DR. YANGA’S COLLEGES, INC.

Wakas, Bocaue, Bulacan

COLLEGE OF HEALTH SCIENCESNURSING ●
MIDWIFERY ● CAREGIVING NC II

This is a Case Study of a

Patient with Cholecystitis
In Partial Fulfillment of the Requirements in NCM 116
Related Learning Experience

Submitted by:
Alcantara, John Emmanuel
Cruz, Machelle
Dimaiwat, Marvin C.
Dionisio, Alessandra Dennise
Feliciano, Anabelle
Franco, Mary Joy
Garcia, Carl Marvin
Gasgonia, Regine
Meneses, Joy
Torres, Dorina

Submitted to:
CHS Faculty
2023

1
Table of Contents
I. Introduction............................................................................................3
II. Objectives...............................................................................................4
III. Anatomy and Physiology....................................................................5
IV. Pathophysiology....................................................................................9
V. Nursing History.....................................................................................11
VI. Physical Assessment............................................................................15
VII. Course in the Ward.............................................................................17
VIII. Diagnostic and Laboratories..............................................................18
IX. Drug Study...........................................................................................22
X. Nursing Care Plan.................................................................................32
XI. Health Teaching...................................................................................38
XII. Evaluation...........................................................................................40
XIII. REFERENCES..................................................................................41

2
I. Introduction

Choledocholithiasis is the presence of gallstones in the common bile duct. This duct
carries bile from the gallbladder. The stone formed may be made up of bile pigments or
calcium and cholesterol salts. They can develop in any place bile flows through.

According to the National Library of Medicine (2017), choledocholithiasis can be

classified into two according to its origin. These classifications are primary and
secondary. Primary choledocholithiasis refers to stones formed directly within the biliary
tree, while secondary choledocholithiasis refers to stones ejected from the gallbladder.

The most common sign and symptom of Choledocholithiasis is a sharp pain in the
right upper quadrant of the abdomen. Some individuals with this condition manifest
fever, loss of appetite, yellowish skin color and sclera, nausea, and vomiting.

The etiology of Choledocholithiasis according to Tanaja et al. (2023), is when stones

obstruct the common bile duct impeding the flow of bile from the liver to the intestine.
An individual is at risk for developing this disease when ages 40 or older and with a high
level of cholesterol or one’s diet.

In order to diagnose choledocholithiasis, the physician will likely conduct a physical

examination in addition to identifying symptoms and medical background. The following
tests and techniques are also used to identify this condition: a blood test and a
computerized tomography scan. CT scan is used to produce images of bile ducts and
gallbladder. These images can demonstrate the signs and symptoms of the disease.

Surgical management of choledocholithiasis is usually a two-staged procedure

consisting of ERCP, followed by early laparoscopic cholecystectomy. These are effective
management for the majority of cases of the disease. On the other hand, for medical
management the following medications are prescribed: Omeprazole, Tramadol,
Ketorolac, Cefuroxime, Metronidiazole, and Acetaminophen.

Choledocholithiasis patients require nursing care planning and management that

includes providing pain relief, encouraging rest, preserving fluid and electrolyte balance,
avoiding complications, and providing information on the disease process, prognosis, and
therapy.

As reported by Cleveland Clinic (2022), about 15% of the total population is

diagnosed with Choledocholithiasis.

3
 REFERENCE:

National Library of Medicine. (2017). Choledocholithiasis: Evaluation, Treatment, and Outcomes.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5088099/#:~:text=Choledocholithiasis%20is%20clas
sified%20as%20primary%20or%20secondary%20according%20to%20stone%20origin.&text=Pri
mary%20choledocholithiasis%20refers%20to%20stones,stones%20ejected%20from%20the%20gall
bladder.

Tanaja et al. (2023). Choledocholithiasis.

https://www.ncbi.nlm.nih.gov/books/NBK470440/#:~:text=Choledocholithiasis%20is%20a%20compl
ication%20of,of%20liver%20enzymes%20and%20jaundice.

Cleveland Clinic. (2022). Choledocholithiasis. https://my.clevelandclinic.org/health/diseases/24210-

choledocholithiasis

4
II. Objectives

General Objectives
The mere purpose of this study is to provide and expand understanding of
choledocholithiasis disease for both patients and students. Its goal is to apply what has
been learned in real-life scenarios and in clinical settings, as well as to create characters
that will help nurses become more effective in the future.

Specific Objectives

For the student nurse

At the end of this case study, the student nurse will be able to:
Knowledge
 Analyze the case of the patient through systematic readings and research.
 Understand the etiology and pathophysiology of the disease.
 Define nursing interventions that can help treat the disease.
 Enhance understanding when providing care to the patient.
Skills
 Interpret each nursing intervention prepared and make sure the patient can tolerate it.
 Apply effective nursing interventions related to Choledocholithiasis.
 Execute those interventions with care and precision.
Attitude
 Build strong therapeutic relationships with the patient and family.
 Show some compassion to come up with continuous patient interaction.
 Build a sense of duty and obligation until the patient is fully healed.

For the Patient and relatives

At the end of this case study, patients will be able to
Knowledge
 Recognize the significance of medication therapy towards effective disease
management.
 Understand the health teachings imparted by nurses.
 Verbalize understanding regarding disease management given by
healthcare providers.
Skills
 Apply health teachings given by healthcare providers to avoid complications.
 Develop appropriate behavior to avoid difficult circumstances.
 Use coping mechanisms to unfocused self from the disease.
Attitude
 Show willingness to recover from the disease.
 Promote positive emotional health towards self-overall well-being.
 Build a positive response to the treatment provided.

5
III. Anatomy and Physiology
A 64-year-old gentleman presented with four days of right upper quadrant abdominal pain.
The patient manifests fever, loss of appetite, nausea, and vomiting. Upon assessment and
diagnostic procedures, he is diagnosed with Choledocholithiasis.

6
 When food entered in your mouth, the digestive process begins (Mechanical digestion).
When you swallow, the food is pushed into your throat by your tongue. To prevent choking, a
small flap of tissue called the epiglottis folds over your windpipe, allowing food to pass into your
esophagus. Your esophagus, once you begin swallowing, the process becomes automatic. Your
brain signals the muscles of the esophagus and peristalsis begins. In addition, the lower esophageal
sphincter it will relax and allow the food to pass within the stomach and LES keep closed to keep
it inside the stomach and prevent from backflow in to esophagus. After the food enters your
stomach, the stomach muscles mix the food and liquid with digestive juice and stomach slowly
empties its contents, called chyme, into your small intestine. The small intestine, its muscle is to
mix food with digestive juices from the pancreas, liver, and intestine and push the mixture for
further digestion. The walls of small intestine absorb water and the digested nutrients into your
blood stream. As peristalsis continues, the waste products of the digestive proves move into the
large intestine which waste products from the digestive process include undigested parts of food
and fluid. However, the large intestine absorbs water and changes the waste from liquid into stool.
Peristalsis helps the stool to move into your rectum. Lastly, the rectum stores the stool until it
pushes out your anus during a bowel movement.

MOUTH
The first section of the digestive system is the mouth, or oral
cavity. It is designed to absorb food, break it into small particles,
and then combine it with saliva (Mechanical digestion). The
boundaries are formed by the palate, cheeks, and lips

SALIVARY GLANDS
The salivary glands are organs on each side of the face. It plays
a role for lubrication of the mouth and throat, aid in swallowing and
digestion, and help shield your teeth from cavity-causing bacteria and
contains an enzyme called amylase, which helps your stomach break
down starches in food.

PHARYNX
From the mouth, food
passes posteriorly into the oropharynx and laryngopharynx.
In addition, it permits the passage of swallowed solids and
liquids into the esophagus, or gullet, and conducts air to and
from the trachea, or windpipe, during respiration.

7
 ESOPHAGUS
Carries the food from mouth to stomach. It essentially a passageway
that conducts food (by peristalsis) series of wave-like muscle
contractions that move food through the stomach. The upper
esophageal sphincter (UES) is a high-pressure zone at the transition of
the pharynx and the cervical esophagus. The lower esophageal sphincter
(LES) is a high-pressure zone located where the esophagus meets the
stomach and protects the esophagus from the reflux of gastric
contents.

STOMACH
It produces enzymes (substances that create
chemical reactions) and acids (digestive juices). This mix
of enzymes and digestive juices breaks down food so it can
pass to your small intestine.

LIVER
The liver
makes a digestive
juice called bile that helps digest fats and some vitamins. In
addition, the liver processes this blood and breaks down,
balances, and creates the nutrients and also metabolizes drugs
into forms that are easier to use for the rest of the body or that
are nontoxic.

GALLBLADDER
Gallbladder is small pear-shaped organ is connected to your
liver and intestines. It stores digestive fluid made by the liver called
bile. When you eat fatty foods, your gallbladder releases it through
tubes, or ducts, to help break down your food. Bile helps with
digestion by breaking fats into fatty acids. It travels through the duct
system and enters your digestive system at the duodenum. During
mealtime, your gallbladder contracts, and the valve opens, pushing
the stored bile out of your gallbladder, through the cystic duct and
down the common bile duct into your intestine. Bile mixes with the
partially digested food, further helping the breakdown of the fat in
your diet.

8
 PANCREAS
The pancreas is an organ and gland. In addition, it performs 2 main
functions. The Exocrine function: Produces substances (enzymes)
that help with digestion and the Endocrine functions: Produces
substances (enzymes) that help with digestion. Furthermore, enzymes
are produced in the pancreas. These enzymes breakdown
carbohydrates, lipids, and sugars. By producing hormones, the
pancreas also supports your digestive system. These chemical
messengers move throughout your bloodstream.

SMALL INTESTINE
Absorption is the major function of small intestine.
After foods mix with stomach acid, they move into the
duodenum where they mix with bile from the gallbladder
and digestive juices from the pancreas. In addition, after
chemical digestion in the duodenum, food moves into the
jejunum (accomplished by active transport and diffusion
across the intestinal wall into circulation), where the muscle
work of digestion picks up and the ileum, it absorbs any
final nutrients, with major absorptive products being
vitamin B12 and bile acids.

LARGE INTESTINE
The process of absorbing water and electrolytes from digestive
wastes, which typically takes 24 to 30 hours, as well as holding on to
feces until they can be passed. In addition, by the time partially
digested foodstuffs reach the end of the small intestine (ileum), about
80% of the water content has been absorbed. The colon absorbs most
of the remaining water.
ANUS
The anus is where food waste exits your body after passing
through your digestive system. The anus is the opening at the lower
end of the digestive tract that controls the expulsion of feces
(Defecation).

9
IV. Pathophysiology

10
 A.D is a patient diagnosed with the presence of stones that obstructs the common
bile duct, Choledocholithiasis, in which modifiable and non-modifiable risk factors of
choledocholithiasis contribute to the occurrence of the disease. The non- modifiable risk
factor in our study only includes the age above 40. This becomes a risk factor because of
asymptomatic gallstone due to gallbladder dysfunction and increase lithogenicity of bile
that predispose the gallbladder of elderly patient. On the other hand, the modifiable risk
factor which is only included in our study is the diet of the patient. This becomes a risk
factor because too much cholesterol intake of the patient can lead to bile cannot be
breakdown. However, other risk factor of the disease can be identified as 4F’s which are
female, fertile, fat and forty.

In the case wherein patient A.D is at high risk of the occurrence of the disease,
abnormal metabolism of cholesterol and bile salt will occur. As this happens, it affects
the patient’s gallbladder motility in which there will be an inability to move bile out into
the bile ducts. When this happen, bilirubin becomes crystallize which it is a condition
with high heme turnover and bilirubin will be present in bile at higher than normal
concentrations. Then, crystals will be build up to form stones. As this happen, gallstone
will be formed. A gallstone is a hard pebble-like piece of material usually made of
cholesterol bilirubin. Subsequently, small and some stones will pass from gallbladder to
common bile duct in which it will get lodges and impacted to the common bile duct. As
the stones becomes impacted, it obstructs the common bile duct which a patient may
have fever as first manifestation. Fever, occurs because as the common bile duct
becomes obstructed there is an inflammation and infection due to the obstruction.

When, the obstruction in the common bile duct occurs, the body will try to dislodge
the stones which will result to the spasm of the biliary tracts. When this happen, patient
will have a manifestation of abdominal pain. Furthermore, with the occurrence of the
obstruction there will be no bile that will reach the GIT. In this case there will be two
results that will occur. First, there will be a decrease bile in small intestine for fat
digestion that could to decrease emulsification of fats. And with that, patient may
experience loss of appetite, nausea and vomiting. Second, a decrease bile in duodenum
will happen and leads to decrease sterobilin. In this case patient may have a
manifestation of a clay colored stool and dark brown urine.

Lastly, with the occurrence of the obstruction in the common bile duct, there will be
a backflow of conjugated bilirubin to the liver. As this happen, the conjugated or formed
together bilirubin will enter the blood stream. When this occur, patient may have a
manifestation of a yellowish discoloration to the skin and sclera.

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Nursing History

1. Personal Data

Patient A.D. is a 64-year-old male patient born on September 13, 1958. He is married and
living with her spouse residing in Meycauayan City, Province of Bulacan. A.D was a Filipino
Citizen and speaks the Filipino language. He is baptized as a Roman Catholic. He has been
working as a construction worker before he retired.

Patient arrived at the emergency department accompanied by his wife at exactly 9:00 am
on March 15, 2023, with a chief complaint of “Napakasakit na ng tiyan tapos mas
sumasakit siya kapag humihinga ako ko kaya naisip ko magpunta na sa ospital ” as
verbalized by the patient.

2. Present Health History

Four days prior to admission, patient A.D. stated that he experienced abdominal
pain. He thought he ate irritating food that caused this pain so he ignored it.

The next day, 3 days prior to admission, he still experiencing abdominal pain that
fades for some times. In the afternoon, he noticed that the pain he’s experiencing
spreads to his right shoulder.

Two days prior to admission, the patient is experiencing the same manifestations.
On that morning, he manifested nausea and vomiting and developed fever. He still did
not consult to a doctor but do self-medications such as taking Paracetamol for fever
and pain relief.

One day prior to admission, the abdominal pain becomes more severe and other
symptoms are still present. Along with this, medications don’t relieve these symptoms.
He and his wife decided to go to the doctor the next day for check-up.

An hour prior to admission, the patient was still experiencing the same with an
elevated body temperature of 38.9°C.

At around 9 in the morning, upon arrival in the emergency department and upon
the evaluation by the ER nurse, the patient appears weak and slightly yellowish in the
color of the skin and eyes. His vital signs are temperature: 38.9°C, BP: 100/60, RR: 21,
HR: 128.
3. Past Health History
Patient A.D. stated that his past laboratory results, he was assessed with high
cholesterol level. He had been given medications and health teaching regarding this,
but due to financial constraints and noncompliance to it, he didn’t maintain this
treatment.

12
4. Family Health History

5. Social and Economic History

Patient A.D is a 64-year-old male, a father of 4, and has been working as a

construction worker for over 20 years. Living with his wife, he usually wakes up at 4
in the morning to prepare and have breakfast and usually finishes in about an hour. He
usually leaves the house at around 5:30 in the morning and takes his bike to the place
where he is working. He usually travels for thirty minutes to one hour, depending on
the location. A.D usually spends 8 hours of work with a one-hour lunch break. His wife
is the one who is preparing his meal. He usually gets home around 6 in the evening if
there is no overtime work. Most of the time, A.D spends his free time with his neighbors
who happen to be his workmates at the construction site. They are spending their time
drinking alcohol. After drinking, A.D will then eat dinner with his wife and will take a
rest for tomorrow’s same-day activity.

A.D earns an average monthly salary of P 5,000 to 10,000 (including overtime). As

a provider, he needs to pay for electricity and water consumption and needs to give
almost all of his salary to his wife for the food and other necessities.

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6. Nutrition and Metabolic Pattern

A.D eats three heavy meals every day with snack times in between. The patient usually
eats affordable and easy to prepare breakfasts like eggs, processed meats, and canned
products. For lunch, the patient usually eats in carinderia near his work. He usually eats
sinigang na baboy and chicken, nilagang baboy and adobo with usually one and half cup
of rice. Furthermore, in snack time he usually eats monay bread with peanut butter, chips
and soft drinks. For dinner, he usually eats fried chicken brought in carinderia, egg and
processed meats with one and half cup of rice.

14
7. Elimination Pattern

A.D. reported that does not experience pain in urinating and urinates for about 5-6
times a day. He described his urine as dark brown and slightly cloudy. He added that
his stools appeared to be small, hard, dry and clay colored.

8. Home and Environment

The patient resides in their hometown in Meycauayan Bulacan. It is a bungalow type
of house with a small gate and a small backyard. It is a little bit small for a family of five
but is well-ventilated. It was built with mixed materials such as concrete, wood, and steel.
It has 2 rooms with wooden walls. They have easy access to transportation and are near
grocery storesand public markets. Their electric supply comes from Meralco and the
water supply is from Nawasa.

15
V. Physical Assessment
A. General Survey
A.D. arrives at the emergency room with abdominal pain. He described that the
pain started on his right upper quadrant and much worse during breathing. The
following are vital signs obtained upon admission:
 Blood pressure (BP): 100 / 60 mmHg
 Heart rate (HR): 128
 RR: 21
 Temperature: 38.9 C
 Oxygen saturation: 95%
 Height 5'6" (170 cm)
 Weight 170 lbs. (77kg)

B. Review of System

Parts Method Normal Actual Actual Clinical

Findings Findings Findings Significance
Day: 1 Day: 2
Eyes Inspection Visual acuity is The patient The patient Patients with
intact. has a has a Choledocholithias
Conjunctivae are yellowish yellowish is experience
clear without sclera. sclera. jaundice (yellow
exudates or color of the eyes)
hemorrhage. due to reduced
Sclera is non- excretion which
icteric. EOM is may be caused by
intact, PERRLA. pressure on the
Fundiappear ducts by the
normal distended
including optic gallbladder
discs and
vessels. Nosigns
of nystagmus.

16
 Skin warm, dry,
Skin Inspection The patient's The patient's Yellow skin
with good turgor,
skin is skin is discoloration is
No abnormal
yellowish, yellowish, the common
pigmentation,
warm, and warm, and causeof skin
bleeding, rash, or dry. The skin dry. The skin problems in
other lesions. turgor is turgor is poor patients with
poor and the and the Choledocholithia
patient patient sis due to
appears appears abnormally high
dehydrated. dehydrated. levels of bilirubin
(bile pigment) in
the bloodstream.

17
Upper and Inspection/ Both extremities Reported Reported Indicates swollen
Lower Palpation are equal in size sudden sudden and inflamed
Extremities and also have sharp pain sharp pain gallbladder.
the same in the upper in the upper
contour with right right
prominences of quadrant of quadrant of
joints. No the the
voluntary abdomen. abdomen.
movements, no
edema, and the
color is even
and has an equal
contraction.

Genito- Inspection, Clear, pale-yellow The patient The patient Dark urine and
urinary palpation, urine, absence of presents presents clay-colored
and pain, urgency, dark dark urine stools are
observation frequency, or brown and clay- indicative of
retention urine and colored common bile duct
no foul odor clay- stools. obstruction in
colored patients with.
stools.

18
VI. Course in the Ward

Day 1

Patient A.D. with a chief complaint of abdominal pain was admitted to the Emergency
Room on March 14, 2023, at 9:00 AM with the following vital signs: BP: 100/60 mmHg,
HR: 128 bpm, RR: 21 cpm, Temp: 38.9 degrees and O2 Sat of 95%.

The patient was placed on NPO while vital signs were monitored every 4 hours
including fluid intake and output. The patient was given IVF D5LR 1L to run for 8 hours.
Diagnostics for CBC, Urinalysis, CBG, 12-lead ECG, Chest X-Ray (PA), Abdominal X-
Ray (UR and Supine), BUN/Creatinine, Na, K, SGPT, SGOT and Troponin I was
requested. Medications ordered were Omeprazole 40 mg TIV once a day, Tramadol 50
mg every 8 hours PRN, Ketorolac 30 mg TIV every 8 hours, Cefuroxime 750 mg TIV
every 8 hours, Metronidazole 500 mg TIV every 8 hours and Paracetamol 300mg TIV
every 4 hours. The patient was requested for FC insertion with strict output monitoring as
well as NGT insertion for open bottle feeding. The patient was also scheduled for an
abdominal pelvic CT-Scan, CBG and ECG whereas results were seen and cleared by the
doctor.

At 2 PM
Patient was scheduled for Exploratory Laparotomy at 2 o'clock in the afternoon so a
fast drip of 200 CC of PNSS was given to the patient as ordered. The patient was seen and
examined by the doctor in charge before the operation, meanwhile, pre-operative checklist
and consent were secured. The patient was endorsed to the OR and underwent surgery.

At 9 PM
The patient was successfully received from the Post Anesthesia Care Unit (PACU)
conscious and coherent with NGT, O2 support 2L/min, IVF #2 D5LR 1L x 8 hours, SP
drain and FC attached. Patient was transferred to bed safely and comfortably by the nurses
in-charge. Diet was NPO and scheduled for CBC, Na, K, Creatinine, and histopathology
of the gallbladder later on.

Day 2
The patient has received continuous care from the healthcare providers and has not
shown further complaints or further complications. There are negative signs of subjective
pain on the operative site as well as on the abdominal area. The patient was still NPO.

Day 3
The patient was reported positive for flatus and negative for subjective pain. The
patient was still on NPO diet up until seen by the doctor. Patient was introduced to a soft
diet such as jelly ace, clear liquids and crackers. Care for the incision site and the patient
himself was successfully rendered by the healthcare providers.

Day 4
Patient was up for discharge with health teachings successfully understood.

19
VII. Diagnostic and Laboratories

A. Diagnostic Tests

Patient A.D undergoes a computerized tomography (CT) scan, a diagnostic imaging

procedure that uses a combination of X-ray and computer technology to produce detailed
images inside of the body. Ct scan can detect the presence of cholecystitis that include
wall thickening, peri cholecystitis stranding, distention high-attenuation bile, peri
cholecystitis fluid,and subserosal edema. Patient A.D’s CT scan result shows irregular
wall thickening in the region of the duodenum with inflammatory changes and
lymphadenopathy, small bowel ileus, minimal pleural effusion( right), cholelithiasis and
associated with biliary choledocholithiasis.ductal dilatation and with CT evidence of
cholecystitis.

On the other hand, there are the following diagnostic test that can be done to diagnose
Choledocholithiasis:

Abdominal ultrasounds

Abdominal ultrasound is often the first test done to evaluate

for cholecystitis. Ultrasound uses sound waves to produce
pictures of the gallbladder and the bile ducts. It is used to
identify signs of inflammation involving the gallbladder and is
very good at showing gallstones.

Endoscopic ultrasound

Endoscopic ultrasound works similarly to abdominal

ultrasound, except the source of thesound waves is inside your
body. As the high-frequency sound waves travel from the
echoendoscope, they hit tissues of various densities and
bounce back. This procedure allow access to the gallbladder
under endoscopic ultrasound guidance and place stents through
the wall of the small intestine into the gallbladder to relieve the
gallbladder obstruction and resulting infection.

Endoscopic Retrograde Cholangiopancreatography (ERCP)

The ERCP procedure, also known as endoscopic retrograde

cholangiopancreatography, is used to identify and address issues with the
pancreas, liver, gallbladder, and bile ducts. It combines the use of an endoscope
—a long, flexible, lighted tube—with X-ray technology. Due to its invasiveness
and capacity to treat choledocholithiasis if it is found, ERCP is advised for
patients with a high likelihood of developing it.
20
 B. Laboratory Test

HEMATOLOGY

LAB TEST RESULTS REFERENCE REMARKS CLINICAL SIGNIFICANT

RANGE

Neutrophile 0.89 0.40-0.60 INCREASE A high Neutrophil Count in a CBC

mostly indicates the presence of
infection.

URINALYSIS

LAB TEST RESULTS REFERENCE RANE REMARKS CLINICAL

SIGNIFICANT
Color Dark ABNORMAL Dark urine is a
Yellow/orange/amber/red/blue/colorless/straw/
dark common
indicative of
common bile
duct
obstruction. the
common bile
duct is probably
blocked by a
stone, causing a
backup of bile
in the liver
Transparency hazy Clear, cloud, milky, hazy ABNORMAL Hazy
transparency of
urine may
indicate
complication in
liver or bile duct
Protein +2 0 to 0.1 g/24 hour ABNORMAL Urine dipstick
proteinuria of
2+ or greater
was
significantly
associated with
increased risk

21
CHEMISTRY

LAB RESULTS REFERENCE REMARKS CLINICAL SIGNIFICANT

TEST RANGE

Total 3.7 mg/dL 0.3 – 1.2 mg/dL INCREASE Higher than usual levels of bilirubin
Bilirubin may indicate different types of liver or
bile duct problems. It may also lead to
yellow cast to the skin and the
yellowish discoloration of the sclera of
the eyes.

Direct 1.3 mg/dL 0.0 – 0.2 mg/dL INCREASE Higher than usual levels of bilirubin
Bilirubin may indicate different types of liver or
bile duct problems. It may also lead to
yellow cast to the skin and the
yellowish discoloration of the sclera of
the eyes.

Amylase 120.96 U/l Up to 95 INCREASE High amylase levels in the gallbladder is

associated with causes of chronic bacterial
infections with occult pancreaticobiliary
reflux

Lipase 185.7 U/l 0-60 U/l INCREASE Increase in level of lipase indicates that
heterotopic pancreas tissue plays a role
in exocrine functioning. As such, it is
possible that the exocrine activity of
heterotopic pancreas could cause pain
and lead to the onset of acalculous
cholecystitis.

22
VIII. Drug Study

General Actu Mechanism Indication Contraindicat Adverse Nursing

Name al of Action ion effects Responsibilities
Dosa
ge

Omeprazole 40 mg Increases - Short-term None known. Pancreatitis, - Evaluate for

TIV gastric pH, treatment (4– hepatotoxici therapeutic
Brand once reduces 8 wks.) of Cautions: ty, response
Name a day gastric acid erosive May increase interstitial (relief
production. esophagitis, risk of nephritis of GI symptoms). -
Prilosec
Converted symptomatic fractures, occur - Question if GI
to active gastroesophag gastrointestinal rarely. discomfort, nausea,
Classificatio metabolites eal reflux infections. diarrhea occurs.
n that disease
Omeprazole Hepatic
irreversibly (GERD) impairment,
belongs to a PATIENT/FAMI
bind to, poorly pts of Asian
class of LY TEACHING
inhibit responsive to descent.
medications hydrogen- other - Avoid
called potassium treatment, H. alcohol.
Benzimidazo adenosine pylori– - Take before
le. triphosphata associated eating
se, an duodenal - Swallow capsules
enzyme on ulcer, whole; do
the surface - Long-term not chew/crush.
of gastric treatment of - Report headache,
parietal pathologic onset of black,
cells. hypersecretory tarry
Inhibits conditions; stools, diarrhea,
hydrogen treatment of abdominal pain.
ion active
transport duodenal ulcer
into gastric or active
lumen. benign gastric
ulcer.
- Maintenance
healing of
erosive
esophagitis.

23
General Actu Mechanis Indicatio Contraindic Adverse Nursing Responsibilities
Name al m of n ation effects
Dosa Action
ge

Tramadol 50 Reduces Manage Acute alcohol Seizures BASELINE

mg pain as it ment of intoxication, reported in ASSESSMENT
Brand q8h binds to - moderate concurrent use those - Assess onset, type,
Name opioid to of centrally receiving location, duration of
receptors, moderate acting tramadol pain.
Ultram
inhibits ly severe analgesics, within - Assess drug history, esp.
reuptake of pain. hypnotics, recommen carbamazepine, analgesics,
Classifica norepineph opioids, ded dosage CNS depressants, MAOIs.
tion rine, psychotropic range. May Review past medical
Tramadol serotonin. drugs, have history, esp. epilepsy,
belongs Reduces hypersensitivit prolonged seizures.
to a class intensity of y to opioids. duration of - Assess renal/hepatic
of pain ConZip, action, function lab values.
medicatio stimuli Ryzolt: cumulative
ns which incoming (Additional) effect in
is INTERVENTION/EVAL
from Severe/ acute pts with
centrally sensory hepatic/ren UATION
bronchial
acting nerve asthma, al - Monitor pulse, B/P,
synthetic endings. hypercapnia, impairment renal/hepatic function.
opioid significant , serotonin - Assist with ambulation if
analgesic. respiratory syndrome dizziness, vertigo occurs.
depression. (agitation, - Dry crackers, cola
hallucinati may relieve nausea.
ons, - Palpate bladder for
tachycardia urinary retention.
, - Monitor daily pattern of
hyperreflex bowel activity, stool
ia). consistency.
- Sips of tepid water may
relieve dry mouth.
- Assess for clinical
improvement, record
onset of relief of pain.

24
General Actu Mechani Indicatio Contraindica Adverse Nursing Responsibilities
Name al sm of n tion effects
Dosa Action
ge

Ketorolac 30 Reduces PO, Advanced Peptic ulcer, BASELINE

mg, intensity injection, renal GI bleeding, ASSESSMENT
Brand TIV of pain nasal: impairment, gastritis, - Assess onset, type,
Name q8h, stimulus, Short-term active peptic severe location, duration of
PRN reduces (5 ulcer disease, hepatic pain.
Toradol
intraocula days or chronic reaction - Obtain baseline
r less) relief inflammation (cholestasis, renal/hepatic function tests.
Classifica inflamma of mild to of GI tract, GI jaundice)
tion tion. moderate bleeding/ulcer occur INTERVENTION/EVAL
Ketorolac Inhibits pain. ation, history rarely. UATION
belongs to prostagla of Nephrotoxic - Monitor renal/hepatic
a class of ndin hypersensitivi
Ophthalm ity function tests, urinary
medicatio synthesis, ty to aspirin,
ns called c: Relief of (glomerular output.
reduces ocular NSAIDs. nephritis,
NSAID. prostagla - Monitor daily pattern of
itching due Perioperative interstitial
ndin bowel activity, stool
to seasonal pain in setting nephritis,
levels in consistency.
allergic of CABG nephrotic
aqueous - Observe occult blood loss.
conjunctivi surgery. syndrome)
humor. - Assess for therapeutic
tis. may occur
response: relief of pain,
Treatment in pts with
stiffness, swelling; increased
post op for preexisting
joint mobility; reduced joint
inflammati renal
tenderness; improved grip
on impairment. strength.
following Acute
cataract - Be alert to signs of
hypersensiti
extraction, bleeding (may also occur
vity reaction
pain with ophthalmic route due to
(fever,
following systemic absorption).
chills, joint
incisional pain)
refractive occurs PATIENT/ FAMILY
surgery. rarely. TEACHING
- Avoid aspirin, alcohol
during therapy with oral or
ophthalmic ketorolac
(increases tendency to
bleed).
- If GI upset occurs, take
with food, milk.
- Avoid tasks that require
alertness, motor skills until
response to drug is
established.

Ophthalmic

25
- Transient stinging, burning
may occur upon
installation.
- Do not administer while
wearing soft contact
lenses.

26
General Act Mecha Indication Contraindicatio Adverse Nursing
Name ual nism n effects Responsibilities
Dos of
age Action

Cefuroxime 750 It is a Treatment of History of Antibiotic- BASELINE

mg bacteri susceptible hypersensitivity/a associated ASSESSMENT
Brand TIV cidal infections naphylactic colitis, - Question for history
Name ever that due to group reaction, other of allergies,
Apo- y8 binds B hypersensitivity superinfect particularly
hour to streptococci, to ons cephalosporins,
Cefuroxime
s bacteri pneumococci cephalosporins. (abdominal penicillin.
al cell , cramps,
Classificatio membr staphylococc severe
n INTERVENTION/E
anes, i, H. watery VALUATION
cefuroxime inhibits influenzae, diarrhea,
belongs to a - Assess oral cavity for
cell E. coli, fever) may white patches on
class of wall Enterobacter, result from
medications mucous membranes,
synthes Klebsiella altered tongue (thrush).
called is. including bacterial
Second - Monitor daily pattern
acute/ balance.
generation of bowel activity, stool
chronic Nephrotoxi
cephalospori consistency. Mild GI
bronchitis, city
n. effects may be
gonorrhea, may occur, tolerable (increasing
impetigo, esp. in pts severity may indicate
early Lyme with onset of antibiotic-
disease, otitis preexisting associated colitis).
media, renal
- Monitor I&O, renal
pharyngitis/t disease. Pts
function tests for
onsillitis, with a
sinusitis, nephrotoxicity.
history of
skin/skin - Be alert for
allergies,
structure, superinfection: fever,
esp. to
UTI, vomiting, diarrhea,
penicillin,
perioperative anal/ genital pruritus,
are at
prophylaxis. oral mucosal changes
increased
(ulceration, pain,
risk for
erythema).
developing
a severe
hypersensit PATIENT/FAMILY
ivity TEACHING
reaction - Discomfort may
(severe occur with IM
pruritus, injection.
angioedem - Doses should be
a, evenly spaced.
bronchospa - Continue antibiotic
sm therapy for full length
of treatment.

27
anaphylaxi - May cause GI upset
). (may take with food,
milk).

28
General Actu Mechanism Indication Contraindi Advers Nursing
Name al of Action cation e Responsibilities
Dosa effects
ge

Metronida 500 Produces - Treatment of Hypersensiti Oral BASELINE

zole mg bactericidal, anaerobic vity to other therapy ASSESSMENT
TIV antiprotozoal, infections nitroimidaz may result - Question for history of
Brand ever amebicidal, (skin/ skin ole in furry hypersensitivity to
Name y8 trichomonaci structure, derivatives tongue, - Metronidazole, other
Apo- hour dal effects. CNS, lower (also glossitis, nitroimidazole
Metronida s Produces M respiratory parabens cystitis, derivatives (and parabens
zole underlined – tract, with topical dysuria, with topical).
top bone/joints, application), pancreatiti - Obtain specimens for
prescribed intra- pregnancy s. diagnostic tests,
Classifica drug anti- abdominal, (first Peripheral
tion - Cultures before giving
inflammatory gynecologic, trimester). neuropath first dose (therapy
Metronida , endocarditis, y
zole - May begin before
immunosupp septicemia). (manifeste
belongs to results are known).
ressive d as
a class of effects when numbness,
- Treatment of INTERVENTION/EVA
medicatio applied tingling of
trichomoniasis LUATION
ns called topically.Disr hands/feet
, amebiasis,
Nitroimid upts DNA, ) usually i - Monitor daily pattern of
antibiotic
azole inhibiting reversible bowel activity,
associated
derivative nucleic acid if - Stool consistency.
pseudomembr
. synthesis. treatment Monitor I&O, assess for
anous colitis
(AAPC). is stopped - Urinary problems. Be
immediate alert to neurologic
ly upon - Symptoms (dizziness;
- Topical
appearanc paresthesia of
treatment of
e of extremities). Assess for
acne rosacea.
neurologic rash, urticaria.
symptoms - Watch for onset of
Vaginal gel: Seizures superinfection
- Treatment of occur (ulceration/change of
bacterial occasional oral mucosa, furry
vaginosis. ly. tongue,
- Vaginal discharge,
genital/anal
pruritus).

PATIENT/FAMILY
TEACHING
- Urine may be red-
brown or dark.
- Avoid alcohol, alcohol-
containing preparations
(cough syrups, elixirs)

29
for at least 48 hrs after
last dose.
- Avoid tasks that require
alertness, motor skills
until response to drug is
established.
- If taking metronidazole
for trichomoniasis,
refrain from sexual
intercourse until full
treatment is completed.
- For amebiasis,
frequent stool specimen
checks will be
necessary.

Topical:
- Avoid contact with
eyes.
- May apply cosmetics
after application.
- Metronidazole acts on
erythema, papules,
pustules but has no effect
on rhinophyma
(hypertrophy of nose),
telangiectasia, ocular
problems (conjunctivitis,
keratitis, blepharitis).
- Other recommendations
for rosacea include
avoidance of hot/spicy
foods, alcohol, extremes
of hot/ cold temperatures,
and excessive sunlight.

30
General Name Act Mechan Indicati Contraindi Adverse Nursing
ual ism of on cation effects Responsibilities
Dos Action
age

Acetaminophen/Pa 300 Appears - Relief Severe Early BASELINE

racetamol mg to of mild hepatic Signs of ASSESSMENT
TIV inhibit to impairment Acetamino - If given for analgesia,
Brand Name ever prostagl moderat or severe phen assess onset, type,
Ofirmev y4 andin e pain, active liver Toxicity location, duration of
Classification hour synthesi fever. disease includes: pain.
Acetaminophen s s in the IV: (Ofirmev). Anorexia, - Effect of medication is
belongs to a class PRN CNS (Additio nausea, reduced if full pain
of medications and, to a nal) diaphoresis response recurs prior to
called Central lesser , fatigue next dose.
analgesic. extent, Manage within first - Assess for fever.
block ment of 12–24 hrs. - Assess alcohol usage.
pain moderat Later Signs
impulses e to of
through Toxicityinc INTERVENTION/EVA
severe LUATION
peripher pain ludes:
al Vomiting, - Assess for clinical
when
action. right upper improvement and relief
combin
Acts quadrant of pain, fever.
ed with
centrally tenderness, - Therapeutic serum
opioid
on elevated level: 10–30 mcg/ml;
analgesi
hypothal hepatic toxic serum level: greater
a.
amic function than 200 mcg/ml.
heat- tests within - Do not exceed
regulatin 48–72 hrs maximum daily
g center, after recommended dose: 4
producin ingestion. g/day.
g Antidote:
peripher Acetylcyst PATIENT/FAMILY
al eine (see TEACHING
vasodila Appendix - Consult physician for
tion K for use in children younger
(heat dosage). than 2 yrs, oral use longer
loss, than 5 days (children) or
skin longer than 10 days
erythem (adults), or fever lasting
a, longer than 3 days.
diaphore - Severe/recurrent pain or
sis). high/ continuous fever
Results may indicate serious
in illness.
antipyre - Advise not to take
sis. more than 4 g/24-hr
Produce period.
s

31
analgesi - Many nonprescription
c effect. combination products
contain
acetaminophen.
- Avoid alcohol use.

32
 IX. Nursing Care Plan

ASSESSMENT PLANNING INTERVENTION RATIONALE EVALUATION

Subjective: Wholly Independent: Patient’s condition
> “Napakasakit na ng Compensatory - Observe and - To assists in differentiating improved as
tiyan ko kaya naisip document location, causes of pain, and provides manifested by relief
ko magpunta na sa Short-term severity, and information about disease or control of pain.
ospital” as verbalized Goal: character of pain. progression and resolution,
by the client. After 2 hours of development of
nursing complications, and
Objective: interventions, the effectiveness of
- Abdominal pain of 8 to patient will report interventions.
10 in pain scale relief or control - Promote bedrest, - Bedrest in low-Fowler’s
- facial grimace of pain. allowing the patient position reduces intra-
- guarding behavior to assure a position abdominal pressure;
- Blood pressure of Long-term of comfort. however, the patient will
100/60 Goal: naturally assume the least
- Pulse rate of 128 After 3 days of painful position.
bpm nursing - Encourage the use - To promote rest, and
- Respiratory rate of interventions, the of relaxation redirecting attention that may
21 bpm patient will be techniques. Provide enhance coping.
free from pain diversional
Nursing Diagnosis: and perform activities.
Acute pain related to activity of daily - Maintain NPO - Removes gastric secretions
biological injuries living. status, insert and/or that stimulate the release of
agents like maintain NG cholecystokinin and
cholecystitis, suction as indicated. gallbladder contractions.
cholecystolithiasis, - Make time to - It is helpful in alleviating
appendicitis. listen to and anxiety and refocusing
maintain frequent attention, which can relieve
contact with the pain.
patient.

Dependent:
- Note the response - Pain not relieved by routine
to medication, and measures may indicate
report to the developing complications or
physician if the pain a need for further
is not being intervention.
relieved.

33
- Administer - To reduce pain that the
narcotics agents as client is experiencing.
prescribed by the
physician.
- Administer - Promotes rest and relaxes
sedatives smooth muscle, relieving
medication as pain.
indicated.
Collaborative:

34
ASSESSMENT PLANNING INTERVENTION RATIONALE EVALUATION
Subjective: Wholly Independent: Patient’s condition
> “Ilang araw na ako Compensatory - Assess vital signs, - This may suggest improved as
hindi natatae at noting presence of hypoperfusion or developing manifested by
nagaalala na ako at Short-term low blood pressure, sepsis. reestablished and
baka kung ano na ang Goal: elevated heart rate, maintained normal
nangyayari saakin” as After 1 hour of and fever. pattern of bowel
verbalized by the nursing - Discuss fluid - Water is necessary to functioning.
client. interventions, the intake appropriate general health and GI
patient will to individual function; client may need
verbalize situation. encouragement to increase
Objective: understanding of intake or to make appropriate
- 2 bowel movement causative factors fluid choices if intake is
for a week and rationale for restricted for certain medical
- Hard, dry, and small treatment conditions.
stool regimen - Encourage eating - High fiber diet and
- Difficulty defecating foods rich in fiber increased fluid intake can
- Hypoactive bowel Long-term and increase fluid promote bowel movement.
sounds Goal: intake.
After 3 days of
Nursing Diagnosis: nursing
Dysfunctional interventions, the
gastrointestinal patient will - To manage fluid losses and
- Measure GI output
motility related to reestablish and replacement needs and
periodically and
decreased and lack of maintain normal electrolyte balance.
note characteristics
peristaltic activity pattern of bowel
of drainage
within the functioning.
- Emphasize the - To stimulate peristalsis and
gastrointestinal importance of and help reduce GI complications
system. assist with early associated with immobility.
ambulation,
especially following
surgery
- Studies have shown various
- Recommend deleterious short and long-
smoking cessation term effects of smoking on
the GI circulation and
organs. Smoking is a risk
factor for acquiring or
exacerbation certain GI
disorders.

35
- Maintain GI rest - To reduce intestinal
when indicated – bloating and risk for
nothing by mouth vomiting.
(NPO), fluids only,
or gastric or
intestinal
decompression.

36
ASSESSMENT PLANNING INTERVENTION RATIONALE EVALUATION
Subjective: Partially Independent: The risk was
Compensatory - Weigh as - To monitor the effectiveness prevented as evidence
indicated. of the dietary plan by patient
Objective: Short-term - Provide oral - A clean mouth enhances demonstrated
- Blood pressure of Goal: hygiene before appetite. progression toward
100/60 After 3 hours of meals. desired weight gain.
-Dry skin and mucous nursing - Provide a - Useful in promoting
membrane interventions, the pleasant appetite/reducing nausea.
- Weight loss patient will atmosphere at
demonstrate mealtime; remove
- Decrease in urine
behaviors to noxious stimuli.
output
monitor current - Offer - May lessen nausea and
deficit, as effervescent drinks relieve gas.
Nursing Diagnosis:
indicated. with meals, if
Risk for Imbalance
tolerated.
Nutrition
Long-term Goal:
After 3 days of - Ambulate and
- It’s helpful in the expulsion
nursing increase activity as
of flatus, and reduction of
interventions, the tolerated.
abdominal distention.
patient will
Contributes to overall
demonstrate
recovery and a sense of well-
progression
being and decreases the
toward desired
possibility of secondary
weight gain.
problems related to
immobility.
- Begin a low-fat - Limiting fat content reduces
liquid diet after the stimulation of the gallbladder
NG tube is and pain associated with
removed. incomplete fat digestion and
is helpful in preventing
recurrence.
- Provide - Alterative feeding may be
parenteral and/or required depending on the
enteral feedings as degree of disability and
needed. gallbladder involvement and
the need for prolonged gastric
rest.

37
Dependent:
- Administer bile - To promote digestion and
salts: Bilron, absorption of fats, fat-soluble
Zanchol, and vitamins, and cholesterol.
dehydrocholoic Useful in chronic
acid (Decholin), as cholecystitis.
indicated.

Collaborative:
- Consult with a - Useful in establishing
dietitian or individual needs and the most
nutritional support appropriate route.
team as indicated.

38
 ASSESSMENT PLANNING INTERVENTION RATIONALE EVALUATION
Subjective: Independent: Patient's condition
Partially improved as manifested
"Medyo nagsusugat yung Compensatory - Perform wound - Wound care differs depending by patient or significant
lugar kung saan ako care per guidelines on the type of skin breakdown, other demonstrate proper
inoperahan" as verbalized Short-term and orders wound cleaning and
by the patient. location on the body, and size
Goal: of the wound. Wound care helps hygiene.
prevent infection.
Objective: After 3 hours of
nursing
- Pruritus interventions, the - Skin at risk for breakdown
- Continued
- Disruption of skin patient will verbalize assessment of skin should be closely monitored at
surface understanding of least once a shift. Observed
and wounds
- T: 38.5 preventing skin wounds should be monitored to
irritation. ensure dressings are intact or
Nursing Diagnosis: that skin breakdown is not
worsening, such as increased
Risk for Impaired Skin Long-term Goal: redness.
integrity related to
surgical procedure. After 3 days of
nursing - Body secretion thru the
- Keep the skin
interventions, the suture site is considered
clean and dry
patient or abnormal.
significant other Maintaining a dry skin can avoid
demonstrate attracting of microorganisms.
proper wound
- Encourage
cleaning and - Proper intake of fluids increases
nutrition and
hygiene. oxygen and nutrient delivery.
hydration
understanding of Intake of high protein foods and
daily skin supplements is essential for
inspection. repairing body tissues.
- Encourage
ambulation as - Ambulation reduces pressure
indicated on the skin from immobility
thus lessening the factors that
may result in impaired skin
- Encourage integrity.
patients and
caregivers about - Educating patients and
proper skin care caregivers on methods to
maintain skin integrity
enhances their sense of self-
efficacy and prevents skin
39
 breakdown.

Dependent:

- Administer - To reduce pain that the client

narcotics as is experiencing.
prescribed by the
physician

40
41
X. Health Teaching

M- Advise the patient to take all medication prescribed by the physician.

Medications Compliance to the medications is the most effective means of treating
disease and preventing its complications.

Educate the patient about home medications that should be taken and
administered with strict monitoring.

Educate the patient about the possible adverse effects of the

medications and advise to report it immediately once experienced.

Educate patient about using antibiotics like Cefuroxime and

Metronidazole for infection treatment, oral analgesic like Tramadol
for severe pain, Omeprazole and ketorolac to relieve moderately
severe pain, Acetaminophen/Paracetamol to moderate pain and fever.

Inform the client that if constipation occurs talk with the physician and
ask for bowel regimen. Pain medicines can be constipating.

E- Advised the patient to eliminate noxious sights or smells from the

Environment environment. This will reduce the stimulation of the vomiting center.

Advised the patient and family to control the environmental

temperature. Cool surroundings can aid in minimizing dermal
discomfort.

Always promote rest to relieve and lessen pain.

T- Instruct the patient to continue prescribed medications to avoid further

Treatment complications.
Educate the patient about adhering to the full treatment regimen and
provide support.

H- Instruct the patient to perform frequent oral hygiene with an alcohol-

Hygiene free mouthwash. This will decrease the dryness of the oral mucous
membrane.

For post-op care, instruct the client to gently wash the skin around the
incision with soap and water.

Educate and instruct the patient that if there is a gauze dressing on the
incision, change it daily or as often as needed to keep it dry and clean.

42
O- Instruct a patient about the continuity of prescribed medications and
Outpatient schedule follow-up checkups.

Remind the patient to take a lot of rest for fast recovery.

D-Diet Instruct the patient about the appropriate and right diet including low-
fat diet and avoid foods/ fluids that contain high-fat such as fried
foods, canned fish, processed meats, full fat dairy products, fast foods,
whole milk, carbonated beverages, coffee, gas producers like cabbage,
beans, and etc.

S- Advise the relatives of patient to never leave unattended on bed and

Safety/Spiritual/Sexual avoid cluttering the bed with things that may be harmful to the patient.
(case based)

43
XI. Evaluation

The case of patient A.D. with a diagnosis of Choledocholithiasis was able to get treated
successfully inside the hospital with no further complications. The student nurses were able to
broaden their knowledge and understanding about the disease and its process. They also executed
with care and precision each intervention prepared for the patient with Choledocholithiasis.
Lastly, the student nurses build a strong therapeutic relationship with the patient up until fully
healed. Meanwhile, the patient and relatives understood the disease management and health
teachings imparted by the healthcare providers and were able to apply health teachings provided
to prevent further complications as well as appropriate behavior during the entire course of
treatment, and lastly, willingness for healing and recovery from the disease was successfully
achieved.

Nursing Theory

Virginia Avenel Henderson also known as “The Nightingale of Modern Nursing” was a nurse,
theorist, and author known for her Need Theory. She defined nursing as, “The nurse’s unique
function is to be in service to individuals, well or sick, in the activity performances contributing to
the health or recovery (or to peaceful death) that he/she would perform unaided if possesses the will,
strength, and knowledge (Gonzalo, 2023). The theory shows great relevance to the case study since it
deeply emphasizes the importance of patients’ independence by allowing them to performand
function on their own inside the hospital with the guidance of healthcare providers like nurses. This
would permit the patient to have fewer setbacks during recovery and have a smoother transition
when finally, out for discharge.

44
 XII. REFERENCES

Anonymous. (n.d.). WHAT ARE THE SYMPTOMS OF A GALLBLADDER ATTACK. THE

SURGICAL CLINIC.
https://thesurgicalclinics.com/symptoms-gallbladder-attack/
Carter, C. (2015). Acute thoracolumbar pain due to cholecystitis: a case study. Chiropractic & Manual
Therapies, 34.
https://doi.org/10.1186/s12998-015-0079-2
Gonzalo, A. (2023). Virginia Henderson: Nursing Need Theory.
Nurseslabs. https://nurseslabs.com/virginia-hendersons-need-
theory/

Lindenmeyer, C. (2021). Acute Cholecystitis. MSD MANUAL Professional Version.

https://www.msdmanuals.com/professional/hepatic-and-biliary-disorders/gallbladder-and-bile-
duct-disorders/acute-cholecystitis
Musana, K. & Yale, S. (2005). John Benjamin Murphy (1857 - 1916). National Library of Medicine, 3, 110
- 112.
https://doi.org/10.3121/cmr.3.2.110

Pisano, M., Allievi, N., Gurusamy, K. et al. 2020 World Society of Emergency Surgery updated guidelines
for the diagnosis and treatment of acute calculus cholecystitis. World J Emerg Surg 15, 61 (2020).
https://doi.org/10.1186/s13017-020-00336-x

Christopher, F., Pastorino, A., Farooq, U., et al. (2023). Choledocholithiasis. National Library of Medicine.
https://www.ncbi.nlm.nih.gov/books/NBK441961/

Anonymous. (n.d.). Choledocholithiasis. Mount Sinai. https://www.mountsinai.org/health-library/diseases-

conditions/choledocholithiasis?

Tanaja, J., Lopez, R., & Meer, J. (2022). Cholelithiasis. National Library of Medicine.
https://www.ncbi.nlm.nih.gov/books/NBK470440/?fbclid=IwAR3qYo27ANIxSdc3nKnzphfPP9o7TI3_ib-
sCEukzq87_598rwzZKkrB_jY#:~:text=Choledocholithiasis%20is%20a%20complication%20of,of%20liver
%20enzymes%20and%20jaundice

Khatri, M. (2023). Digestive Diseases and ERCP Testing. WebMD. https://www.webmd.com/digestive-

disorders/digestive-diseases-ercp

Park, Y., Kim, D., Lee, J., et al. (2017). Association between diet and gallstones of cholesterol and pigment among patients
with cholecystectomy. National Library of Medicine,36. https://doi.org/10.1186/s41043-017-0116-y

45