G3 Open Cholecystectomy

Republic of the Philippines
Isabela State University

Echague, Isabela
COLLEGE OF NURSING
In Partial Fulfillment
Of the Requirement in
NUR 422
(Intensive Nursing Practicum)
Case Study Of
Open Cholecystectomy, CBDE Choledocholithotomy,
Choledochoscopy, T-tube Insertion
Presented to:
Clinical Instructor of NUR 422

(Intensive Nursing Practicum)
College of Nursing –Isabela State University Echague, Isabela
By:
Acio, Stephany G.
Ching Sai, Jasmine M.
Estonactoc, Allen Francis U.
Facun, Nica Mae M.
Floresca, Hannah Rendel B.
Genove, Wishfer Joyce S.
Gallardo, Angelyn P.
Garcia, Pearl Jasmine P.
Ibarra, Rapunzel C.
Ibarra, Rachel B.
Ramos, Alice Jane A.
BSN 4-1
S.Y 2023-2024
2nd Semester
Echague, Isabela
COLLEGE OF NURSING
I. OBJECTIVES
A. General Objective:
The major purpose of the case study is to equip students with the skills and for them
to gain knowledge about Cholecystitis with Cholecystolithiasis, Choledocholithiasis, along
with its surgical procedure, medical and pharmacological management in order to provide
support, health education, and care for patient. It also seeks to increase awareness about the
overview of the disease in order to improve the capability of student nurses in providing
competent nursing care plans.
B. Specific Objectives:
● To assess the patient's previous and present experiences as it relates to her
current condition.
● To describe the overview of the disease and other necessary information
regarding the case.
● To obtain and document the patient’s demographic profile.
● To comprehend the diagnostic procedures, analyze and interpret laboratory
results.
● To discuss the anatomy of the surgical incision site.
● To chronologically describe the surgical procedure done during the operation.
● To enumerate the surgical instruments used in the surgical procedure and
describe their functions.
● To formulate an appropriate nursing care plan perioperatively.
● To understand what pharmacological treatments are utilized, how the
medications operate, and how it improves the patient's condition.
● To develop a framework of study regarding the subject that can serve as a guide
and foundation for future studies and research related to the disease.
2
Echague, Isabela
COLLEGE OF NURSING
II. OVERVIEW OF THE DISEASE
A. Definition
Cholecystitis- Inflammation of the gallbladder which can be acute or chronic that
causes pain, tenderness, and rigidity of the upper right abdomen.
There are two categories of acute cholecystitis which include calculous cholecystitis
and acalculous cholecystitis.
➢ Calculous cholecystitis is the cause of more than 90% of cases of acute
cholecystitis. In calculous cholecystitis, there is a gallbladder stone that
obstructs bile outflow. Bile remaining in the gallbladder initiates a chemical
reaction; autolysis and edema occur; and the blood vessels in the gallbladder
are compressed, compromising its vascular supply. Bacteria play a minor role
in acute cholecystitis; however, secondary infection of bile occurs in
approximately 50% of cases. The organisms involved are generally enteric
(normally live in the GI tract) and include Escherichia coli, Klebsiella species,
and Streptococcus. The trapped bile in the gallbladder can be a medium for
bacterial infection which lead to further inflammation of the gallbladder.
➢ Acalculous cholecystitis describes acute gallbladder inflammation in the
absence of obstruction by gallstones. This is most commonly occurred in
seriously ill patient. Acalculous cholecystitis occurs after major surgical
procedures, orthopedic procedures, severe trauma, or burns.
Chronic cholecystitis is the most common form of gallbladder disease which can occur
due to repeated attacks of acute cholecystitis. It is almost always associated with gallbladder
stones.
Cholecystolithiasis- Calculi, or gallstones, usually form in the gallbladder from the
solid constituents of bile; they vary greatly in size, shape, and composition
There are two major types of gallstones: those composed predominantly of pigment
and those composed primarily of cholesterol.
▪ Pigment stones probably form when unconjugated pigments in the bile
precipitate to form stones. The risk of developing such stones is increased in
patients with cirrhosis, hemolysis, and infections of the biliary tract. Pigment
stones cannot be dissolved and must be removed surgically.
▪ Cholesterol stones, which is a normal constituent of bile, is insoluble in water.
Its solubility depends on bile acids and lecithin (phospholipids) in bile (Hammer
& McPhee, 2019). In gallstone- prone patients, there is decreased bile acid
synthesis and increased cholesterol synthesis in the liver, resulting in bile
supersaturated with cholesterol, which precipitates out of the bile to form stones
(Hammer & McPhee, 2019). The cholesterol-saturated bile predisposes to the
formation of gallstones and acts as an irritant that produces inflammatory
changes in the mucosa of the gallbladder (Hammer & McPhee, 2019).
3
Echague, Isabela
COLLEGE OF NURSING
Choledocholithiasis-Choledocholithiasis occurs as a result of either the formation of
stones in the common bile duct or the passage of gallstones that are formed in the gallbladder
into the CBD. Stones that are too large to pass through the ampulla of Vater remain in the distal
common bile duct, causing obstructive jaundice that may lead to pancreatitis, hepatitis, or
cholangitis. Gallstones are differentiated by their composition. Cholesterol stones are
composed mainly of cholesterol, while black pigment stones are mainly made of pigment, and
brown pigment stones are composed of a mix of pigment and bile lipids. Cholesterol stones
make up approximately 75% of the secondary common bile duct stones, while black pigment
stones comprise the remainder. Primary common bile duct stones are usually brown pigment
stones. Obstruction of the CBD by gallstones leads to symptoms and complications that include
pain, jaundice, and sepsis.
B. Epidemiological Report
International
● Cholecystitis, cholecystolithiasis, and choledocholithiasis pose substantial global

health challenges, each characterized by distinct epidemiological features. According
to a comprehensive review conducted by the World Health Organization (WHO), the
prevalence of cholecystolithiasis worldwide ranges between 10-15%, with higher rates
documented in Western countries compared to their counterparts in Asia and Africa.
Choledocholithiasis, though less prevalent, remains a significant concern due to its
potential complications, including obstructive jaundice and pancreatitis. The global
incidence of these conditions is intricately influenced by demographic variables such
as age, ethnicity, and socioeconomic status, as well as lifestyle factors like dietary
habits. Consequently, addressing these conditions mandates tailored public health
interventions and collaborative efforts on an international scale.
Local
● In the Philippines, cholecystitis, cholecystolithiasis, and choledocholithiasis pose

significant healthcare challenges, particularly in urban areas. Data from the Philippine
Department of Health (DOH) indicates a rising prevalence of gallstone-related diseases,
with cholecystolithiasis affecting approximately 6-10% of the population.
Choledocholithiasis, though less prevalent, contributes substantially to biliary tract
disorders requiring medical intervention. Lifestyle factors including dietary changes,
sedentary behaviors, and increasing obesity rates are recognized as key contributors to
the escalating incidence of these conditions in the country. As such, effective preventive
healthcare strategies and equitable access to healthcare services are imperative to
address these evolving public health concerns nationwide.
4
Echague, Isabela
COLLEGE OF NURSING
B. Causes/Risk Factors
All of the factors below are associated with an increased risk of cholecystitis,
cholelithiasis, and choledocholithiasis include:
MODIFIABLE
Cholecystitis Cholecystolithiasis Choledocholithiasis
● Sedentary Lifestyle ● Westernized Diet ● Westernized Diet

and Obesity ● Sedentary lifestyle ● Sedentary lifestyle
● Estrogen-containing and obesity and obesity
medications ● Cholesterol lowering ● Estrogen-containing
● Blockage caused by: drugs medications
○ Gallstones ● Estrogen-containing
○ Tumor medications
○ Bile duct
blockage
○ Infection
○ Severe illness
NON-MODIFIABLE
● Being Female ● Being Female ● Being Female

● Age 40 and above ● Age 40 and above ● Age 40 and above
● Fair skin ● Fair skin ● Fair skin
● Blockage caused by: ● Family History
o Liver disease
C. Clinical Manifestations
● Fever ● Abdominal pain ● Jaundice

● Nausea and vomiting ● GI distress ● Abdominal pain
● Murphy’s Sign ● Vitamin A, D, E, ● Tea-colored Urine
and K deficiency ● Clay-colored Stool
● Nausea and vomiting
● Fever and chills
5
Echague, Isabela
COLLEGE OF NURSING
D. Complications
● Gallbladder ● Cholecystitis ● Obstructive Jaundice

Empyema ● Choledocholithiasis ● Cholangitis
● Gallbladder ● Cholangitis ● Acute Pancreatitis
perforation ● Gallstone Pancreatitis ● Biliary Stricture
● Gangrenous ● Gallstone ileus ● Gallstone Ileus
Cholecystitis ● Gallbladder cancer ● Liver Damage
● Biliary Obstruction
● Systemic Infection
(Sepsis)
III. OVERVIEW OF THE SURGICAL PROCEDURE
A. Background information
Open Cholecystectomy
An open cholecystectomy involves removing the gallbladder through an abdominal

incision (typically right subcostal) after ligating the cystic duct and artery. The procedure is
used to treat acute and chronic cholecystitis. If a bile leak occurs, a drain is inserted near the
gallbladder bed and removed through a puncture cut. The drain type is selected based on the
surgeon's preferences. A minor leak should close spontaneously in a few days, with the drain
preventing bile accumulation. Usually, just a tiny amount of serosanguineous fluid drains in
the first 24 hours after surgery; the drain is then removed. If there is excessive oozing or bile
leakage, the drain is usually kept in condition to operate.
CBDE Choledocholithotomy
CBDE Choledocholithotomy, or Common Bile Duct Exploration

Choledocholithotomy, is a significant surgical procedure designed to address the presence of
stones in the common bile duct (CBD) that can lead to various complications. Common bile
duct stones, known as choledocholithiasis, can cause symptoms such as jaundice, abdominal
pain, and pancreatitis, necessitating prompt intervention to alleviate biliary obstruction and
prevent further complications.
6
Echague, Isabela
COLLEGE OF NURSING
CBDE Choledocholithotomy plays a crucial role in the management of CBD stones by
providing a direct and effective method for their removal, thereby restoring the normal flow of
bile and ensuring the proper functioning of the biliary system. This procedure can be performed
either laparoscopically or through an open surgical approach, depending on the patient's
condition and the surgeon's expertise. By combining stone extraction from the CBD with other
biliary surgeries like cholecystectomy, CBDE Choledocholithotomy offers a comprehensive
solution to biliary pathologies, reducing the need for multiple procedures and minimizing the
risk of recurrent biliary issues. The effectiveness of CBDE Choledocholithotomy lies in its
ability to achieve complete stone clearance, alleviate symptoms, and promote optimal patient
outcomes by addressing the underlying cause of CBD obstruction.
Choledochoscopy insertion
Choledochoscopy insertion is a procedure that may be performed in conjunction with

open cholecystectomy surgery. If the surgeon suspects the presence of stones or other
abnormalities in the common bile duct during the open cholecystectomy, they may choose to
perform choledochoscopy insertion. This involves inserting a thin, flexible tube called a
choledochoscope into the common bile duct to visualize and potentially treat any stones or
obstructions.
The choledochoscope is inserted through a small incision made in the common bile
duct, which is usually located near the opening of the duodenum. The surgeon can then use the
choledochoscope to directly visualize the area and perform interventions such as stone
removal, dilation of strictures, or placement of stents.
Choledochoscopy insertion during open cholecystectomy allows for a comprehensive

evaluation and treatment of any common bile duct abnormalities, ensuring that all stones or
obstructions are addressed during the surgery. This can help prevent complications and the
need for additional procedures.
T-Tube Insertion
A T-tube, is termed because of its shape, is rarely inserted into the common bile duct
during an open operation; instead, it is only utilized when a complication arises (such a retained
common bile duct stone). In the course of surgical exploration, a T-tube is placed into the
common bile duct. It permits bile to be externally drained into a collection bag, promoting
healing of the surgical site.
B. Indication
With the introduction of laparoscopic cholecystectomies, the need for open

cholecystectomy has diminished. The most common reason for an open cholecystectomy (2%
7
Echague, Isabela
COLLEGE OF NURSING
to 10%) is to transition from laparoscopic to open surgery. This adjustment is done for multiple
reasons. When there is a doubt of anatomy, surgeons may switch to an open method.
Indications for converting to an open cholecystectomy include extensive inflammation,
adhesions, anatomical variances, bile duct damage, retained bile duct stones, and uncontrolled
bleeding. Converting to an open procedure may be necessary for common bile duct exploration
due to difficulties with laparoscopic methods. A planned open cholecystectomy may be
performed in cases of cirrhosis, gallbladder cancer, extensive upper abdominal procedures with
adhesions, and associated comorbidities (particularly diabetes mellitus). Critically ill patients
may also require an open cholecystectomy, which can be planned and less stressful for them.
This avoids the physiologic changes that can occur from a surgical pneumoperitoneum, such
as decreased cardiac return and increased ventilation pressures.
Indications for this procedure are stones discovered by cholangiography during

cholecystectomy or intraop cholangiogram showing stones during open chole, specifically
choledolithiasis, and jaundice pre-operatively as well as during the operation. Furthermore, the
criteria for choledocholithotomy were common bile duct stones that can be felt, preoperative
ultrasound or radiographic evidence of CBD stones, or dilated CBD.
Choledochoscopy insertion may be indicated for patients undergoing open

cholecystectomy surgery in the following situations:
● Suspected common bile duct stones: If imaging studies or clinical findings suggest
the presence of stones in the common bile duct, choledochoscopy insertion can be
performed to directly visualize and remove the stones during the same surgical
procedure.
● Abnormal liver function tests: If preoperative blood tests indicate elevated liver
enzymes or bilirubin levels, choledochoscopy insertion can be used to evaluate the
common bile duct for any obstructions or abnormalities that may be causing the
abnormal liver function.
● Suspicion of biliary strictures or tumors: In cases where there is a suspicion of biliary
strictures or tumors, choledochoscopy insertion can provide direct visualization of the
bile ducts and aid in the diagnosis and potential treatment of these conditions.
● Intraoperative findings: During open cholecystectomy surgery, if the surgeon
encounters unexpected findings such as abnormalities or stones in the common bile
duct, choledochoscopy insertion can be performed to further evaluate and address these
issues.
8
Echague, Isabela
COLLEGE OF NURSING
C. Contraindication
● Medical instability. Patients with severe illness, uncontrolled medical problems

(advanced heart and respiratory disease), or acute systemic infections may not be
acceptable for surgery until their state stabilizes.
● Bleeding disorders. Patients who have bleeding disorders or are taking anticoagulants
may be more likely to experience excessive bleeding after surgery. In some situations,
these drugs may need to be changed or temporarily discontinued before surgery.
● Previous abdominal surgery. A history of abdominal surgery may raise the chance of
problems like adhesions, which could technically complicate an open cholecystectomy.
Less invasive techniques like robotic-assisted cholecystectomy or laparoscopic
procedures may be chosen in certain situations.
● Pregnancy. Unless there are serious side effects, including acute cholecystitis, that
cannot be treated responsibly, cholecystectomy is usually avoided during pregnancy. It
is important to carefully consider the dangers of surgery and anesthesia for the mother
and the fetus, as well as the risks of delaying treatment.
● Allergy or intolerance to anesthesia. Individuals with a known allergy to anesthetic

medicines or a history of severe anesthesia-related adverse effects may not be eligible
candidates for surgery. Alternative therapeutic methods or customized anesthetic
procedures may be considered in such circumstances.
• Stones larger than 1 cm in diameter: Larger stones not only pose challenges for
removal but also increase the risk of bile duct injury during extraction. In cases where
stones are particularly large, fragmentation techniques or alternative treatment
modalities may be considered to reduce the risk of complications.
• Stones located proximal to the entrance of the cystic duct into the common bile
duct (CBD): Stones in this location may require more extensive dissection and
manipulation to access, increasing the risk of injury to surrounding structures such as
the cystic duct or hepatic ducts. Careful preoperative imaging and planning are essential
to assess the precise location of stones and anticipate potential challenges.
• Presence of a small, friable cystic duct: A small or fragile cystic duct is prone to
injury during surgical manipulation, which can lead to bile leakage, bile duct strictures,
or even bile peritonitis. Special care must be taken during dissection and stone
9
Echague, Isabela
COLLEGE OF NURSING
extraction to avoid damage to the cystic duct, and alternative treatment options may be
considered in high-risk cases.
• Ten or more stones within the common bile duct: A high stone burden within the
CBD increases the complexity of the procedure and the likelihood of incomplete stone
clearance. In such cases, fragmentation techniques, sequential clearance, or staged
procedures may be necessary to achieve successful stone extraction while minimizing
the risk of complications such as bile duct injury or postoperative pancreatitis.
• Severe structural abnormalities of the biliary tree: Structural anomalies, including

strictures, anomalous ductal anatomy, or significant tortuosity, present technical
challenges for CBDE Choledocholithotomy. Thorough preoperative assessment
utilizing advanced imaging modalities assists in delineating anatomical variations and
guiding surgical planning to mitigate risks associated with complex biliary anatomy.
• Nonuniform Gallstones: Patients with nonuniform gallstones are not recommended

for choledochoscopic gallbladder-preserving surgery. Nonuniform gallstones refer to
gallstones that vary in size, shape, or composition within the gallbladder. These stones
can pose challenges during the procedure and increase the risk of complications.
D. Complications
● Bleeding. There could be a danger of excessive bleeding during or after surgery.

Transfusions or other surgical procedures might be necessary to control this. An
accidental puncture or damage to a major blood artery might result in bleeding.
Following surgery, the nurse keeps a careful eye on the patient's vital signs and checks
for blood around any wounds and drains.
● Digestive issues. Some patients may have temporary digestive issues following a
cholecystectomy, including bloating, diarrhea, or trouble breaking down fatty foods.
As the body gets used to not having the gallbladder, these symptoms get better over
time.
● Chronic pain. Some people may endure chronic abdominal pain or discomfort
following surgery, which is known as post-cholecystectomy syndrome. This could be
related to a number of causes, including persistent gallstones, bile duct damage, or
sphincter of Oddi malfunction.
10
Echague, Isabela
COLLEGE OF NURSING
● Bile duct injury. A significant complication of cholecystectomy, but it is less common
than with the laparoscopic method. Damage to the bile ducts or gallbladder can cause
bile leaking into the abdominal cavity. This can lead to inflammation and infection,
requiring more surgery to repair.
● Blood clots. Prolonged immobility during and after surgery increases the likelihood of
blood clots forming in the legs (deep vein thrombosis) or spreading to the lungs
(pulmonary embolism).
● Bleeding. Surgical manipulation of the bile ducts during common bile duct exploration
can lead to vascular injury, resulting in bleeding. Bleeding complications can lead to
hypovolemia, hemodynamic instability, and the need for blood transfusions or surgical
interventions to achieve hemostasis.
● Infection. Choledocholithotomy is a surgical procedure that carries a risk of surgical

site infections (SSIs) or systemic infections such as cholangitis. This infection can occur
due to contamination of the surgical site and bile ducts. Surgical site infection prolongs
hospitalization, delays recovery, and increases morbidity and mortality rate.
● Bile leakage. Bile leakage may occur if there is an inadequate closure of the common
bile duct or surgical site leading to bile peritonitis or biliary fistula formation. Bile
leakage can cause abdominal pain, distention, fever, and peritoneal signs.
● Pancreatitis. Exploration of the common bile duct can lead to pancreatic injury or
irritation, resulting in pancreatitis. Pancreatitis can cause severe abdominal pain,
nausea, vomiting, and systemic complications such as fluid and electrolyte imbalances
or respiratory distress.
● Bleeding. Insertion of choledochoscopy may cause trauma to the mucosa or blood

vessels within the bile duct, leading to bleeding.
● Perforation. Forceful insertion of the choledochoscope or manipulation within the bile

duct can result in perforation, especially in cases of narrow ducts. Perforation can lead
to bile leakage, peritonitis, or abscess formation and may require immediate surgical
intervention.
● Infection. Choledochoscopy can introduce bacteria into the bile duct, potentially
causing cholangitis or systemic infection.
11
Echague, Isabela
COLLEGE OF NURSING
● Pancreatitis. Manipulation of the sphincter of Oddi or injection of contrast agents
during choledochoscopy can cause pancreatic duct irritation or spasm, leading to
pancreatitis.
● Bile duct injury. Improper handling or advancement of the choledochoscope within

the bile duct can result in mechanical injury, including mucosal abrasions, strictures, or
avulsions. Bile duct injury can lead to bile leakage, biliary obstruction, or subsequent
complications such as cholangitis or bile peritonitis.
● Retained stones. Choledochoscopy may fail to detect or adequately address all bile
duct stones, leading to retained stones and recurrent symptoms such as biliary colic,
cholangitis, or pancreatitis. Incomplete stone clearance may necessitate additional
interventions, such as repeat choledochoscopy or endoscopic retrograde
cholangiopancreatography (ERCP).
E. Pre operative preparation
The patient will undergo a thorough medical evaluation including blood tests, imaging
studies, abdominal ultrasound and electrocardiogram to assess their overall health status, any
preexisting medical conditions, allergies, and medications they are currently taking.
The nurse ensures that the patient follows fasting guidelines to prevent aspiration
during anesthesia. Preoperative instructions are also important to ensure that surgical
complications will be prevented. The nurse administers preoperative medications ordered, such
as antibiotics or any other ordered pre-op medications. Coordinating with other healthcare team
members is also necessary to address any special needs or considerations of the patient.
The patient should meet with the surgeon who will be performing the cholecystectomy
to discuss the procedure, potential risks, benefits, and any questions or concerns the patient
may have. The patient will receive counseling regarding the procedure, expected outcomes,
potential complications, and postoperative care instructions. Informed consent will be obtained
after the counseling. The nurse can witness the consent and must make sure that the consent
was signed.
F. Patient preparation
1. Medical Evaluation:
● The patient should undergo a thorough medical evaluation to assess their overall
health status, any preexisting medical conditions, allergies, and medications
they are currently taking.
2. Consultation with Surgeon:
● The patient should meet with the surgeon who will be performing the
cholecystectomy to discuss the procedure, potential risks, benefits, and any
questions or concerns the patient may have.
12
Echague, Isabela
COLLEGE OF NURSING
3. Preoperative Testing:
● Blood tests: To check blood cell counts, blood type, electrolyte levels, and liver
function.
● Imaging studies: Such as ultrasound or MRI to confirm the presence of
gallstones and assess the condition of the gallbladder.
● ECG (Electrocardiogram)
4. Preoperative Instructions:
● Instruct the patient to fast for a specified period before surgery, typically at least
8 hours for solids and 2-4 hours for clear liquids, to reduce the risk of aspiration
during anesthesia.
● Advise the patient to shower with antiseptic soap the night before or on the
morning of surgery to reduce the risk of surgical site infections.
● Advise the patient to avoid smoking and alcohol in the days leading up to
surgery, as they can interfere with anesthesia and wound healing.
● Instruct the patient to trim their nails short to reduce the risk of harboring
bacteria.
5. Preoperative Teaching
● Explain pre-operative instructions such as fasting requirements and medication
management.
● Educate the patient on deep breathing and coughing exercises to prevent post-
operative complications.
● Discuss pain management strategies, such as splinting, and what to expect
during the recovery period.
● Provide information on potential lifestyle changes post-surgery, such as dietary
modifications.
6. Medications:
● Adjustments to current medications: Some medications may need to be adjusted
or temporarily stopped before surgery, especially blood thinners or medications
that can affect blood clotting.
● Provide clear instructions regarding which medications to continue or
discontinue before surgery, especially blood thinners, nonsteroidal anti-
inflammatory drugs (NSAIDs), and herbal supplements that may increase the
risk of bleeding or interact with anesthesia.
● Antibiotics: Prophylactic antibiotics may be prescribed to reduce the risk of
infection during surgery.
7. Dietary Instructions:
● Instruct the patient to consume only clear liquids the day before surgery to
ensure the stomach is empty.
● Avoidance of certain foods: Patients may be advised to avoid heavy or fatty
foods that could exacerbate gallbladder symptoms.
8. Arrangements for Transportation and Accompaniment:
13
Echague, Isabela
COLLEGE OF NURSING
● Patients should arrange for transportation to and from the hospital on the day of
surgery, as they will likely be unable to drive themselves home after anesthesia.
● Having a family member or friend accompany them can provide support and
assistance during the preoperative and postoperative periods.
9. Informed Consent:
● The patient should sign a consent form indicating their understanding of the
procedure, its risks, benefits, and alternatives.
10. Preparation for Anesthesia:
● Patients may meet with an anesthesiologist before surgery to discuss anesthesia
options, address any concerns, and ensure they are physically prepared for
anesthesia.
11. Emotional Support:
● Preoperative anxiety is common among patients undergoing surgery. Providing
emotional support and addressing any fears or concerns can help alleviate
anxiety and improve the patient's experience.
G. Operative operation
The circulating nurse gathers all the instruments needed for the surgical procedure
while maintaining its sterility. The scrub nurse also helps in preparing the instruments into the
mayo table. Both the SN and CN then count the instruments and announce the counting to the
OR team through a surgical time-out.
Applying a povidone-iodine solution at the abdomen and surrounding areas with the
proper technique is also necessary to reduce the risk for surgical site infections. This procedure
involves one swipe of a cherry balls with an antiseptic solution then discarding it. It starts from
the umbilicus, then with a different cherry ball, a clockwise circular motion is done until it
covers the whole abdomen.
Draping is also important to only expose the areas necessary for the procedure. The
draping also prevents touching other areas of the body of the patient which is unsterile. The
arms of the patient are also secured at the arm boards of the operating bed which helps in
securing the patient in place, and keeping the arms away from the operative site.
H. Postoperative care
1. Promoting Effective Breathing Pattern

● Assist the patient to turn, cough, and deep breathe periodically. Help the patient
to take deep breaths and cough to expand the lungs fully and prevent atelectasis.
14
Echague, Isabela
COLLEGE OF NURSING
● Teach the patient how to splint the incision to support the abdomen when
coughing. The use of a pillow or abdominal binder over the incision may reduce
pain during the patient's turn, cough, breathe deeply, and ambulate.
● Elevate the head of the bed and maintain a low- or semi-Fowler’s position.
2. Maintaining Skin Integrity and Wound Care
● Assess color and consistency of drainage.
● Check the incisional drains; make sure that it is free-flowing.
● Observe for hiccups, abdominal distension, or signs of peritonitis, or
pancreatitis.
● Note and report right upper quadrant abdominal pain, nausea and vomiting, bile
drainage around any drainage tube, clay-colored stools, jaundiced color of eyes
and skin, and a change in vital signs.
● Change the dressings to keep it dry and clean. Place a sterile 4x4 gauze pad or
transparent dressing over the T-tube and the drain dressing and secure it with
tape.
● Fasten the tubing to the dressings or to the patient's gown, with enough leeway
for the patient to move without dislodging or kinking the tube.
3. Optimizing Fluid Volume and Managing Potential Complications
● Monitor vital signs. Assess mucous membranes, skin turgor, peripheral pulses,
and capillary refill.
● Observe signs of bleeding: hematemesis, melena, petechiae, and ecchymosis.
● Do a periodic drainage of the T-tube and wound collection bag. Document and
record the output.
● Administer IV fluids, and blood products, as indicated.
4. Mobility and Activity
● Avoid lifting objects exceeding 5 lbs. after surgery. This includes a child, heavy
grocery bags and milk containers, a heavy briefcase or backpack, and other
activities that makes the client breathe hard, strain, cause pain or pull on the
incision.
● Avoid all strenuous activity, such as biking, jogging, weightlifting, and aerobic
exercise
● Take short walks. Start out by walking a little more than the client did the day
before.
● Take a shower or bath after 1 or 2 days.
5. Diet
● Emphasize the importance of maintaining a low-fat diet and high in
carbohydrates and proteins immediately after surgery. Avoid excessive fats and
greasy foods.
● Encourage the patient to avoid or limit the use of alcoholic beverages.
6. Medications
15
Echague, Isabela
COLLEGE OF NURSING
● Administer analgesic agents as prescribed to relieve the pain.
● Administer Vitamin K as indicated.
● Administer antibiotics as indicated.
IV. DEMOGRAPHIC PROFILE
A. Patient’s History
Patient R is a 47-year-old woman who resides in Brgy. Nappaccu Grande, Reina
Mercedes, Isabela. She is a Roman Catholic and is married to her husband for 24 years and has
4 children. She weighs 61.8 kg and her height is 156 cm upon admission.
She was admitted last April 14, 2024 at 3:37pm due to an aching pain across her upper
abdomen, especially at the RUQ. Her pain is continuous that feels like something is squeezing
or gripping inside her right upper abdomen with a pain scale of 10/10. The suspected diagnosis
for her upon admission was “Peptic Ulcer Disease vs Cholelithiasis” but was later changed to
“Cholecystitis with cholecystolithiasis, choledocholithiasis” with her admitting physician Dr.
V.
B. History of Present Illness
Back in 2014, Mrs. R suffered an abdominal pain at the RUQ. During that time, the
pain is tolerable, subsides in a short period of time, and only felt occasionally. In her
ultrasound, stones on her gallbladder were detected. They did not proceed with the surgery
since her physician did not require it due to the findings that the stone is with a size of 0.3 cm
in diameter. She was prescribed with a certain medication but when asked, she stated that she
already forgot the name of her medication. Further, she was also ordered to follow a prescribed
diet such as restrictions to fats, soft drinks, caffeine, and high-sodium foods.
For the few years, she strictly follows all the regimen advice to her by the doctor.
However, as the years had passed, she slowly go back to her old lifestyle which resulted that
her abdominal pain recurred in 2020 but they did not want to ask for a consultation in the
hospital due to the fear of the pandemic at that time. She said that she endured the recurring
pain until it went away. During pandemic, she consulted her chief complaint in their Rural
Health Unit wherein, they suspected her to have a Peptic Ulcer Disease and prescribed a
Ranitidine as her medication. Later on, whenever the pain occurs, she avails Ranitidine in the
pharmacy as an over-the-counter drug. Also, she applies hot compress on her abdomen until
the pain subsided and continued her day. Moreover, she drinks barley as her herbal remedy.
The pain was said to be aching where she feels as if something is compressed and
squeezing on her upper abdomen. She claimed that the pain occurs especially when she skips
meals and when her stomach is full.
Before admission, she stated that her RUQ abdominal pain became unbearable and
continuous with a pain scale of 10/10. The pain can’t subside with Ranitidine nor hot compress
that leads her to come in the hospital. The assessment upon her admission states that there was
an inflammation and tenderness on her RUQ. With this, she was advised to be admitted and
have a further test.
16
Echague, Isabela
COLLEGE OF NURSING
C. History of Past Illness
In her childhood days, she experienced chicken pox. When asked about her
vaccinations, she claimed to have completed her immunizations. She does not take any
maintenance drugs as well as vitamins.
When asked about hospitalization, she stated that it was her first time being admitted
in a hospital and her 4 children were delivered at home via NSD. Her first child was born on
2000 and her last pregnancy was on 2007. It was also her first-time undergoing surgery and
she never experienced blood transfusion.
Additionally, the patient does not have any known allergies to food or medications. The
patient also does not participate in any vices.
D. Family History
When asked about family history, she claimed that none of her families had a history of
cholecystitis, cholelithiasis nor choledolithiasis. When asked about hypertension and diabetes,
she stated that none of her families, specifically her mother and father, experienced such
illnesses.
E. Social History
Mrs. R is a housewife with 4 children and a husband who is a tricycle driver that stays
in Cavite. Her husband can only be with them during Christmas or when there is a family
celebration.
Their family was originally from Cavite but relocated to Reina Mercedes, Isabela as
she needed to take care of her mother-in-law who was terminally diagnosed with cancer.
During the time that they were residing in Cavite, she claimed to participate in free
Zumba sessions in their community every morning. As she lives in Reina Mercedes, she
typically takes small walks around the compound and talks with her small circle of friends who
she is acquainted with. Mostly, her time was consumed in accomplishing all the household
chores.
In 2014, she used to drink coffee twice a day and always had soft drinks as her snack.
She claimed that she was obese back then. Fried foods are usually the cooking methods she
used to prepared in their tables but as the doctor had ordered a diet modification to her, she
started to stopped drinking a caffeine and soft drinks and eat boiled camote tops, okra, and
eggplant. But as years goes by, she gradually goes back to her old diet wherein, she
occasionally drinks soft drinks and eat fried foods. When asked regarding her diet, she
explained that her children only want to eat a fried foods like fried egg, fried chicken, and fried
fish, which on her side, preparing two different foods is expensive and will consume her time.
She also loves to eat a “bulanglang/dinengdeng” – a boiled vegetable soup dish with a bagoong
(salted and fermented fish paste) as the based for the soup.
During admission, she is able to talk with her husband from time to time and her
children take turns staying with her, especially the younger child. Her sister-in-law who is an
OFW helps them for her medical bills.
17
Echague, Isabela
COLLEGE OF NURSING
V. COURSE IN THE WARD
(Pre-operative)
Date and Order Rationale Nursing Rationale
Time Responsibility
4-15-2024 For Biliary Biliary surgery, such Checked the doctor’s This ensures that the
3:24 pm surgery at 3:30 as cholecystectomy order. right procedure will be
pm is indicated to done accordingly.
alleviate symptoms
associated with Witnessed that the To respect the patient’s
cholelithiasis, such patient has provided autonomy or right to
as abdominal pain. informed consent for self-determination.
This surgical the surgery.
intervention is
necessary to manage
the underlying
pathology and
prevent further
deterioration.
Inform OR and To provide advance Checked the doctor’s To ensure that the right
Dr. M notice that allows the order. order will be done
operating room team effectively.
to prepare the
necessary Communicated with Effective
equipment, the OR staff and the communication ensures
instruments, and surgeon regarding the that all members of the
supplies specific to scheduled surgery, surgical team are aware
the biliary surgery, ensuring all the of the specific details of
ensuring efficiency parties are aware of the surgery and other
and readiness for the the date, time, and relevant information
procedure. details of the that could impact
procedure. patient safety.
Informing the
surgeon ensures that Checked the To ensure that the OR
the appropriate availability of the OR staff and the surgeon
surgical expertise is and the are readily available
available for the anesthesiologist for and present in the
procedure, allowing the scheduled surgery scheduled time which
for optimal surgical and confirmed that can lead to improved
technique and there are no surgical outcomes and
outcomes. scheduling conflicts patient satisfaction.
that could affect the
procedure.
18
Echague, Isabela
COLLEGE OF NURSING
Documented that the This provides a legal
doctor’s order is done. basis that the doctor’s
order is done.
Vitamin K 10 mg Vitamin K helps

IV now normalize
coagulation
parameters and
reduce the risk of
perioperative Same Nursing Responsibilities and Rationales
bleeding in Drug Study
complications as
biliary surgery
carries risk of
intraoperative and
postoperative
bleeding.
Void prior to OR Voiding before

surgery ensures that
the bladder is empty,
allowing for better
visualization and
manipulation of
intra-abdominal
structures, which is
crucial for the
success of biliary
surgery.
Voiding prior to
surgery also helps
minimize
complications such
as decreased venous
return and impaired
ventilation caused by
increased intra-
abdominal pressure
due to distended
bladder.
(Post-operative)
Date and Order Rationale Nursing Rationale
Time Responsibility
19
Echague, Isabela
COLLEGE OF NURSING
4-15-2024 To PACU after PACU admission Accompanied the PACU admission
Biliary Surgery allows for close patient to the PACU allows for close
Cholecystectomy monitoring of the monitoring of the
CBDE patient’s vital signs, patient’s vital signs,
Choledolithotomy, oxygen saturation, oxygen saturation,
Choledoscopy, T level of level of consciousness,
tube drain / CSEA consciousness, and and pain level in the
pain level in the immediate
immediate postoperative period.
postoperative
period. Endorsed patient to the To inform the PACU
PACU nurses. nurses about the current
The patient received condition of the patient.
anesthesia To provide a legal basis
temporarily Documented the that the doctor’s order
impaired airway actions done, as well is done accordingly.
reflexes and as the relevant
respiratory function. findings.
With this, admission
to PACU ensures
close monitoring of
the airway and
intervenes in case of
airway obstruction
or respiratory
depression.
VS q 15 mins x 2° To monitor the Checked the doctor’s To ensure that the right
then q 30 mins x 2° patient’s status order. order will be done.
Verified the patient’s To ensure that the right

identity patient will get the right
order.
It is recommended that
Monitored VS every the vital signs should be
15 minutes for 2 hours. recorded every 15
minutes for the first 15
Monitored VS every minutes, then every 15
30 minutes for 2 hours. minutes for 1 hour, then
every 30 minutes for 2
hours, and then every
hour until the patient is
discharged from the
PACU. Post-operative
patients in the PACU
require more frequent
20
Echague, Isabela
COLLEGE OF NURSING
vital signs to ensure
their safety and to
detect any
postoperative
complications that may
arise.
Recorded the patient’s
vital signs. For documentation
purposes that is also
essential for continuity
of care.
O2 inhalation Oxygen inhalation Checked the doctor’s To confirm that oxygen

3L/min ensures adequate order. therapy is prescribed
oxygenation of based on the patient’s
tissues, promoting needs and clinical
cellular metabolism, condition. This also
tissue perfusion, and ensures that the right
wound healing. It order will be done.
helps counteract the
respiratory Verified the patient’s To ensure that the right
depressant effects of identity. patient will be
anesthesia, receiving the right
minimizing the risk order.
of hypoxemia and
hypoxia. Monitored the Helps identify signs of
patient’s oxygen hypoxemia or
saturation levels using respiratory distress,
pulse oximetry, and which are common
assess respiratory rate, complications
depth, and effort. postoperatively.
Administered oxygen To ensure adequate

inhalation at a delivery of oxygen to
prescribed rate of tissues, especially
3L/min via nasal during the immediate
cannula. postoperative period
when respiratory
function may be
impaired by anesthesia.
Monitored the To allow for timely

patient’s response to adjustment of oxygen
oxygen therapy, delivery parameters
including changes in based on the patient’s
oxygen saturation, needs.
21
Echague, Isabela
COLLEGE OF NURSING
respiratory rate, and
comfort level.
To ensure accurate
Documented oxygen recording of
therapy interventions,
administration, facilitates
including the delivery communication among
device used, flow rate, healthcare providers,
and patient’s response. and provides a legal
record of care provided.
NPO The intestinal tract Checked the doctor’s To ensure that the right
of the patient after order. order will be done.
surgery is still
affected by Verified the patient’s To ensure that the right
anesthesia, the identity patient will get the right
patient is placed on order.
NPO to prevent
complications such To ensure that the
as aspiration and Informed and patient and the
vomiting. explained to the significant others
patient and significant understand the
others about the importance of the NPO
ordered NPO status. status.
To provide a legal basis

Documented that the that the doctor’s order
doctor’s order is done. is done accordingly.
IVF to run for 45 Checked the doctor’s To confirm the correct

gtts/min then to order. solution, infusion rate,
follow and duration of the IV
therapy. This helps to
• D5NSS x 8° Helps maintain fluid prevent medication
balance, preventing errors and ensures
dehydration and adherence to prescribed
hypovolemia, which protocols, promoting
are common after patient safety.
surgical procedures.
Adequate hydration
supports Assessed: To check the patient’s
cardiovascular • Presence of current condition and to
function and tissue fluid avoid causing further
perfusion, infiltration, harm to the patient such
promoting overall bleeding, or as allergic reaction,
patient well-being phlebitis at the bleeding tendencies,
and recovery. IV site. and injury to the
22
Echague, Isabela
COLLEGE OF NURSING
• Allergy to tape puncture site.
or iodine.
• D5LR 1L x D5LR provides • Infusion rate
KVO hydration and and amount
electrolyte absorbed.
replacement, • Blockages in
including sodium, the IV system.
potassium, and • Appearance of
chloride, which are the dressing for
essential for cellular integrity,
function and moisture, and
neuromuscular need for
transmission. change.
Maintaining a KVO • The date and
infusion of D5LR at time of the
a controlled rate previous
ensures continuous dressing
flow of fluid change.
through the To minimize time and
intravenous Assembled all the effort
catheter, preventing materials/equipment
stagnation of blood needed.
in the vein and To give the correct
reducing the risk of Obtained the correct order of IVF solution
venous thrombosis solution container:
or phlebitis. • Read the label
of the new
container.
• Verify that you
have the
correct
solution,
correct client,
correct
additives (if
any), and
correct dose
(number of
bags or total
volume
ordered).
To prevent pathogenic
Performed hand microorganisms from
hygiene and observed being
aseptic technique introduced to the
throughout the patient.
procedure.
23
Echague, Isabela
COLLEGE OF NURSING
To provide a secure
Provided for client environment for
privacy. patients where they
receive medical care
and provide complete
and accurate
information, and which
reinforces confidence
in health care.
To help maintain fluid

Set up the intravenous balance. Labels are
equipment with the attached to increase
new container, and accuracy and efficiency
labelled it. in the correct
identification of IV
infusion.
To reestablish the
Connected the new infusion.
tubing and re-establish
the infusion.
To ensure that the IV
Secure the IV tubing. fluid will not leak.
To ensure that the

Regulated the rate of infusion rate is correct
flow of the solution and is able to infuse
according to the order completely as ordered.
of the chart
Because the buildup of
Ensured that the IVF fluid can cause tissue
bag is intact and not damage at the site and
leaking. leakage also prevents
the fluid from being.
sent into the
bloodstream for
treatment as intended.
To make sure that the
Assessed the IV site. treatment is directly
flowing into the
patient’s vein.
To evaluate the
Assessed patient’s effectiveness and
response to IV fluid safety of the treatment.
therapy, including
24
Echague, Isabela
COLLEGE OF NURSING
vital signs, urine
output, and fluid
balance.
Legal basis that the IVF
Documented the as ordered is being
infused IV, including infused and carried out.
all assessment and
interventions done.
Medication:
• Ketorolac 30 For short-term
mg IV q 8° management of
moderately severe,
acute pain
• Fentanyl 25 For management of

mcg IV q 6° postoperative pain Same Nursing Responsibilities and Rationales in
x 2 doses Drug Study
then PRN for
(+) pain
• Forgram 1 To prevent bacterial
gm IV q 12° infection
• Zefxon 40 To
mg IV q 24°
Flat on bed x 6° To prevent spinal Verified the doctor’s To ensure that the right
headache. order. order will be done.
Verified the patient. To ensure that the right

patient will get the right
order.
Placed the patient flat To alleviate the

on bed for 6 hours. pressure on the
abdominal area,
encouraging the
healing process and
minimizing the
likelihood of
complications.
Documented that the To provide a legal basis

doctor’s order is done. that the doctor’s order
is done accordingly.
25
Echague, Isabela
COLLEGE OF NURSING
Measure I&O hourly To check and Verified the doctor’s To ensure that the right
and record monitor order. order will be done.
hemodynamic
status. Verified the patient. To ensure that the right
patient will get the right
order.
Hourly measured and To measure the

recorded the type and patient’s input
amount of all fluids accurately.
that the patient
received and described
the route as oral,
parenteral, rectal, or by
enteric.
Hourly measured and To measure the

recorded the type and patient’s output
amount of all fluids the accurately.
patient has lost and its
route.
Documented that the To provide a legal basis

Refer accordingly Referral is an Verified the doctor’s To ensure that the right
essential means of order. order will be done.
communication
between healthcare Informed the receiving To give the receiving
providers, which physician/healthcare physician/healthcare
gives the receiving provider regarding the provider a detailed
physician/healthcare referral as well as the summary of the
provider a detailed status of the patient. patient’s current
summary of the situation and medical
patient’s current history to ensure a
situation and smooth transition of
medical history to care.
ensure a smooth
transition of care. Documented that the To provide a legal basis
26
Echague, Isabela
COLLEGE OF NURSING
VI. LABORATORY FINDINGS:
April 14, 2024
HEMATOLOGY
NORMAL
PARAMETER RESULTS INTERPRETATION
VALUES
HIGH
White Blood High levels of WBC may indicate
11.0 4.0000-10.0000
Cells Count that the body has an infection or
inflammation.
HIGH
High levels of neutrophil are a
Neutrophils 85.2 51.00 – 67.00 %
response to help heal damaged
tissues and fight infection.
LOW
Lymphocytes 8.0 25 – 33 % Low levels of lymphocytes may
indicate a high risk in infection.
HIGH
A high monocyte count indicates
Monocytes 6.5 2–6%
that the body is fighting a viral or
bacterial infection.
LOW
It helps to fight bacterial and viral
Eosinophils 0.1 1–4%
infections and can also play a role
in the inflammatory response
April 14, 2024

Examination: ULTRASOUND of the WHOLE ABDOMEN
· Gallbladder is moderately distended.
· Gallbladder wall is thickened with no pericholecystic fluid seen.
· 2 lithiasis seen at the fundus, measuring 2.01 cm and 0.81 cm in diameter with shadowing.
· Lithiasis at common bile duct measuring 0.73 cm in diameter with shadowing.
· Cystic structure seen at the left ovary measuring 4.19cm x 3.50 cm (LW)
Impression:
· Cholecystitis with cholecystolithiasis and choledocholithiasis, as described.
27
Echague, Isabela
COLLEGE OF NURSING
· Normal findings in the liver, pancreas, spleen, abdominal aorta, kidneys and urinary
bladder
· Normal anteverted uterus
· Left ovarian cyst, within physiologic size.
April 14, 2024

PTPA Coagulation Test - Normal
April 15, 2024

X-RAY REPORT
Examination: Chest PA
Radiological Findings:
· Both lung fields are clear.
· Heart is not enlarged.
· Diaphragm and sulci are intact.
Impression:
· Normal Chest Findings
April 15, 2024
Electrocardiogram Result
· Normal bundle branch block
VII. ANATOMY OF THE SURGICAL SITE:
GALLBLADDER
Gallbladder is a muscular organ that serves as a reservoir for bile, present in most
vertebrates. In humans, it is a pear-shaped membranous sac on the undersurface of the right
lobe of the liver just below the lower ribs. It is generally about 7.5 cm (about 3 in) long and
2.5 cm (1 in) in diameter at its thickest part; it has a capacity varying from 1 to 1.5 fluid ounces.
The body (corpus) and neck (collum) of the gallbladder extend backward, upward, and to the
28
Echague, Isabela
COLLEGE OF NURSING
left. The wide end (fundus) points downward and forward, sometimes extending slightly
beyond the edge of the liver. Structurally, the gallbladder consists of an outer peritoneal coat
(tunica serosa); a middle coat of fibrous tissue and unstriped muscle (tunica muscularis); and
an inner mucous membrane coat (tunica mucosa).
The function of the gallbladder is to store bile, secreted by the liver and transmitted
from that organ via the cystic and hepatic ducts, until it is needed in the digestive process.
Between meals, when the sphincter of Oddi is closed, bile produced by the hepatocytes enters
the gallbladder. During storage, a large portion of the water in bile is absorbed through the
walls of the gallbladder; thus, bile in the gallbladder is five to 10 times more concentrated than
that originally secreted by the liver. When food enters the duodenum, the gallbladder contracts
and the sphincter of Oddi (located at the junction of the CBD with the duodenum) relaxes.
Relaxation of this sphincter allows the bile to enter the intestine. This response is mediated by
secretion of the hormone cholecystokinin (CCK) from the intestinal wall (Norris, 2019). CCK
is the major stimulus for digestive enzyme secretion and acts by stimulating the gallbladder to
contract.
The gallbladder, when functioning normally, empties through the biliary ducts into the
duodenum to aid digestion by promoting peristalsis and absorption, preventing putrefaction,
and emulsifying fat. Digestion of fat occurs mainly in the small intestine, by pancreatic
enzymes called lipases. The purpose of bile is to; help the lipases to work, by emulsifying fat
into smaller droplets to increase access for the enzymes, enable intake of fat, including fat-
soluble vitamins: Vitamin A, D, E, and K, rid the body of surpluses and metabolic wastes
cholesterol and bilirubin.
COMMON BILE DUCT

The common bile duct is a vital component of the biliary system, responsible for
transporting bile from the liver and gallbladder to the duodenum. It typically measures around
6 to 8 millimeters in diameter. Originating at the confluence of the common hepatic duct and
the cystic duct, it extends through the head of the pancreas before joining the pancreatic duct.
This union forms the hepatopancreatic ampulla, also known as the ampulla of Vater, which
empties into the duodenum. The common bile duct plays a crucial role in digestion, facilitating
the delivery of bile that contains bile salts, cholesterol, bilirubin, and water for the
emulsification and absorption of fats in the small intestine. Its dynamic function highlights its
significance in maintaining digestive homeostasis.
COMMON HEPATIC DUCT

The common hepatic duct, an integral part of the biliary system, is a short tube with a
diameter typically ranging from 4 to 5 millimeters. Emerging from the confluence of the left
and right hepatic ducts within the liver, it plays a key role in transporting bile. The common
hepatic duct then joins forces with the cystic duct, originating from the gallbladder, to form
the common bile duct. This merging typically occurs at a junction known as the
hepatopancreatic ampulla, also known as the ampulla of Vater, just before entering the
duodenum. The common hepatic duct's main function is to serve as a conduit for bile flow
from the liver to the common bile duct, contributing to the digestive process. Its relatively short
length and pivotal role in bile transport underscore its significance in maintaining physiological
balance within the biliary system.
29
Echague, Isabela
COLLEGE OF NURSING
CYSTIC DUCT
The cystic duct is a short, narrow tube that connects the gallbladder to the common bile
duct, allowing the passage of bile. Typically measuring around 2.5 to 5 centimeters in length,
the cystic duct plays a crucial role in the storage and concentration of bile produced by the
liver. Its strategic location enables the release of bile into the common bile duct, facilitating
digestion in response to dietary fat intake. The cystic duct is characterized by its spiral valve,
known as the "spiral valve of Heister," which aids in preventing the duct from collapsing. This
anatomical feature ensures the continuous flow of bile without obstruction. Despite its
relatively small size, the cystic duct's structural intricacies contribute significantly to the
efficient functioning of the biliary system.
VII. SURGICAL PROCEDURE
1. Pre-Operative Preparation for Surgery

Prior to the operation, consent was secured and the patient underwent tests such
as Chest X-ray and an ECG to check for abnormalities. The physician also ordered an
UTZ to check for the gallbladder stones for the size, number, and location, and a CBC
to assess the laboratory status including the platelet count of the patient to check
whether the surgery is applicable and safe for the patient.
The Plasma Thromboplastin Antecedent Test, RBS, creatinine, Sodium and
Potassium levels of the patient were also tested to assess the urinary tract of the patient
which is essential for the excretion of the anesthesia. Additionally, the patient was
asked to prepare by bathing, voiding, removing dentures, as well as jewelries for safety
reasons. For easier administration of medications and possible administration of blood
transfusion if needed, an 18-gauge needle was also prepared for administration.
2. Preparation of Surgical Instruments

Before the whole OR team arrived at the operating room, the circulating nurse
identified and prepared the instruments needed while maintaining its sterility while the
scrub nurse arranged the instruments including sharps, needles, sponges, sutures and
other equipment.
The instruments counted were as follows:
• 4 - Allis Forceps
• 2 - Army Navy
• 2 - Babcock
• 23 - Bakes Dilator
• 3 - Blade
• 4 - Blade Holder
• 2 - Cautery Tip
• 2 - Deaver Medium
• 1 - Deaver Narrow
• 6 - Kelly Curved
• 4 - Kelly Straight
30
Echague, Isabela
COLLEGE OF NURSING
• 1 - Mayo Curved
• 4 - Metzenbaum
• 2 - Mixter
• 6 - Mosquito Curved
• 4 - Mosquito Straight
• 10 - Needle
• 5 - Needle Holder
• 7 - Randalls
• 2 - Richardson Big
• 1 - Suction Tip
• 4 - Thumb Forceps
• 2 - Tissue Forceps
• 5 - Towel Clips
• 2 - Vicryl 1.0
• 1 – Vicryl 2.0
• 1 - Chromic 2.0
• 1 - Skin stapler
• 4 – LOS
• 3 – Peanut
• 6 – Abdominal pack
3. Anesthesia
The anesthesiologist administered CSEA or a Combined Spinal and Epidural
Anesthesia with the patient in a fetal position to ensure a painless operation for longer
periods and to keep the patient immobile during the procedure. In this procedure, the
needle is inserted through the epidural into the subarachnoid space.
31
Echague, Isabela
COLLEGE OF NURSING
4. Catheter Insertion
An indwelling foley catheter was inserted after positioning the patient in supine.
This procedure is done to monitor the urine output of the patient during the procedure
and to prevent urinary retention due to the administration of anesthesia.
5. Skin Preparation and Draping

A povidone-iodine solution was used in preparing the skin for incision. This
helped in maintaining the asepsis of the procedure along with the drapings prepared.
Towel clips were used to secure the drapings, suction tube, and the wife of the cautery
pen to prevent it from accidentally falling from the sterile field.
6. Incision Site
A scalpel and a cautery pen were used to incise the incision site at the RUQ also
known as the Kocher or a right subcostal incision. With this and retracting the layers
of skin using an army navy, the gallbladder was visible to the surgeon and he was able
to perform the planned procedure.
32
Echague, Isabela
COLLEGE OF NURSING
7. Gallbladder Identification and Removal
After incising the site, the gallbladder was exposed using the army navy
retractor and the anatomy was identified. Aside from the gallbladder, the cystic duct
was identified as well as the cystic artery. The cystic duct was noted to be inflamed
with the measurement of 1.2 cm.
The cholecystectomy started from the fundus of the gallbladder down to the
cystic artery. The cystic artery was then ligated using silk 2.0 to prevent excessive
bleeding in preparation for the removal of the gallbladder. The gallbladder was then
removed or amputated at the cystico choledocal junction. The organ removed was then
placed on a specimen tray in preparation for dissection after the procedure.
8. CBDE, Stone Retrieval and Choledoscopy

CBDE or Common Bile Duct Exploration was then performed to check and
remove the stones that are noted to be lodged in this location. After retrieving the
stones, it was placed on a specimen tray then the surgeon performed a choledoscopy to
view if there were more stones blocking the common bile duct of the patient's biliary
tract. In this process, the surgeon called the SO of the patient into the operating room
to view the specimen as well as the common bile duct of the patient.
9. T-Tube insertion
The physician cut the T-tube smaller to fit the patient’s ducts. This tube also
known as the biliary drainage tube is inserted to collect the bile and prevent its
accumulation. This can also help in assessing the patient and monitoring the function
of the biliary system of the patient. In this procedure, one end is connected at the duct
for facilitation of bile produced by the liver to the drain connected on the other end.
Additionally, the physician left an allowance of the tube before securing it to prevent
disconnecting the tube when accidentally pulled.
33
Echague, Isabela
COLLEGE OF NURSING
10. JP drain insertion
Before inserting the JP drain or Jackson-Pratt drain, it was tested by suctioning

sterile water on a basin using the negative pressure by the drain. After ensuring the
patency of the drain, it was secured at the Morrison’s Pouch which is a compartment
located at the RUQ near the liver. The reason for this is to drain the fluid which
accumulates in the pouch post-operatively.
11. Closure, Insertion of a Suction Drain, Dressing

Before the closure of the incision site, all instruments including sharps, needles,
and sponges are all counted complete to ensure that none of these materials are
unnecessarily retained inside the patient’s body.
The peritoneum layer was then closed using a vicryl 1.0 which is a suture
usually used in approximating soft tissues. The same type of suture was used in closing
the fascia—a layer that is given most importance in closing a suture for a more effective
prevention of dehiscence and evisceration.
34
Echague, Isabela
COLLEGE OF NURSING
After closing the fascia, the physician let the chief nurse who is licensed and
experienced to close the subcutaneous layer using a chromic 2.0 suture and a skin
stapler for the skin layer.
Finally, they applied a povidone-iodine solution at the suture before dressing
the patient. The operation was done successfully.
12. Post-Operative Interventions

After closure, the nurses dressed the patient properly and transferred the patient
to the recovery room where she was monitored for any complications. Fluids suctioned
in the drains were also collected.
35
Echague, Isabela
COLLEGE OF NURSING
VIII. INSTRUMENTS USED:
INSTRUMENT FUNCTION PICTURE
Allis Forcep During cholecystectomy (surgery

to remove the gallbladder), Allis
clamps are often used to grasp and
hold tissues. These clamps have
serrated jaws that provide a firm
grip, allowing the surgeon to
manipulate and control the
gallbladder or surrounding tissues
during the procedure.
Army Navy In cholecystitis surgery, the Army

Navy retractor may be used to
retract the abdominal wall, liver, or
other adjacent tissues to expose the
gallbladder and surrounding
structures. This allows the surgeon
to perform the necessary dissection
and manipulation of tissues while
minimizing trauma to surrounding
structures.
36
Echague, Isabela
COLLEGE OF NURSING
Babcock Forcep In cholecystitis surgery, Babcock
forceps may be used for tasks such
as grasping the gallbladder or
surrounding tissues, providing
traction, or holding structures in
place during dissection or removal.
Bakes Dilator In cholecystitis surgery, Bakes

dilator may be used to dilate the
cystic duct, which is the tube that
connects the gallbladder to the
common bile duct. Dilating the
cystic duct facilitates the passage of
instruments or allows for easier
access during the surgical removal
of the gallbladder.
Blade In cholecystitis surgery, a blade

typically refers to a scalpel blade,
which is a sharp, surgical cutting
instrument used by the surgeon to
make precise incisions and perform
dissections during the procedure.
37
Echague, Isabela
COLLEGE OF NURSING
Blade Holder In cholecystitis surgery, a blade
holder is a surgical instrument used
to securely hold and manipulate the
scalpel blade during various stages
of the procedure. The blade holder
typically consists of a handle with a
mechanism to firmly attach and
secure the scalpel blade.
Cautery tip In cholecystitis surgery, a cautery

tip is often used as part of an
electrocautery device. The cautery
tip serves the function of
cauterising tissues, which means it
generates heat to coagulate blood
vessels and seal off small blood
vessels to control bleeding.
Deaver Medium Deaver medium retractor is used to

Retractor hold back organs and tissues during
the surgical procedure. It is a
versatile retractor that offers a
balance between size and strength,
making it suitable for a wide range
of surgical applications.
38
Echague, Isabela
COLLEGE OF NURSING
Deaver Narrow Deaver narrow retractor is used to
Retractor hold back organs and tissues during
the surgical procedure. The
surgeon needs to access deeper
structures while keeping
surrounding tissues out of the way.
Kelly Curved In cholecystitis surgery, Kelly

Forcep curved forceps may be used for
tasks such as grasping tissues or
securing sutures in areas that are
difficult to reach with straight
forceps
Kelly Straight In cholecystitis surgery, Kelly

Forcep straight forceps may be used for
tasks such as holding and
manipulating tissues, securing
sutures, or providing traction
during dissection or removal of the
gallbladder.
39
Echague, Isabela
COLLEGE OF NURSING
Mayo In cholecystitis surgery, Mayo
Scissor curved scissors may be used for
(Curved) tasks such as cutting through the
gallbladder's cystic duct or blood
vessels, dividing tissues during
dissection, or trimming sutures.
Metzenbaum In cholecystitis surgery,

Scissors Metzenbaum scissors may be used
for tasks such as dissecting tissues
surrounding the gallbladder,
separating adhesions, or trimming
delicate structures without causing
excessive trauma.
Mixter Forceps In cholecystitis surgery, Mixter

as grasping and retracting the
gallbladder or surrounding tissues,
dissecting adhesions, or
compressing blood vessels to
control bleeding.
40
Echague, Isabela
COLLEGE OF NURSING
Mosquito In cholecystitis surgery, mosquito
Forceps (curve) curved forceps may be used for
tasks such as securing sutures,
controlling bleeding, or
manipulating tissues in tight spaces
around the gallbladder.
Mosquito In cholecystitis surgery, mosquito

Forceps straight forceps may be used for
(straight) tasks such as holding tissues or
securing sutures in a straight-line
approach.
Needle Needles are used to stitch up

incisions made during the surgery.
After the gallbladder is removed,
the incisions in the abdominal wall
need to be closed securely to
facilitate proper healing.
41
Echague, Isabela
COLLEGE OF NURSING
Needle Holder In cholecystitis surgery, its function
is to hold and manipulate needles
during suturing, allowing for
precise stitching and closure of
incisions or tissue layers.
Randall Kidney Randall Kidney Stone Forceps used

Stone Forceps to hold the deep tissues into the
body cavity during the surgical
procedures. These surgical forceps
feature a standard pattern that is
highly suitable for stone removal.
Richardson Used to hold back the edges of an

Retractor incision or wound during the
procedure. It is to provide the
surgeon with better visibility and
access to the surgical site.
42
Echague, Isabela
COLLEGE OF NURSING
Suction Tip Suction tip is used to remove fluid
collections and other residues from
the operating area during the
surgery.
Thumb Forceps In cholecystitis surgery, thumb

as holding and manipulating
tissues, securing sutures, or
handling surgical drapes and
dressings.
Tissue Forceps In cholecystitis surgery, tissue

forceps can be used to hold and
manipulate the gallbladder,
allowing the surgeon to have better
access to the organ and surrounding
tissues. They are also useful for
controlling bleeding by
compressing blood vessels.
43
Echague, Isabela
COLLEGE OF NURSING
Towel Clip In cholecystitis surgery, they may
be used to secure drapes that keep
the surgical site clean and free from
contamination. Additionally, towel
clips can be used to secure tissues
or structures out of the way to
provide better visibility and access
to the surgical site.
Chromic Chromic Catgut Suture is a

naturally absorbable surgical suture
that is absorbed by a simple
enzymatic mechanism. It tends to
absorb faster in affected tissues.
The suture initial tensile strength is
lost within 14 to 21 days and is
absorbed completely in 90 to 120
days. It is non-adhering and
biologically inert.
Vicryl Vicryl is an absorbable braided

suture material made from
polyglactin 910. It looks and feels
like a fine cotton thread you might
use for sewing at home. Vicryl
comes in two colors: dyed (purple)
and undyed (white). Dyed Vicryl is
helpful for deeper tissues as it is
much easier to see and follow.
Skin Stapler Skin Staplers, also referred to as

Wound Staplers, are used to close
large wounds and incisions more
efficiently, quickly and less
painfully for many patients
following surgical procedures
when compared to wound closure
by means of stitches.
44
Echague, Isabela
COLLEGE OF NURSING
Sponges Sponges are used absorb bloods
and fluids to keep the surgical area
dry and clear by applying pressure
to bleeding vessels. It is also used
as cushion and safeguard the
surrounding tissues from damage.
Peanut A peanut sponge, also known as a

dissector sponge, is a small, oval-
shaped sponge used in open
cholecystectomy to assist in
separating and dissecting tissues
with precision by applying pressure
to small bleeding vessels. It is also
used to gently move tissues aside
for better visibility and access.
Abdominal pack In an open cholecystectomy, an

abdominal pack (often called a
laparotomy pad) is used to soak up
blood, bile, and other fluids to keep
the surgical field clear by applying
pressure to large areas to control
bleeding.
It is also used to hold back organs
or tissues to provide better access
and visibility for the surgeon.
45
Echague, Isabela
COLLEGE OF NURSING
IX. NURSING CARE PLAN

PRE-OPERATIVE
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
Subjective: Acute pain Within 2 hours of Independent: Goal Met.
“Sumasakit itong related to nursing intervention, • Promote • Bedrest in After 2 hours of
bandang taas ng tiyan presence of the patient will be bedrest, low-Fowler’s nursing intervention,
ko sa may kanan,” as
stones in the able to verbalize allowing the position the patient verbalized
verbalized by the
patient. gallbladder and relief of pain, with a patient to reduces intra- relief of pain with a
common bile duct decrease of pain scale resume a abdominal decreased pain scale
Pain assessment: as manifested by from 7/10 to 5/10. position of pressure. from 7/10 to 5/10.
*Character - gripping patient’s verbal comfort like Abdominal
*Onset - gradual reports of pain at knee-chest pain may be
increase right upper position. relieved with
*Location - RUQ
quadrant of the a specific
*Duration -
continuous abdomen, with a position that
*Severity - pain scale pain scale of promotes
of 7 out of 10 7/10, non-verbal comfort. A
*Precipitating factors cues observed knee-to-chest
- pain increases on such as guarding or side-lying
empty and full behavior and position tends
stomach
difficulty in to decrease
*Alleviation factor -
Ranitidine and hot moving. the intensity
compress of abdominal
*Associated factors - pain.
jaundice and fever. • Encourage use • Promotes rest,
of relaxation redirects
Objective:
46
Echague, Isabela
COLLEGE OF NURSING
• Guarding techniques attention, may
behavior (e.g., guided enhance
through imagery, coping
bracing (stiff,
visualization,
pain-avoidant
posturing deep-
while in static breathing
position) exercises,
• Difficulty in focused
moving breathing). • Reduces
• Vital signs: • Provide a tension on the
• BP: 130/80
quiet inflamed
• RR: 22
• PR: 98 environment. gallbladder
• Temp: 37.7 and to provide
degrees good lung
Celsius expansion,
• Labs: thus reducing
• increased
pain.
WBC: 11
• increased
Neutrophils:
85.2 Dependent: • To alleviate
• decreased • Administer pain and
Lymphocytes: analgesics facilitate other
8 like therapeutic
• increased
Ketorolac interventions
monocytes:
6.5 and
• decreased paracetamol
eosinophils: as indicated. • Relieves
0.1 % abdominal
47
Echague, Isabela
COLLEGE OF NURSING
• UTZ: 2 Collaborative: pain by
lithiasis seen • Provide and reducing the
at the fundus, implement peristaltic
measuring activity. Helps
prescribed
2.01 cm and relieve pain by
0.81 cm in dietary neutralizing
diameter with modifications. stomach acid
shadowing; and increasing
Lithiasis at bicarbonate
common bile and mucus
duct secretion.
measuring
0.73 cm in • To promote
diameter with comfort and as
shadowing; ▪ Inform the preparation
Cystic family about for the
structure seen the prescribed operation.
at the left dietary
ovary
modifications
measuring
4.19cm x 3.50 (NPO)
cm (LW)
48
Echague, Isabela
COLLEGE OF NURSING
INTRA-OPERATIVE
Objective: Decreased blood Within 30 minutes – Dependent: Goal Met.
• BP: 90/50 volume related to a 1 hour of • Verify the • Verifying the
• PR: 107 surgical procedure as intervention, the vital doctors order After 30 minutes – 1
surgeon’s
• RR: 25 to ensure that
evidenced by a blood signs of the patient order for hour of nursing
• Presence of the correct
pallor on the pressure of 90/50, will remain in the blood intervention, the vital
procedure will
face and pulse rate of 107, normal value transfusion signs of the patient
be performed.
extremities. respiratory rate of 25, remained in the
• Decrease and presence of pallor Independent: normal value
• Performing
capillary refill on the face and • Perform tasks using the
to 10 seconds extremities. using an aseptic
aseptic technique
technique prevents
sepsis from
occurring.
• Check the • This is to
label of the ensure that the
blood such as blood for
serial number, administration
blood is safe and
component, compatible for
blood type, Rh the patient.
factor,
expiration
date, and
screening
tests. Perform
with another
nurse.
49
Echague, Isabela
COLLEGE OF NURSING
• Warm blood • Warming the
at room blood prevents
temperature the patient
before from chilling
transfusion. • This is to
• Identify the ensure that the
client properly blood is
using the wrist transfused to
band and the right
name on the patient.
IV line.
• Administer
0.9% NaCl • 0.9% NaCl is
before, during, safe to
and after BT. administer
with blood
and prevents
hemolysis
from
• Start infusion occurring.
slowly.
• The slow
infusion of
blood will also
slow its
effects which
means it will
• Observe be easier to
complications manage if
such as complications
anaphylactic arise
shock,
50
Echague, Isabela
COLLEGE OF NURSING
hemolysis, • Blood
circulatory transfusions
overload, and includes risks.
etc. Monitoring
• Frequently these risks
monitor vital will be helpful
signs in immediate
interventions.
• This will help
in assessing if
the procedure
is successful
Collaborative:
or if there is a
• Obtain blood presence of
from the complications.
blood bank
• Coordinating
with the staff
in the blood
bank ensures
that the blood
to be used is
from a safe
source.
51
Echague, Isabela
COLLEGE OF NURSING
POST-OPERATIVE
Subjective: Knowledge Deficit Within 30 minutes to Independent: Goal Met.
related to 1 hour, the patient 1. Educate the 1. Timely
“Hindi ko postoperative dietary will: patient about education is After 30 minutes to 1
naintindihan ‘yong • verbalize the importance crucial to hour, the patient:
restrictions as
sinabi sa akin ng understanding of adhering prevent • verbalized
doctor kaya kumain evidenced by non- to NPO
of NPO further non- understanding
ako ng lugaw kanina compliance with status and the status ` to compliance of NPO status
kasi gutom na ako,” NPO status. rationale reduce the and potential and the
as verbalized by the behind it. likelihood of complications. rationale
patient • refrain from nausea and behind it.
consuming vomiting. • refrained from
any further consuming
Objective: food or 2. Engage in open 2. Patient any further
beverages for dialogue with engagement food or
• Inaccurate the remainder the patient, fosters active beverages for
follow- of the shift. encouraging participation the remainder
through of questions and in the learning of the shift
instruction or addressing any process and
performance concerns or increases the
on a diet misconceptions. likelihood of
3. Offer compliance.
alternative 3. Providing
activities or alternative
distractions to distractions
occupy the helps redirect
patient's time the patient's
and attention focus away
away from from food
food. consumption.
52
Echague, Isabela
COLLEGE OF NURSING
4. Regularly
monitor the 4. Regular
patient's monitoring
behavior and ensures
intervene prompt
promptly if any intervention to
further attempts reinforce
to consume compliance
food or and prevent
beverages are further non-
observed. compliance.
X. DRUG STUDY
Drug Name Mechanism of Action Indication/s Side Effects Nursing Responsibilities
Generic Name: Interferes with bacterial • Intra-abdominal • chest pain BEFORE

Ceftriaxone cell wall synthesis by infections caused by • cough • Review the
inhibiting cross-linking of escherichia coli, • painful or patient's medical
Brand Name: peptidoglycan strands. klebsiella difficult history, including
Forgram Peptidoglycan makes the pneumoniae, urination allergies and
cell membrane rigid and bacteroides fragilis, • shortness of previous
protective. Without it, clostridium species breath reactions to
Classification: bacterial cells rupture and or pepto- • sore throat antibiotics.
Therapeutic class: die. streptococcus • swollen glands • Assess the
Antibiotic species. • unusual patient's vital
• Perioperative bleeding or signs and
Pharmacologic class: prophylaxis to bruising laboratory values.
Third-generation reduce the incidence • unusual • Verify the
cephalosporin of postoperative tiredness or prescription,
53
Echague, Isabela
COLLEGE OF NURSING
infections in patients weakness dosage, route,
Dosage: 1 gram undergoing and compatibility
Route: IV contaminated or with other
potentially medications.
• Prepare the
contaminated such
Frequency: q12 medication and
as cholecystectomy equipment,
for chronic ensuring proper
Timing: 6am, 6pm calculous aseptic technique.
cholecystitis. • Check for any
Contraindication/s: Adverse Reaction/s: contraindications,
such as known
Hypersensitivity to CNS: Chills, fever, hypersensitivity
ceftriaxone, other beta- headache, hypertonia, to cephalosporins
lactam antibacterials or reversible hyperactivity, or lidocaine (if
cephalosporins, penicillins, seizures applicable).
or their components; CV: Edema • Provide patient
intravenous administration GU: Acute renal failure, education about
of elevated BUN level, the medication,
ceftriaxone solutions nephrotoxicity, oliguria, including
containing lidocaine vaginal candidiasis, potential side
ureteric obstruction, effects and the
urolithiasis importance of
HEME: Agranulocytosis, completing the
aplastic anemia, full course of
eosinophilia, hemolytic treatment.
anemia,
hemorrhage, DURING
hypoprothrombinemia, • Administer the
leukopenia, neutropenia, medication
thrombocytopenia slowly over the
MS: Arthralgia recommended
54
Echague, Isabela
COLLEGE OF NURSING
RESP: Allergic infusion time,
pneumonitis, dyspnea typically over 30
SKIN: Allergic dermatitis, minutes to 1 hour,
ecchymosis, erythema, to minimize the
erythema multiforme, risk of adverse
exanthema, pruritus, rash, reactions.
Stevens–Johnson • Monitor the
syndrome, toxic epidermal patient for any
necrolysis, urticaria signs of adverse
Other: Anaphylaxis; drug reactions,
fever; injection-site pain, including allergic
redness, and swelling; reactions,
serum sickness; injection site
superinfection reactions.
• Ensure the IV site
remains patent
and assess for any
signs of
infiltration or
extravasation.
AFTER
• Monitor the
patient closely for
any delayed or
ongoing adverse
reactions, such as
allergic reactions.
• Document the
administration,
including the
date, time,
55
Echague, Isabela
COLLEGE OF NURSING
dosage, route,
and any observed
reactions.
• Follow up with
the patient to
assess response to
treatment and
monitor for any
complications.
• Collaborate with
the healthcare
team to adjust the
treatment plan as
needed based on
the patient's
response and
laboratory values.
56
Echague, Isabela
COLLEGE OF NURSING
Mechanism of Indication/s
Drug Name Side Effects Nursing Responsibilities
Action
Generic Name: Inhibits proton pump BEFORE

Omeprazole activity by binding to To reduce risk of aspiration CNS: Headache, • Assess the patient's medical
hydrogen–potassium pneumonia as it inhibits dizziness, somnolence history, including allergies
Brand Name: adenosine gastric secretions during and previous reactions to
Zefxon triphosphatase, NPO phase Skin: Rash, dermatitis, PPI’s.
located at the pruritus • Confirm the prescription
Classification: secretory surface of To mimimize stress ulcer details, including the
gastric parietal cells, formation. Respiratory: Cough dosage, and administration
Therapeutic class: to suppress gastric route.
Antacid acid secretion. • Assemble the necessary
Contraindication/s Adverse Reaction/s medication and equipment.
Pharmacologic • Assess and teach significant
class: Contraindicated in patients CNS: paresthesia, vertigo, others of the patient the
Proton Pump hypersensitive to drug or asthenia, taste disturbance common side effects of the
Inhibitors (PPIs) its components and in drug and to report any
patients receiving Respiratory: URI. severe adverse effects stat.
Dosage: 40 mg rilpivirine-containing • Advise patient to avoid
Route: IV products. Musculoskeletal: alcohol and foods that may
Arthralgia, muscular cause an increase in GI
weakness and myalgia irritation and caution to
Frequency: OD avoid driving or other
Hema: Leukopenia, hazardous activities.
thrombocytopenia,
Timing: 6am agranulocytosis and DURING
pancytopenia • After reconstitution the
injection should be given
General: hypersensitivity slowly over a period of time.
• Provide appropriate safety
57
Echague, Isabela
COLLEGE OF NURSING
reactions, anaphylactic and comfort measures if
reactions CNS effects occur to
prevent patient injury.
• Monitor improvements in
GI symptoms (gastritis,
heartburn, and so forth) to
help determine if drug
therapy is successful.
AFTER
• Monitor the patient for any
delayed allergic reactions
and report it to physician if
any allergic reaction occurs
• Document the findings,
administration of
medication such as the
route, dosage etc.
58
Echague, Isabela
COLLEGE OF NURSING
Generic Name: • Antipyretics: • Post-operative ● Nausea and BEFORE

Paracetamol Reduces fever care for pain vomiting, • Verity the correct dosage and
by acting management ● Headache, Local concentration of IV paracetamol
directly on the • To alleviate irritation based on the patient's weight,
Brand Name: hypothalamic hyperthermia medical condition, and prescribed
Amcetam heat-regulating regimen.
center to cause • Before administering IV
vasodilation paracetamol, assess the patient's
Classification: and sweating, Contraindication/s Adverse Reaction/s medical history, allergies, current
Therapeutic which helps medications, and vital signs.
class: dissipates heat Evaluate the patient for any
Analgesic, ● Hypersensitivity to Hematologic: Hemolytic contraindications or risk factors that
Antipyretic • Inhibits the paracetamol Anemia, Leukopenia, may affect the safety or efficacy of
(non-opioid) enzyme Neutropenia paracetamol.
cyclooxygenas Skin: rash, urticaria • Follow the manufacturers for
e (COX), preparation and administration
Pharmacologic primarily in the carefully to prevent dosing errors.
class: central nervous • Provide clear instructions to the
Para- system. This patient regarding the purpose of
aminophenol inhibition leads paracetamol, expected effects,
derivative decreased possible side effects, and signs of
production of overdose or toxicity.
prostaglandins.
Dosage: 1 amp DURING
Route: IV • Regulated to 30 minutes to 1 hour.
• Monitor the patient closely during
and after paracetamol
Frequency: Now administration for any adverse
59
Echague, Isabela
COLLEGE OF NURSING
reactions or side effects, such as
allergic reactions, local irritation at
Timing: 8pm the injection site, changes in vital
(04/16/24) signs
AFTER
• Reassess and document patient’s
temperature.
Generic Name: Blocks cyclooxygenase, an To treat moderate to severe • Swelling of face, BEFORE
Ketorolac Tromethamine enzyme needed to pain that requires analgesia fingers, lower legs, ● Verify the doctor’s
synthesize prostaglandins. at the opioid level ankles, and/or feet order.
Brand Name: Prostaglandins mediate • high blood pressure ● Read ketorolac
Toradol inflammatory response and • skin rash or itching label carefully.
cause local vasodilation, • small, red spots on Don’t use I.M. form
Classification: pain, and swelling. They skin for I.V. route. Know
Therapeutic class: also promote pain Contraindication/s: Adverse Reaction/s: that ketorolac isn’t
Analgesic transmission from for epidural or
Pharmacologic class: periphery to spinal cord. Contraindicated in patients CNS: Aseptic meningitis, intrathecal use.
NSAIDs By blocking hypersensitive to drug or its cerebral hemorrhage, ● Monitor BP upon
cyclooxygenase and components and in those coma, CVA, dizziness, administration. <
Dosage: 30 mg inhibiting prostaglandins, with bronchial asthma drowsiness, headache, 90/80 never
Route: IV this NSAID reduces (history of obstructive psychosis, seizures administer.
inflammation and relieves airway disease), overt HF, CV: Edema, hypertension ● Assess for aspirin,
pain. greater than first-degree EENT: Laryngeal edema, induced asthma,
Frequency: Now and q8 heart block (except in stomatitis allergy, and nasal
for abdominal pain patients with a functioning ENDO: Hyperglycemia polyps are at
pacemaker), cardiogenic GU: Interstitial nephritis, increased risk for
shock, severe bradycardia, renal failure, urine developing
60
Echague, Isabela
COLLEGE OF NURSING
Timing: 8pm, 4am, 12pm and other conditions that retention hypersensitivity
may cause severe and HEME: Agranulocytosis, reactions.
prolonged hypotension. anemia, aplastic or ● Assess for rhinitis,
hemolytic anemia, asthma, and
eosinophilia, leukopenia, urticaria.
lymphadenopathy, ● Explain that
pancytopenia, ketorolac may
thrombocytopenia increase risk of
RESP: Bronchospasm, serious adverse
pneumonia, respiratory cardiovascular
depression reactions;
SKIN: Diaphoresis, ● Advise patient not
erythema multiforme, to take aspirin, other
exfoliative dermatitis, NSAIDs, or other
photosensitivity, pruritus, salicylates without
rash, Stevens–Johnson consulting
syndrome, toxic epidermal prescriber.
necrolysis, urticaria ● Alert patient to the
Other: Anaphylaxis, possibility of
angioedema, hyperkalemia, serious skin
hyponatremia, injection- reactions, although
site pain, sepsis, unusual rare, occurring with
weight gain ketorolac therapy.
DURING
● Give I.V. injection
over at least 15
seconds.
AFTER
● Assess patient’s
skin routinely for
61
Echague, Isabela
COLLEGE OF NURSING
rash or other
evidence of
hypersensitivity
reactions.
● Assess pain (note
type, location, and
intensity)
● Instruct him to
immediately report
easy bruising,
itching, rash,
swelling, or yellow
eyes or skin.
● Caution patient to
avoid hazardous
activities until
drug’s CNS effects
are known.
● Teach patient
proper oral hygiene
measures, and
encourage him to
use a soft-bristled
toothbrush while
taking ketorolac.
62
Echague, Isabela
COLLEGE OF NURSING
Generic Name: Vitamin K is a cofactor of Vitamin K is given before ● Decreased appetite BEFORE
Vitamin K gamma-carboxylase. surgery to help prevent ● decreased ● Evaluate the
Gamma carboxylase unusual bleeding by movement or patient's medical
Brand Name: attaches carboxylic acid increasing the body's activity history, including
Phytonadione ● general body any known allergies
functional groups to production of blood
swelling or sensitivities
glutamate, allowing clotting. ● irritability ● Assess baseline
Classification:
Therapeutic class: precursors of factors II, ● muscle stiffness coagulation
Vitamin supplement VII, IX, and X to bind ● paleness parameters such as
calcium ions. ● yellow eyes or skin prothrombin time
Pharmacologic class: Binding of calcium ions (PT), international
fat-soluble vitamin converts these clotting Contraindication/s: Adverse Reaction/s: normalized ratio
factors to their active form, (INR), and
Dosage: 10 mg Phytonadione is activated partial
which are then secreted contraindicated in
Route: IV ● Anaphylactoid thromboplastin
from hepatocytes into the phytonadione time (aPTT).
reactions
blood, restoring normal hypersensitivity, hereditary ● Check the patient's
Frequency: Now ● Dyspnea
clotting function. hypoprothrombinemia, current medication
● Chest tightness
heparin over- list to identify any
● Injection site
anticoagulation. potential
Timing: 4:16pm reaction
interactions or
(04/15/24)
contraindications.
● Inform the patient
about the purpose
of the medication,
potential side
effects, and the
importance of
compliance with
63
Echague, Isabela
COLLEGE OF NURSING
the treatment plan.
DURING
● Ensure the correct
dosage based on the
patient's weight,
condition, and
prescribed regimen.
● Administer
phytonadione via
the prescribed
route.
● Monitor vital signs
and observe for any
signs of adverse
reactions, such as
allergic reactions or
anaphylaxis.
● Use proper aseptic
technique during
administration to
prevent infection or
contamination.
AFTER
● Monitor for
hypersensitivity
reactions,
especially when
64
Echague, Isabela
COLLEGE OF NURSING
administered IV
● Assess coagulation
parameters as
indicated by the
healthcare provider
to evaluate the
effectiveness of the
treatment.
● Reinforce
instructions
regarding any
follow-up care,
including
medication
adherence and any
additional
monitoring or
testing required.
● Document the
administration,
including the dose,
route, time, and
patient response, in
the patient's
medical record.
65
Echague, Isabela
COLLEGE OF NURSING
Generic Name: Synthetic opioid agonist Severe pain management, ● Sedation BEFORE
Fentanyl that binds to central typically in cases such as ● Nausea and
nervous system opioid post-operative. vomiting • Assess the
Brand Name: receptors, inhibiting pain ● Constipation patient's pain
Sublimaze signal transmission. ● Itching or pruritus intensity, vital
● Bradycardia signs, respiratory
Classification: Contraindication/s: Adverse Reaction/s: status, and
Therapeutic class: previous opioid
Analgesic use to determine
● Known ● Respiratory the appropriate
hypersensitivity to depression leading dose and route of
Pharmacologic class:
fentanyl or other to hypoventilation administration.
Opioid Agonist
opioids or apnea • Obtain a
● Respiratory ● Hypotension thorough
Dosage: 25 mcg
depression leading to medical history,
Route: IV
● Paralytic ileus cardiovascular including
● Severe bronchial collapse allergies and
asthma ● Opioid tolerance, medications, to
Frequency: q6 x 2 doses dependence, and
then PRN for pain identify potential
withdrawal contraindications
symptoms upon and drug
cessation interactions.
Timing: 6pm, 12am ● Potential for abuse • Ensure the
and addiction availability of
naloxone (opioid
antagonist) and
resuscitation
equipment for
emergency use.
• Educate the
66
Echague, Isabela
COLLEGE OF NURSING
patient and
family members
about the proper
use of fentanyl,
including
potential side
effects, the
importance of
adherence to
prescribed
dosages, and
proper disposal
of unused
medication.
DURING
• Monitor vital
signs,
particularly
respiratory rate
and depth,
closely during
and after
administration,
intervening
promptly in case
of respiratory
depression.
• Administer
fentanyl slowly
67
Echague, Isabela
COLLEGE OF NURSING
and titrate the
dose cautiously
to minimize the
risk of adverse
effects.
• Assess for signs
of sedation,
nausea, or
hypotension and
intervene as
necessary.
AFTER
● Continuously
monitor the patient
for ongoing pain
relief, adverse
reactions, and signs
of opioid tolerance
or dependence.
68

G3 Open Cholecystectomy

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

G3 Open Cholecystectomy

Uploaded by

Copyright:

Available Formats

Republic of the Philippines

Isabela State University

(Intensive Nursing Practicum)

Clinical Instructor of NUR 422

College of Nursing –Isabela State University Echague, Isabela

● Cholecystitis, cholecystolithiasis, and choledocholithiasis pose substantial global

● In the Philippines, cholecystitis, cholecystolithiasis, and choledocholithiasis pose

Cholecystitis Cholecystolithiasis Choledocholithiasis

● Sedentary Lifestyle ● Westernized Diet ● Westernized Diet

Cholecystitis Cholecystolithiasis Choledocholithiasis

● Being Female ● Being Female ● Being Female

Cholecystitis Cholecystolithiasis Choledocholithiasis

● Fever ● Abdominal pain ● Jaundice

Cholecystitis Cholecystolithiasis Choledocholithiasis

● Gallbladder ● Cholecystitis ● Obstructive Jaundice

III. OVERVIEW OF THE SURGICAL PROCEDURE

An open cholecystectomy involves removing the gallbladder through an abdominal

CBDE Choledocholithotomy, or Common Bile Duct Exploration

Choledochoscopy insertion is a procedure that may be performed in conjunction with

Choledochoscopy insertion during open cholecystectomy allows for a comprehensive

With the introduction of laparoscopic cholecystectomies, the need for open

Indications for this procedure are stones discovered by cholangiography during

Choledochoscopy insertion may be indicated for patients undergoing open

● Medical instability. Patients with severe illness, uncontrolled medical problems

● Allergy or intolerance to anesthesia. Individuals with a known allergy to anesthetic

• Severe structural abnormalities of the biliary tree: Structural anomalies, including

• Nonuniform Gallstones: Patients with nonuniform gallstones are not recommended

● Bleeding. There could be a danger of excessive bleeding during or after surgery.

● Infection. Choledocholithotomy is a surgical procedure that carries a risk of surgical

● Bleeding. Insertion of choledochoscopy may cause trauma to the mucosa or blood

● Perforation. Forceful insertion of the choledochoscope or manipulation within the bile

● Bile duct injury. Improper handling or advancement of the choledochoscope within

E. Pre operative preparation

1. Promoting Effective Breathing Pattern

IV. DEMOGRAPHIC PROFILE

B. History of Present Illness

Vitamin K 10 mg Vitamin K helps

Void prior to OR Voiding before

Verified the patient’s To ensure that the right

O2 inhalation Oxygen inhalation Checked the doctor’s To confirm that oxygen

Administered oxygen To ensure adequate

Monitored the To allow for timely

To provide a legal basis

IVF to run for 45 Checked the doctor’s To confirm the correct

To help maintain fluid

To ensure that the

• Fentanyl 25 For management of

Verified the patient. To ensure that the right

Placed the patient flat To alleviate the

Documented that the To provide a legal basis

Hourly measured and To measure the

Hourly measured and To measure the

Documented that the To provide a legal basis

April 14, 2024

April 14, 2024

April 15, 2024

VII. ANATOMY OF THE SURGICAL SITE:

COMMON BILE DUCT

COMMON HEPATIC DUCT

VII. SURGICAL PROCEDURE

1. Pre-Operative Preparation for Surgery

2. Preparation of Surgical Instruments

5. Skin Preparation and Draping