Cholecystitis Case Pres
Cholecystitis Case Pres
Cholecystitis Case Pres
Silliman University
Dumaguete City
Case Description
Case Description:
This case presentation focuses on Cholecystitis. The anatomy and physiology of the gallbladder will be reviewed to enhance understanding of the case.
Pharmacologic interventions as well as the rationale for each medication will also be mentioned. Nursing care plans and functional health pattern specifically for
this case will also be presented.
Central Objective:
At the end of the case presentation, the learners will augment their knowledge, strengthen their learned skills, and project qualities intended for the care of the
patient with cholecystitis.
Specific Objectives:
At the end of the case presentation, the learners will:
Vision
As a leading Christian Institution committed to total human development for the well-being
of society and environment.
Mission
o Infuse into the academic learning the Christian faith anchored on the gospel of Jesus
Christ; provide an environment where Christian fellowship and relationship can be
nurtured and promoted.
o Provide opportunities for growth and excellence in every dimension of the University life
in order to strengthen character, competence and faith.
o Instill in all members of the university community an enlightened social consciousness
and a deep sense of justice and compassion.
o Promote unity among peoples and contribute to national development.
LETTER OF PERMISSION
Silliman University, College of Nursing
Dumaguete City, Negros Oriental
Philippines
July 7, 2016
Asst. Prof. Maria Ellaine Adarna
Clinical Instructor, Surgery Rotation
Silliman University College of Nursing
Dear Maam:
Greetings!
I, Antonio C. Laurenciana III, a senior student currently rotated in the Surgery Rotation, at Silliman University Medical Center would like
to apply for a case study regarding the condition of my patient.
My patient is Ms. M.L.Y., a 43-year old client who was admitted last June 11, 2016 due to the presence of right upper quadrant pain and
vomiting. She was diagnosed with Cholecystitis. She was under my care last June 29, 2016.
I am grateful to have been assigned to this very interesting and challenging case because not only did I get the opportunity to augment
our knowledge with regarding this condition but also it enhanced the application of my skills and knowledge and attitude. Furthermore,
presenting this case to the class will be a good benefit for everyone. I assure you that the confidentiality of my patients case will be
maintained.
Hoping for your kind consideration.
Thank you very much!
Respectfully yours,
Antonio C. Laurenciana III
TABLE OF CONTENTS
CASE DESCRIPTION............................................................................................................................................. 1
INTRODUCTION................................................................................................................................................... 7
DEMOGRAPHIC DATA........................................................................................................................................... 8
DEFINITION OF COMPLETE DIAGNOSIS................................................................................................................ 10
PSYCHOSOCIAL PROFILE.................................................................................................................................... 11
PHYSICAL ASSESSMENT..................................................................................................................................... 20
ANATOMY AND PHYSIOLOGY.............................................................................................................................. 28
ETIOLOGY AND SYMPTOMATOLOGY..................................................................................................................... 32
PATHOPHYSIOLOGY........................................................................................................................................... 38
DIAGNOSTIC EXAM............................................................................................................................................ 40
DRUG STUDY..................................................................................................................................................... 46
PROCEDURAL REPORT........................................................................................................................................ 60
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INTRODUCTION
One of the body organs that we can live without is the gallbladder. However, does this mean it is of no use to the body? The gallbladder is a
pear-shaped organ situated underneath the liver. Its function is to store bile and release it as needed for digestion. Bile emulsifies the fats in food,
breaking them to small fragments so they can be further digested and absorbed in the small intestine. If the gallbladder is not working as it should,
the digestion of fats can be seriously impaired.
One of the common gallbladder diseases is cholecystitis. Cholecystitis is a condition wherein gallstones obstruct the gallbladder outlet leading
to poor drainage of bile. Trapped bile can irritate and inflame the walls of the bladder, thus leading to inflammation. It affects women more often than
men and is more likely to occur at the age of 20-50 or over 60. Asians are also more prone to develop pigment stones. Moreover, people who are
obese and those who had had low fat diet are at an increased risk for developing cholelithiasis. In the United States, it is estimated that 6.3 million
men and 14.2 million women aged 20 to74 had gallbladder disease (Everhart, Khare, Hill, Maurer, 1999). In the Philippines, an extrapolated
prevalence of 5, 073, 040 people are affected by the disease (http://digestive.niddk.nih.gov/statistics). Gallstones that do not cause symptoms do not
require treatment. However, if gallstones cause, disruptive, recurring episodes of pain, surgical removal of the gallbladder is recommended.
Recently, I had a patient who was diagnosed with symptomatic cholecystitis and underwent open cholecystectomy. I chose this case for I find
the condition very interesting and very challenging to work with. I am hoping that through this case study, I will be more knowledgeable and aware
about such gallbladder disorder and the surgical procedure done for the said disease. I am also interested to know the proper and necessary nursing
management that will be given to a patient affected by the disease. Moreover, Iwould also like to impart their learning to their families and their
community regarding the prevention and care if ever such condition will arise in the scenario.
As a nursing student, I am hoping that this study will help me and my colleagues become more efficient and better nurses in the future. The
student nurses also hope to apply their learning in taking care not only of their patients but of themselves as well.
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DEMOGRAPHIC DATA
Name: M.L.Y. Civil Status: Single
Occupation: Secretary
Natioality: Filipino
Age: 43 y/o
3 years ago, was hospitalized in NOPH for the same reason but was only given medications to relieve pain and no further actions were taken as
claimed.
12 hours PTA, patient had onset of pain and vomiting with food particles associated with RUQ pain, it is continuous and non radiating.
General impression:
Received on bed, awake, alert, and verbally responsive with wound dressing @ RUQ of abdomen, dry and without signs of infection on
surrounding site. Vital Signs : BP- 100/80 mmHg T- 36.2C P-71 bpm strong and regular R- 19 cpm without use of accessory muscles.
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compromised which in turn will cause problems with the filling and emptying of the gallbladder. A stone may block the cystic duct which will
result in bile becoming trapped within the bladder due to inflammation around the stone within the duct. Chronic cholecystitis occurs when
there have been recurrent episodes of blockage of cystic duct.
PSYCHOSOCIAL PROFILE
According to Taylor, Lillis, LeMone and Lynn (2008), growth and development are orderly and sequential as well as continuous and complex.
All humans experience the same growth patterns and developmental levels, but, because these patterns and levels are individualized, a wide
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variation in biologic and behavioral changes is considered normal. Within each developmental level, certain milestones can be identified; for
example, the time the infant rolls over, crawls, walks, or says his or her first words. Although growth and development occur in individual ways for
different people, certain generalizations can be made about the nature of human development for everyone.
Robert Havighursts Developmental Task Theory
Robert Havighurst believed that living and growing are based on learning, and that a person must continuously learn to adjust to changing societal
conditions. He described learned behaviors as developmental tasks that occur at certain periods in life. Successful achievement leads to happiness
and success in late tasks, whereas unsuccessful achievement leads to unhappiness, societal disapproval, and difficulty in later tasks. The
developmental tasks arise from maturation, personal motives, and values that determine occupational and family choices, and civic responsibility.
(Taylor, et al. 2008)
Stage
Description
Middle
In the middle years, men and women reach the peak of their
Age(30-50)
influence upon society, and at the same time the society makes
Result
Justification
Selecting a mate
Learning to live with a partner
Starting family
Rearing children
Achieved
The patient got pregnant last 1998. She and the father
or her child works together with her husband in taking
care of and rearing their child by providing especially
financially. She verbalized that she and the father of
her child have a very good relationship as friends and
as providers for their child.
Achieved
1. Infancy
2. Early childhood
3. Late childhood
4. School age
5. Adolescence
6. Young adulthood
7. Adulthood
8. Maturity
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9. Each stage signals a task that must be accomplished. The resolution of the task can be complete, partial, or unsuccessful.
10.
11. Stage
12. Description
13. Result
14. Justification
15. Middle
21.
29.
33.
30.
34.
31.Working
towards
achievin
g goal
Adulthood:
25-65 years
16.
17. Ego
Developmen
t
Outcome:
Generativity
vs.
Self
absorption
or
Stagnation
18.
19. Basic
Strengths:
Production
and Care
32.
will
leave
home
someday.
as
those
are
the
responsibilities of a mother.
24. Significant relationships are within the workplace, the
community and the family.
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20.
self-concern,
lack
of
interests
and
commitments
26.
27. Kozier and Erbs, Fundamentals of Nursing, Chap. 20,
page 352
28. http://www.learningplaceonline.com/stages/organize/E
rikson.htm
37.
38.
39.
40.
41.
42.
43.
44.
45.
Page | 16
46.
47. Lawrence Kohlbergs Levels of Moral Development
48.
Lawrence Kohlberg outlined the different planes of moral adequacy, based on his continued interest in how children would react to
varying moral dilemmas. Kohlberg stated that ethical behavior was based on moral reasoning, which in turn could be broken down into six specific
developmental stages. The stages are progressive, in that it is highly improbable for someone to regress backwards. Once a person acquires the
functionalities of higher stages of moral development, it will be difficult for him to lose these abilities and revert to lower levels of growth. Every stage
follows another, making it difficult for a person to jump forward and virtually skip an entire stage.
49.
50. The levels and stages are as follows:
51. Level 1: Preconventional
52. Stage1: Punishment/obedience
53. Stage2: Instrumental/relativist
54.
55. Level 2: Conventional
56. Stage3: Approval Seeking
57. Stage4: Law and order
58.
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64. Description
65. Resu
66. Justification
lt
67.Postconve
ntiona
74.
79.
75. At
stage
social
orientation,
Level
correct
behavior is defined in
68.Stage
5:
Social
however,
Contr
societys needs,
act
to
meet
while
69.
70.
80.Achie
77. Stage
6,
universal
89. She sees that most of the laws are correct and
ved
81.
82.
83.
84.
85.
86.
76.
88.
87.Worki
Page | 18
71.
ethical
principle
orientation,
towar
ds
achie
6:
beings,
guided
by
ving
Unive
personal
values
and
goal
rsal-
standards regardless of
ethica
72.
73. Stage
represents
ng
internalized at an even
higher level than society.
Few adults ever reach
this
stage
of
development.
78. (Taylor et. al, 2008)
94.
95.
96.
97.
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100.
101.
Sex: Female
102.
103.
104.
105.
106.
107.
108.
109.
110.
111.
112.
113.
1. Temperatur
2. 36.2 C
e:
3. Pulse Rate:
4. 71 bpm
5. Respiratory
6. 19 cpm
Rate:
7. Blood
Pressure:
8. 100/80 mmHg
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I.
General Survey
114.
The patient was received lying on bed, awake, alert, and verbally responsive with wound dressing @ RUQ of abdomen, dry and
without signs of infection on surrounding site. Patient complains of pain on the incision site and rated this pain as 6 out of 10 in the pain scale. She is
oriented to time (verbalized it was late in the afternoon), person (identified watcher correctly), place (verbalized shes in the hospital) and reason for
admission (stated that she was admitted due to right upper quadrant abdominal pain and vomiting). Patient is not in respiratory distress.
115.
Patient appears appropriate for her stated age. She stands 5 feet and 2 inches tall and weighs 57 kg. Her body mass index (BMI) is
22.9 which is normal. She has an endomorphic body type. Patient is in fair grooming as evidenced by unsoiled gown she is wearing, well-kept hair
and clean linens and pillows. Nails were short and clean.
116.
Through the course of the physical assessment, it was observed that the patient is cooperative and has an accommodating attitude
towards the student. The patient is calm. Patients speech was audible, comprehensible and in moderate pace.
117.
II.
Skin
118.
Skin is fair in color, intact and with hairs, except in the palms, soles and dorsa of the distal phalanges. Skin is dry and slightly warm
upon palpation. It returns quickly to its normal state when picked up between two fingers and released. Skin texture is soft and fine while extensor
surfaces such as the elbows have coarser skin. The palms and the soles are calloused. No skin breaks present aside from the incision sites on her
abdomen. No edema present.
119.
III.
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120.
Upon inspection, hair was noted to be black. It is thick, oily, straight, long and well-kept. Hair is also evenly distributed as evidenced by
absence of bald spots. Dandruff or flaking was not present. Other infestations, such as lice, were not noted. The color of scalp is lighter than the color
of skin.
121.
Nails on both hands and feet are short and clean. Nail polish was removed. Client has a capillary refill time of 2 seconds. No clubbing of
Head
123.
Patients head is round and normocephalic in configuration with smooth skull contour. There were no palpated masses, nodules,
deformities or fractures. Facial features are symmetric as evidenced by palpebral fissures being equal in size and symmetric nasolabial folds. Facial
movements are symmetrical and patient is able to perform different kinds of expression effortlessly and without any obstructions. Patient can move
her head up and down and side to side. No lesions noted on the face.
124.
V.
Eyes
125.
Hairs of eyebrows are thick and evenly distributed. Eyebrows are symmetrically aligned and theres equal movement as
evidenced by the patients ability to elevate and lower the eyebrows. No edema, lesions, puffiness or tenderness noted upon inspection and palpation
of the periorbital area. Eyelashes are equally distributed and curled slightly outward. Eyelids surface is intact with no discharges and no discoloration
but with noted eye bags on the lower surface. No lid lag noted. Blink reflex is present. Palpebral fissure is equal in both eyes. Bulbar conjunctiva is
pale pink. Cornea is transparent and without cloudiness. Sclera is anicteric. Eyeballs are symmetrical with no bulging observed. Pupils were black in
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color, equally round, and reactive to light and accommodation. Pupils quickly constrict when a penlight is shone towards the pupil from a lateral
position. Iris is dark brown in color.
126.
Client has central and peripheral vision. She can see things on the side of her eye, like the adjacent bed, even when looking
straight ahead. Moreover, pupils constrict when looking at near objects and dilate when looking at far objects. During ocular testing, patient was
asked to follow the examiners finger in the six cardinal fields of gaze. There was smooth, parallel movement of eyes in all direction. Both eyes move
in unison. No nystagmus noted. To test her visual acuity, she was asked to read the newspaper placed about 1 feet away from her. She was able
to correctly read the names without any difficulty. Patient verbalized she doesnt use any corrective aids. She also did not report any vision difficulty
or eye pain.
127.
VI.
Ears
128.
The color of the patients ears is the same as her facial skin. The skin behind the ear in the crevice is smooth and without breaks.
The left and right pinna are symmetrical and aligned with the inner canthus of the eye. Pinna recoils after it is folded. Auricle is nontender upon
palpation. Mastoid process is smooth and hard and no tenderness or swelling noted. External canals have minimal cerumen. No sanguinous
discharges noted on the meatus. Patient was able to hear a soft whisper equally in both ears. She can also hear normal voice tones as evidenced by
prompt responses to questions asked.
129.
VII.
Nose
130.
It was noted that the nostrils were symmetrical and the nasal septum is midline. There were no observed discharges draining
from the clients nose. Hair is noted on the nares. Nares are patent since patient is able to breathe normally on both nostrils without difficulty when
one nose is closed with digital compression and patient inhaled with mouth closed. No lesions on the external nose structure were seen. There was
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no tenderness over the maxillary and frontal sinuses upon palpation of the cheeks and supraorbital ridges. Clients gross smell was functional as she
could identify the scent of alcohol.
131.
132.
133.
VIII.
Mouth
134.
Mouth is proportional and symmetrical. Lips are cracked, dry, pink in color and with no masses or congenital defect. Buccal
mucosa was uniform pale pink in color and moist. The patients gum was, moist, firm and pinkish in color. No gum retraction or bleeding was noted.
Teeth are of complete set. There are no spaces in between teeth. Dental carries are evident in lower right and left molar. Teeth are yellow in color.
Patient has no dentures. Tongue is pink, moist, slightly rough and has thin whitish color on the surface. It is also in central position and moves freely.
The base of tongue is smooth with prominent veins. No tenderness, lesions or any unusualness noted. Soft palate is light pink in color. On the other
hand, hard palate is much lighter and more irregular in texture. Uvula is positioned in midline of soft palate and rises when the patient says ah.
Tonsils are not inflamed. No ulcerations and exudates present. Patient has no difficulty of masticating and swallowing. Patient has no speech
disorders.
135.
IX.
Neck
136.
Neck is symmetrical with no masses or unusual swelling upon palpation. No jugular vein distention noted. Pulsation at carotid
arteries is strong and regular in rhythm. Range of motion is normal and no pain elicited upon flexion, extension, and rotation of head. Thyroid is not
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enlarged upon palpation with no nodules, masses or irregularities upon palpation. Thyroid also rises when patient was asked to swallow. Trachea is
symmetrical and in midline without deviation. No lymph adenopathies appreciated. No torticollis present.
137.
138.
X.
Breast
139.
Breast is conical, symmetrical and skin color is lighter than exposed areas. No lesions, redness, or edema and texture is even. No
dimpling or retraction. Nipples are in midline and everted pointing in the same direction. Areola and nipples are dark brown in color and has no
discharges, crusting and masses.
140.
XI.
Chest/Lungs
141.
Chest skin integrity is good and intact. Patient has symmetrical chest wall movement. Point of maximal impulse is at 5 th intercostal
space left midclavicular line. Apical pulse is 71bpm. Patient has distinct heart sounds, with S1 louder than S2; negative for murmurs. There were no
noted deformities in the clients thoracic area. There are no bulges or retraction of the intercostal spaces.
142.
Clients respiratory rate is 19 cycles per minute. Patient did not complain of chest pain or chest tightness. Guarding of the chest noted
upon respiration due to the proximity of the incision site to the diaphragm. Patient is not in respiratory distress. Coughing episodes were also not
observed. Vesicular breath sounds are soft and low pitched. Her breathing is deep, regular and slow with a long inspiratory phase and a short
expiratory phase. With no adventitious sounds, lungs are clear to auscultation and no crackles, wheezes or rubs. It was observed that vocal fremitus
is present both at the back and front of the chest when the patient says ninety-nine.
143.
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XII.
Abdomen
144.
Abdomen is round. Color of skin in abdomen is slightly lighter than the rest of the body. Patient complains of pain on the surgical
site and verbalized, Nagangulngol tong gioperhan. Pwede makapangayo ug tambal para sa sakit? Patient reported a pain scale of 6 out of
10. Aortic pulsations are not visible. Umbilicus is midline and inverted. Symmetrical movement of abdomen upon respiration was noted. Upon
auscultation of the abdomen, it was noted that patient has normal bowel soundshigh-pitched and occurred 16 times per minute. Abdomen is
soft and there is no point tenderness. Patient was on Low Fat Diet as ordered.
145.
XIII.
Peripheral pulse of the patient was symmetrical and regular in rhythm; radial pulse is 71 bpm. Patient has normal capillary refill
of 2 seconds. The nails were pinkish in color without cyanosis and clubbing. Patient is able to ambulate freely. She was able to sit up on bed and
perform range of motion on both upper and lower extremities. However, it was noted that patient has guarded and slow movement for she feels pain
on her abdomen. Clients grasping ability was moderately strong on both hands. No edema or cyanosis was noted on both upper and lower
extremities. There is no swelling, tenderness or nodules palpated on each joint. The shoulders, arms, elbows and forearms are free of nodules,
swelling, deformities and atrophy.
147.
The skin at the back of the patient is uniform in color. Symmetrical chest expansion with respirations noted. No spinal tenderness
noted. There are no skin breaks present. The back is also symmetrical with the spinal cord aligning from the neck down to the buttocks. There were
no deformities or abnormalities on the bone such as scoliosis, osteoporosis and alike to be noted.
148.
XIV.
Genito-urinary
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149.
Pubic hair is present, thick in each strand, curly and equally distributed on the mons pubis. No vaginal bleeding or any other
unusual discharges noted. Patient voids freely. She has no difficulty urinating and did not report dysuria. She verbalized her urine is amber in color.
150.
XV.
Neurological
151.
Patient was received lying on bed, awake, conscious, coherent and afebrile. Reflexes are normal and symmetrical bilaterally in both
extremities. Patient is oriented to person, place and time. She is also alert and attentive.
152.
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153.
154.
155.
156.
GALLBLADDER
The gallbladder is a hollow organ that sits just beneath the liver. In adults, the gallbladder measures approximately 8 cm in length and
4 cm in diameter when fully distended. It is divided into three sections: fundus, body, and neck. The neck tapers and connects to the biliary tree via
the cystic duct, which then joins the common hepatic duct to become the common bile duct. Its function is to store and release bile, a fluid made by
the liver.
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157.
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158.
159.
CYSTIC DUCT
The cystic duct is the short duct that joins the gall bladder to the common bile duct. The cystic duct varies from 2 to 3 cm in length and
terminates in the gallbladder. Throughout its length, the cystic duct is lined by a spiral mucosal elevation, called the valvula spiralis (valve of Heister)
which is a series of crescentic folds of mucous membrane in the upper part of the cystic duct, arranged in a somewhat spiral manner. Its length is
variable and usually ranges from 2 to 4 cm. The cystic duct is usually 2-3 mm wide. It can dilate in the presence of pathology (stones or passed
stones).
160.
The duct and spiral folds contain muscle fibers responsive to pharmacologic, hormonal, and neural stimuli. There is, however, no
convincing evidence of a discrete muscular sphincter within the duct. Although the cystic duct is unlikely to play a major role in gallbladder filling and
emptying, it appears to function as more than a passive conduit. Coordinated, graded muscular activity in the cystic duct in response to hormonal and
neural stimuli may facilitate gallbladder emptying. The principal function of the internal spiral folds that are found in man may be to preserve patency
of this narrow, tortuous tube rather than to regulate bile flow.
161.
162.
BILE
163.
The main components of bile include contains water, cholesterol, fats, bile salts, proteins, and bilirubin.
164.
Bile, is produced by hepatocytes in the liver and and then flows into the common hepatic duct, which joins with the cystic duct from the
gallbladder to form the common bile duct. The common bile duct in turn joins with the pancreatic duct to empty into the duodenum. If the sphincter of
Oddi, a muscular valve that controls the flow of digestive juices (bile and pancreatic juice) through the ampulla of Vater into the second part of the
duodenum, is closed, bile is prevented from draining into the intestine and instead flows into the gallbladder, where it is stored and concentrated to up
to five times its original potency between meals. This concentration occurs through the absorption of water and small electrolytes, while retaining all
the original organic molecules.
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165.
When food is released by the stomach into the duodenum in the form of chyme, the duodenum releases cholecystokinin, which causes
Bile helps to emulsify the fats in the food. Besides its digestive function, bile serves also as the route of excretion for bilirubin, a
The alkaline bile also has the function of neutralizing any excess stomach acid before it enters the ileum, the final section of the small
intestine. Bile salts also act as bactericides, destroying many of the microbes that may be present in the food.
168.
In the absence of bile, fats become indigestible and are instead excreted in feces, a condition called steatorrhea.
169.
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170.
171.
Etiology
172.
P
redispo
sing
Factors
176.
173.
Prese
nt/
Ab
se
nt
174.
180.
177.
183.
181.
EN
179.
Justification
186.
187.
PRES
178.
175.
182.
emale
Rationale
184.
185.
188.
190.
189.
193.
iabetes
191.
mellitu
ABSE
192.
NT
195.
196.
194.
Page | 32
197.
201.
198.
203.
A
ge
199.
204.
202.
20-50;
206.
207.
become less efficient with age. Body systems and processes become
PRES
old.
sluggish.
EN
205.
over
age 60)
200.
208.
212.
209.
214.
thnicity
210.
Native
Americ
an,
Mexica
n
215.
213.
PRES
218.
219.
pigment stones.
EN
have gallstones by age 60. Mexican American men and women of all
Americ
an)
Page | 33
211.
Asian)
220.
221.
222.
223.
224.
225.
226.
P
recipit
ating
Factor
s
227.
Presen
t/
Abs
ent
228.
Rationale
229.
Justification
Page | 34
230.
231.
P
regna
ncy
232.
233.
ABSEN
T
234.
235.
Excess estrogen from pregnancy, hormone replacement
therapy, or birth control pills appears to increase cholesterol levels in
bile and decrease gallbladder movement, both of which can lead to
gallstones.
237.
238.
236.
239.
240.
241.
R
apid
weight
loss
244.
242.
ABSEN
T
248.
249.
O
besity
250.
251.
252.
253.
260.
262.
261.
F
asting
243.
254.
ABSEN
T
246.
247.
245.
255.
256.
The most likely reason is that obesity tends to reduce the
amount of bile salts in bile, resulting in more cholesterol. Obesity also
decreases gallbladder emptying.
258.
259.
269.
268.
The patient doesnt fast.
257.
265.
266.
263.
ABSEN
T
Page | 35
270.
271.
H
ormon
e
replac
ement
therap
y, or
birth
contro
l pills
264.
267.
272.
274.
273.
ABSEN
T
275.
Excess estrogen from pregnancy, hormone replacement
therapy, or birth control pills appears to increase cholesterol levels in
bile and decrease gallbladder movement, both of which can lead to
gallstones.
278.
277.
The patient has not been
on birth control pills.
276.
279.
280.
281.
282.
283.
284.
285.
286.
Page | 36
287.
288.
289.
Symptomatology
290.
Signs
and
Symptoms
291.
Presen
t/
292.
Absent
293.
Rationale
294.
Justification
Page | 37
295.
296.
299.
301.
Right
upper
quadrant
pain
302.
304.
Obstruction of ducts connected to the gallbladder
300.
will
cause
inflammation
produced
by
increased
PRESE
305.
NT
303.
297.
(may
radiate to
right
scapula,
shoulder, or
interscapula
r area)
298.
biliar
y colic
306.
307.
308.
310.
Fever
(low grade)
311.
313.
Fever is a nonspecific response that is mediated
309.
ABSEN
314.
312.
315.
316.
317.
319.
Nause
a and
vomiting
320.
322.
Nausea and vomiting sometimes occur with biliary
323.
318.
PRESE
projectile vomiting
NT
324.
321.
325.
326.
327.
329.
Mildly
elevated
serum
bilirubin
330.
332.
Biliary obstruction causes suppression of bile flow,
328.
ABSEN
bloodstream.
333.
not increased.
331.
334.
335.
Page | 39
336.
337.
338.
339.
340.
341.
PATHOPHYSIOLOGY
Precipitating
Factors:
Birth control
Predisposing Factors:
pills
Low Fat Diet
Pregnancy
Rapid weight
loss
Female
Age 43
Ethnicity
Diabetes Mellitus
342.
343.
344.
345.
Pigment solute
precipitate as solid
crystals
346.
Crystals clump
together and form
stones
347.
Gallstones
348.
349.
350.
351.
352.
353.
Gallbladder contracts
after intake of fat to
release bile
Upon contraction, a stone is moved
and becomes impacted on the
cystic duct
CHOLELITHIASIS
Page | 40
Lumen is obstructed
by stones
354.
Bile stasis
355.
356.
357.
358.
359.
360.
(Prostaglandins)
361.
362.
363.
364.
Inflammation of the
gallbladder
Edema
365.
366.
Increased
intraluminal
pressure and
distention of the
Constriction of
blood vessels
Surgery, proper
diet (low fat,
high fiber),
Good
compliance
If treated to
Biliary
Colic
(RUQ
Murphys Sign
CHOLECYSTITIS
Continued
Spread
of bile and
Continued
lack
ofPerforation
blood supply
Gangrene
and
Necrosis
ofgallbladder
to
increase
in
indigenous
intraluminal into
microorganisms
Rupture of
pressure
of
If cavity
not
peritoneal
gallbladder
Sepsi
s
Death
Page | 41
367.
368.
DIAGNOSTIC EXAM
CBC a determination of red and white blood cells per cubic millimeter of blood. It helps health professional check any symptoms such
as weakness, fatigue, or bruising. It also helps diagnose conditions such as anemia, infection and other disorders
369.
6/19/16
370.
Test
376.
Hemoglo
bin
371.
Nor
m
a
l
V
a
l
u
e
s
377.
372.
Res
u
lt
373.
Re
m
a
r
k
378.
379.
12-
11.4
Nor
374.
380.
Rationale
375.
Interpretation
381.
387.
m
382.
%
383.
384.
385.
386.
Page | 42
Hematocr
it
37-
37.0
Nor
388.
%
389.
390.
l
391.
RBC
4.2-
4.45
Nor
/c
/c
392.
393.
399.
u
m
394.
m
395.
396.
397.
WBC
4500
1260
High
infections tuberculosis,
pneumonia, meningitis,
tonsillitis, appendicitis,
colitis, etc.
398.
be caused by acute
0
c
Page | 43
u
m
400.
Neutrophi
l
406.
Lymphoc
ytes
m
401.
402.
403.
55-
74
Nor
407.
408.
l
409.
20-
21
Nor
404.
405.
411.
419.
410.
412.
Monocyte
s
413.
414.
415.
1-6
Nor
m
a
l
416.
Page | 44
420.
Eosinoph
421.
422.
417.
423.
1-4
Nor
il
424.
425.
431.
426.
427.
428.
l
429.
Platelet
150.
292
Nor
/c
430.
.
0
T
/c
u
m
m
432.
433.
Page | 45
434.
435.
Urinalysis - Urinalysis is a physical, microscopic, or chemical examination of the urine. It is done to detect urinary tract infection. It also
measures the level of ketones, sugar, protein, blood components and many other substances
436.
6/12/16
437. TEST
441. Glucos
438.
RESU
LT
442.
439.
NORMA
L
443.
Negat
<50mg/d
445. Protein
ive
446.
447.
Negat
<30mg/d
Negat
<1mg/dL
453. Urobilin
ive
454.
455.
ogen
Norm
<2mg/dL
457. pH
al
458.
459.
CLINICAL SIGNIFICANCE
Glucose is the type of sugar found in blood. Normally there is very little or no glucose in
urine. When the blood sugar level is very high, as in uncontrolled diabetes. Glucose can also be
448.
451.
444.
ive
450.
449. Bilirubin
440.
4.5-8
452.
This is a substance formed by the breakdown of red blood cells. If it is present, it often
means the liver is damaged or that the flow of bile from the gallbladder is blocked.
456.
460.
Urine pH is used to classify urine as either a dilute acid or base solution. The lower the pH,
the greater the acidity of a solution; the higher the pH, the greater the alkalinity. The glomerular
filtrate of blood is usually acidified by the kidneys from a pH of approximately 7.4 to a pH of about
461. Blood
462.
463.
6 in the urine
464.
Red blood cells in the urine may be caused by kidney or bladder injury, kidney stones, a
Page | 46
Negat
ive
<5-
urinary tract infection (UTI), inflammation of the kidneys (glomerulonephritis), a kidney or bladder
10R
BC/
mL
465. Ketone
466.
Negat
ive
467.
468.
<5
Ketones in the urine may mean a very serious condition, diabetic ketoacidosis, is present.
A diet low in sugars and starches (carbohydrates), starvation, or severe vomiting may also cause
mg/d
L
469. Nitrite
470.
471.
Negat
Negative
473. Leukoc
ive
474.
475.
ytes
25
<25WB
478.
C/mL
479.
480.
Urine is normally clear. Bacteria, blood, sperm, crystals, or mucus can make urine look
481. Specific
Clear
482.
Clear
483.
484.
cloudy.
This checks the amount of substances in the urine. It also shows how well the kidneys
gravity
1.010
1.010-
477. Clarity
472.
Bacteria that cause a urinary tract infection (UTI) make an enzyme that changes urinary
nitrates to nitrites. Nitrites in urine show a UTI is present.
476.
Leukocyte esterase shows leukocytes in the urine. WBCs in the urine may mean a UTI is
present.
balance the amount of water in urine. The higher the specific gravity, the more solid material is in
1.03
the urine.
0
485. Color
486.
487.
489.
Many things affect urine color, including fluid balance, diet, medicines, and diseases. How
Yello
Pale to
dark or light the color is tells you how much water is in it. Vitamin B supplements can turn urine
dark
bright yellow. Some medicines, blackberries, beets, rhubarb, or blood in the urine can turn urine
yello
red-brown.
Page | 47
w
488.
490.
491.
Blood Chemistry - A number of tests performed on blood serum (liquid portion of the blood). It determines certain enzymes that may
be present (including lactic dehydrogenase [LDH], certain kinase [CK], aspartate aminotransferase [AST], and alanine aminotransferas [ALT]),
serum glucose, hormones such as thyroid hormone and other substances such as cholesterol and triglycerides. These tests provide valuable
diagnostic cues.
492.
6/19/16
9. TEST
10. R
ES
14. Total
Bilirubin
11. REFERE
NCE
12. REM
13. RATIONALE
ARK
UL
494.
495.
15. 8.
16. 2.0
21.0
17. Norm
al
19. Direct
493.
20. 0.
Bilirubin
24. Inderct
25. 7.
26. 2.0
Bilirubin
17.0
22. Norm
al
27. Norm
al
496.
497.
498.
499.
500.
501.
Page | 48
502.
503.
504.
505.
506.
507.
Medical sonography (ultrasonography) is an ultrasound-based diagnostic medical imaging technique used to visualize muscles,
tendons, and many internal organs, to capture their size, structure and any pathological lesions with real time tomographic images. Ultrasound
has been used by sonographers to image the human body for at least 50 years and has become one of the most widely used diagnostic tools
in modern medicine.
508.
509.
6/17/16
510.
Impression:
Chronic Cholecystitis with cholelithiasis
511.
512.
Page | 49
513.
DRUG STUDY
514.
515.
Gener
ic Name:
517.
Class
ification:
519.
Order
ed Dose:
521.
Mode
Of Action:
516.
Lanzoprazole
518.
520.
Lanzoprazole 30 mg IV every 12 h
523.
Indica
tions:
524.
525.
Contr
aindications
:
526.
522.
Inhibits proton pump and binds to hydrogen or potassium adenosine triphosphatase thus decreasing gastric acid
formation
Ampicillin, esters, digoxin, iron salts, ketoconazole: May interfere with absorption of these drugs
527. Drug
Interactions:
528.
Adver GI: abdominal pain. diarrhea, nausea
se Effects:
529. Nursing
Assess patient's condition before starting therapy and regularly thereafter to monitor drug's effectiveness
Be alert for adverse reactions and drug interactions
Responsibilities:
Page | 50
530.
Biblio
graphy:
531.
532.
536.
537.
538.
540.
541.
543.
Metronidazole
545.
546.
Hinders growth of selected organisms, including most anaerobic bacteria and protozoa
548.
549.
550.
551.
552.
553.
554.
556.
557.
558.
533.
534.
535.
Gener
ic Name:
539.
Class
ification:
542.
Order
ed Dose:
544.
Mode
Of Action:
547.
Indica
tions:
555.
Contr
aindications
:
Antibacterial
Antiprotozoal
500 g IV every 6h
Page | 51
559. Drug
Interactions:
565.
Adver
se Effects:
574. Nursing
Responsibilities:
560.
561.
562.
563.
564.
566.
567.
568.
569.
570.
571.
572.
573.
575.
576.
577.
578.
579.
580.
581.
582.
583.
584.
585.
586.
587.
588.
589.
590.
>cimetidine
>phenobarbital
>warfarin
>disulfiram
>fluorouracil
CNS: seizures, dizziness, headache
EENT: Tearing(topical only)
GI: abdominal pain, anorexia, nausea and vomiting, diarrhea, dry mouth, glossitis
Derm: rashes, urticarial, mild dryness, skin irritation
Hemat: leukopenia
Local: Phlebitis at Iv site
Neuro: peripheral neuropathy
Misc: superinfection
>assess pts. Infection
>watch carefully for edema because it may cause sodium retention
>assess skin for severity areas of local adverse reactions
>record number and character of stools
>assess pts and familys knowledge of drug therapy
During
>give drug with meals to minimize GI distress
>to treat trichomoniasis, give drug for 7days instead of 2-g single dose
>use only after T.vaginalis has been confirmed by wet smear
>tablets may be crushed for pts. with difficult swallowing
>do not use aluminium needles or hubs, color will turn orange/rust
After
>tell pt. that metallic taste and dark or red brown urine may occur
>instruct pt. to take oral form with meals to minimize reactions
>instruct to complete full course of therapy
>tell pt. not to use alcohol or drugs that contain alcohol.
Page | 52
592.
Biblio
graphy:
594.
595.
596.
597.
598.
599.
600.
Gener
ic Name:
602.
Class
ification:
604.
Order
ed Dose:
606.
Mode
Of Action:
608.
Indica
tions:
610.
Contr
aindications
:
612. Drug
Interactions:
591.
593.
601.
Cefuroxime
603.
605.
607.
609.
Perioperative prophylaxis
611.
613.
Side
614.
Stomach upset, nausea, vomiting, diarrhea
Effect:
615.
Adver
CNS:, dizziness, lethargy, headache
se Effects:
Page | 53
CV: peripheral circulatory collapse, tachycardia, bradycardia, arrhythmia, palpitations, hypertension, hypotension
GI: nausea, vomiting, diarrhea, anorexia, abdominal pain, psuedomembranous colitis
GU: Nephrotoxicity
Hematologic: bone marrow depression, thrombocytopenia
616. Nursing
Responsibilities:
620.
621.
Gener
ic Name:
622.
Metoclopramide
Page | 54
623.
624.
625.
626.
627.
629.
Classification:
Dopaminergic blocker
Ordered Dose:
Mode Of Action:
628.
10 g IV every 6 h
630.
Stimulates motility of upper GI tract without stimulating gastric, billiary, or pancreatic secretions; appears to sensitize tissues to action of
acetylcholine; relaxes pyloric sphincter, which, when combined with effects on motility, accelerates gastric emptying and intestinal transit; little
effect on gallbladder or colon motility; increases lower esophageal sphincter pressure; has sedative properties; induces release of prolactin.
631.
632.
633.
634.
635.
636.
637.
638.
639.
640.
641.
642.
Indications:
- Prophylaxis of postoperative nausea and vomiting when nasogastric suction is undesirable
643.
644.
Contraindications:
- Allergy to metoclopramide
- GI hemorrhage
- Mechanical obstruction or perforation
- Pheochromocytoma
- Epilepsy
Drug Interactions:
Page | 55
645.
646.
Adverse Effects:
647.
CNS: Restlessness, drowsiness, fatigue, lassitude, insomnia, extrapyramidal reactions, parinsonism-like reactions, akathisia, dystonia,
myoclonus, dizziness, anxiety
648.
649.
CV: Transient hypertension
650.
651.
GI: Nausea, diarrhea
652.
653.
654.
655.
656.
657.
658.
659.
Nursing Responsibilities:
- Monitor BP carefully dring IV administration.
- Monitor for extrapyramidal reactions, and consult physician if they occur.
- Instruct patient to take drug exactly as prescribed.
- Instruct not to use alcohol, sleep remedies or sedatives; serious sedation could occur
Bibliography:
660.
661.
662.
663.
664.
Gener
ic Name:
667.
Class
665.
666.
668.
Paracetamol
Analgesics ( Non-opioid)
Page | 56
ification:
671.
Order
ed Dose:
673.
Mode
Of Action:
675.
Indica
tions:
678.
Contr
aindications
:
680.
Adver
se Effects:
687. Nursing
Responsibilities:
669.
670.
672.
Antipyretics
500 g IV every 4 h prn >38 C
674.
Paracetamol may cause analgesia by inhibiting CNS prostaglandin synthesis. The mechanism of morphine is
believed to involve decreased permeability of the cell membrane to sodium, which results in diminished transmission of
pain impulses therefore analgesia.
676.
Temporary relief of pain and discomfort from headache, fever, cold, flu, minor muscular aches, overexertion,
menstrual cramps, toothache, minor arthritic pain.
677.
679.
Hypersensitivity to the drug and its components
681.
682.
683.
684.
685.
686.
688.
689.
690.
691.
692.
693.
694.
695.
696.
Hematologic:
hemolytic anemia, leukopenia, neutropenia, pancytopenia, thrombocytopenia.
Hepatic:
liver damage, jaundice
Metabolic: hypoglycemia
Skin: rash, urticuria
Assess patients pain or temperature before therapy and regularly thereafter.
Asses patients drug history and calculate total daily dosage accordingly.
Be alert for signs of reactions
and drug interactions.
Assess patients and familys knowledge of drug therapy.
Page | 57
697.
Biblio
graphy:
698.
699.
700.
701.
702.
706.
Gener
ic Name:
708.
Brand
Name:
710.
Class
ification:
712.
Order
ed Dose:
714.
Mode
Of Action:
707.
Phytonadione
709.
Hema K
711.
713.
1amp now
716.
Indica
tions:
718.
Contr
aindications
:
717.
Preoperatively: to activate clotting factors to decrease chances of bleeding during surgical procedure
719.
703.
704.
705.
715.
Vitamin K is required for the liver to make factors that are necessary for blood to properly clot (coagulate),
including factor II (prothrombin), factor VII (proconvertin), factor IX (thromboplastin component), and factor X (Stuart
factor).
Page | 58
720. Drug
Interactions:
722.
Side
Effect:
724.
Adver
se Effects:
726. Nursing
Responsibilities:
727.
Source
721.
723.
No known side effects for this drug; bruising and bleeding are less likely to happen.
725.
731.
732.
Gener
ic Name:
734.
Class
ification:
736.
Order
ed Dose:
733.
Celecoxib
735.
737.
Page | 59
738.
Mode
Of Action:
739.
Celecoxib reduces pain and inflammation by blocking COX-2, an enzyme in the body.celecoxib does not block
COX-1, the enzyme involved in protecting the stomach from ulcers.Other anti-inflammatory medicines (NSAIDS) block
both COX-1 and COX-2.celecoxib relieves pain and inflammation with less risk of stomach ulcers compared to NSAID
740.
Indica
tions:
742.
Contr
aindications
:
741.
743.
Hypersensitivity to celecoxib
744. Drug
Interactions:
745.
Side
746.
Nausea, vomiting, diarrhea, Headache, Rash, Blurred vision, Difficulty in sleeping, Muscle cramps, Fatigue
Effect:
747.
Adver CNS: headache, malaise, dizziness, hallucinations, insomnia, vertigo, anxiety, drowsiness, confusion
se Effects:
CV: bradycardia, tachycardia, hypertension
Dermatologic: rash, urticaria
GI: constipation, diarrhea, nausea, anorexia, vomiting, abdominal pain, hepatic dysfunction, jaundice
Page | 60
Do not take a double dose to make up for the dose that you missed.
If you get an infection while taking Celecoxib, tell your doctor. Celecoxib may hide fever and may make you think,
mistakenly, that you are better or that your infection is less serious than it might be.
749.
Biblio
750.
MIMS 113th edition 2007
graphy:
751.
Page | 61
752.
Gener
ic Name:
754.
Brand
Name:
756.
Class
ification:
758.
Order
ed Dose:
760.
Mode
Of Action:
762.
Indica
tions:
765.
Contr
aindications
:
767.
Side
Effect:
769.
Adver
se Effects:
772. Nursing
Responsibilities:
776.
Biblio
graphy:
753.
Ferrous Sulfate
755.
Propan
757.
Supplement
759.
1 cap OD
761.
Elevates the serum iron concentration, which then helps to form Hgh or trapped in the reticuloendothelial cells
for storage and eventual conversion to a usable form of iron.
763.
Prevention and treatment to iron deficiency anemias
764.
Dietary supplement for iron
766.
Contraindicated with allergy to any ingredient; sulfate allergy; hemochromatosis, hemosiderosis, hemolytic
anemias
768.
770.
CNS: CNS toxicity, acidosis, coma and death with overdose
771.
GI: GI upset, anorexia, nausea, vomiting, constipation, diarrhea, dark stools, temporary staining of teeth
773.
Confirm the patient does have iron deficiency anemia before treatment.
774.
Give drug with meals (avoiding milk, eggs, coffee and tea) if GI discomfort is severe: slowly increase to build up
tolerance.
775.
Administer liquid preparations in water or juice to mask the taste and prevents staining of teeth; have the
preparations drink solution with a straw.
777.
2005 Lippincotts Nursing Drug Guide
778.
Page | 62
779.
Gener
ic Name:
781.
Brand
Name:
783.
Class
ification:
785.
Order
ed Dose:
787.
Mode
Of Action:
780.
Multivitamins
782.
AminoVita
784.
786.
1 cap BID
788.
789.
Indica
790.
Conditions associated with nutrient loss
tions:
791. Nursing
Encourage to take with meals
Responsibilities:
792.
Biblio
793.
2005 Lippincotts Nursing Drug Guide
graphy:
794.
795.
Gener
ic Name:
797.
Class
ification:
799.
Order
ed Dose:
801.
Mode
Of Action:
796.
Ciprofloxacin
798.
Antibiotic
800.
802.
Inhibits bacterial DNA synthesis by inhibiting DNA gyrase thus inducing death of susceptible bacteria
Page | 63
803.
Indica
tions:
806.
Contr
aindications
:
808.
Adver
se Effects:
817. Nursing
Responsibilities:
804.
Ciprofloxacin is used to treat infections of the skin, lungs, airways, bones, and joints caused by susceptible
bacteria.
805.
It is also frequently used to treat urinary infections caused by bacteria such as E. coli.
807.
Hypersensitivity to celecoxib
809.
CNS: Seizures, dizziness, drowsiness, headache, insomnia, acute psychoses, agitation, confusion,
hallucinations, increased intracranial pressure, tremors.
810.
GI: pseudomembranous colitis, abdominal pain, diarrhea, nausea, altered taste
811.
GU: interstitial cystitis, vaginitis
812.
Derm: rash
813.
Endo: hyperglycemia, hypoglycaemia
814.
Local: phlebitis at IV site
815.
MS: tendinitis, tendon rupture
816.
Misc: hypersensitivity reactions including anaphylaxis, Stevens-Johnson syndrome, lymphadenopathy
818.
-Assess for infection prior to and during therapy.
819.
820.
-Obtain specimens for culture and sensitivity before initiating therapy. First dose may be given before receiving
results. To prevent development of resistant bacteria, therapy should only be used to treat infections that are proven or
strongly suspected to be caused by susceptible bacteria.
821.
822.
-Observe for signs and symptoms of anaphylaxis (rash, pruritus, laryngeal edema, wheezing). Discontinue drug
and notify physician immediately if these problems occur. Keep epinephrine and resuscitation equipment close by in
case of an anaphylactic reaction.
823.
824.
-Encourage patient to maintain a fluid intake of at least 1500-2000 ml/day to prevent crystalluria.
825.
826.
-Advise patients that antacids or medications containing iron or zinc will decrease absorption and should not be
taken.
Page | 64
827.
828.
830.
832.
Gener
ic Name:
834.
Class
ification:
836.
Order
ed Dose:
838.
Mode
Of Action:
833.
Bearse
835.
Digestant
837.
1 cap BID
839.
840.
Indica
tions:
842.
Contr
aindications
:
844.
Adver
se Effects:
847. Nursing
Responsibilities:
850.
Biblio
graphy:
841.
843.
845.
846.
848.
849.
851.
GI: GI irritation
829.
Biblio
graphy:
831.
852.
Page | 65
853.
854.
855.
856.
857.
858.
859.
860.
861.
862.
863.
864.
865.
866.
867.
868.
PROCEDURAL REPORT
869.
Date of
operation:
870.
Page | 66
871.
Time of
Operation:
873.
Time Ended:
875.
Age:
877.
Diagnosis:
879.
Operation
Performed:
881.
Type of
Anesthesia:
883.
Name of
Surgeon:
885.
Anesthesiolo
gist:
872.
4:48 pm
874.
876.
878.
6:25 pm
43 years old
Cholecystitis
880.
Open Cholecystectomy
882.
884.
Dr. LSS
886.
Dr. JAO
887.
888.
889.
Procedural Report
The surgery to remove the gallbladder is called a cholecystectomy. The gallbladder is removed through a 5 to 8 inch long incision, or
cut, in the abdomen. The cut is made just below the ribs on the right side and goes to just below the waist. This is called open cholecystectomy.
891.
Open Cholecystectomy is a surgery in which the abdomen is opened to permit cholecystectomy -- removal of the gallbladder
892.
Page | 67
893.
894.
B. Nursing Responsibilities
Preoperative Phase
o Secure the informed consent for legal purposes and take note of the following things:
1. The surgeon must provide a clear and simple explanation of the surgical procedure.
895.
896.
4. If the patient needs additional information about the procedure, nurse notifies the surgeon.
897.
5. The nurse ascertains that the consent form has been signed before administering psychoactive drugs.
898.
899.
o Assess for drug and alcohol abuse. Persons with history of chronic alcoholism often suffer from malnutrition and other systemic
problems that increase the surgical risk.
o Assess the respiratory status. The goal for potential surgical patients is optimal respiratory function.
o Assess the cardiovascular status. The goal in preparing any patient for surgery is to ensure a well functioning cardiovascular system
to meet the oxygen, fluid and nutritional needs.
o Assess the hepatic and renal functioning. Presurgical goal is optimal function of the liver and urinary system to enhance removal of
medications.
o Assess the immune functioning. An important function of the preoperative assessment is to determine the existence of allergies.
Page | 68
o Assess for the previous medication use. A medication history is obtained from each patient because of the possibility of drug
interactions
o Make nursing diagnoses, and prepare nursing care plans to address patients needs
o Teach deep-breathing, coughing and incentive Spiro meter to aid the patient post operatively
o Encourage mobility and active body movement to avoid complications
o Teach cognitive coping strategies such as imagery, distraction and optimistic self-recitation to reduce fear and anxiety
o Explain the activities that may occur inside the operating room to reduce anxiety
o Inform the patient on the following to impart knowledge on the part of the patient and to avoid delay in surgery due to noncompliance:
What to leave at home such as jewelry, watch, medications and contact lenses
o Acquire and document patients vital signs for baseline data and maintain the preoperative record
o Transport the patient to the presurgical area to prepare the patient for surgery
o Attend to the family needs to reduce the anxiety felt by the family
o Make sure that preoperative checklist which contains the following is accomplished:
Patient is scheduled in OR
Anesthesiologist informed
Page | 69
Medicines in
Sponged or bathed
Enema given
Jewelry removed
Medicine for OR in
900.
Intraoperative phase
o Position the patient:
o Skin preparation
o Circulating nurse:
Manages the operating room
Page | 70
Protects patients safety and health by monitoring the activities of the surgical team
Checks and verifies the consent form
Ensures fire safety precautions, cleanliness, proper temperature, humidity and lighting of the operating room
Monitors safe functioning of the equipments
Coordinates with the surgical/ perioperative team and monitors aseptic practices
Documents operating room surgical activities
Count all needles, sponges and instruments together with the scrub nurse
901.
o For the scrub nurse:
Assisting the surgeon and assistant surgeon, taking care of tissue specimens
Count all needles, sponges and instruments together with the circulating nurse
902.
903.
Postoperative Phase
o Assess patient : appraise air exchanges status & note skin color; verify & identify operative status & surgeon performed; assess
neurological status (LOC)
o Perform safety checks good body alignment, side rails and maintain patent airway and cardiovascular stability
o Medication
Inform the patient about the importance of complying with the prescribed medication.
Encourage the client to have the prescribed diet for her condition.
Encourage to have early ambulation in order to promote circulation and wound healing.
904.
Page | 72
905.
906.
1.
2.
3.
4.
5.
Acute pain related to presence of surgical incision secondary to status post open cholecystectomy.
Impaired skin integrity related to surgical procedure: open cholecystectomy secondary to cholecystitis
Deficient knowledge regarding illness and treatment course related to lack of information presented.
Risk for infection related to presence of surgical incision.
Risk for imbalanced body temperature related to exposure to anesthesia secondary to status post open cholecystectomy.
907.
908.
Page | 73
909.
910.
1. Acute pain related to presence of surgical incision secondary to status post open cholecystectomy.
912.
911.
C
ues
ursing
915.
913.
Diagno
Objecti
914.
ve/Goal
Nursing
916.
Rationale
Interventions
917.
Evaluation
974.
GOAL MET
sis
918.
921.
923.
At the
925.
1. Monitor and
ubjecti
cute
end of my
ve
pain
care, the
2 hours.
Cues:
related
patient will be
926.
to
able to:
927.
Verbalize
presenc
d Sakit pa
e of
akong
opera, ngulngul pa.
bjectiv
e
Cues:
incision
second
919.
920.
surgical
ary to
status
post
open
cholecy
1. Report a
decrease in pain
intensity to a
928.
10.
930.
2. Demonstrate
2. Administer
Celecoxib) as ordered.
929.
R: Vital
analgesics (e.g
scale of 3 out of
954.
956.
975.
At the end of
R:
controlled as evidenced by
Celecoxib is an
NSAID. It is for
relief of moderate
to severe pain.
957.
non
of analgesic at regular
pharmacological
methods and/or
administration, also
analgesic dose
use of relaxation
may not be
958.
R: The
out of 10
2. Demonstrate non
pharmacological methods
and/or use of relaxation
Page | 74
pain scale of
stectom
skills and
symptoms of untoward
adequate to raise
6 out of 10
y.
diversional
the clients
activities, as
Grimaced
indicated, for
face noted.
pain
vomiting)
threshold or may
individual
931.
be causing
performed diversional
Guarding
situation.
932.
intolerable or
behavior
924.
933.
dangerous side
noted.
noted.
Slow and
limited
movement
of the upper
extremities
Patient is 1
day post
operative
Incisions @
RUQ of the
abdomen.
Incisions
are covered
with dry and
922.
959.
960.
effects or
976.
Vital Signs: T-
both. Ongoing
evaluation will
pain scale.
assist in making
934.
necessary
935.
961.
adjustment
936.
937.
management.
962.
963.
R: Allows
evaluation of the
severity of the
exercises.
patient. Pain is a
938.
subjective
Page | 75
intact
939.
experience and
dressing.
940.
Vital Signs:
941.
T- 36.2C;
BP- 100/70;
964.
RR-18; PR-
Maintain anatomic
965.
81.
alignment
breathing
942.
increases oxygen
7. Encourage diversional
R: Deep
activities (TV/radio,
prevents
atelectasis. Deep
mental imaging).
breathing exercise
943.
also provides
944.
comfort.Splinting
945.
946.
breathing is to
R:
947.
Alignment helps
948.
949.
malposition and it
Page | 76
enhances comfort
967.
968.
R: These
highten ones
concentration
upon nonpainful
stimuli to decrease
one's awareness
and experience of
pain.
969.
970.
R: The
patient's
experiences of
pain may become
exaggerated as
the result of
fatigue. Adequate
rest helps provide
comfort
971.
R: Helps
reduce pain
Page | 77
brought about by
the exertion of
force necessary to
perform activities
972.
973.
R: Severe
pain is more
difficult to control
and increases the
clients anxiety
and fatigue.
977.
978.
979.
980.
981.
982.
983.
984.
985.
Page | 78
986.
987.
988.
2. Impaired skin integrity related to surgery: open cholecystectomy secondary to cholecystitis.
989.
Cues
995.
Subje
ctive:
996.
Giop
erahan ko
diri sa tiyan,
as
verbalized
by the
patient
997.
998.
tive:
Objec
999.
-post
open
cholecystect
omy
1000.
990.
Nursing
Diagnosis
991.
Objectiv
es/Goals
1005.
Impaired
1008.
At the
skin integrity
end of my
related to
carethe patient
surgery: open
will be able to:
cholecystectom
y secondary to 1. Display improvement
in wound healing as
cholecystitis.
evidenced by intact
1006.
incision site.
1009.
1007.
2. Remain free from
infection
as
evidenced by normal
vital
signs
and
absence of purulent
discharge.
1010.
3. Demonstrate
behaviors/techniques
to promote healing or
992.
Nursing
Interventions
1.
993.
Rationale
994.
Assess dressings/
wound every shift.
Describe wounds and
observe for changes.
1011. .
1035.
:Establish
es comparative
baseline providing
opportunity for
timely intervention
1012.
2.
Encourage
early
ambulation.
Assist
patient in doing active
and passive range of
motion exercises.
1015.
1058.
Evaluation
Goal Met
1059.
At the end of my
care, the patient was able
to:
1036.
3.Demonstrate
behaviors/techniques to
1039. :
Movement promote healing or prevent
stimulates
circulation complications (e.g patient
and assists in the washes hands after using the
bodys natural process
1038.
Page | 79
disruption of
the dermis,
epidermis,
and
subcutaneou
s tissues.
1001.
-with
incision at
the RUQ of
the
abdomen
1002.
incisions
covered with
dry and
intact
dressing
1003.
-skin
slightly warm
to touch.
Temperature
: 36.3C
1004.
prevent
complications
4.
Monitor temperature
every 4 hours.
1016.
1017.
1018.
1019.
5.
Place
in
semiFowlers position or
moderate high back
rest.
1020. .
1021.
1040.
1041.
: Early
recognition of
developing
infection enables
rapid institution of
treatment and
prevention of
further
complications.
1042.
1043.
6.
Instruct to wear
clean, dry, loose-fitting
clothes,
preferably
cotton fabric
1022.
:Proper
positioning
decreases
tension in the
operative site and
promotes healing
1044.
1023.
1024.
1025.
1026.
7.
of repair.
Emphasize
importance
of
adequate nutrition and
fluid intake. Encourage
patient to eat foods
rich in protein, iron and
vit. C.
1027.
1028.
1029.
1030.
8.
Instruct the client in
proper
postoperative
skin care. Teach client
and her significant
others the importance
of
proper
hand
washing.
1031.
1032.
1033.
9.
reduces pressure on
compromised tissues,
which may improve
circulation/healing
1046.
1047. :
Improved
nutrition and hydration
will
improve
skin
condition. Protein and
iron helps in repair of
tissues. Vitamin C is
important for immune
system function and
increases resistance to
some pathogens.
1048.
1049. :
This is to
involve the patient in
caring
for
skin,
promoting comfort, and
preventing infection or
other
complications.
Proper
washing
of
hands deter the spread
of microorganisms.
Page | 81
surgical
incision,
purulent discharge, or
breakdown of sutures
around the incision,
and report to the
physician.
10.
Administer
antibiotics as indicated
(cefuroxime)
1034.
1050.
1051.
1052. : Provides for
prompt recognition of
complications
and
facilitates
prompt
treatment.
1053.
1054.
1055.
1056.
1057.
: May be
given
prophylactically or
to treat specific
infection and
enhance healing.
1062.
1063.
1064.
1065.
1066.
Page | 82
1067.
1068.
1069.
1070.
1071.
1072.
1073.
1074.
1075.
1076.
1077.
3.Deficient knowledge regarding illness and treatment course related to lack of information presented.
1078.
Cu
1079.
Su
g Diagnosis
1088.
Knowle
es
1084.
bjective
dge
cues:
regarding
Verbalized: Para
asa diay ni siya
(holds
Nursin
deficit
illness
and
treatment
course related
to
lack
of
1080.
Objecti
1081.
Nursing
ve/Goal
Interventions
1091.
At the 1. Assess the patients
1082.
Rationale
end of my
care, the
builds on previous
patient will be
knowledge or
able to:
experience. Assessing
of complications if these
explanations as well as
1092.
1.
1083.
1165.
1166.
Evaluation
Goal Met
At the end
of 2 hours nursing
intervention, the
patient was able
to:
Page | 83
medications)?
Verbalized: "Di
ko muinom lang
ana na tambal
kay pait"
1085.
Obj
ective
cues:
information
Verbalize
presented.
understanding
likelihood of cure or
experiences and
1089.
of disease
disease control.
exposure to health
1090.
process and
information provides an
treatment.
physicians explanations
opportunity for
malabanan ang
1093.
2.
Initiate
necessary
lifestyle
Frequent
changes and
questioning
participate in
treatment
Incorrect verbal
regimen.
experiences.
1094.
2. Ask how much the patient
wants to know. Consider
patients preference for
information in planning and
feedback
teaching.
regarding
1095.
understanding of
treatment
1096.
regimen.
1097.
1086.
1098.
1087.
1099.
1100.
1101.
1102.
1103.
1104.
3. Determine learning needs.
appropriate content.
1105.
1106.
1107.
1108.
1109.
1110.
1111.
concerns and
responses and
necessary self-care
1112.
1113.
1114.
1115.
4. Present manageable
amounts of information at
1116.
5. Inform the patient about
indication of medication,
drug interaction and its
side effects
1117. .
6. Inform the patient about
the diet specific for her
condition (low fat, high fiber
foods; avoid spicy foods,
alcohol and caffeine)
1118.
Page | 86
1119.
1120.
1121.
1122.
1123.
1124.
1125.
1126.
1127.
1128.
1129.
1130.
1131.
7. Provide simple
occur.
1158.
1159.
R:
Page | 87
1132.
1133.
1134.
8. Discuss to the patient and
to the family the
importance of complying
with the medications and
other doctors orders.
1135.
1136.
1137.
1138.
1139.
1140.
Ask for feedback.
Medical and
nursing jargon
distances the
patient and
family members.
Intricate
explanations
may confuse or
overwhelm
them.
1160. R: This lets the
patient be aware of the
significance of the
doctors instructions. It
also lets the patient
know the
consequences which
might occur if
instructions werent
followed. Knowing the
1141.
benefits of complying
with the instructions
Page | 88
1142.
1143.
1144.
1145.
10.Use review and repetition
judiciously, considering
individual factors.
1146.
11. During and after teaching,
determine what learning
has occurred.
1147.
1148.
1149.
12.Provide information about
encourages
participation.
1161.
R: The
patient may
initially feel
overwhelmed
and insecure
about learning
because of the
magnitude,
urgency or
unfamiliarity of
necessary
adaptations to
illness.
1162. R: The unit
additional learning
contribute to a short
their area.
1150.
retention.
Page | 89
1163. R: Determining
learning
accomplishment
permits resolution of
some learning needs
and provides guidance
for meeting others.
1164.
R:
Patients should
be informed that
there are health
services in the
health centers
which are for
free, so as to
persuade them
to avail it.
1168.
Page | 90
1172.
1173.
1174.
USUAL
FUNCTIONAL PATTERNS
1178.
Healthperception Healthmanagement pattern
- General health in the past
year is good
- 3 years ago, was
hospitalized in NOpH for
the same reason but was
only given medications to
relieve pain and no
further actions were taken
as claimed
- Has a family history of DM
on both sides,
hypertension on maternal
side and gallbladder
disease on maternal side.
- No known disease
- Would take TUMS
(antacid) orally to relieve
epigastric pain had a
history of epileptic
1175.
-
INITIAL APPRAISAL
1176.
ONGOING
APPRAISAL(06-30-16)
Verbalized that she is
now feeling better and
feels that she can go
home already
was alert, conscious
and oriented
Shows interest to
recover easily and fast
as she participates and
listens to what the
health care team
instructs on what to do
and what to eat
1177.
ONGOING
APPRAISAL(07-01-16)
Shows great interest
in recovering fast
Participates during
health teaching
was alert, verbally
responsive and
oriented
Verbalized feeling
much better now
compared to
previous days
Claimed that she will
now be very
conscious on her
health and will
continue to seek
regular check ups
Page | 91
Weight: 57 kgs
Height: 5 ft 2
Normal Body index22.4
Average Body
temperature- 36 c
On full low fat diet
Medications:
1189.
Bearse 1 cap OD
1190.
Propan + iron 1
cap OD
1191.
Ciprofloxacin
500 mg 1 tab BID
1192.
Amino vita 1
cap BID
1193.
Celecoxib 200mg/cap
1 cap BID
Consumed about 2-3
glasses of water and 1
glass of Non fat milk
skin is relatively dry
and warm to touch
Mucuous membranes
were moist but lips
were slightly cracked
color of conjunctiva
Page | 92
1199.
Elimination
Pattern
- Bowel elimination:
1200.
Twice a day, early
morning and late evening
1201.
Brown color
1202.
Small, of a cup
full, solid
1203.
No discomforts on
eliminating
- Urinary elimination:
1204.
Aprrox. 4 times a
day
1205.
Uses a urinal
1206.
No discomforts
1207.
Straw-like color
1208.
1/8-1/4 of a cup full
depending of amt of fluid
intake
1209.
No problem
controlling urination
- Does note easily perspire
Blo
1231.
N
egativ
e
1233.
one
Ket
1236.
Nitr
1234.
N
egativ
e
1237.
N
1214.
NO
RMAL
1217.
<5
0mg/dL
1220.
<3
0mg/dL
was pinkish
Bowel sounds 7 clicks
per minute
1194.
No pain or burning
sensation during
urination
Not yet defecated
Urinated twice.
characteristic of urine:
color- light yellow, no
unusual odor, approx.
24 cc
1253.
No pain or burning
sensation during
urination
Defecated once @ 5
am with firm brown
stool without
difficulty
Voided 2x
approximately 600 cc
no difficulty voiding
skin perspiration is
minimal
no notable body odor
1223.
<1
mg/dL
1226.
<2
mg/dL
1229.
4.5
-8
1232.
<5
10RBC/m
L
1235.
<5
mg/dL
1238.
Ne
Page | 93
1258.
8:00 takes bath.
1259.
8:30- Goes to her
aunt for work
1260.
9:00 eats snack
1261.
11:30 lunch
1262.
1:00 resume work
1263.
9:00 bedtime
- Perceived ability for
activities:
1264.
Feeding =lvl 0
1265.
Bathing = lvl 0
1266.
Toileting = lvl 0
1267.
Bed mobility = lvl 0
1268.
Dressing = lvl 0
1269.
Grooming = lvl 0
1270.
General mobility =
lvl 0
1271.
Cooking =lvl 0
1272.
Home maintenance
= lvl 0
1273.
Shopping = lvl 0
- Extremities function well
1299.
Sleep-rest
Pattern
- Generally rested and
ready for daily activities
after sleep
- No sleep onset problems
or sleep aids
- Onset: 9:00 pm
- Awakening: 5:00 am
- Amount of sleep: 8 hours
- No sleep interruptions
- Feels rested after sleep
1300.
Cognitive-
1290.
General mobility
= lvl 0
II
1296.
Grooming = lvl
0
1297.
General
mobility = lvl 0
1298.
Sleeps at 10 pm
wakes up at 7 am
Sleep is sometimes
interrupted by medical
procedures
claims to be generally
rested after sleep
Claimed pain to be
sleeps at 10 pm
wakes up at 7 am
claims to be sleepy
and drowsy after
taking meds
claimed to be
generally rested after
sleep
Responds well to
Page | 95
perceptual Pattern
- Far sighted
- History of sore eyes,
cannot remember details
- Several missing teeth
- Comfortable language to
use: Cebuano
- Visual learner
- No hearing problems
1302.
Self-perceptionself-concept Pattern
- Believes she is a religious
and godly person
- Does not subscribe to
vices
- Describes herself as hot
tempered but usually is
able to cope with it by
confronting
1305.
Role relationship
Pattern
- Lives in their ancestral
home
- supports her son together
with the father
- close relationship with her
relatives
1306.
Sexualityreproductive Pattern
intermittent but is
bearable and choose
not to take
medications
Performs deep
breathing exercises if
pain is felt
stimuli
Pain is less frequent
Performs relaxation
techniques
Slight grimacing
when moving around
1303.
- though weak
she still manages to
appear calm and
relaxed
- very hopeful and
positive to have a fast
recovery
- views herself as a
strong person and
hopes to be
discharged
immediately
1304.
- loves her family so
much
- visited by her sister
- well supported by the
family
no change in attitude
still hopeful of a safe
and fast recovery
major concern is her
recovery
symptoms of
menopause
no restrictions in the
procedure brought by
religion
Page | 97
1311.
1312.
1313.
1314.
1315.
1316.
1317.
1318.
1321.
By Dr. Kathryn Wheel
Ask the Doctor
1322.
In the case of gallbladder removal, doctors typically perform that procedure to provide permanent relief to patients suffering from gallstones
and other problems associated with the gallbladder, which is a small organ located on the underside of the liver that aids digestion. Unfortunately,
the gallbladder isnt always the most efficient organ and is also prone to develop gallstones hard deposits of substances in the bile that get stuck
inside the gallbladder that can cause infections to form, which can then cause bloating, nausea, vomiting and further pain. Gallstones can be as small
as a grain of sand or as large as a golf ball. Gallstone disease, called cholelithiasis, can cause short or lasting pains in the abdomen.
1323.
To remove the gallbladder, many surgeons use minimally invasive surgery and robotic techniques for this operation, called a cholecystectomy.
Quite simply, robotic surgery also known as robot-assisted surgery allows physicians to perform a variety of complex procedures with greater
vision and more precision, flexibility and control than is possible with conventional techniques that have been around for many years.
Page | 98
1324.
Robotic surgery with the da Vinci Surgical System was approved by the Food and Drug Administration in 2000. Since then the robotic
technique has been rapidly adopted by technologically advanced hospitals across the United States. During robotic-assisted surgery, surgeons
operate from a console near the patient that is equipped with two master controllers that precisely maneuver four robotic arms. By viewing a highdefinition 3-D image on the console, the surgeon is able to see the surgical procedure better than ever before, and computer software takes the
place of actual hand movements and can make movements precise. Robotic surgery allows doctors to perform delicate and complex procedures
through small incisions that may have been difficult or required invasive, or open surgery.
1325.
Robotic surgery goes hand in hand with minimally invasive surgery. During minimally invasive surgery, procedures are performed through
small incisions. Benefits of minimally invasive surgery include less pain, lower risk of infection, a shorter hospital stay, quicker recovery time, less
scarring and reduced blood loss during the procedure.
1326.
Along with gallbladder removal, some common treatment procedures for which robotic surgery is now available at Pocono Medical Center
include hernia repair; hysterectomy; female urologic surgery, such as bladder suspension; prostate surgery for prostate cancer; and colon surgery in
the near future. Not all hospitals perform all types of robotic surgery, so be sure to ask your doctor about treatment options if you are considering
robotic surgery.
1327.
The good news is, many people who require gallbladder removal are candidates for robotic, single-incision surgery which typically can be
performed in less than one hour as a same-day procedure. This method allows for a single incision at the belly button where instruments are placed
and the diseased organ is removed, with the benefits of minimal scarring, less pain and bleeding, and faster recovery.
1328.
However, robotic surgery isn't an option for everyone, so its always best to talk with your doctor about the benefits and risks of robotic
surgery and how it compares with other techniques, such as other types of minimally invasive surgery and conventional open surgery. Together you
can find an option that works best for you and that gets you quickly on the road to
Page | 99
1329. REFERENCES
Berman, A. et. al. (2008) Kozier & Erbs Fundamental of Nursing Concepts, Process and Practice 8 th Edition. Pearson Prentice Hall, volume Two,
Chapter 42, stress and coping
Boyer, M. (2006). Brunner and Suddarths Textbook of Medical-Surgical Nursing, 11th ed.
Carol Mattson Porth (2005). Pathophysiology, Seventh edition.
Crowley, L. (2010). An Introduction to Human Disease: Pathology and Pathophysiology Correlations, 8 th ed., p. 563. USA: Jones and Bartlett
Publishers.
Digiulio, M. & Jackson, D.(2007). Medical-Surgical Nursing Demystified, p. 288. USA: McGraw-Hill.
Everhart, JE, Khare, M, Hill, M, Maurer, KR. Prevalence and ethnic differences in gallbladder disease in the United States. Gastroenterology
1999; 117:632.
Ginsber, G. & Ahmad, N. (2006) The Clinicians Guide to Pancreaticobiliary Disorders, p. 121-123. USA: SLACK Incorporated.
Harrisons Principles of Internal Medicine, Tenth Edition 1983.
Iyengar, V. Elemental Analysis of Biological Systems: Biomedical, Environmental, Compositional and Methodological Aspects of Trace Elements,
Vol. 1, p. 49.
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