects the "voice box" (larynx) with the bronchial parts of the lungs. - Fundamentals of Nursing 8th edition vol. I by Kozier & Erbs, Copyright 2008 (p.608)

Thyroid Gland

Inspection Palpation

Not visible in inspection. Gland ascends during swallowing. lobes may not be palpated.

Not visible in inspection. No nodules noted upon palpation

No indication of hyperthyroidism, hypothyroidism or endemic goiter. Ref. Fundamental of Nursing 7th Edition by Kozier

Upper Extremities Body part Skin Technique used Inspection Normal findings Actual findings Analysis Jaundice is due to an abnormally high accumulation of bilirubin in the blood, as a result of which there is a yellowish discoloration of the skin. Jaundice develop when the plasma contains about twice the normal amount of bilirubin. (Pathophysiology, Lipincott, Page 850, Fourth Edition)

No presence of edema, skin No presence of edema lesions. and skin lesions. Yellowish in color

Muscle Strength and tone

Inspection Palpation

Equal strength on each body side

Decrease of strength and Due to lack of activity tone

Joint range of motion

Inspection

Flexion: Normal full movement of The range of motion (ROM) Decreasing the angle of the joint. of a joint is the maximum joint movement that is possible for that joint. Joint range of Extension: Normal full movement of motion varies from Increasing the angle of the joint. individual to individual and joint is determined by genetic makeup, developmental patterns, the presence or absence of disease, and the amount of physical activity in which the person normally engages. - Fundamentals of Nursing 8th edition vol.2 by Kozier & Erbs, Copyright 2008 (p.1107)

Thorax

Body part Posterior Thorax

Technique used Inspection

Normal findings Chest symmetric, transverse diameter of 3:5 skin intact; uniform temperature, chest wall intact Full/symmetric chest expansion

Actual findings

Analysis

Anteroposterior Normal to transverse diameter on ratio of 3:5; chest symmetric

Respiratory Excursion

Inspection Palpation

Symmetric chest Normal expansion. Chest expand for about 34 cm. Normal

Percuss Posterior Thorax

Percussion

Percussion notes resonate, Resonance except over scapula /flatness over the lung during percussion was heard. Vesicular and bronchovesicular breath sounds

Auscultate Posterior Thorax

Auscultation

Vesicular and Vesicular breath sounds are bronchovesicular breath soft, low pitch sound, heard sound best over base of the lungs during inspiration, which is longer than expiration. Bronchovesicular are heard over the main stem

bronchus and are Moderate blowing sounds, with inspiration equal to expiration. - Fundamentals of Nursing by Taylor,Lillis,LeMone, Copyright 2005, (p.587) Body part Breathing patterns and sound Technique used Inspection Normal findings Quiet, rhythmic and effortless respiration Actual findings Shallow breathing Analysis Because of abdominal pain

Repiratory Excursion

Inspection Palpation

Full/ symmetric Chest expansion

Symmetric chest, expand Full symmetric excursion; for about 3-4cm thumbs normally separate 35 cm. - Fundamentals of Nursing 8th edition vol.1 by Kozier & Erbs, Copyright 2008, (p.578)

Percuss Anterior Thorax

Percussion

Percussion notes resonate down to sixth rib at the level of diaphragm but flat over areas of heavy muscles and bone, dull on areas over the heart and liver, tympanic over the underlying stomach

Resonance sounds which is moderate and low, flat sounds on the areas of muscles and bone, dull on the heart and liver and loud tympanic on the stomach

Normal- symmetry percussion sounds on the anterior thorax. When a normal air filled lung is percussed, the sound is hollow, loud, low in pitch and long of duration. This percussion tone is known as resonance. A flat tone is heard over a bony or well developed muscle tissue. - Fundamentals of Nursing by Taylor,Lillis,LeMone, Copyright 2005, (p.586)

Body part Auscultate the aortic, pulmonic, tricuspid, and apical valve

Technique used Auscultation

Normal findings Usually heard at all sites dystole: silent interval; slightly shorter duration than diastole at normal heart rate

Actual findings Usually heard at all sites systole: silent interval; slightly shorter duration than diastole at normal heart rate

Analysis The normal first two heart sounds are produced by closure of the valves of the heart. S is louder at the tricuspid and apical areas and its a dull, low pitched sound described as lub. S occurs at the termination of systole and corresponds to the onset of ventricular diastole. Its louder at the aortic and pulmonic areas and has a higher pitch than S and is shorter in duration and sound as dub. - Fundamentals of Nursing by Taylor,Lillis,LeMone, Copyright 2005, (p.591)

Diastole: silent interval; slightly longer duration than systole at normal heart rates

Diastole: silent interval; slightly longer duration than systole at normal heart rates

- Fundamentals of Nursing 8th edition vol.1 by Kozier & Erbs, Copyright 2008, (p.619)

Axillary

Inspection Palpation

no tenderness, no masses, no nodules

no tenderness, no masses, no nodules

The nodes are generally not palpable; if palpable, they should be small, mobile, smooth, and nontender. - Fundamentals of Nursing by Taylor,Lillis,LeMone, Copyright 2005, (p.591)

Abdomen for skin integrity

Inspection palpation

Unblemished skin, uniform color

Jaundice

Increased level of bilirubin Due to water retention, the liver and kidney are compensated

(+) edema

Body part Abdominal Contour

Technique used Inspection

Normal findings )No evidence of enlargement of the liver and spleen Symmetric Contour

Actual findings Symmetric contour

Analysis Normal

Movements

Inspection

Symmetric movement

Slowed movements

Limited movements be due to pain

Vascular Pattern

Inspection

No vascular pattern

No visible vascular pattern Audible bowel sounds, absence of arterial bruits, absence of friction rub

Normal

Auscultation of the abdomen

Auscultation

Audible bowel sounds, absence of arterial bruits, absence of friction rub

They are heard as clicks and gurgles & usually occur every 5-20 seconds. Bruits are low-pitched, murmur-like sounds that occur when blood flow of an artery is obstructed.

- Fundamentals of Nursing by Taylor,Lillis,LeMone (p.596)

Muscoloskeletal System Body part Muscle size Technique used Inspection Normal findings Equal size in both sides of the body Actual findings Equal size in both sides of the body Analysis Muscles groups are observed forbilateral symmetry. Normally, they are symmetric in size. - Fundamentals of Nursing by Taylor,Lillis,LeMone, Copyright 2005, (p.597) Muscle tremors Inspection No tremors No tremors Normal

Body part

Technique used

Normal findings

Actual findings

Analysis

Muscle activity

Inspection

Equal strength In both sides

Weak muscle

Due to his condition and pain felt by the patient

Range of motion

Inspection

Can perform freely

Limited movements

Due to his present condition and pain felt by the patient Bones is assessed for normal form. Bones is dense, hard and somewhat flexible connective tissue constituting the bones of the human skeletal & it has normal findings. - Mosbys Pocket Dictionary of medicine, nursing & health professionals (p.189)

Bone Structures Bone Tenderness

Inspection

No deformities

No deformities

Palpation

No swelling, no tenderness

No swelling, no tenderness

Neurologic System Body part Neurologic System Technique used Inspection Normal findings Good sensation, reflexes, speech and oriented with time place and persons. Actual findings Good sensation, reflexes and oriented with time, place and persons Analysis Normal

Lower Extremities Body part Skin Technique used Inspection Normal findings Actual findings Analysis Jaundice is due to an abnormally high accumulation of bilirubin I the blood, as a result of wich there is a yellowish discoloration of the skin. Jaundice develop when the plasma contains about twice the normal amount

No presence of edema, skin No presence of edema, no lesions. visible bleeding and no discharge seen. Yellowish in color.

of bilirubin. (Pathophysiology, Lipincott, Page 850, Fourth Edition)

GENITALIA: the patient refuses to be assessed

Post-operative Vital Sign Temp Technique Digital Thermometer via Axilla Normal Findings 35.8-37.0C Actual findings 37.2C Analysis Normal Interpretation The normal axillary temperature is between 35.8 to 37.0C (Udan, 2009, p.249).

In other literature, the usual range of normal is 36.0 to 37.8 [without routes indicated]. (Kozier, 2008, p.528) Pulse Rate Taken in radial artery (thumb side of the inner aspect of the wrist) 60-100bpm 80bpm, regular rhythm, normal strength, bilaterally equal on radial pulses Normal The normal pulse rate for adults is between 60 to 100 beats per minute. (Udan, 2009, p.251)

Respiratory Rate

Inspection of the rise and fall of chest cavity over 1 minute

12-20 cpm

20cpm

Normal

Normal respiration is between 12-20 Cpm in adults. (Udan, 2009, p. 253)

B/P Rate

Auscultation and BP apparatus, left arm

Systolic: 90-120 mmHg Diastolic 60-80mm Hg

130/80mm Hg

Normal

The normal blood pressure is a systolic pressure of 90-120 mmHg. and it is diastolic between 60- 80mmHg. (Udan, 2009, p. 253)

POST OPERATIVE General appearance Method Inspection Observation Normal finding Relaxed, erect posture, coordinated movement Actual finding Slouched, uncoordinated movement Analysis Deviation from normal due to the pain @ the incision on the right upper quadrant of the abdomen Deviation from normal due to present condition; Post cholecystectomy Deviation from normal due to pain at the site of incision at right upper quadrant of the abdomen Deviation from normal due to pain at the site of incision at right upper quadrant of the abdomen.

Psture and gait

Signs of Distress

Inspection and Observation

No signs of illness or disease

Appears weak with facial grimace and guarding behavior (+) facial grimace

Emotional Status

Inspection

No facial grimace

Affect/mood, appropriateness of Responses

Inspection

Appropriate to the situation

Responses are appropriate to the situation; irritated

Physical Assessment

Color

Inspection

Uniform in color

Yellowish discoloration

Presence of Edema

Inspection and Palpation

Absence of Edema

Presence of Lesions

Inspection

No Lesions

Color

Inspection

Sclera appears white

Breathing Pattern

Inspection

Rhythmic; effortless

Skin integrity

Inspection

Unblemished skin; uniform color

Bowel sounds

Auscultation

Audible bowel sounds

Deviation from normal due to the effect of bilirubin that is still present at the blood streams. (+) peripheral edema Deviation from normal due to water retention caused by fluid shifting from intracellular to intravascular. With incision at the right Deviation from normal upper due to status post quadrant of abdomen cholecystectomy Yellowish Deviation from normal due to effect of bilirubin in the blood streams Use of accessory Deviation from normal muscles upon due to pain breathing; shallow (compensatory breathing mechanism) Impaired skin integrity Deviation from normal with due to Cholecystectomy incision on the right on the right upper upper quadrant of the quadrant abdomen. Hypoactive bowel Deviation from normal sounds due to status post cholecystectomy

Areas of tenderness

Palpation

No tenderness; relaxed abdomen

Presence of tenderness

Deviation from normal due to status post cholecystectomy

CONTRAPTIONS Body part Genitalia Tecnique used Normall findings Actual findings Folley catheter is noted Analysis This tubing is then advance until it reaches the bladder.performed to drain urine from the bladder or to instill solution into the bladder. To drain the urine of the patient who in trautamized tp prevent infection or bacteria into the organ. (Fundamental by Kozier)

IV.DEFINITION OF THE DISEASE Calculous cholecystitis is caused by obstruction of stone in the bile duct leading to inflammation of the gallbladder. The gallbladder is an organ which aids in the digestive process. Its function is to store and concentrate bile. The bile in turn emulsifies fats and neutralizes acids in partly digested food. Despite its importance in the digestion of fat, many people are unaware of their gallbladder. Fortunately enough, the gallbladder is an organ that people can live without. Perhaps, this fact contributes to the laxity of the majority. The gallbladder tends to be taken for granted or ignored of the proper care and conditioning. Lifestyle together with heredity, sex, race and age are just some factors that leave a room for gallbladder complications to occur. Gallstone disease is a disease of hepato-biliary system, caused by cholesterol and/or bilirubin metabolic disorder, and characterized by formation of stones in the gallbladder and/or the biliary tract. Gallstones are categorized as cholesterol, mixed, black pigment, or brown pigment stones. Cholesterol gallstones are the main type of gallstones and contain cholesterol as the major chemical constituent. Mixed cholesterol gallstones are composed of more than 50% cholesterol. Cholesterol and mixed gallstones are formed from biliary sludge, which stays for a long time in the gallbladder lumen. Biliary sludge consists of calcium bilirubinate granules, cholesterol monohydrate crystals, and biliary polymerized glycoprotein mucin. The dynamics of the transformation of biliary sludge into cholesterol stones has been shown as follows: diffused biliary sludge surface biliary sludge precipitating biliary sludge a cholesterol gallstone without acoustic shadow. The time of formation of cholesterol stones depends on the intensity of the precipitation processes of cholesterol monohydrate crystals in biliary sludge, and equals 3 to 36 months. Transformation proportion varies from 5 to 50% depending on the cause. Black pigment stones are composed of either pure calcium bilirubinate or polymer-like complexes consisting of calcium, cooper, and large amounts of mucin glycoproteins. Brown pigment stones are composed of calcium salts of unconjugated bilirubin, with varying amounts of cholesterol and protein. These stones are usually associated with infection. The natural history of gallstones is typically defined in two separate groups of patients: those with symptomatic gallstones and those who are asymptomatic. The vast majorities of gallstones are asymptomatic and remain asymptomatic. As a rule, gallstone disease is asymptomatic, which is called silent stones. The rate of development of biliary pain is approximately 2% per year for 5 years and then decreases over time. The incidence of complications in patients with asymptomatic stones is low, and prophylactic

removal of the gallbladder for this condition is not necessary. Patients who had an episode of uncomplicated biliary pain in the year, 38% per year had recurrent biliary pain. An incidence of recurrent biliary pain as high as 50% per year in those with symptomatic gallstones. 30% of patients with one episode of biliary pain will not have a recurrent episode. The estimated risk of developing biliary complications is estimated to be 1% to 2% per year and is thought to remain relatively constant over time .

V. Anatomy and Pathophysiology

LIVER Largest organ in the body Lies under the diaphragm; occupies most of the right hypochondrium and part of the epigastrium. Weighing 1.5 kgs. LIVER LOBES AND LOBULES The liver has two lobes, separated by the falciform ligament Left lobe- about one sixth of the liver Right lobe- about five sixth of the liver. BILE DUCTS Right hepatic duct- drains bile from the right functional lobe of the liver

 Left hepatic duct- drains bile from the left functional lobe of the liver Common hepatic duct-is the duct formed by the convergence of the right hepatic duct and the left hepatic duct ; Length: Usually 68 cm. Approximate width: 6 mm in adults; merges with cystic duct to form common bile duct, which opens into the duodenum. Cystic duct- is the short duct that joins the gall bladder to the common bile duct. Common bile duct- formed by the union of the common hepatic duct and the cystic duct (from the gall bladder). FUNCTIONS OF THE LIVER The liver stores a multitude of substances, including glucose (in the form of glycogen), vitamin A (12 years' supply), vitamin D (14 months' supply), vitamin B12, iron, and copper. Glucose metabolism- after meal, glucose is taken up from the portal venous blood by the liver and converted into glycogen (glycogenesis), which is stored in the hepatocytes. Glycogen is converted back to glucose (glycogenolysis) and release as needed into the blood stream to maintain normal level of the blood glucose Ammonia conversion- use of amino acid from protein for glycogenesis results in the formation of ammonia as a byproduct. Liver converts ammonia to urea. Protein metabolism- liver synthesizes almost all of the plasmas protein including albumin, alpha and betaglobulins, blood clotting factor plasma lipoproteins. Fat metabolism- fatty acid can be broken down for production of energy and production of ketone bodies. Bile formation- bile is formed by the hepatocytes Composed of water, electrolytes such as sodium, potassium, calcium, bicarbonate, lecithin, fatty acids, cholesterol, bile salts Collected and stored in the gallbladder and emptied in the intestine when needed for digestion. BILE Bile is the greenish-yellow fluid (consisting of waste products, cholesterol, and bile salts) that is secreted by the liver cells to perform two primary functions,

including the following: to carry away waste to break down fats during digestion Bile salt is the actual component which helps break down and absorb fats. Bile, which is excreted from the body in the form of feces, bile gives feces its dark brown color. TRANSPORT BILE 1. When the liver cells secrete bile, it is collected by a system of ducts that flow from the liver through the right and left hepatic ducts. 2. These ducts ultimately drain into the common hepatic duct. 3. The common hepatic duct then joins with the cystic duct from the gallbladder to form the common bile duct, which runs from the liver to the duodenum (the first section of the small intestine). 4. However, not all bile runs directly into the duodenum. About 50 percent of the bile produced by the liver is first stored in the gallbladder, a pear-shaped organ located directly below the liver. 5. Then, when food is eaten, the gallbladder contracts and releases stored bile into the duodenum to help break down the fats. GALLBLADDER The gallbladder is a small organ whose function in the body is to store bile and aid in the digestive process. A hallow pear- shaped sac from 7- 10 cm (3-4 inches) long and 3 cm broad. It consists of a fundus, body and a neck. Fundus - the lower free and the expanded end of the Gall bladder. Body - the body of the gall bladder is the portion that is lying between that of the fundus and also the neck. The direction of the body is upwards, backwards, and to the left. Neck- takes a turn and becomes downwards and backwards. It can hold 30 to 50 ml of bile. right lobe and attached there by areolar connective tissue.

 The cystic duct connects the gallbladder to the common hepatic duct to form common bile duct. FUNCTION OF THE GALLBLADDER Stores bile enters to the gallbladder by way of the hepatic and cystic duct. During this time the gallbladder concentrates bile five folds to ten folds. Then later when digestion occurs in the stomach and in the intestines, the gallbladder contracts, ejecting the concentrated bile into the duodenum. Jaundice, a yellow discoloration of the skin and the mucosa, results when obstruction of bile flow into the duodenum occurs. Bile is thereby denied its normal exit from the body in the feces. Instead, it absorbed in the blood, and an excess of bile pigments with a yellow hue enters the blood and is deposited in the tissues. The gallbladder stores bile, which is released when food containing fat enters the digestive tract, stimulating the secretion of cholecystokinin (CCK). The bile, which is produced in the liver, emulsifies fats and neutralizes acids in partly digested foods.

Pathophisiology Book base Concentration and storage of bile Stasis of bile

Stone formation

Obstruction of bile flow

Smooth muscle contractions

Impairment of fat absorption

Acute or chronic inflammation or infection of gallbladder

perforation

Reference (Virginia L. Cassmeyer p.P1500)

VI. Diagnostic Procedure

COMPLETE BLOOD COUNT

COMPONENT WBC Count

NORMAL FINDINGS 5- 10 X 10q/L

ACTUAL FINDINGS 10.9

HEMATOCRIT

0.40-0.50

0.38

INTERPRETATION WBC is slightly elevated based on the normal value which confirms the presence of infection A low hematocrit value usually indicates the person has anemia, overhydration, hyperthyroidism, and dietary deficiency. (Fundamentals of Nursing by Kozier, page 759) . Hematocrit is the one that control the level of space (volume) red blood cells takes up in the blood.

NEUTROPHILS

55-70

50

A low neutrophils indicate that the person has Aplastic Anemia, dietary deficiency, radiation therapy. (Fundamentals of Nursing by Kozier, page 759) Neutrophils are one of the first-responders of inflammatory cells to migrate towards the site of inflammation

LYMPHOCYTES

20-40

40

MONOCYTES

2-8

0.6

EOSINOPHIL

1-4

0.4

The lymphocytes helps provide a specific response to attack the invading organisms. Monocytes helps the WBC to remove damage tissues, destroy cells and regulate immunity against foreign substances. Eosinophils become active when you have certain allergic diseases, infections, and other medical conditions. The result showed normal level of

BASOPHIL PLATELETS

0.5-1 150-400x 10/ml

0.5-1 283

Mean Corpuscular Volume

80-95

87.9

Mean Corpuscular Hemoglobin

27-31pg

27.9

Mean Corpuscular Hemoglobin Concentration

320-360 g/dl

317

eosinophils. Normal Platelets play a fundamental role in hemostatis and are natural source of growth factors. They are involved in hemostatis leading to the information og blood clots. The result shows MCV is in normal range,it is measure of the average red blood cell volume that is reported as part of a standard complete blood count. The average amount of hemoglobin (MCH) is calculated value derived from the measurement of hemoglobin and the red cell count. Decrease level may indicate iron deficiency anemia or hemoglobinopathy. (Medical-surgical,Workman, page 882) It is a measure of the

concentration of hemoglobin in a given volume of packed red blood cells. It is reported as part of a standard complete blood count.

URINALYSIS Urinalysis is a physical, microscopic, or chemical examination of urine . The specimen is physically examined for color, turbidity, specific gravity, and pH. The it is spun in a centrifuge to allow collection of a small amount of sediment that is examined microscopically for blood cell, casts, crystals, pus and bacteria. Chemical analysis may be done to identify and quantify any of a large number of substances, most often for ketones, sugar, protein, and blood. MACROSCOPIC Result Dark yellow color Normal values Straw; amber Interpretation The excretion of the bile pigments by the kidney gives the urine a very dark color There is a presence of pus cells in the urine which means that there is also the presence of infection. Normal The result indicated

Color

Transparency Specific gravity

Clear 1.013

Clear 1.010- 1.025

Ph

3.5

4.6- 8

normal value. Specific gravity is an indication of urine concentration, or the amount of solutes ( metabolic waste and electrolytes) present in the urine (Kozier, p.770) Acidic( decrease pH) is due to inability of the kidney to excrete hydrogen ions. Associated with the dehydration, and with a diet high in protein fruits (Kozier, p.770)

MICROSCOPIC RESULT 0.3/ hpf NORMAL VALUES 0-3hpf INTERPRETATION RBC is only present in glomerulonephritis, lupusnephritis, urinary tract disease, and heart failure. WBC is only present in acute UTI, fever and strenuous exercise.

RBC

WBC

1.5/hpf

0-4 hpf

Epithelial Cells

Many

None

Bacteria

Few

None

Epithelial cells in urine indicate presence of infections, inflammation and malignancies. Bacteria are common in urine specimen because of presence of infection and their ability to rapidly multiply in urine.

CHEMICAL TEST RESULT Negative NORMAL FINDINGS Negative INTERPRATAION The result indicated that there is no presence of sugar in the urine. Normally, the amount of glucose in the urine is negligible, although individuals who have ingested large amount of sugar may show small amounts of glucose in their urine. (Kozier,p771) Albumin is only presence in glomerular damage in renal disease, including glomerulonephritis, kidney stones.

SUGAR

ALBUMIN

Negative

Negative

Is a protein produced by the liver. (Fundamental by Kozier,8th edition,p. 803)

CRYSTALS RESULT Few NORMAL VALUES None INTERPRETATION Urates in the urine are sign that your urine had gotten solidified through the process of dehydration and have lodge themselves in your urinary tract.

Amorphous urates

SERUM EXAM TEST NAME Alkaline phosphate RESULTS 187.6-high NORMAL VALUES 50.00-136.00U/L INTERPRETATION High alkaline phosphate is valuable in differentiating obstructive from hepato cellular jaundice. Alkaline phosphate level rise with post hepatic obstruction (obstructive jaundice) or in intra hepatic cholestatis hepatocanalicular jaundice. when there is bilary obstruction the total cholesterol level is elevated. It is because of the diet of the patient. A high triglycerides level combined with low HDL cholesterol or high LDL cholesterol seems maybe genetics (hereditary) induced A total serum protein test measures the total amount of protein in the blood. It also measures the amounts of two major groups of proteins in the

Cholesterol

6.5-high

0-5.2mmol/L

Triglycerides

3.2-high

0.4-1.7mmol/L

Total protein

76.4

64-82g/L

blood, albumin and globulin. Albumin 36.6 34-50g/L Albumin helps move many small molecules through the blood, including bilirubin, calcium, progesterone, and medications. It plays an important role in keeping the fluid from the blood from leaking out into the tissues. Globulin high. Its have a disturbances in beta lipoprotein metabolism are seen in patients with obstructive jaundice. The usefulness of A/G ratio is limited, since it gives only the proportion of the two types of protein measure. A/G ratio low. There maybe a low ratio that might have occurred because of either an unchanged albumin with an increased globulin. Increase in conjugated hyperbilirubinemia may result from impaired excretion of

Globulin

39.9-high

30-32g/L

A/G ratio

0.92-low

1.1-1.6

Total bilirubin

144.8-high

0.00-17.1Umol/L

bilirubin from the liver due to hepato cellular disease, or extra hepatic biliary obstruction. Reference: medical-surgical nursing volume 2, 6th edition by joyce black Increase level because jaundice is caused by hepato cellular dysfunction (hepatitis) results in elevated the levels of indirect bilirubin. When the formation of unconjugated bilirubin exceeds the liners capacity to conjugate and excrete it. Jaundice results the term hemolytic jaundice is often used to describe this condition. AST exist in large amounts in liver and myocardial cells and in smaller but significant amounts in kidneys, pancreas and the brain. Serum AST are usually associated with hepatocellular diseases in an acute phase. High ALT because jaundice patients an abnormal ALT will

Indirect bilirubin

25.77-high

12.1-15.1Umol/L

AST Aspartate aminotransferase

236-high

15.00-37.00U/L

ALT

501-high

30-65U/L

Alanine transaminase

incriminate the liver rather than RBC, hemolysis as a source of the jaundice. Diseases affecting the liver parenchyma will cause a release of this hepatocellular enzymes into the blood stream, thus elevating serum ALT levels.

COAGULATION REPORT COMPONENTS PT Prothrombine time RESULT 12.9 NORMAL VALUES 12.9-15.7seconds INTERPRETATION The test of prothrombine time determines defects in extrinsic clotting mechanism by reflecting the activity of fibrinogen and prothrombine. PT evaluation can now be based on an INR using standardized thromboplastin reagent to assist in making decisions regarding oral anticoagulation therapy. Increase in hepato cellular damage (increase risk for bleeding)

INR

0.89

APTT Activated thromboplastin time Control partial

34.0

26-31 seconds

28.0

Seconds

TEST NAME Cholesterol

RESULT 7.5-high

NORMAL VALUES 0-5.2mmol/L

Triglycerides

3.8-high

0.4-1.7mmol/L

HDL cholesterol

0.45-low

0.91-1.56mmol/L

LDL

5.3-high

1.89-3.09mmol/L

INTERPRETATION When there is biliary obstruction the total cholesterol level is elevated. It is because of the diet of the patient. A high triglycerides level combine with low HDL cholesterol or high ADL cholesterol since may be genetics (hereditary) induced. Low HDL cholesterol is a caused of his obesity and cholestasis. High LDL cholesterol is a caused of his acute stress and illness.

COMPONENT Creatinine

INDICATION This is the indicator of the renal function

NORMAL FINDINGS 0.60-1.7mg/dl

ACTUAL FINDINGS 1.0

Possible Causes of Abnormal Findings Normal

Fecalysis Result MACROSCOPIC COMPONENTS COLOR RESULTS Clay colored Normal Value Brown INTERPRETATION Absence of bile pigment (bile obstruction) Reference: Kozier 1227

CONSISTENCY

Soft

Soft

CROSS PLUS CROSS BLOOD COMPONENTS RBC

Negative Negative RESULTS NONE/ HDF

Negative Negative Normal value None INTERPRETATION Normally there is no red cell in the urine. It caused by inflammation of the intestines, such as a bacterial infection.

WBC

1-2/ HDF

Negative

REPORT OF ULTRASOUND EXAMINATION Name: Mr. SP Age: 39 years old Date: July 06, 2011 OPD WARD

Upper Abdominal Sonography contains two strong shadowing echoes of less than 0.9 cm and two intra abdominal nodules of less than 0.6 cm. Biliary duct are not diluted. Great vessel are normal in caliber. Para aortic and primary retopenial areas are clear. Gastro intestinal pattern is unremarkable. Anterior abdominal wall is intact. Urinary Tract and Prostatic Sonography Both kidneys are normal in size and echo texture. Right and left kidneys measure 9.8 x3.6 cm and 8.9 x 4.1 cm respectively. Pelvis and ureters are not dilated. Urinary bladder is physiologically distended with normal anechoeic lumen. Prostate is normal in size measuring 3.2 x 3.1 x 3.1 cm and weight 17 grams. remainder is unremarkable. IMPRESSION: Gallstone, multiple Gallbladder polyps, multiple Negative, KUB and prostatic sonography

VII. Medical Management ReducePain. Pain may arise from contraction of the gallbladder during transient obstruction of the cystic duct by gallstones. Analgesic may be administered intramuscularly or intravenously with a patient-controlled analgesia or as needed for pain. During an acute attack of biliary colic, the client remains on NPO status, with IV fluids administered to maintain hydration(D5LR 1L x 8 @31gtts). The client is advised to avoid foods that precipitate biliary colic. Antibiotics are administered to reduce the likelihood of infection. Other medications ordered such as: Pre- operative Medication: Omeprazole Ceftriaxone Tramadol Fentanyl Mefenamin Acid 4g OD 750mg OD 10 mg !V 50 mg IV 500mg (PRN)

Surgical Management Laparoscopic Cholecystectomy has become the treatment of choice of asymptomatic gallbladder disease. The procedure is suitable tor most clients, because there is minimal trauma to the abdominal wall.(Med-surgical, Black page 1124)

Cholecystectomy consist of excising the gallbladder from the posterior liver wall and ligating the cystic duct.When stone are susoected in the common duct, operative cholangioraphy my be performed.(Med-surgical, Black page 1125)

A conventional open cholecystectomy is indicated when a laparoscopic cholecystectomy does not allow for retrieval of a stone in the common bile duct and and when the clients physique does not allow access to the gallbladder.(Med-surgical, Black page 1125)

VIII. Statement of the Problem -ineffective breathing patter related to abdominal pain - Risk For Infection r/t inadequate Primary defenses -Acute pain r/t inflammation of the gallbladder as evidenced by guarding behavior, facial mask, sleep disturbance, and expressive behavior such as fetal position. -risk for bleeding -fluid and electrolyte imbalance -risk for aspiration -hyperthermia -hypertension

IX. Nursing Care Plan

Assessment Subject: Sumasakit ang tyan ko kapag humihinga ako Objective: -Shallow Breathing -Respiratory Rate IS 32

Nursing Diagnosis Ineffective Breathing Pattern R/T Abdominal Pain

Inference Super saturation of bile Bile stasis Cholelithias Obstruction of cystic duct Inflammation of gallbladder Wall Irritation of gallbladder wall Inflammatory response Cholecystitis

Goal After 4 hours of nursing interventions, the client will be able to establish normal/effective respiratory pattern

Nursing Intervention INDEPENDENT: - Assess respiratory rate and depth by listening to lung sounds. - Encourage sustained deep breaths by emphasizing slow inhalation, holding end inspiration) -Elevelate head of bed; maintain lowfowlers position. Support Abdomen when coughing, ambulating.

Rationale

Evaluation After 4 hours of nursing Interventions, the client was able to establish normal/effective respiratory pattern

- Respiratory rate and rhythm changes are early warning signs of impending respiratory difficulties - these promote deep inspiration & ventilation of all lung segments

-Facilitates lung expansion. Splinting provides incisional support/decreases muscle tension to promote cooperation with therapeutic regimen

Abdominal pain Ineffective breathing pattern

- pace and schedule activities providing adequate rest periods

- This prevents dyspnea resulting from fatigue

-To maximize respiratory -Stress importance of effort good posture and effective use of accessory muscles COLLABORATIVE: >Tramadol 10 mg IV -Assess for Hypersensitivity to tramadol; acute intoxication with alcohol, opioids, psychotropic drugs or other centrally acting analgesics; past or present history of opioid addiction -Tell patient that he may experience these side effects: Dizziness, sedation,

-Relief of moderate to moderately to severe pain. -Binds to mu-opioid receptors and inhibits the reuptake of norepinephrine and serotonin; causes many effects similar to the opioids- dizziness, somnolence, nausea, constipation- but does not have the respiratory depressant effects.

drowsiness, impaired visual acuity (avoid driving or performing tasks that require alertness); nausea, loss of appetite (lie quietly, eat frequent small meals). >Mefenamin Acid 500mg (PRN) -tell patient to take drug with food. -Assess patient for allergies and history of liver disease, diabetes, or stomach or bowel Problems. -Discontinue drug and consult your health care provider if rash, diarrhea, or digestive problems occur. - Anti-inflammatory, analgesic and antipyretic activities related to inhibition of prostaglandinsynthesis; exact mechanisms of action are not known.

-Tell patient that Dizziness or drowsiness can occur.

Assessment Objectives: >With a temperature of 38.2 C >(+) Drainage on the incision >Increased WBC of 10.9 g/l. normal value 510x10g/l >Wet dressing

Nursing diagnosis Risk For Infection r/t inadequate Primary defenses

Inference Super saturation of bile Bile stasis Cholelithiasis Obstruction of cystic duct Inflammation of Gallbladder Irritation of gallbladder wall Inflammatory response Cholecystitis Cholecystectomy Risk for infection

Goal After 30 mins. of nursing intervention the patient will be able to identify interventions to prevent/reduce risk of infection

Nursing Intervention > establish rapport

Rationale

Evaluation

> Gain Patients trust and After 30 mins cooperation of of nursing the patient intervention, the patient was > assess Patients able to identify general condition >To provide proper interventions Nursing intervention. to prevent/reduce > Teach patient to risk of infection wash hands often, >Hand washing reduces especially before the risks for infection toileting , before and also in transmitting meals and before pathogens from one area and of the body to another as after administering well as from one patient self-care. to another. > Discuss to patients the following signs of infection redness, swelling, increased pain ,or purulent drainage on the site and fever

>To provide early detection of infection and to provide early nursing management.

>Monitor wound for Redness, swelling, increased pain, or purulent drainage .

> Redness, swelling, increased pain, or purulent drainage is suspicious of infection and should be cultured.

> Monitor temperature and the presence of sweating and chills.

> In the first 24-48 hours fever up to 38 degrees C (100.4F) is related to the stress of surgery. After 48 hours fever above 37.7C (99.8F) suggests infection. High fever with sweating and chills suggests septicemia.

> Maintain strict aseptic technique with all dressing changes

> Strict asepsis is necessary to prevent cross-contamination and nosocomial infections.

> Optimal nutritional > Encourage intake status promotes wound of protein and healing. calorie rich foods. Provide enteral

feeding in patients who are NPO. COLLABORATIVE: > Administer Anti microbial drug as prescribed or ordered by the physician

>to fight further infection

ASSESSMENT S: Masakit po yung tiyan ko sa may bandang kanan na tumatagal ng 15-30 minuto. 7/10 po yung sakit niya as verbalized by the pt. O: >guarding behavior >(+) facial mask >(+) sleep disturbance >(+) expressive behavior; fetal position

DIAGNOSIS Acute pain r/t inflammation of the gallbladder as evidenced by guarding behavior, facial mask, sleep disturbance, and expressive behavior such as fetal position.

INFERENCE Super saturation of bile Bile stasis Cholelithiasis Obstruction of cystic duct Inflammation of gallbladder Irritation of gallbladder wall Inflammatory response Cholecystitis Acute Pain

GOAL After 30 minutes of nursing intervention, the pt. will be able to verbalize that pain is relieved/ controlled.

INTERVENTION Independent: >Assess the pts level of pain. observe and document location, severity (0- 10 scale), and character of pain

RATIONALE >assist in differentiating cause of pain, and provides information about diseases progression or resolution, development of complications and effectiveness of interventions >promote bed rest in lowfowlers position reduces intraabdominal pressure ; however, patient will naturally assume least painful position. >promotes rest, redirects attention may

EVALUATION After 30 minutes of nursing intervention, the pt. was able to verbalize that pain is relieved/ controlled. Goal partially met, with a pain scale of 3/10.

>promote bed rest, allowing patient to assume position of comfort

> encourage use of relaxation technique (deep breathing exercise) provide diversional

activities > make time to listen to and maintain frequent contact with patient

enhance coping

Collaborative: >Administered the following meds as ordered by the physician: Tramadol 10 mg IV

>Helpful in alleviating anxiety & refocusing attention, which can relieve pain

Nursing considerations: Assess onset, type, location, and duration of pain. Effect of medication is reduced if full pain recurs before next dose. Assess drug history > Analgesic Centrally acting

especially carbamazepine, CNS depressant medication, MAOIs. Review past medical history, especially epilepsy or seizures. Assess renal or hepatic function laboratory values. Give without regards to meals Monitor pulse and blood pressure. Assist with ambulation if dizziness or vertigo occurs. Dry crackers or cola may relieve nausea.

Palpate bladder for urinary retention. Monitor pattern of daily bowel activity and stool consistency. Sips of tepid water may relieve dry mouth. Assess for clinical improvement and record onset of relief from pain.

X. Discharge Planning A. Medication Tramadol Fentanyl Omeprazole Ceftriaxone Mefenamin Acid

10 mg !V 50 mg IV 4g OD 750 mg OD 500mg (PRN)

B. Exercise Maintaining mobility to improve the overall function status, an appropriate program of exercise will help to decrease pain and improve function. . C. Treatment The major goal for the treatment of patient include Increase knowledge about the disease and treatment regimen, adherence to the medication and activity and observed for complication. Practicing proper hygiene. Consuming nutritious and adequate rest Participating in appropriate level of activity Taking medication as prescribed Teach patient and family about infection control behaviour Emphasize importance of completing antibiotic regimen

D. E. F.

Health Teaching Maintain body hygiene Advice the client to avoid extraneous activity like running, jumping and high impact exercise Advice the patient to increase high fiber diet and high protein diet Remind the patient to take medication as exactly doctors prescribe Out Patient Instruct the client for follow up check-up referral Doctor Ceverero at EAMMC Diet Emphasize the strict low calorie diet Emphasize high fiber diet especially vegetable Advise patient on the importance of an individualized meal plan in maintaining the appropriate weight. Assist patient to identify problems that may have an impact on dietary adherence and possible solutions to these problems. Emphasize that lifestyle changes should be maintainable for life. Each meal should consist of a balance of carbohydrates, proteins, and fats. Consistency in timing of meals and amounts of food eaten on a day-to-day basis help regulate blood glucose levels. Increase the intake of soluble and insoluble fiber. Avoid salt whenever possible. Prepare foods to retain vitamins and minerals and reduce fats. Distribute snacks in the meal plan Prohibit use of alcohol.

G. Spiritual Provide emotional support coming from the family. Encourage the patient to participate in family affairs.