FINAL CHOLE,,,Sa Wakas Tpoz

Republic of the Philippines
Tarlac State University

College of Nursing
Lucinda Campus
A.Y.: 2008-2009
Case Study
of
CHOLEDOCHOLITHIASIS
Submitted by:
Castanar, Aimelyn C.
Coquia, Benjamin III S.
Cortez, Christian Jay B.
Dumlao, Jennifer M.
Gabriel, Rutzki S.
Justo, Jonalyn V.
Mamucod, Madel S.
Marcos, Shierly Luz D.
Natividad, Manuelito A.
Pasamba, Janine P.
Group B3
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TABLE OF CONTENTS
I. Introduction…………………………………………………………………1
II. Nursing Process……………………………………………………………..3
A. Assessment
1. Personal Data……………………………………………………3
2. History of Past Illness…………………………………………...6
3. History of Present Illness………………………………………..6
4. Physical Assessment
i. 13 Areas of Assessment……………………………………..6
5. Diagnostic and Laboratory Procedures……………………...….17
6. Anatomy and Physiology……………………………………….22
7. Pathophysiology
i. Book Based…………………………………………………24
ii. Client Based………………………………………………...25
B. Planning
1. Nursing Care Plan………………………………………………26
C. Implementation
1. Medical Management…………………………………………...34
2. Drug Study……………………………………………………...38
3. Diet……………………………………………………………...43
4. Activity or Exercise……………………………………………..45
5. Surgical Management…………………………………………...48
6. SOAPIE…………………………………………………………50
D. Evaluation
1. Patient’s Daily Program in the Hospital………………………...57
2. Discharge Planning……………………………………………...58
III. Conclusion…………………………………………………………………..59
IV. Recommendation……………………………………………………………59
V. Bibliography………………………………………………………………...60
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ACKNOWLEDGEMENT
The group would like to thank almighty God for giving us strength and courage to fulfill
this case study.
The group wishes to extend a sincere thank you to the talented Dean of our college, and
level coordinators for being the contributors and reviewers of this case study, who provide many
valuable and very helpful ideas, and suggestions. To our clinical instructor for this case study
Ms. Mylene Romero for her attention to detail that promoted an excellent outcome, and to our
fellow 3rd year students, for their questioning minds and motivation for this case study. And also
the group would like to thank to our parents that serves as our seeking light and reflections, and
for allowing us to pursue this case study and have our overnight for almost a week. And finally,
to our panelist for sharing their knowledge, for us to have a beautiful new designs of our selected
case.
GROUP B3
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I. INTRODUCTION
Choledocholithiasis is the presence of gallstones in the common bile duct. This condition
causes jaundice and liver cell damage, and is a medical emergency, requiring the endoscopic
retrograde cholangiopancreatography (ERCP) procedure or surgical treatment. A tendency for
this disease can be inherited.
Doctors can use a blood test of alkaline phosphatase, bilirubin and cholesterol to diagnose
choledocholithiasis. However, ultrasound demonstrating an enlarged common bile duct is the test
of choice.
Treatment involves removing the stone using ERCP. Typically, the gallbladder is then
removed, an operation called cholecystectomy, to prevent a future occurrence of common bile
duct obstruction.
Gallstones are more common among women after 40 years of age and among certain groups
of people, such as Native Americans. They are uncommon in children and young adults. The risk
factors for gallstone formation include increased age, obesity, a typical Western diet, and a
family history of gallstones.
About 15% of people with gallstones will develop stones in the common bile duct, the small
tube that carries bile from the gallbladder to the intestine. Risk factors include a previous medical
history of gallstones. However, choledocholithiasis can occur in people who have had their
gallbladder removed. (http://www.umm.edu/ency/article/000274.htm)
In the United States, the incidence rate for gallstones is approximately 40% in individuals
older than 60 years. In individuals undergoing cholecystectomy for symptomatic cholelithiasis,
8-15% of patients younger than 60 years have CBD stones, compared to 15-60% of patients
older than 60 years. (http://emedicine.medscape.com/article/172216-overview)
The incidence of cholelithiasis increases after the age of 40 years, affecting 30% to 40% of
the population by the age of 80 years. Four times more women than men develop cholesterol
stones and gallbladder disease; the women are usually older than 40, multiparous, and obese. The
incidence of stone formation rises in users of oral contraceptives, estrogens and clofibrate; these
substances are known to increase biliary cholesterol saturation. The incidence of stone formation
increases with age as a result of increase hepatic secretion of cholesterol and decrease bile acid
synthesis. In addition, there is an increase risk because of malabsorption of bile salts in patients
with gastrointestinal disease or T-tube fistula or in those who have had ileal resection or bypass.
The incidence also increases in people with diabetes. (endnote 11th edition by brunners and
suddarth’s, volume 2)
In the Philippines, there were 131 males (18%) and 609 (82%) females, with a female ratio
male 4.6:1. Benign lesions comprised 99% (mean age 36), mostly chronic cholelithiasis (97%)
and acute cholelithiasis which constituted 15 cases only (2%), malignant lesions comprised only
7 cases for example 1% of all lesions (mean age 65).
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(http://www.thedoctorsdoctor.com/diseases/gallbladder_chronic_cholelithiasis.htm#epidemiolog
y)
Reasons for choosing this case:
As the group go on with our weekly duty at the Tarlac Provincial Hospital, the group
observed a case of choledocholithiasis. So, as nursing students, the group decided to study this
kind of case. The significance of studying this case is to enhance or broaden our knowledge as
well as the patient’s who are suffering this disease and also to those people who are in high risk
of having this disease for us to share our knowledge for the primary prevention and simple
interventions of the disease.
Importance of the study:
It is of fundamental importance that case studies are to be performed in the nursing

profession; it is where understanding of the disease’ description, pathophysiology and etiology
that satisfactorily contribute to the formation of proper holistic management to the patient is
being learned.
Thorough exploration and completion of case studies provide nurses a systematic way of
looking events analyzing information regarding a certain. It expands medical knowledge and
expertise in the nurses’ part
The primary significance of the study is to stimulate the mind and awareness of the
patient as well as the family members to properly acquire enough knowledge and correct
information in dealing and recognizing such kind of disease. To make also the health team to be
more aware about the status of our health care system where they can analyze and apply towards
themselves and others in fulfilling good health condition.
Through this study, the people will know and be aware about what Choledocholithiasis
mean when it comes to our health by educating them the importance of this condition. Case
study is specially designed to provide information in which both the patient and the student nurse
benefits from it. With this, we, as student nurses will be able to provide appropriate nursing
interventions that would help in restoring the wellness of the patient in accordance to his or her
condition. This is primarily essential because it enhances the student’ skills, knowledge and
attitude in the practice of the nursing process. It provides broader understanding about the
condition chosen through research and actual observation as it is a training ground and practice
in developing learned skills in the assessment and management of the disease.
This can serve as an instrument for the future reference of the next nursing students of the
school. To share the book based and actual clinical management of the disease and may be used
as a base line for more advance and depth study in accordance to the changing society.
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Objectives:
Comprehensive understanding about the condition will formulate a good perception and
information to both patients and nurse in dealing and exploring such kind of disease. These
objectives will help to attain such benefits in knowledge and skills to identify
Choledocholethiasis.
General
 Enhance understanding regarding Choledocholethiasis and together factual data and
current trends in regards to the condition
Specific
 Establish rapport with the client thus enhancing communication skills and to be able to
gather pertinent information to the client and significant others.
 Know and apply corresponding intervention regards to post-op Choledocholithotomy
surgery.
 Evaluate effectiveness of the nursing intervention rendered.
 Perform continuous physical assessment in order to gather pertinent information the
disease condition.
II. Nursing Process:
A. ASSESSMENT
1. Personal Data
a. Demographic Data:
Name : Mr. D
Age : 51 yrs. Old
Sex : Male
Civil Status : Married
Occupation : Farmer, Construction Worker
Religious Affiliation : Roman Catholic
Role Position in the Family : Head of the family
Address : Ramos, Tarlac
Date & Place of Birth : Toledo Ramos, Tarlac
Nationality : Filipino
Usual Source of Medical Care : none
Chief Complaint : Abdominal Pain
Diagnosis : choledocholithiasis secondary to
ruptured gall bladder
Date of Admission : February 9, 2009
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b. Environmental status
According to Mr. D, they regularly clean their own house that is bungalow and
made of pure concrete. Their house has 3 bedrooms and in the living room they have
appliances television, radio and electric fan. Their house is located near in the farm with their
relatives. Drainage system is open. Source of water is forced pump.
They have pets, dogs and cat that live outside their house.
c. Lifestyle
Mr. D likes planting vegetables in their backyard during his leisure time. He
usually eat foods rich in fats like meats cooked with oil, fried fish, and vegetables. He is fond
of drinking alcohol, and verbalizes that they usually eat “chicharon” as their pulutan. In terms
of rest pattern Mr. D only sleeps for about 7-8 hours every night. Usually he sleeps at 7:00
p.m. and wakes up at 3:00 a.m. He usually drinks coffee every morning and sometimes in
afternoon while having some chat with his friends. At 4:00 AM he’ll eat his breakfast. After
his morning routine he go to work and go home at 6:00 p.m. He spend his day doing his
work.
d. Social Status
. The patient spends his time during weekends with his family and friends by
doing his favorite routine which is planting. The family lives in their own house along with
their relatives. There is no conflict between the family members. Whenever some issues or
problem arises, they handle it by talking about it in a calm and respectful manner.
According to the patient, he is not anymore active in community activities or
project because he doesn’t have any time to join and participate.
e. Psychologic Status
According to the client he often experience fatigue in some of his work. But
concluded that it is just normal because of the type of his work. It was his goal to provide all
the necessary things needed by his family. He believes he will only achieve this goal if he
will look forward and treat his family as his only treasure. And whenever life doesn’t go well
with his plans, he gets a little depressed. He always thinks about his family problems
specifically financial accountabilities.
Whenever he is anxious, he usually had conversations and seeks some advises with
his wife.
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FAMILY HISTORY OF HEALTH AND ILLNESS
N/ N
/ N
LEGEND: A N/
/
A A
A
= Male
= Female
8 7 7 8 7 7 7
= deceased male 0 5 4 2 9 7 5
A&W HPN A&W N/A DM A&W A&W
= deceased female
= the patient
As = Asthma N
N 5 5 4 4 4 4 4 4 4 3
A&W = Alive and well /
B 6 A 1 9 8 6 5 4 3 0 8
C = Choledocholithiasis N/A A&W N/A C A&W DM HPN A&W A&W HPN A&W A
DM = Diabetes Mellitus
HPN = Hypertension
NB = Newborn
N/A = not applicable
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2. History of Past Illness
Mr. D had experienced childhood illnesses such as cough and cold, mumps at the
age of 9 years old, chicken pox when he was 12 years of age. The patient verbalized that he
cannot remember if he completed his immunization during his childhood. It was in the month
of December when he experienced the first onset of pain in his right upper quadrant while he
was eating and concluded that it was just an ulcer. He said that the pain lasted for five
minutes and reoccur after a minute with the same area, he said he never prompted to seek
medical help. And he said he never take any over the counter drugs to relieve pain. But
instead he only sat or lied until the
pain relieves.
3. History of Present Illness
During the two months duration before his hospitalization, the pain still occur
once week, but still the patient can tolerate it until the time when he was eating the pain again
arises in his right upper quadrant and he said that the pain was continues without any interval
that makes him decided to take consultation at Tarlac Provincial Hospital. But when he
arrived, his gallbladder was already ruptured according to his physician. So he was directly
brought to operating room and Cholecystectomy was done.
4. Physical Assessment
13 AREAS OF ASSESSMENT
SOCIAL STATUS
Mr. D is 51 years of age, and was married. They make decision for the family together;
they are a type of nuclear family. According to him, he never experiences any intimate
family violence. They located in a compound area and most of his neighbors are his relatives.
He originally lives at Ramos Tarlac City. He proudly said that he has no conflict with people
around him, although some misunderstanding happened to him, but he tries to solve it in a
good manner like talking to them calmly. When he feels stress, he just takes rest and sleep.
His hobbies are planting vegetables on their backyard, listening to music and sometimes
chatting with his friends and neighbors. He denies any membership of any social
organization; he doesn’t attend any barangay assembly. He is a Roman Catholic, but he
rarely attends holy Mass due to lack of time, he mentioned that he only attends mass twice a
year. He denied drug abuse. He was fond of smoking and drinking alcohol.
Standard and Norms

Social status is the determinant of patient’s response to the things he encounters and how
he treats or how he deals with other person. Social status of the patient is also a determinant
of many factors that can affect the patient’s health. Getting social history is included if the
patient is an alcoholic or drug and tobacco user. Alcohol can interfere with normal body
metabolism and normal body function, drugs can affects the clients normal body function
(Health Assessment by Zator, Estes 2006)
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Interpretation
He has a good relationship with family and relatives and also with his neighbors which is
an indication of good social stability. He does his responsibility as a good husband for his
wife and responsible father to his childrens. He is able to cope or handle social conflicts. He
has a good spiritual status. He has lack of interest with regards to the social organization.
Body function can affect by drugs and tobacco because he is fond of using it.
MENTAL STATUS
• Posture and Movements

Post-operative
Mr. D is comfortably positioned flat on bed. He is restless due to pain on his right upper
quadrant abdomen. He can do his activity of daily living but sometimes needs assistance. His
facial expressions are inappropriate with his feelings and mood of conversation. The patient
is sometimes stiff due to pain episodes he experience because of the operation done to him.
He usually moves slowly and carefully with minimal assistance. She wears loose and light
clothing appropriate for his condition. He is not well groomed with uncombed hair and has
clean and trimmed nails and pale in appearance.
• Level of consciousness
Post-operative
After the said operation, Mr. D were able to respond with the questions given to him,
with an appropriate answer, and was able to do eye contact while answering.
• Mood
Post-operative
Upon assessing Mr. D, he cooperates attentively with appropriate mood. He talks with
us calmly with low voice. But he also verbalizes that after he had the operation he was at
times moody and was selective with the topic, and questions to be discussed. The patient also
mentioned that after his operation he easily gets tired and so he was not able to answer some
of our questions at that time.
• Thought Process and Perception

Post-operative
Mr. D was able to expresses his thoughts and feelings. He is willing to answer our
questions appropriately and sometimes he also asked related questions related on the topics
being discussed to him and share his ideas and experiences in life to the group.
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• Cognitive Abilities
Post-operative
Mr. D shown awareness to about his present condition, about the treatment and surgical
procedure he undergone. He is aware regarding the people around him and the time and place
where he is. He is also able to recall significant events in his life.
Standard and Norms

The patient should appear relaxed with the appropriate amount of concern for the
assessment. He should exhibit erect posture, a smooth gait symmetrical body movement. The
patient should be clean and well groomed and should wear appropriate clothing for age,
weather and socioeconomic status. Facial expression should be appropriate to the content of
the conversation and should be symmetrical. The patient should b able to produce
spontaneous, coherent speech. The patient should have an effortless flow with normal
inflections, volume, pitch, articulation, rate and rhythm. The patient should be able to
respond or answer questions appropriately. (Health Assessment by Mary Elle Zator
Estes,2006)
Interpretation
Mr. D responds well and can answer appropriately. He is also aware about the time and
the place where he was. Based on the data gathered he possesses the appearance; thought
processes, mood and was conscious at the time of monitoring. He also interacts upon
assessment and interview with appropriate mood. But due to his condition as he undergoes
surgical procedure, his movements were sometimes limited and thus he needs assistance to
attain his needs.
EMOTIONAL STATUS
Post-operative
Mr. D expresses and verbalizes his emotions and feelings during the interview; he seems
uncomfortable because of the pain episodes he feels after the operation. He said that his
stress though he was resting and sleeping. Despite of his condition he still possesses a brave,
relaxed attitude. He approached us in a kind attitude. He is fully supported by his family as
we see that he is cared by his siblings and children. And he also verbalize that he was able to
accept his present condition.
Standard and Norms

Emotional wellness involves the ability to recognize, accept and express feelings and to
accept one’s limitation. It is also the ability to manage stress and to express emotions
appropriately. (Fundamentals of Nursing 7th Edition by Kozier, Erb, Berman)
11
Interpretation
Mr. D has the ability to manage stress by means of expressing his thoughts and feelings
of willingness to participate in our group. He has positive coping mechanism because he
approached our group in a kind manner. He possess ability to recognized an accept condition.
Therefore his emotional status is in normal state.
SENSORY PERCEPTION
Post-operative
• Sense of Sight
The patient is able to read with the use of his reading glass with a visual acuity of
30/30. His external eyes were symmetrical in shape and size, have no lesion and no bleeding
found. His sclera is yellowish in color whole his conjunction in pinkish. The patient can raise
both eyelids asymmetrically. His pupils are black and round.
Standard and Norms

The normal visual acuity is 20/20. There should be no presence of lesions or any
perforation in the eye of the patient.
• Sense of Smell
The patient’s nose is on the midline, it is symmetrically in shape and the nostrils are
intact. He is able to distinguish different color like alcohol, perfume or cologne and different
scent of fruits provided like orange.
Standard and Norms

Patient must be able to identify different smell; nose should be at the midline position,
free from lesions and intact nostrils. (Health Assessment by Mary Elle Zator Estes,2006)
• Sense of Hearing
Our group performed a hearing test in order to check if the patient had a good sense of
hearing by whispering words about 3 inches away from the ear and asked him to repeat the
words that were spoken to him to check if he really hear the words. The patient is able to
answer questions correctly that means his hearing ability is good. No bleeding, wounds, or
lesions are found on his external ear.
Standard and Norms

Patient should hear whispered words or watch tick test and ear must free from lesions and
masses. (Health Assessment by Mary Elle Zator Estes,2006).
• Sense of Taste
Tongue and oral cavities are symmetrical and no lesions or abnormalities were found.
The patient was able to determine taste of salty, sweet, sour, and bitter taste.
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Standard and Norms
Patient should be able to sense the different kind of tastes like sweet, bitter, sour, and salty.
(Health Assessment by Mary Elle Zator Estes,2006)
• Pain Sensation
The patient is able to response with the pain sensation when we pinched his skin. And he was
able to determine if the object is sharp or not and can able to determine if the object is smooth or
rough.
Standard and Norms

Identifies correct object, identifies correct number and identifies correct direction of body
part is move. (Nurse Handbook of Heath Assessment by J.R Weber,2004)
Interpretation
Regarding the patient’s sense of perception, before and after his operation, there is no
problem found except with his sense of sight because he is using reading glasses whenever he
read. It only means that his visual acuity is not in normal. Other than that’s he already possesses
normal perception in other areas.
MOTOR STABILITY
Post-operative
Mr. D cannot tolerate heavy movement. He was moderately weak. He needs assistance when
ambulating and eating. He moves slowly in changing his position when he sleeps and rest.
Standard and Norms
Over-all Appearance: The patient should be able to stand on the bedside via independent
ambulation. Structural effects should be absent. There should be no outward indications of
discomfort during rest, weight bearing, or joint movement.
Posture: In standing position the torso and head are upright. The arms hang freely from the
shoulders. The feet are aligned and the toes point forward. In sitting position both feet should
be placed firmly on the floor surface, with toes pointing forward.
Gait and Mobility: Walking is initiated in one smooth, rhythmic fashion. The patient should
remain erect and balanced during all stages of gait. (Estes, Mary Elen Zator. (2006),Health
Assessment and Physical Examination (3rd Edition
Interpretation
The patient’s motor stability is not normal because he cannot stand on the bedside, and
independently ambulate himself and needs assistance in doing his ADL.
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BODY TEMPERATURE
DATE TIME ROUTE TEMPERATURE INTERPRETATION

02-19-2009 5 am 36.5 °C Normal
10 am 37.2 °C Normal
2 pm 37.5 °C Normal
4pm 37.5 °C Normal
6pm 37.4 °C Normal
02-20-2009 10 am Axillary 37 °C Normal
2 pm 37 °C Normal
4pm 37.4 °C Normal
6pm 37.2 °C Normal
02-21-2009 6 am 36 °C Normal
10 am 36.5 °C Normal
2 pm 37 °C Normal
02-22-2009 5 am 36.7 °C Normal
02-23-2009 5 am 37 °C Normal
Standard and Norms
Route for Body Temp. Measurement Average Normal Range

Oral 37.0˚C / 38.6˚F 36.0˚ - 38.0˚C / 96.8˚ – 100.4˚F
0.4˚C / 0.7˚F
Rectal higher than oral 36.7˚ – 38.0˚C / 98.0˚ - 100˚F
0.6˚C / 1.0˚F
Axillary lower than oral 35.4˚ - 37.4˚C / 95.8 – 99.4˚F
Calibrated to
Tympanic oral/rectal scale See oral / rectal
Reference:
Estes, Mary Elen Zator. (2006)
Health Assessment and Physical Examination (3rd Edition
RESPIRATORY STATUS
DATE TIME RESPIRATORY RATE INTERPRETATION

02-19-2009 5 am 26 cpm Tachypneic
10 am 18 cpm Normal
2 pm 21 cpm Tachypneic
4pm 30 cpm Tachypneic
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10 am 30 cpm Tachypneic
Standard and Norms

In a resting adult, the normal respiratory rate is12- 20 bpm, normal respirations are
regular. The normal depth of inspiration is non-exaggerated and effortless. The healthy adults’
thorax rises and falls in unison in the respiratory cycle. The patient’s respiratory cycle can be
heard by the unaided ear a few centimeters away from the patient’s nose and mouth. A healthy
adult breathes comfortably in a supine position, prone or upright position and most patient inhale
and exhale through the nose. No pulsation of masses, thoracic tenderness and crepitus should be
present. (Fundamentals of Nursing 7th Edition by Kozier, Erb, Berman).
Analysis:
Patient was tachypneic, as a result of his compensatory mechanism of his heart (post op).
CIRCULATORY STATUS
DATE TIME BLOOD PRESSURE INTERPRETATION

02-19-2009 5 am 120/90 mmHg Normal
10 am 120/80 mmHg Normal
2 pm 120/80 mmHg Normal
4pm 110/70 mmHg Hypotensive
6pm 110/80 mmHg Normal
10 pm 110/70 mmHg Hypotensive
02-20-2009 10 am 100/80 mmHg Hypotensive
02-21-2009 6 am 110/80 mmHg Normal
10 am 100/80 mmHg Hypotensive
15
Standard and Norms
Normal blood pressure varies with age. As a person ages, blood pressure generally
increases. The normal blood pressure of an adult is 120/80 mmHg. Normally baroreceptors
(Receptors that are located in the walls of most of the great arteries that sense hypotension and
initiate reflex vasoconstriction and tachycardia to bring the blood pressure back to normal) help
a patient to maintain a normal blood pressure when changing from supine from a sitting or
standing position. Processes increasing cardiac output, such as exercise, will normally increase
blood pressure. Pulse pressure is normally 30 – 40 mmHg. Normal pulse rate also varies with
age. The normal pulse rate of an adult is 60 – 100 BPM. The heart rate normally increases during
periods of exertion. Normal pulse rhythm is regular with equal intervals between each beat. The
pulse volume is normally the same with each pulse beat. A normal pulse volume can be felt with
a moderate amount of pressure of the fingers and obliterated with greater pressure. Capillary
refill is an indicator of peripheral circulation. Normal capillary refill may also vary with age, but
the color should not return to normal within 2 -3 seconds. (Health Assessment by Mary Elle
Zator Estes)
Analysis:
Based on the standard and norms the patient is hypotensive but he is able to tolerate his
condition as evidenced by not experiencing dizziness and body weakness.
NUTRITIONAL STATUS
The patient weighs 60 kg and 5’7” in height. The patient was on high protein diet. He
was given an IV fluid of D5LRS to maintain fluid and electrolytes balance in his body. He eats
three times a day and take some snacks between the periods of eating hours. And was fond of
eating foods rich in fats such as fried fish, meats cooked with oil.
BMI=weight in kg
Height in m2
=60 kg
(1.7018)2
= __60__
2.89612324
= 20.75
Standard and Norms

Normal human being usually eats 3 times per day and a fluid intake of 8 - 10 glasses of
water. Nutrients must be taken equally according to their standards. There should be no problem
regarding food and drug allergies and anything associated with nutrition. Nutritional of patient is
a good determinant of a possible heart condition. Nutrition can be a prevention and treatment for
some diseases. Normal body mass index is 20 – 25, less than 20 is associated with heart problem,
and in some people more than 27 indicates higher risk for developing heart problems.
(Fundamentals of Nursing 7th Edition by Kozier, Erb, Berman)
16
BMI
<16 malnourished
16-19 underweight
20-25 normal
26-30 overweight
31-40 moderately to severely obese
>40 morbidly obese
Interpretation
With regards to Mr. D’s nutritional status, it appears that he is able to meet her nutritional
needs and can tolerate all type of foods. There are no known problems associated with his
nutrition and any drug or food allergies. He’s weight is suited with the height.
ELIMINATION STATUS
Post-operative
Mr. D verbalizes that he usually urinates 3 times within the shift and it is characterized by
dark yellow in color. He reported absence of defecation for 2 days, but was able to defecate once
daily with clay color stool for the next three days. Also, he verbalizes that he never felt any pain
during urination and defecation. He was also inserted with T-tube, with 250 cc in the first duty
and 230 cc for the next day characterized by coffee ground in color and slimy, without any stain
of blood.
Standard and Norms

Elimination of the waste products of digestion from the body is essential to healthy people
who have had a bowel movement once a day for 75 years can view as a missing 1 day as a
serious problem. Normal feces are made of about 75% of water and 25% solid materials. They
are soft but formed. Feces were normally brown, chiefly due to the presence of stercobilin and
urobilin, which are derived from bilirubin. An adult usually forms 7 – 10 liters of flatus in the
large intestines every 24 hours.
Urine elimination should be at least 30 – 50ml per hour when a normal person was urinated
and the normal bowel movement is 1 – 2 times per day. (Fundamentals of Nursing 7th Edition by
Kozier, Erb, Berman and Nutrition 2005 by 2nd Edition by Alex B. Abalos)
Interpretation
With regards to the patient’s elimination status, it appears that his urine output is in normal
ranges. He experienced constipation in two days and was normally defecated for the next three
days of our monitoring.
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REPRODUCTIVE STATUS
Mr. D has three children. He is happily married to his wife and still enjoying his life with his
family.
Standard and Norms

Sex has been defined as one of the basic physiologic need according to Maslow’s Hierarchy
of needs. It is therefore, sex is an essential part for the well being of a person. An average normal
individual should have a nature reproductive status in order to meet or attain sexual satisfaction.
(Fundamentals of Nursing 7th Edition by Kozier, Erb, Berman)
Interpretation
The patient is sexually healthy but not as active like on her early age. It because of his
condition and age, his reproductive activities was decreased.
STATE OF PHYSICAL REST AND COMFORT
Post-operative
After the said operation, Mr. D was complaining of difficulty in getting sleep. He usually
sleeps for only 5-6 hours and it was not continuous because of the doctor and nurses rounds,
including the onset of pain in his right upper quadrant which has an interval of 10-15 minutes.
Observable signs of inadequate sleep are still seen on the patient such as eyebags, frequent
yawning and sometimes irritable.
Standard and Norms

The sleep wake cycle is very important to young adults they usually have an active lifestyle,
and are thought to have required 7-8 hours of sleep each night but may do well on less.
(Fundamentals of Nursing 7th Edition by Kozier, Erb, Berman and Nutrition 2005 by 2nd Edition
by Alex B. Abalos)
Interpretation
In terms of rest and sleep pattern of the patient, it appears that he has a disturbed sleeping
pattern and inadequate sleep before and after the operation due to pain he experienced and
unfamiliarity of the environment. He only have 5-6 hours of sleep at night, this is indicate that
Mr. D sleep pattern is not normal.
STATE OF SKIN APPENDAGES
The color of his skin is brown. No rashes found in the incision site and reddish in color.There
is no bed sores found. Hairs are well distributed in black color. Nail plate is clear, firm and the
tissue surrounding the nails are intact with no lesion. The skin of the patient is slightly dry and
when you pinched, it takes 2 seconds to turns back to its original state.Some skin damage is
found due to IV insertion, Lab test such as CBC and operation that was done (cholecystectomy).
18
Standard and Norms
Normally, the skin is uniform whitish pink or brown color, defending on the patient race.
Exposure to sunlight results increased pigmentation of an exposed area. Normally, there are no
areas of bleeding. No skin lesions should be present except for freckles, birthmarks or moles,
which may be flat or elevated. The skin is dry with minimum of perspiration. Moisture also
varies with changes in environment, muscular activity, and body temp. stress and activity levels.
Skin surface temp. should be warm and equal bilaterally. Skin surface should be non tender. It
should be smooth, even and firm except where there is significant hair growth. When the skin is
released, it should returns to its original contour rapidly. Edema should no be present. Terminal
hair is found in the eyebrows, eyelashes and scalp, and in the axilla and pubic areas after puberty.
Males may experience a certain degree of normal balding and may also develop terminal facial
and chest hair. The scalp should be pale white to pink in light skinned individuals and light
brown in dark skinned individuals. There should be no signs of infestations or lesions. Dandruff
may be present. Hair may feel thin, straight course, thick or curly. It should be shiny and resilient
when traction is applied and should no come out in clumps in your hands. Normally, the nails
have a pink cast in light skinned individuals and are dark brown in dark skinned individuals. It
should be smooth and slightly rounded or flat. Curve nails are normal variant. Nail thickness
should be uniform throughout, with no brittle edges. The angle of the nail bed should be
approximately 160 degrees. It should be firm on palpation. (Health Assessment by Mary Elle
Zator Estes)
Interpretation
The patient has a poor skin turgor. Dryness of the skin was observed and it can be a sign of
dehydration also it may reflects on his age.
19
5. Diagnostic and Laboratory Procedures
Diagnostic/ Date Ordered Indications/ Purposes Results Normal Analysis and

Laboratory Values Interpretation
Procedures
Hematology February 13, 2009 The CBC is used for the
• WBC following purposes: 7.36 4.1-10.9 • Within normal values.
•as a preoperative test to
ensure both adequate
• Gran oxygen carrying capacity 5.4 2.0-7.8 • Within normal values.
and homeostasis.
•to identify persons who
• RBC may have an infection. 3.84 4.20-6.30 • Decreased level of RBC
•to diagnose anemia. indicated hemorrhage.
•to identify acute and
chronic illness, bleeding
tendencies, and white
• Hgb blood cell disorders such 121g/L 120-180 g/L • Within normal values.
as leukemia.
•to monitor treatment for
• Hct anemia and other blood 326g/L 370-510g/L • Decreased level of Hct indicated
diseases. hemorrhage
371g/L 310-360g/L
• MCHC • Increased MCHC value
indicates hemorrhage
272g/L 140-440g/L
• Plt • Within normal values.
20
Diagnostic/ Date Ordered Indications/ Purposes Results Normal Values Analysis and
Laboratory Interpretation
Procedures
Hematology February 17, 2009 The CBC is used for the
• WBC following purposes: 12.0 4.1-10.9 • Increased WBC
•as a preoperative test to indicates
ensure both adequate inflammatory and
oxygen carrying capacity infectious processes
and hemeostasis
•to identify persons who
may have an infection
• Gran •to diagnose anemia 9.0 2.0-7.8 • Increased gran
•to identify acute and (neutrophil)
chronic illness, bleeding indicates acute
tendencies, and white infection or
blood cell disorders such inflammatory
as leukemia processes.
•to monitor treatment for
• RBC anemia and other blood 3.62 4.20-6.30 • Decreased level of
diseases. RBC indicated
hemorrhage.
• Hgb 115g/L 120-180 g/L • Decreased Hgb

indicates hemolytic
reactions,
hemorrhage.
• Hct
309g/L 370-510g/L • Decreased Hct
indicates hemolytic
reactions,
hemorrhage.
21
• MCHC 372g/L 310-360g/L • Increased MCHC
indicates
hemorrhage
• Plt 499g/L 140-440g/L • Increased platelet

indicates acute
infection, anemia,
or leukemia.
Nursing Responsibilities
Before:
1. Check for the doctor’s order.
2. Discuss the importance of the procedure.
3. Explain to the client how to participate to the procedure.
After:
1. Apply pressure on the site for 5-10 minutes after the procedure.
2. Have the patient take a rest after the procedure.
3. Encourage patient to eat foods rich in iron such as beans, green leafy vegetables and meats.
22
Procedures
Blood Chemistry February 20. 2009 • Measurement of the
• CHON blood levels of other 50g/L 60-78 g/L
elements regulated in
part by the kidneys
• Albumin can also be useful in 20g/L 32-45g/L • Decreased albumin
evaluating kidney indicates
function. malabsorption.
• Globulin
30g/L 23-35g/L • Within normal
values.
Before:
After:
23
Procedures
Serum February 13, 2009 • To determine
Electrolytes electrolyte and acid-
>Sodium base imbalances. 145.5mmol/L 136-142mmol/L • Increased sodium
indicates dehydration,
excessive IV sodium,
insufficient water
intake or impaired
renal function.
>Potassium 4.01mmol/L 3.8-5.0mmol/L • Within normal values
>Chloride 117.2mmol/L 95-103mmol/L • Increased chloride

indicates dehydration,
metabolic acidosis or
respiratory alkalosis.
Before:
After:
3. Instruct patient to increase fluid intake.
6. Anatomy and Physiology
The common hepatic duct is the duct formed by the convergence of the right hepatic duct
(which drains bile from the right functional lobe of the liver) and the left hepatic duct (which
drains bile from the left functional lobe of the liver). The common hepatic duct then joins the
cystic duct coming from the gallbladder to form the common bile duct.
The liver is also the largest gland in the human body. It lies below the diaphragm in the thoracic
region of the abdomen. It produces bile, an alkaline compound which aids in digestion, via the
emulsification of lipids. It also performs and regulates a wide variety of high-volume
biochemical reactions requiring very specialized tissues.
The gallbladder (or cholecyst, sometimes gall bladder) is a small organ whose function in the
body is to store bile and aid in the digestive process.
The cystic duct is the short duct that joins the gall bladder to the common bile duct. It usually
lies next to the cystic artery. It is of variable length. It contains a 'spiral valve', which does not
provide much resistance to the flow of bile. Bile can flow in both directions between the
gallbladder and the common hepatic duct and the (common) bile duct. In this way, bile is stored
in the gallbladder in between meal times and released after a fatty meal.
Bile, which is synthesized in the liver, is carried to the right and left hepatic ducts, which
converge along with the Cystic duct to form the common hepatic duct. There it enters the
superior end of the common bile duct and either empties into the second (and retroperitoneal)
part of the duodenum, or enters the cystic duct to be stored in the gallbladder.
The duodenum is largely responsible for the breakdown of food in the small intestine. Brunner's
glands, which secrete mucus, are found in the duodenum. The duodenum wall is composed of a
very thin layer of cells that form the muscularis mucosae. The duodenum is almost entirely
retroperitoneal. The duodenum also regulates the rate of emptying of the stomach via hormonal
pathways. Secretin and cholecystokinin are released from cells in the duodenal epithelium in
response to acidic and fatty stimuli present there when the pyloris opens and releases gastric
chyme into the duodenum for further digestion. These cause the liver and gall bladder to release
bile, and the pancreas to release bicarbonate and digestive enzymes such as trypsin, lipase and
amylase into the duodenum as they are needed.
The pancreatic duct, or duct of Wirsung, is a duct joining the pancreas to the common bile
duct to supply pancreatic juices which aid in digestion provided by the "exocrine pancreas". The
pancreatic duct joins the common bile duct just prior to the ampulla of Vater, after which both
ducts perforate the medial side of the second portion of the duodenum at the major duodenal
papilla.
The stomach is a highly acidic environment due to hydrochloric acid production and secretion
which produces a luminal pH range usually between 1 and 2 depending on the species, food
intake, time of the day, drug use, and other factors. Combined with digestive enzymes, such an
environment is able to break down large molecules (such as from food) to smaller ones so that
they can eventually be absorbed from the small intestine. A zymogen called pepsinogen is
secreted by chief cells and turns into pepsin under low pH conditions and is a necessity in protein
digestion.
The pancreas is a dual-function gland, having features of both endocrine and exocrine glands.
• Endocrine
The part of the pancreas with endocrine function is made up of a million cell clusters called islets
of Langerhans. There are four main cell types in the islets. They are relatively difficult to
distinguish using standard staining techniques, but they can be classified by their secretion: α
cells secrete glucagon, β cells secrete insulin, cells secrete somatostatin, and PP cells secrete
pancreatic polypeptide.
The islets are a compact collection of endocrine cells arranged in clusters and cords and are
crisscrossed by a dense network of capillaries. The capillaries of the islets are lined by layers of
endocrine cells in direct contact with vessels, and most endocrine cells are in direct contact with
blood vessels, by either cytoplasmic processes or by direct apposition. According to the volume
The Body, by Alan E. Nourse, the islets are "busily manufacturing their hormone and generally
disregarding the pancreatic cells all around them, as though they were located in some
completely different part of the body."
• Exocrine
In contrast to the endocrine pancreas, which secretes hormones into the blood, the exocrine
pancreas produces digestive enzymes and an alkaline fluid, and secretes them into the small
intestine through a system of exocrine ducts. Digestive enzymes include trypsin, chymotrypsin,
pancreatic lipase, and pancreatic amylase, and are produced and secreted by acinar cells of the
exocrine pancreas. Specific cells that line the pancreatic ducts, called centroacinar cells, secrete a
bicarbonate- and salt-rich solution into the small intestine.
PATHOPHYSIOLOGY BOOK BASED
RISK FACTORS
Non-modifiable: Modifiable:
• FEMALE • ↑FAT
• FERTILITY Intake
• FORTY YEARS
OLD and ABOVE
GALLSTONE IN BILE
DUCTS
IN LIVER
BILE STASIS
BILE ACCUMULATES BACTERTIAL ABNORMAL FAT

IN LIVER PROLIFERATION DIGESTION
GALLBLADDER AND DIARRHEA

CHOLESTATIC DUCT INFECTION
JAUNDICE BILLIARY CIRRHOSIS
RUPTURE OF
GALLBLADDER CHOLECYSTITIS
BLOOD FLOW AND LYMPHATIC

DRAINAGE AS COMPROMISED S/SX
• Pain in right upper quadrant
• Anorexia, nausea and vomiting
• Pain radiate to the back
MUCOSAL SCHEMIA AND
NECROSIS
PATHOPHYSIOLOGY CLIENT BASED
Modifiable: Non-modifiable:
HIGH FAT DIET 51 YEARS OLD
↑ BILIARY CHOLESTEROL
SATURATION
CRYSTALLIZATION OF
BILE CHOLESTEROL
GALLSTONE IN BILE
DUCTS
BILE STASIS
BACTERIAL GALLBLADDER AND
PROLIFERATION DUCT INFECTION
CHOLECYSTITIS OBSTRUCTION IN THE

CYSTIC DUCT
S/SX
>Pain in right hypochondriac region
>feeling of fullness
>nausea and flatulence
CHOLEDOCHOLETHIASIS
RUPTURED GALL
BLADDER
CHOLECYSTECTOMY
Complications:
• PAIN ON INCISION SITE
• ↑RESPIRATORY RATE
• ↓BLOOD PRESSURE
• CLAY COLORED STOOL
• DISTURBED SLEEP PATTERN
Nursing Care Plan # 1
POST-OPERATIVE
ASSESSMENT SCIENTIFIC PLANNING INTERVENTION RATIONALE EXPECTED

EXPLANATION OUTCOMES
S>“Masakit yung Unpleasant sensory > Within one hour Independent: >After one hour of
inopera sa akin”, as and emotional of appropriate > Offer divertional > Heighten one’s appropriate nursing
verbalized by the experience arising nursing activities such as concentration upon intervention, the
patient. from actual or intervention, the reading newspaper nonpainful stimuli to patient’s pain scale
> pain scale of potential tissue patient’s pain scale or magazines, decrease one’s will alleviate from
7/10 damage or will alleviate from socialization with awareness and 7/10 to 3/10 as
O >weak in described in terms 7/10 to 3/10. others or listening experience of pain. evidenced by:
appearance of such damage; radio. a. can move
>guarding sudden or slow freely
behavior/self- onset of any > Monitor vital > vital signs usually b. verbalized
protective behavior intensity from mild signs: altered in acute pain increase
>limited movement to severe with an (RR and BP) level of
>grimace upon anticipated or comfort
movement predictable end and > to improve
> irritable and duration of less > Instruct deep pulmonary gas
restless than 6 months. breathing exercises. exchange or to
maintain respiratory
Nursing Diagnosis: function
Acute pain and
discomfort related to
surgical incision. > Provide comfort > to provide
measures such as nonpharmacological
backrub and pain management and
changing position to prevent pressure
every 2 hours. ulcer
> Provide quiet > to provide comfort

environment and and prevent fatigue
calm activities.
> Encourage > to prevent fatigue

adequate rest
periods.
Dependent:
> Administer > to maintain
analgesics as “acceptable” level of
indicated to pain or to alleviate or
maximal dosage as totally eliminate pain
needed.
POST-OPERATIVE

S> “Nanghihina >Introduction of > Within 2 to 3 Independent: > After 2 to 3 hours
ako” as verbalized spinal anesthesia hours of > Plan care with >To reduce or of appropriate
by the patient into the appropriate nursing rest periods prevent fatigue. nursing
subarachnoid space intervention the between activities >To increase mobility interventions the
O >grimace at the lumbar area patient will be able >Assist in self care and to protect or patient will
>pale and weak in usually L4 and L5 to demonstrate activities, before prevent patient from demonstrate activity
appearance which causes increase activity ambulation injury. tolerance as
>mostly confined on anesthetic effect or tolerance. >Promote comfort >To enhance ability evidence by:
bed the absence of measures and to participate in a. verbalization of
>restless sensation in the provide for relief of activities. patients mobility
>limited lower extremities pain. progression.
movements and lower abdomen >Perform ROM >Inability rapidly b.demonstration of
>inability to perform resulting traumatic exercise (active contributes to muscle patients positive
ADL or pathophysiologic assistive). shortening and attitudes towards
damage to their changes in activities.
NURSING tissue causing body periarticular and c. patients wide
DIAGNOSIS: weakness cartilaginous joint understanding about
>Activity structure which the importance of
intolerance r/t contribute to the activity tolerance.
generalize weakness limitation of motion.
>Encourage >To enhance self
participation in self concept and sense of
care and divertional independence.
or recreational
activities.
>Observe and >Activity intolerance
document skin may lead to pressure
integrity at least 3 ulcer.
times within the
shift.
>Emphasize >Promotes well being

adequate intake of and maximizes
fluids at least 1500- energy production.
2000 ml and
nutritious foods
such as fruits and
vegetables
>Encourage to >To enhance sense of
maintain positive well being.
attitude; suggest
use of relaxation
techniques such as
deep breathing
exercise.
>Pr> Provide emotional >Fear of
sup support and breathlessness, pain
encouragement to or falling may
the client to decrease willingness
gradually increase to increase activity.
activity
POST-OPERATIVE

S> Infection indicates > Within 8 hours of Independent: After 8 hours of
O: a host interaction appropriate nursing >Inspect the skin > Presence of these appropriate nursing
> with incision at the with an organism or intervention, the for pre-existing symptoms may be an intervention, the
right upperquadrant, an infection agent. patient will be free irritation, redness, indicative sign of patient is free from
characterized by Colonization of this from manifesting swelling or burning infection. signs and symptoms
reddish color agent may damage signs and sensation. of infection as
> body weakness a human cell and symptoms of evidenced by:
noted the body’s major infection. >Provide sterile >To prevent cross a. afebrile
> blood results: defense to fight wound care and contamination and b. (-) redness,
- WBC: 12.0(4.1- these agents is the exercise proper possibility of swelling,
10.9) increased in the hand washing. infection. burning
-Gran: 9.0 (2.0-7.8) body’s temperature. sensation on
- RBC: 3.84 (4.2- >Instruct patient >Minimize the incision
6.3) not to touch the opportunity for site
- Hct: 326g/L (370- incision site. contamination.
510g/L)
-MCHC: 371g/L >Monitor VS: Note >Fever may reflect
(310-360g/L) for signs of fever as developing infection.
-Hgb: 115g/L (120- necessary.
180g/L)
- Plt:499 (140- >Assist in self care >To prevent further
440g/L) activities. injury.
Nursing Diagnosis:
Risk for infection r/t
broken skin.
POST-OPERATIVE
ASSESMENT SCIENTIFIC PLANNING INTERVENTION RATIONALE EVALUATION
EXPLANATION
S> Ø > Vague, uneasy > Within the Independent: > After the shift,
feeling of shift, the patient >Facilitate development > Trust is necessary before the patient
O>Expressed discomfort or will as a trusting relationship patient and family can feel acknowledged
concerns due to dread acknowledge with patient and family free the open personal lines feelings and
change in life accompanied by feelings and and communication with identify healthy
events autonomic identify healthy hospice team and address ways to deal with
> restlessness response. ways to deal sensitive issues. them.
> worried about with them.
his condition >Provide open, >Promotes and encourage
> unpleasant nonjudgmental dialogue about feelings and
thoughts about environment. Use concerns.
any event related therapeutic
to death or dying communication skills.
> feelings of
hopelessness >Encourage verbalization >Patient may feel
of thoughts and concerns supported expression of
Nursing and accept expressions of feelings by understanding
Diagnosis: sadness and anger. that deep and often
Anxiety r/t conflicting emotions are
change in health normal in this situation.
status.
>Reinforce teaching > Patient/SO’s benefit from
regarding disease process factual information. Honest
and treatments and answer promotes trust.
provide information as
requested. Be honest; do
not give false hope while
providing emotional
support.
POST-OPERATIVE

S>“Hindi ko alam Lack of information >After 3 hours Independent: > After 3
ang gagawin sa regarding his of nursing > Review disease >Provides hours of
sugat ko” as condition. interventions process, surgical knowledge nursing
verbalized by the the patient will procedure or base on which intervention
patient. verbalize prognosis. patient can the patient
O> uncooperative understanding about make informed was able to
> irritable the disease process choices. verbalize
> inability to understanding of
understand > Demonstrate care > Promotes the disease
procedures of incisions or independence process.
> lack of interest dressing or in care and
> unfamiliarity with drains. reduces risk of
information complications.
Nursing Diagnosis: >Emphasize >During initial 6

> Knowledge deficit importance of months after
r/t disease condition maintaining low surgery, low fat
fat diet, eating diet limits need
small frequent for bile and
meals, gradual reduces
reintroduction of discomfort
foods or fluids associated with
containing fats inadequate
over 4 to 6 month digestion of
period. fats.
> Discuss avoiding >Minimizes the

or limiting use of risk of
alcoholic pancreatic
beverages. involvement.
> Inform patient > Intestines
that loose stools require time to
may occur for adjust to
several months. stimulus of
continuous
output of bile.
>Identify signs and > Indicators of

symptoms obstruction of
requiring bile flow or
notification of altered
healthcare provider digestion, requiring
like dark further
urine, jaundiced evaluation and
color of eyes or intervention.
skin, clay colored
stools.
> Review activity > Resumption of

limitations usual activities
depending on is normally
individual accomplished
situation within 4-5
weeks.
C. Implementation
i. Medical Management
I. IVF, BT, NGT, Nebu, TPN, Oxygen
Medical Management/ Date Ordered/ General Description Indication/ Purposes Client Reaction to
Treatment Performed Treatment
Date Changed/ Date
Continued
PLRS 1L regulated @ Date ordered: An Isotonic solution that Used in treatment of None
10-15 gtts/min. February 19, 2009 contains multiple hypovolemia, burns,
Date performed: electrolytes in roughly fluid loss as bile or
February 19, 2009 the same concentration diarrhea, and for acute
Date Changed: as found in plasma; blood loss replacement.
February 20, 2009 provides 9 cal/L.
Date replaced:
February 20, 2009
NURSING RESPONSIBILITIES
Before:
1. Inspect each container. Read the label. Ensure solution is the one ordered and is with in the expiration date.
2. Invert container and carefully inspect the solution in good light for cloudiness, haze, or particulate matter. Any container which
is suspect should not be used.
3. Use only if solution is clear and container and seal are intact.
After:
1. Watch for infection at the site of injection, venous thrombosis or phlebitis extending from the site of injection, extravasation
and hypervolemia.
2. Symptoms may result from an excess or deficit of one or more of the ions present in the solution; therefore, frequent
monitoring of electrolytes levels is essential.
3. Monitor the regulation of the IVF.
4. Check for any signs of any infiltration complication in the IV site.
Medical Management/ Date Ordered/ General Description Indication/ Purposes Client Reaction to
Treatment Performed Treatment
Date Changed/ Date
Continued
D5LR 1L regulated @ Date ordered: hypertonic. 5% Dextrose This Solution is None
30 gtts/min. February 20, 2009 in Lactated Ringer’s indicated for use in
Date performed: Injection is sterile, non- adults and pesiayric
February 20, 2009 pyrogenic and contains patients as a source of
Date Changed: no bacteriostatic or electrolytes, calories and
February 21, 2009 antimicrobial agents. water for hydration.
Date replaced: This product is intended
February 21, 2009 for intravenous
administration.
D5LR 1L regulated @ Date ordered:

10-15 gtts/min. February 21, 2009
Date performed:
February 21, 2009
Date Changed:
February 22, 2009
Date discontinued:
February 22, 2009
Before:
1. Inspect each container. Read the label. Ensure solution is the one ordered and is with in the expiration date.
2. Invert container and carefully inspect the solution in good light for cloudiness, haze, or particulate matter. Any container which
is suspect should not be used.
3. Use only if solution is clear and container and seal are intact.
After:
1. Watch for infection at the site of injection, venous thrombosis or phlebitis extending from the site of injection, extravasation
and hypervolemia.
2. Symptoms may result from an excess or deficit of one or more of the ions present in the solution; therefore, frequent
monitoring of electrolytes levels is essential.
3. Watch for sings and symptoms of potassium intoxication include paresthesias of the extremeties, are flexia, muscular or
respiratory paralysis, mental confusion, weakness, hypotension, cardiac arrhythmias, heart block, electrocardiographic
abnormalities and cardiac arrest.
4. Monitor the regulation of the IVF.
5. Check for any signs of any infiltration complication in the IV site.
Medical Date ordered/Date General Description Indication/Purpose Client Reaction to the

Management/Treatment Preformed/Date Treatment
Change/Date
Continued
 T-tube February 9, 2009 >a narrow flexible tube in T-tube is inserted to None
the form of a T that is preserve the patency of
used for drainage the common duct and to
especially of the common ensure drainage of bile
bile duct out of the body
until edema in the
common bile duct has
subsided enough
for bile to drain into the
duodenum normally.
Nursing Responsibility:
If the patient is being discharged with the T-tube in place, the following instructions will be given:
1. The patient must have instruction about whether the tube should be connected to continuous drainage, clamped continuously, or
drained intermittently.
 If it is drained continuously, the patient must know how to empty the bag, the importance of keeping the bag below the level of
the T-tube insertion site, and ways to maintain mobility with a continuous drainage system.
2. The patient must be instructed about the self-monitoring that will be necessary.
 Assessment for infection (redness, warmth and swelling at insertion site, temperature elevation, or purulent drainage from T-
tube site).
 Assessment for obstruction (recurrence of pain in right upper quadrant, bile drainage around T-tube, recurrence of nausea and
vomiting, clay-colored stools, mahogany urine, or jaundice).
 Assessment for tube dislodgement (sudden decrease in drainage or evidence that tube has shifted).
3. The patient will be instructed to report signs and symptoms or complications immediately.

Change/Date Continued
> Cholangiogram February 9, 2009 > an x-ray film on the To visualize gallbladder None
bile ducts produced after and bile duct and to
injection of a radiopaque determine the exact
contrast medium. location of the stones.
BEFORE:
1. Ask the patient if he is allergic to sea foods or iodine.
2. Explain to the patient the procedure to prevent or reduce anxiety
3. Monitor VS prior to procedure.
AFTER:
1. Patient should remain on bed after the procedure.
2. Monitor VS.
3. Assess for any bleeding on the incision site.
Change/Date Continued
> Peritoneal lavage February 9,2009 > involves the For the cleaning of None
instillation of 1 L of excess materials (dye)
warmed LR’s or normal left during
saline solution in to the cholandiogram.
abdominal cavity.
BEFORE
1. Explain to the patient the procedure to prevent or reduce anxiety
2. Monitor VS prior to procedure
AFTER:
1. Secure tunings of the lavage in a drainage bottle to avoid leak.
2. Monitor the amount and characteristics of the secretions.
3. Monitor VS and signs of infection such as redness in the area of insertion and any purulent discharges.
ii. Drugs
NAMES OF DRUG DATE ROUTE ADMIN. & GEN. ACTION, MECH. INDICATION/S, CLIENT RESPONSE
ORDERED/DATE DOSAGE & OF ACTION PURPOSES TO MED W/ ACTUAL
TAKEN/GIVEN, DATE FREQUENCY OF S/E
CHANGED/DATE ADMIN
DISCONTINUED
Generic Name: Date Ordered: 750 mg IVP every 8 Chemical Effect: Perioperative >No usual allergic
>Cefuroxime  February 9, hours >Inhibits cell wall prophylaxis response
Sodium 2009 synthesis promoting
osmotic instability
Brand Name: Date Taken: usually bactericidal.
>Kefurox, Zinacef
 February 9, Therapeutic Effect:
Pharmacologic 2009 > Hinders or kills
Class: susceptible bacteria
>Cephalosporin including many
gram positive
Therapeutic Class: organism and
>Antibiotic enteric gram
negative bacilli.
BEFORE:
 Check for doctor’s order.
 Assess patient’s infection before therapy and regularly thereafter.
 Before giving first dose, obtain specimen for culture and sensitivity tests.
 Before giving first dose, ask patient about previous reactions to cephalosporins or penicillin.
 Assess patient’s and family’s knowledge of drug therapy.
 Instruct patient to take drug exactly as prescribed, even if he feels better
DURING:
 Instruct patient to take oral drug with food to enhance absorption.
 Explain that tablets may crushed, but drug has bitter taste that difficult to mask even with food.
AFTER:
 Tell patient to report any adverse reactions immediately.
 Be alert for adverse reactions and drug interactions.
CHANGED/DATE ADMIN
DISCONTINUED
Generic Name: Date ordered: 100mg IVP q 8° Chemical action: > Moderate to > Patient is free
>Tramadol  February 12, >Unknown; moderately severe from pain.
Hydrochloride 2009 centrally acting pain
synthetic analgesic
Brand Name: Date taken: compound not
> Ultram  February 12, chemically related
2009 to opioids that is
Pharmacologic thought to bind to
class: opioid receptors and
Opioid agonist inhibits reuptake of
norepinephrine and
Therapeutic class: serotonin.
Analgesic
Therapeutic effect:
>Relieves pain
NURSING RESPONSIBILITIES:
BEFORE:
 Assess patients pain before starting therapy and regularly thereafter to monitor the drugs effectiveness.
AFTER:
 Monitor patient for drug dependence.
 Be alert for adverse reactions and drug interaction.
 For better analgesic effect, give drug before onset of intense pain
 Monitor CV and respiratory status.
 Tell ambulatory patient to be careful when getting out of bed and walking
CHANGED/DATE ADMIN
DISCONTINUED
Generic Name: Date ordered: > 1 amp IVP q 8° Chemical effect: > Duodenal or > No response
> Ranitidine HCl  February 9, > Competitively gastric ulcer
Brand Name: 2009 inhibits action of H2
> Zantac at receptor sites of
Pharmacologic Date taken: parietal cells,
class:  February 9, decreasing gastric
>H2-Receptor 2009 acid secretion.
Antagonist
Therapeutic class: Therapeutic effect:
>Antiulcerative > Relieves GI
discomfort
BEFORE:

 Teach patient to avoid alcohol.
 Instruct patient to take drug with or without food
 Urge patient not to smoke cigarettes; smoking may increase gastric acid secretion and worsen disease
AFTER:
 Be alert for adverse reaction and drug interaction
CHANGED/DATE ADMIN
DISCONTINUED
Generic Name: Date ordered: > 500 mg IVP q 8° Chemical effect: > To prevent > Patient is free
> Metronidazole  February 9, > Direct-acting postoperative from infection as
Brand Name: 2009 trichomonazide and infection evidenced by
> Flagyl amebicide that temperature within
Pharmacologic Date taken: works at both normal range
Class:  February 9, intestinal and
> Nitroimidazole 2009 extraintestinal sites
Therapeutic Class:
> Antibacterial; Therapeutic effect:
antiprotozoal, > Hinders growth of
amebicide selected organisms,
including most
anaerobic bacteria
and protozoa
BEFORE:
 Tell patient not to use alcohol or drugs that contain alcohol during therapy and for at least 48 hours after
therapy is completed
 Urge patient to complete full course of therapy even if he feels better
DURING:
 Tell patient that metallic taste and dark or red-brown urine may occur
AFTER:
 Be alert for adverse reaction and drug interactions
NAMES OF DRUG DATE ORDERED/DATE ROUTE ADMIN. & GEN. ACTION, MECH. INDICATION/S, CLIENT RESPONSE TO
TAKEN/GIVEN, DATE DOSAGE & OF ACTION PURPOSES MED W/ ACTUAL S/E
CHANGED/DATE FREQUENCY OF
DISCONTINUED ADMIN
Generic Name: Date ordered: > 30 mg 1 amp. IVP Chemical effect: > Short- term > Patient is free
> Ketorolac  February 9, q 8 > May inhibit management of pain from pain
2009 prostaglandin
Brand Name: synthesis
> Acular Date taken:
Pharmacologic  February 9, Therapeutic effect:
Class: 2009 > Relieves pain and
> NSAID inflammation
Therapeutic Class:
> Analgesic, anti-
inflammatory
BEFORE:
 Assess patient’s pain before and after drug therapy
 Explain that drug is intended for short-term management
AFTER:
 Advise patient to report persistent or worsening pain.
 Teach patient to re4cognize and immediately report signs and symptoms of GI bleeding.
iii. Diet
TYPE OF DIET DATE ORDERED, GENERAL DESCRIPTION INDICATION/S, SPECIFIC FOODS CLINT RESPONSE
DATE PURPOSE/S TAKEN AND/OR REACTION
STARTED,DATE TO THE DIET
CHANGED
Diet as tolerated Date ordered: It is a normal diet It serves as a basis Rice, meat, The patient accepts
February 19, planned to provide the for the vegetables and the ordered diet and
2009 recommended daily modifications of fruits. he was able to eat
allowance for essential therapeutic diets in the served foods. It
Date Started: , nutrients but designed to the hospital. is good to the
February 19, meet the caloric needs patient’s appetite
2009 of a bedridden or and meets the
ambulatory patients caloric need. He
Date Changed: whose condition does understands and
February 20, not require any dietary appreciates the
2009 modification for benefits of the diet.
therapeutic purposes. Diet tolerated
High protein diet Date ordered: Diet that prescribes a It is used in post 2 egg white, and The patient accepts
February 20-23, specific level of protein operative patients meat the ordered diet and
2009 fraction or amino acid For rapid tissue he was able to eat
repair. the served foods. He
understands and
Date Started: , appreciates the
February 20, benefits of the diet.
2009 Diet tolerated
Date Changed:
February 24,
2009
Low fat Date ordered: Diet that prescribes a To prevent Lean or grilled meat The patient tries to
February 20-23, specific level of fat for aggravation of and fish. eat the served food
2009 patients whose condition accumulation of fats and understands the
requires a small amount in the common bile benefits of the diet
Date Started: , of fat fraction. duct. in his condition.
February 20, Diet tolerated.
2009
Before:
1. Emphasize the importance of the diet
2. Discuss the food sources included in the diet.
3. Explain to the client the purpose of the diet.
After:
1. Assess the client’s response to the diet.
2. Assess the client’s understanding about the diet.
iv. Activity or Exercise
TYPES OF EXERCISE DATE ORDERED, DATE GENERAL DESCRIPTION INDICATIO/S, PURPOSE/S CLIENT’S
STARTED, DATE RESPONSE/REACTION TO
CHANGED. THE ACTIVITY/EXERCISE
Deep Breathing Date ordered: Deep breathing is a Breathing exercises can Participate willingly in
Exercises February 19-23, 2009 relaxation technique that be used to optimize gas the activity.
can be self-taught. Deep exchange, promote lung
Date Started: , breathing releases expansion, minimize Patient verbalizes
February 19, 2009 tension from the body atelectasis, decrease alleviated pain sensation
and clear the mind, dyspnea, and promote and serves as an
Date Changed: improving both physical secretion removal effective relaxation
February 24, 2009 and mental wellness. especially after technique.
prolonged inactivity.
We tend to breathe Understands and
shallowly or even hold appreciates the benefits
our hold our breath of the exercise
when we are feeling
anxious
Range of Motion Date ordered: Maximum possible Strengthens muscle to Participate willingly in
Exercise February 19-23, 2009 movement for a joint. prevent muscle atrophy the activity.
Normal muscle strength or weakness among
Date Started: , for complete voluntary patients who mostly Understands and
February 19, 2009 range of motion. confined on bed. appreciates the benefits
of the exercise
Date Changed: Promotes blood
February 24, 2009 circulation.
Participate willingly in
Date ordered: Increases mobilization, the activity.
Daily walking activity February 23, 2009 strengthens muscle and
Walking with bilateral promotes balance. Understands and
Date Started: , equal strengths. Activity appreciates the benefits
February 23, 2009 to maintain balance of the exercise
NURSING RESPONSIBILITIES:
DEEP BREATHING EXERCISE
BEFORE:
1. Explain the procedure to gain patients cooperation.
2. Discuss the benefits of the exercise
DURING:
1. Help the client perform deep breathing exercise.
2. Advise to rest between activities.
AFTER:
1. Encourage to perform exercise at last 1 hour before every meal.
2. Encourage verbalization of increased comfort.
RANGE OF MOTION EXERCISE

BEFORE:
DURING:
1. Help the client perform deep breathing exercise.
3. Ensure the patient’s safety.
AFTER:
1. Encourage to perform active ROM exercise at last 1 hour before every meal.
2. Encourage verbalization of any pain after the activity
DAILY WALKING ACTIVITY:

BEFORE:
3. Advise to perform activity with enough energy to prevent fatigue.
DURING:
1. Assist the patient or advise the patient to perform daily walking activities with the assistance of SO’s.
3.Ensure the patient’s safety.
AFTER:
1. Encourage daily walking activities.
2. Encourage verbalization of any pain after the activity
v. Surgical Management
Name of Procedure Date ordered/Date General Description Indication/Purpose Client Reaction to the
Preformed Operation
Choledocholithotomy February 9,2009 Operation to make an Removal of stones on Reduce anxiety
incision on the common the common bile duct.
bile duct to remove
gallstones.
Nursing Responsibility
BEFORE:
1. Secure consent
2. Explain to the patient the procedure.
3. Monitor VS.
4. NPO post midnight.
AFTER:
1. Maintain patient flat on bed for 8 hours.
2. Monitor for bleeding on the incision site.
3. Monitor Vs.
4. NPO until positive flatus.
Preformed Operation
Choledochostomy February 9, 2009 Making an incision in Removal of stones Reduce anxiety
the common duct,
usually removal of
stones. After the stones
have been evacuated, a
tube is usually inserted
into the duct for
drainage of bile until
edema subsides.
Nursing Responsibility
BEFORE:
1. Secure consent
2. Explain to the patient the procedure.
3. Monitor VS.
4. NPO post midnight.
AFTER:
1. Maintain patient flat on bed for 8 hours.
2. Monitor for bleeding on the incision site.
3. Monitor Vs.
4. NPO until positive flatus
Preformed Operation
Cholecystectomy February 9, 2009 Making an incision for Removal of gallbladder Reduce anxiety
the removal of
gallbladder
SOAPIE # 1
POST-OPERATIVE
S: “Masakit yung inopera sa akin”, as verbalized by the patient.

O: 8:15pm> received patient flat on bed
> with ongoing IVF of D5LRS 1L regulated at 30-31gtts/min at the level of 800cc
infusing well
> pain scale of 7/10
>weak in appearance
>guarding behavior/self- protective behavior
>limited movement
>grimace upon movement
> irritable
A: Acute pain and discomfort related to surgical incision.
P: Within one hour of appropriate nursing intervention, the patient’s pain scale will alleviate
from 7/10 to 3/10.
I: > Offered divertional activities such as reading newspaper or magazines, socialization with
others
> Monitored vital signs specifically RR and BP.
> Instructed deep breathing exercises.
> Provided comfort measures such as backrub and changing position every 2 hours.
> Provided quiet environment and calm activities.
> Encouraged adequate rest periods.
> Administered analgesics as indicated to maximal dosage as needed.
E: >After one hour of appropriate nursing intervention, the patient’s pain scale will alleviated
from 7/10 to 3/10 as evidenced by:
a. can move freely b. verbalized increase level of comfort
SOAPIE # 2
POST-OPERATIVE
S: > “Nanghihina ako” as verbalized by the patient.

O: 8:15pm > received patient flat on bed.
> with IVF of D5LRS 1L regulated at 30-31 gtts/min at 800 cc level, infusing well
>grimace
>pale and weak in appearance
>mostly confined on bed
>restless
>limited movements
>inability to perform ADL
A: >Activity intolerance r/t generalized weakness.
P: > Within 2 to 3 hours of appropriate nursing intervention the patient will be able to
demonstrate increase activity tolerance
I: > Planned care with rest periods between activities
>Assisted in self care activities.
>Promoted comfort measures and provide for relief of pain.
>Performed ROM exercise (active assistive).
>Encouraged participation in self care and divertional or recreational activities.
>Observed and document skin integrity at least 3x within the shift.
>Emphasized adequate intake of fluids at least 1500-2000 ml and nutritious foods such as
vegetables and fruits .
>Encouraged to maintain positive attitude; suggest use of relaxation techniques such as deep
breathing exercise.
>Provided emotional support and encouragement to the client to gradually increase activity.
E: > After 2 to 3 hours of appropriate nursing interventions the patient had demonstrated activity
tolerance as evidence by:
a. verbalization of patients mobility progression.
b. demonstration of patients positive attitudes towards activities.
c. patients wide understanding about the importance of activity tolerance.
SOAPIE # 3
POST-OPERATIVE
S>
O: > with incision at the right upperquadrant, characterized by reddish color

> body weakness noted
> blood results:
- WBC: 12.0(4.1-10.9)
-Gran: 9.0 (2.0-7.8)
- RBC: 3.84 (4.2-6.3)
- Hct: 326g/L (370-510g/L)
-MCHC: 371g/L (310-360g/L)
-Hgb: 115g/L (120-180g/L)
- Plt:499 (140-440g/L)
A> Risk for infection r/t broken skin.
P> Within 8 hours of appropriate nursing intervention, the patient will be free from manifesting
signs and symptoms of infection such as swelling, redness..
I >Inspected the skin for pre-existing irritation, redness, swelling or burning sensation.
>Provided sterile wound care and exercise meticulous hand washing.
>Instructed patient not to touch the insertion site.
>Monitored VS: Note for signs of fever as necessary.
>Assisted in self care activities.
E> After 8 hours of appropriate nursing intervention, the patient is free from signs and
symptoms of infection as evidenced by:
a. afebrile
b. (-) redness, swelling, burning sensation
SOAPIE # 4
POST-OPERATIVE
S> Ø
O> Expressed concerns due to change in life events

> Restlessness
> Worried about his condition
> Unpleasant thoughts about any event related to death or dying
> Feelings of hopelessness
A>Anxiety r/t change in health status.
P> Within the shift, the patient will acknowledge feelings and identify healthy ways to deal with
them
I>Facilitated development as a trusting relationship with patient and family
> Provided open, nonjudgmental environment. Use therapeutic communication skills.
> Encouraged verbalization of thoughts and concerns and accept expressions of sadness and
anger.
>Reinforced teaching regarding disease process and treatments and provide information as
requested. Be honest; do not give false hope while providing emotional support.
E> After the shift, the patient acknowledged feelings and identify healthy ways to deal with
them.
SOAPIE # 5
POST-OPERATIVE
S: >“Hindi ko alam ang gagawin sa sugat ko” as verbalized by the patient.
O: 3:00pm > received patient flat on bed

> With IFC intact at level of 100cc
> With ongoing IVF of D5LRS 1L regulated at 30-31gtts/min at the level of 800cc
infusing well
> Uncooperative
> Irritable
> Inability to understand procedures
> Lack of interest
> Unfamiliarity with the information
A: Deficit knowledge regarding disease condition.
P: After 3 hours of nursing interventions the patient will verbalize understanding of therapeutic
needs.
I: · Reviewed disease process, surgical procedure or prognosis.
· Demonstrated care of incisions or dressing or drains.
· Emphasized importance of maintaining low fat diet, eating small frequent meals, gradual
reintroduction of foods or fluids containing fats over 4 to 6monthperiod.
· Discussed avoiding or limiting use of alcoholic beverages.
· Informed patient that loose stools may occur for several months.
· Identified signs and symptoms requiring notification of healthcare provider like dark urine,
jaundiced color of eyes or skin, clay colored stools.
· Reviewed activity limitations depending on individual situation
E: · After 3 hours of nursing interventions the patient was able to verbalize understanding of the
disease process.
D. EVALUATION
1. Patient’s daily program in the hospital
Daily program 1st Day 2nd Day 3rd Day 4th Day 5th Day
(Feb 19 2009) (Feb 20 2009) (Feb 21 2009) (Feb 22 2009) (Feb 23 2009)
Nursing Problems
1. Acute pain and

discomfort related  
to surgical
incision.
2. Activity
intolerance r/t
generalize     
weakness
3. Risk for
infection related to
broken skin
4. Anxiety related     
to change in
health status
5. knowledge
deficit r/t disease
condition  
 
• Temperature: • Temperature: • Temperature: • Temperature: • Temperature:
5 am-36.5 °C 10 am-37.2 °C 6 am-37 °C 5 am-36.7 °C 5 am-37 °C
10 am-37.2 °C 2 pm-37.5 °C 10 am-37 °C
2 pm-37.5 °C 4pm-37.5 °C 2 pm-37.4 °C
4pm-37.5 °C 6pm-37.4 °C
6pm-37.4 °C 10 pm-36.5 °C
10 pm-36.5 °C
• Respiratory • Respiratory • Respiratory • Respiratory • Respiratory

Rate: Rate: Rate: Rate: Rate:
5 am-26 cpm 10 am-26 cpm 6 am-24 cpm 5 am-26 cpm 5 am-25 cpm
10 am-18 cpm 2 pm-30 cpm 10 am-30 cpm
2 pm-21 cpm 4pm-29 cpm 2 pm-33 cpm
4pm-30 cpm 6pm24 cpm
6pm-28 cpm 10 pm-28 cpm
10 pm-24 cpm
• Pulse Rate: • Pulse Rate: • Pulse Rate: • Pulse Rate: • Pulse Rate:
5 am-70 10 am-71 6am-72 5 am-70 5 am-69
10 am-65 2 pm-74 10 am-75
2 pm-73 4pm-77 2 pm-69
4pm-79 6pm-76
6pm-76 10 pm-75
10 pm-72
• Blood • Blood • Blood • Blood • Blood

Pressure: Pressure: Pressure: Pressure: Pressure:
5 am-120/90 mmHg 10 am-100/80 6 am-110/80 mmHg 5 am-110/70 mmHg 5 am-100/80 mmHg
10 am-120/80 mmHg 10 am-100/80
mmHg 2 pm-110/70 mmHg mmHg
2 pm-120/80 mmHg 4pm-110/70 mmHg 2 pm-100/70 mmHg
4pm-110/70 mmHg 6pm-110/70 mmHg
6pm-110/80 mmHg 10 pm-100/80
10 pm-110/70 mmHg
mmHg
Diagnostic & Lab. none Blood chemistry none none none

Procedures
Medical and Vital signs Vital signs Vital signs Vital signs Vital signs
Surgical Mgt. monitoring monitoring monitoring monitoring monitoring
PLRS PLRS PLRS PLRS PLRS
Drugs Pro-tab Pro-tab Pro-tab Pro-tab Pro-tab
Tramadol Tramadol Tramadol Tramadol Tramadol
Cefuroxime Cefuroxime Cefuroxime Cefuroxime Cefuroxime
Gentamycin Gentamycin Gentamycin Gentamycin Gentamycin
Metronidazole Metronidazole Metronidazole Metronidazole Metronidazole
Diet High protein diet High protein diet High protein diet High protein diet High protein diet
DAT DAT DAT DAT DAT
Exercise Range of motion Range of motion Range of motion Range of motion Range of motion
2. Discharge Planning
i. General condition of the patient upon discharge
It was February 24, 2009, when the patient was discharge. He was able to
sit on bed without assistance. He was able to consume all the food on the tray. He
is still with his t-tube intact.
The doctor ordered the patient for OPD follow-up after one week, regular
cleaning, changing of dressings at the insertion site. The patient was also advised
to continue low fat and low sodium diet.
ii. METHOD
M: > Ciprofloxacin 500mg twice a day

>Mefenamic Acid 500mg 3 times a day
> Tramadol 100mg once a day
E: > Activities of daily living (ADL)
T: > Ø
H: >
• Encouraged to continue high protein diet, low fat-low sodium
diet.
• Encouraged to continue taking the prescribed medicine.
• Encouraged to resume activities of daily living.
• Emphasized the importance of maintaining proper hygiene,

especially cleaning the t-tube insertion site.
• Teach pt. and significance others to report any signs of infection

like redness, warmth and swelling at insertion site, temperature
elevation, or purulent drainage from T-tube site to avoid further
complications.
• Emphasized to significant others the importance of emotional

support.
O: > Follow up checkup after one week
D: > Low fat low sodium high in protein

III. CONCLUSION
Discipline is one of the major factors needed by the patient with choledolithiasis. He
must be able to know on how to tolerate his foods particularly the limitations of fats and
cholesterol intake which are one of the major factors that lead for the formation of stones in the
gallbladder`. Proper balance nutrition is a good practice for the alleviation and minimal
occurrence of this kind of disease.
With regards to the patients medical and surgical managements, occurrence of problems
such as risk for infection prior to surgery may be prevented by means of proper cleaning of the
incision site and medications should be taken as prescribed with proper dosages to avoid any of
its adverse or side effects.
As we work this kind of study, the group gained wide knowledge and understanding
about Choledolithiasis, the problems related to this condition and the different management that
should be prioritized in order for us to have positive outcomes in nursing problems. Good nurse-
patient relationship was also established as we conduct this study. This study helps us to identify
measures to prevent complications of the disease and also for them to have understanding about
this condition and to practice independent implementation for this kind of disease
IV. RECOMMENDATION
As nursing students, we should have wide knowledge about our patient’s condition in
order for us to give appropriate managements. So we group B3 recommend to our patient to
maintain proper diet that is high in protein for faster tissue repair and low salt-low fat diet to
prevent aggravation of disease. Drinking sufficient water for at least 8 glasses or more, may also
be helpful for proper circulation of nutrients that patient’ take.
Patient should always be practice proper intake of his medication and must always obtain
proper hygiene especially on the insertion site of the t-tube to prevent secondary infections. Any
abnormalities or adverse effects should report to the physician immediately. Patient should also
practice independence to promote sense of well-being.
V. BIBLIOGRAPHY
BOOKS:
Ackley, Betty J. and Ladwig, Gail B., Nursing Diagnosis Handbook, 7th Edition, 2006.
Estes Zator, Mary Ellen. Health Assessment and Physical Examination, 3rd Edition, 2006.
Ignativicius and Workman. Medical- Surgical Nursing, Collaborative and Critical Thinking
Vol. 1 and 2, 2004.
Kozier, Erb, Berman, Synder. Fundamentals of Nursing, Concepts, Process and Practice,
7th Edition, 2004.
Lippicott, Williams and Wilkins. Springhouse Nurse’s Drug Guide, 2007.
Mosby’s Pocket Dictionary of Medicine, Nursing and Health Professions.
Smeltzer, Suzanne C. and Bare, Brenda G., Medical- Surgical Nursing, Vol. 2 10th
Edition, 2004.
Website
http://www.umm.edu/ency/article/000274.htm
http://emedicine.medscape.com/article/172216-overview

FINAL CHOLE,,,Sa Wakas Tpoz

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Republic of the Philippines

Tarlac State University

Reasons for choosing this case:

Importance of the study:

It is of fundamental importance that case studies are to be performed in the nursing

II. Nursing Process:

3. History of Present Illness

Standard and Norms

• Posture and Movements

• Thought Process and Perception

Standard and Norms

Standard and Norms

Standard and Norms

Standard and Norms

Standard and Norms

Standard and Norms

Standard and Norms

DATE TIME ROUTE TEMPERATURE INTERPRETATION

Standard and Norms

Route for Body Temp. Measurement Average Normal Range

DATE TIME RESPIRATORY RATE INTERPRETATION

Standard and Norms

DATE TIME BLOOD PRESSURE INTERPRETATION

Standard and Norms

Standard and Norms

Standard and Norms

STATE OF PHYSICAL REST AND COMFORT

Standard and Norms

STATE OF SKIN APPENDAGES

Diagnostic/ Date Ordered Indications/ Purposes Results Normal Analysis and

• Hgb 115g/L 120-180 g/L • Decreased Hgb

• Plt 499g/L 140-440g/L • Increased platelet

>Potassium 4.01mmol/L 3.8-5.0mmol/L • Within normal values

>Chloride 117.2mmol/L 95-103mmol/L • Increased chloride

BILE ACCUMULATES BACTERTIAL ABNORMAL FAT

GALLBLADDER AND DIARRHEA

BLOOD FLOW AND LYMPHATIC

CHOLECYSTITIS OBSTRUCTION IN THE

ASSESSMENT SCIENTIFIC PLANNING INTERVENTION RATIONALE EXPECTED

> Provide quiet > to provide comfort

> Encourage > to prevent fatigue

ASSESSMENT SCIENTIFIC PLANNING INTERVENTION RATIONALE EXPECTED

>Emphasize >Promotes well being

ASSESSMENT SCIENTIFIC PLANNING INTERVENTION RATIONALE EXPECTED

ASSESSMENT SCIENTIFIC PLANNING INTERVENTION RATIONALE EXPECTED

Nursing Diagnosis: >Emphasize >During initial 6

> Discuss avoiding >Minimizes the

>Identify signs and > Indicators of

> Review activity > Resumption of

D5LR 1L regulated @ Date ordered:

Medical Date ordered/Date General Description Indication/Purpose Client Reaction to the

Medical Date ordered/Date General Description Indication/Purpose Client Reaction to the

 Check for doctor’s order.

iv. Activity or Exercise

RANGE OF MOTION EXERCISE

DAILY WALKING ACTIVITY:

S: “Masakit yung inopera sa akin”, as verbalized by the patient.

A: Acute pain and discomfort related to surgical incision.

> Monitored vital signs specifically RR and BP.

> Instructed deep breathing exercises.

> Provided quiet environment and calm activities.

> Encouraged adequate rest periods.

> Administered analgesics as indicated to maximal dosage as needed.