Table of Contents

I. INTRODUCTION ................................................................................................................ 2
II. OBJECTIVES ..................................................................................................................... 4
III. PATIENT’S DATA ........................................................................................................... 7
IV. HEALTH HISTORY ......................................................................................................... 8
V. DEVELOPMENTAL DATA .................................................................................................14
VI. PATIENT’S DIAGNOSIS ................................................................................................18
VII. ANATOMY AND PHYSIOLOGY .....................................................................................20
VIII. PHYSICAL ASSESSMENT ............................................................................................24
IX. ETIOLOGY .....................................................................................................................28
X. SYMPTOMATOLOGY........................................................................................................30
XI. PATHOPHYSIOLOGY....................................................................................................32
XII. DOCTOR’S ORDER .......................................................................................................33
XIII. DIAGNOSTIC AND LABORATORY TESTS ...................................................................37
XIV. SPECIAL PROCEDURES ..............................................................................................48
XV. DRUG STUDY................................................................................................................49
Arcoxia ......................................................................................................................................61
XVI. NURSING THEORIES....................................................................................................75
XVII. NURSING CARE PLANS ...............................................................................................79
XVIII. PROGNOSIS ..............................................................................................................98
XIX. DISCHARGE PLANS .....................................................................................................99
XX. RECOMMENDATIONS ................................................................................................101
Patient .................................................................................................................................101
Nursing Education ...............................................................................................................101
Nursing Practice ..................................................................................................................102
Nursing Research ................................................................................................................102
XXI. BIBLIOGRAPHY...........................................................................................................104
 2

I. INTRODUCTION

Calculous Cholecystitis remains one of the most common disease concerning the

gallbladder. Patients with gallstones do not develop symptoms. About 1% to 2% of

asymptomatic gallstones become symptomatic each year. Cholecystitis is the most

frequent complication of gallstones and occurs in 10% of symptomatic patients. However,

Cholecystitis accounts for 3–10% of cases of abdominal pain worldwide.

According to the global study by Hale (2014) , the incidence of Cholecystitis was

1.3–1.9%, with the exception of India where it was 8.8%. The incidence of gallbladder

Cancer associated with Cholecystitis was lowest in European studies (3.3%) varying from

5.1–5.9% in the remaining regions. Confusion with or undiagnosed Gallbladder Cancer

led to 10.2% of patients receiving over or under treatment.

According to the Philippine Council for Health and Research Development, the

Philippines have thousands of new cases are diagnosed each year, and cholecystectomy

(the surgical removal of the gallbladder), is one of the most common abdominal

operations done locally. Luckily, most gallstones do not require surgical treatments. But

sometimes cause painful attacks and lead to more serious complications. (Reyes, 2014).

In a study conducted by the Alexian Brothers Health System (2011), Gallstones

are present in about 80% of people with gallbladder cancer. However, this cancer is very

rare, even among people with gallstones. There is a strong association between

Cholelithiasis, chronic Cholecystitis, and Gallbladder Cancer. Symptoms of gallbladder

 3

cancer usually do not appear until the disease has reached an advanced stage and may

include weight loss, anemia, recurrent vomiting, and a lump in the abdomen.

The proponent has chosen to further explore and study about a case regarding

Chronis Calculous Cholecystitis because it affects only minor percentage of the

population and would provide an opportunity to study the nature of the disease and apply

nursing knowledge in an actual patient.

 4

II. OBJECTIVES

Within eight days of Related Learning Experience (RLE) Exposure in the Internal

Ward 3-C of the Davao Medical School Foundation (DMSF) Hospital, The proponent was

able to present a comprehensive case study, particularly on a patient with a hepato-biliary

system disorder, and explain the condition and the appropriate medical and nursing

management regarding the patient’s condition.

Specific Objectives

Cognitive:

 List all necessary information regarding the patient that is necessary for the case

study

 Trace the family background of the client through generating a Genogram or a

Family Tree.

 Ascertain the patient’s past and present health history;

 Distinguish the clinical significance and diagnostic tests that the patient has

undergone including their implications, normal and abnormal values, findings for

comparison, and specific interventions associated with each diagnostic procedure;

 Evaluate the patient’s overall health condition through a Physical Assessment;

 Understand the basic anatomy and physiology of the ears, nose, neck and the

cranial nerve affected.

 Review the common signs and symptoms of the disease condition and compare it

to the patient’s circumstances;

 5

 Trace the Pathophysiology of the disease condition of the patient;

 Identify the drugs prescribed to the patient, including their actions, indications,

contraindications, side and adverse effects, and nursing responsibilities;

 Formulate appropriate nursing care plans for the patient.

 Identify the Nursing Theories that would apply to the patient’s condition.

 Synthesize the disease condition of the patient up to the proponent’s practice

nursing interventions to the patient.

 Prepare recommendations that will be supportive for the benefit of the Patient and

Friends, the Nursing Education, the Nursing Practice, and the Nursing Research.

Psychomotor

 Detect the patient’s non-verbal communication cues and relate it to the sensitivity

of the conversation;

 Treat the patient as an individual using patient focused care with regard to their

preferences, cultures and beliefs.

 To ensure confidentiality of information relating to patient care.

 Display competence while dealing with the patient.

 Respond to the outcomes that the patient has shown by distinguishing the positive

and negative results.

 Utilize caring and Nursing process to implement therapeutic interventions to the

patient.

Affective

 Actively listen with respect to the accounts of the patient.

 6

 Show genuine and willingness in serving the patient.

 Develop a caring, non-judgmental, and therapeutic attitude towards the patient and

significant others; and

 Be aware of the patient progress on the succeeding interactions.

 7

III. PATIENT’S DATA

A. Profile
Name: G. B. S. Name of Mother: J. A. (Housekeeper)
HRN: 06-79-05 Civil Status: Married
Sex: Female Spouse: Mr. R. S.
Age: 36 years old Age: 50 years old
Birthdate: July 7, 1981 Religion: Catholic
Birthplace: San Vicente Occupation of Spouse: Bus inspector
(Ceres Bus Co.)
Religion: Roman Catholic
HMO: Philippine Health Insurance
Address: Purok Talisay, Old Bulatukan., Corporation (PHIC)
Makilala, Cotabato
Nationality: Filipino
Occupation: High School Teacher
(Saguing National High School)
Name of Father: J.B. (Mother)

Clinical/Admitting Data:
Date of Admission: January 10, 2018 @ 1:00pm
Chief Complaint: Right Upper Quadrant Pulse: Regular
Pain, painscale of 5/10
Skin: Pale
Airway: Patent
Level of Consciousness: Alert
Breathing: Labored
Speech: Slurred
Presenting Symptoms: 3 years prior to admission, there was an onset of Right Upper
Quadrant Pain with a pain scale of 5 out of 10, and was radiating to the back.

Vital Signs upon admitting:

Temperature – 35.8 Celsius Blood Pressure – 130/90
Pulse – 85 bpm Weight: 56.4kg
Respiration – 23 cpm Height: 148cm
Admitting Physician: Jonathan Narisma Admitting Clerk: Henry Derla
 8

Admitting Diagnosis: Biliary Colic secondary to Cholelithiasis

Principal and Final Diagnosis: Chronic Calculous Cholecystitis s/p Cholecystectomy

IV. HEALTH HISTORY

A. Genogram

Father’s side Mother’s side

X X X X

🐷 PP

Legend:

- Male - Patient G.B.S. - Hypertension PP- Post Partum

- Female - Cancer Survivor X-Deceased

- Asthma 🐷 – Fatty Food/High Cholesterol Diet

 9

B. Past health History

Medical History:
Communicable Diseases: Occasional Coughs and colds, Sore Throat,
Serious Chronic Illness: Hypertension (Postpartum
2011 – Post Partum Hypertension (controlled by taking Amlodipine 5mg/tab OD x
1 month)
2011 – Incidental finding of gallstone during ultrasound of her second pregnancy.
2014 – Symptoms of intermittent RUQ pain that radiated to the back appeared.
Cholecystitis was revealed through another ultrasound.
July 2017 – Complains of RUQ, 1.2cm Gallstone in Ultrasound result. Self-
medicated with Udcacid.

OB History:
G1 2004 Girl NSVD no complication
G2 2011 Boy NSVD no complication
Childhood Illnesses: None
Injuries/Accidents: Minor scars on her legs due to previous motorcycle accidents
Allergies and Reactions: None
Surgical History: none
Immunizations: The patient verbalized that she completed her Juvenile
Immunizations such as Hepatitis B, OPV, Measles Mumps,
Rubella Vaccines.
Blood Transfusions: None.

C. Present Health History

 Medical/Surgical History

By the year 2017, the patient has been frequently experiencing RUQ pain.
On the month of July, she started self- medication of Udcacid, and had good
results. Thus, discontinuing the medication. However, on the month of December,
 10

the patient admitted of frequent intake of food of high-fat content. She then
experienced such pain, consulted her physician, and was advised for surgery due
to the existing gal stone revealed in the ultrasound result.

 Special Needs
- Watch out for unusualities such as severe, jaundice.
- Soft diet (Low fat)

 Blood Transfusions : None

 Medication and Treatments:

1. Omeprazole 40mg/amp 1 amp OD IVTT

2. Ketorolac 30mg/amp 1 amp, q8 (PRN)
3. Hyoscine Butyl Bromide 10mg/amp 1 amp q6
4. Midazolam 15mg ½ tab
5. Ampi-Subactam 1.5grams IVTT q8 hours x 2 dose
6. Sultamicillin750mg 1 tab BID.
7. Parecoxib 40mg IVTT
8. Etoricoxib 90mg 1 tab BID in the morning.
9. Nalbuphine 50mg IVTT q 8 hours PRN for unbearable pain.
10. Metoclopramide 1 ampule IVTT q8 RN for vomiting
11. Arcoxia 120mg/tab, 1 tab OD PRN for pain.
12. Multivitamins + Minerals (Conzace) 1 capsule OD

D. Social History

1. Alcohol/Tobacco/Drug Use
The patient is not an avid drinker of alcoholic beverages. She also verbalized that
she only tried to drink beer and smoke cigarette once during her teenage years.
 11

2. Travel History
The patient only travels often with her husband and her two offsprings, to holiday
destinations such as Mati, Oriental. The family also visit Davao City to buy school supplies
and clothes for the children.

3. Work Environment
The patient had worked as high school teacher in Saguing National High School
for 5 years. She has been teaching Aralin Panlipunan on the Grade 8 (Second year), and
is one of the moderating class of the same grade-level.

4. Home Environment
The patient currently lives in a Suburban community in Makilala, Cotabato.. They have a
small pigpen outside their house, which has three pigs, used for family consumption of
meat.

5. Hobbies and Leisure Activities

The patient stated that she knows how to play the piano and her husband added
that she also sings well when playing the piano. The patient plays table tennis once a
week on her free time in order to maintain a healthy and active lifestyle.

6. Economic Status
The patient’s family consist of her and her husband, and two of their offspring. Both
parents have decent-paying jobs which sustains the needs of the whole family, as well as
having extra saving for emergency and leisure usage..

7. Religion
The patient is Roman Catholic, along with the rest of her family.

E. Health Maintenance
 12

 Sleep
The patient has usually sleeps at 9 in the evening, making sure that both her
offsprings are comfortably lying on their beds. Then the patient wakes up as early as 4 in
the morning to start the day by cooking breakfast and preparing packed-lunch for both
her offspring. The average sleeping hour of the patient is 7-8 hours.

 Diet
The patient verbalized that she only eats pork and beef meat often, and avoids fish
for its foul stench. He is also not fond of eating vegetable viands, but i=only eats it when
it is mixed with pork meat.

 Use of Safety Devices

The patient does not presently use any at present such as masks, gloves, or
gowns. Also, the patient does not use any ambulatory assistance instruments.

 Health Check – Ups

She frequently consults her physician at a Hospital in Kidapawan, but after the
experiencing an unbearable pain, they were forced to travel to Davao city and sought
consultation to Dr. Lasala at DMSF Hospital.

 Nutritional Assessment
Based on the patient’s narrative, she is fond of eating fatty food such as Pork stew
and Roasted Pork. The patient has not been maintaining his body weight since she was
diagnosed post-partum pregnancy. Currently, the patient is on a low-fat diet in order to
prevwnt any cholesterol build-up in the body.

Weight: 56.4kg
Height: 148cm
Body Mass Index: 25.7 (Overweight)

F. History of Present Illness

 13

6 years prior to admission, the patient was pregnant and underwent ultrasound
of the whole abdomen done by the Obstetrical Sonographer. There was an incidental
finding of a 0.1 cm Cholelithiasis in her gallbladder. She was advised to undergo surgery
after her pregnancy but did not comply due to absence of symptoms. The patient’s
condition was asymptomatic, not until 3 years after.

3 years prior to admission, the patient complained of Right Upper Quadrant Pain
with a pain scale of 5 out of 10, and was radiating to the back. She consulted a physician
in Kidapawan, and was ordered to have another ultrasound, revealing a 1.2 cm gallstone.
The patient was advised for surgery, but did not comply. She underwent self-medication
with herbal medicine (MX3), but intermittent right upper quadrant pain did not stop. The
patient confessed that she was fond of eating fatty and high cholesterol foods at the time.
She tolerated the condition

Six months prior to admission, the patient complained of increased frequency of

RUQ pain, and self-medicated with Udcacid, and was relieved. The patient self-medicated
with Udcacid 300mg/tab for pain per as necessary.

One month prior to admission, persistence of RUQ pain was still noted, and
patient opted for another ultrasound which revealed cholecystolithiasis. Thus, the patient
consulted her physician, and was advised for surgery, leading to the current admission.
 14

V. DEVELOPMENTAL DATA

Erikson’s Stages of Psychosocial Development:

Erikson enumerate eight stages though which healthily developing human should
pass from infancy to late adulthood. At each stage, there is a crisis to be resolved and a
virtue to be gained. According to the theory, failure to properly master each step leads to
problems in the future.

STAGE DESCRIPTION RESULT JUSTIFICATION

Third Stage (3-5 Child learns Achieved Patient verbalized
years) initiative as they that according to her
“Initiative vs. Guilt” begin to do things mother, as early as
for himself or guilt 3 years old, she can
over making his own already identify and
choices choose between
what food she wants
and doesn’t want
and was also able to
say “sorry” when
she hurts someone.
Fourth Stage (6-12 Emerging Achieved The patient was an
years) confidence in own honor student
“Industry vs. abilities; taking before, she was
Inferiority” pleasures ranked top 6 during
accomplishments grade 5.
 15

Fifth Stage (12 to 18 Formulating a sense Achieved Patient verbalized

years) of self and that during these
“Identity vs. Role belonging stage she was able
confusion” to gain self-worth
through her
experiences. She
was able to identify
her strength and
weakness by this
time.
Sixth Stage (18 to Forming adult, Achieved Patients verbalized
35 years) “Intimacy loving relationships she was more
vs. Isolation” and meaningful comfortable to open
attachments to to her friends and
others her partner rather
than to her parents.
But later on, she
was also able to be
involved in coping
with the occurring
family problems.
Seventh Stage (35 Being creative and Working on process The patient and his
to 55 years) productive; partner are now
“Generativity vs. establishing the next working together to
Stagnation” generation. tend their offspring
as they grow old
and become good
citizens.
 16

Havighurst’s Developmental Task:

Havighurst defines a developmental task as one that arises as a certain period in
our lives, the successful achievement of which leads to happiness and success with later
tasks; while leads to unhappiness, social disapproval, and difficulty with later tasks. He
identifies three sources of developmental tasks (1972).
 Tasks that arise from physical maturation
 Tasks that arise from personal values
 Tasks that have source in the pressures of society.
Our client belongs to the 5TH stage, which is the infancy.
The following are the developmental task that an infant must fulfill or achieve.

DEVELOPMENTAL
TASK RESULT JUSTIFICATION
(Middle adulthood)
Achieving adult Achieved The patient finished college, and got a licence as
civic and social a teacher. She works as a public highschool
responsibility teacher in their municipality, and is happy of
having such career.
Establishing and Achieved The patient, and her partner has a budget plan
maintaining an every month. The patient was also able to show
economic standard practicality by spending the money on what is
of living needed than wanted.
Assisting teenage Achieved The patient was able to assist her eldest daughter
children to become to learn and grow up with moral values most
responsible and especially in valuing their parents and being
happy adults responsible enough with their studies.
Developing adult Achieved The patient and her partner allots time for leisure-
leisure-time time activities such as traveling together and going
activities to the beach with their children.
Accepting and Achieved The patient shows positive response in accepting
adjusting to the physiologic changes such as aging and her
 17

physiologic current situation and condition. Yet the patient

changes or middle verbalized that she was having a hard time with
age regards to the illness she got but was able to cope
up later on.
Adjusting to aging Achieved The patient continuously provides support and
parents. care for her mother’s sister who is a cancer
survivor up to this time.
Freud’s Psychosexual Development:
Freud’s Stages of Psychosexual Development are, like other stage theories,
completed in a predetermined sequence and can result in either successful completion
or a healthy personality or can result in failure, leading to an unhealthy personality. This
theory is probably the best known as well as the most controversial; as Freud believed
that we develop through stages based upon a particular erogenous zone. During each
stage, an unsuccessful completion means that a child becomes fixated on that particular
erogenous zone and either over– or under-indulges once he or she becomes an adult.

STAGE RESULT JUSTIFICATION

ANAL (2 to 3 years) Achieved The patient verbalized that her mother
once said that as early as 2 years old,
she was able to respond to some of the
demands of society such as bowel and
bladder control.
PHALLIC (3 to 7 Achieved The patient verbalized that she was able
years) to identify the difference between males
and females and becomes aware of
sexuality within the given range of age.
LATENCY (7 to 11 Achieved The patient agreed that on this stage,
years) sexual urges are relatively quiet.
Instead, it focused more on the
 18

physiologic and psychologic

developmental aspect.

GENITAL (11 to Achieved The patient verbalized that as a grown

adult) up adolescent, she shakes off old
dependencies and learns to maturely
deal with opposite sex especially with
her partner.

VI. PATIENT’S DIAGNOSIS

Admitting Diagnosis Chronic Calculous Cholecystitis s/p Laparoscopic

Cholecystectomy

Chronic Calculous Cholecystitis

1. The major clinical presentation of gallstones is inflammation of the gallbladder, or

Cholecystitis. Cholecystitis can be either acute, chronic, or acute against a
background of chronic disease. An episode of acute Cholecystitis progress to acute
fails to clear the sphincter of Oddi, thereby blocking the pancreatic duct. Likewise, an
inflamed gallbladder can become infected or can undergo infarction and necrosis
pancreatitis if a stone travels down the common bile duct but, setting the stage for
systemic sepsis if the patient does not receive systemic broad-spectrum antibiotics
and undergo emergency cholecystectomy. (Hammer, McPhee, 2014)

2. Cholecystitis results from repeated episodes of acute Cholecystitis or chronic

irritation of the gallbladder by stones. It is characterized by varying degrees of chronic
inflammation. Gallstones almost always are present. Cholelithiasis with chronic
Cholecystitis may be associated with acute exacerbations of gallbladder
inflammation, common duct stones, pancreatitis, and, rarely, carcinoma of the
gallbladder. (Porth, 2014)
 19

3. Chronic inflammation of the gallbladder wall is almost always associated with the
presence of gallstones and is thought to result from repeated bouts of sub-acute or
acute Cholecystitis or from persistent mechanical irritation of the gallbladder wall by
gallstones. The presence of bacteria in the bile occurs in >25% of patients with
chronic Cholecystitis. The presence of infected bile in a patient with chronic
Cholecystitis undergoing elective cholecystectomy probably adds little to the
operative risk. Chronic Cholecystitis may be symptomatic for years (Kasper, 2015)

Laparoscopic Cholecystectomy

1. Laparoscopic cholecystectomy (removal of the gallbladder through a small incision

through the umbilicus). As a result, surgical risks have decreased, along with the
length of hospital stay and the long recovery period associated with the standard
surgical cholecystectomy. (Hinkle, J. L., 2014)

2. Cholecystectomy is one of the most commonly performed abdominal surgical

procedures, and in developed countries many are performed laparoscopically. As an
example, 90 percent of cholecystectomies in the United States are performed
laparoscopically. Laparoscopic cholecystectomy is considered the "gold standard" for
the surgical treatment of gallstone disease. This procedure results in less
postoperative pain, better restoration, shorter hospital stays and disability from work
than open cholecystectomy. (Sopher & Malladi, 2017)

3. This technique is the most common for simple cholecystectomy. The surgeon will
make several small incisions in the abdomen. Ports (hollow tubes) are inserted into
the openings. Surgical tools and a lighted camera are placed into the ports. The
abdomen is inflated with carbon dioxide gas to make it easier to see the internal
organs. The gallbladder is removed, and the port openings are closed with sutures,
surgical clips, or glue. Your surgeon may start with a laparoscopic technique and
 20

need to change (convert) to an open laparotomy technique. The procedure takes

about 1 to 2 hours. (American College of Surgeons, 2013)

VII. ANATOMY AND PHYSIOLOGY

Anatomy and Histology of the Gallbladder

 21

The gallbladder is a muscular sac with a resting volume of about 50 mL that lies
on the inferior surface of the liver. It is connected to the hepatic biliary system by the cystic
duct, which leads to the common bile duct whose opening into the proximal duodenum is
controlled by the sphincter of Oddi. The common bile duct and the pancreatic duct usually
join just proximal to this sphincter.
The gallbladder is a 4-inch sac with a muscular wall that is located under the liver.
Here, most of the fluid is removed from the bile (about 2 - 5 cups a day), leaving a few
tablespoons of concentrated bile.
The gallbladder serves as a reservoir until bile is needed in the small intestine to digest
fats. This need is signaled by a hormone called cholecystokinin, which is released when
food enters the small intestine.
Cholecystokinin causes the gallbladder to contract and deliver bile into the intestine.
The force of the contraction propels the bile down the common bile duct and into the small
intestine, where it emulsifies (breaks down) fatty molecules.
This part of the digestive process enables the emulsified fat, along with important fat-
absorbable nutrients (such as vitamins A, D, E, and K), to pass through the intestinal
lining and enter the bloodstream.
 22

Physiology of the Gallbladder

Bile, which is produced by the liver, flows down the hepatic duct and into the
gallbladder through the cystic duct. It is stored there until stimulation of gallbladder
contraction expels the contents of the gallbladder back through the cystic duct into the
common bile duct and through the sphincter of Oddi into the duodenum. Stimuli for
gallbladder contraction and sphincter of Oddi relaxation necessary for proper bile flow
include both hormones and neural inputs. Fat in the intestine stimulates secretion of the
hormone CCK from I-cells. CCK causes contraction of the gallbladder and relaxation of
the sphincter of Oddi. Depending on how long it remains in the gallbladder, bile becomes
concentrated. Bile composition is further modified by mucin production under the control
of prostaglandins and by saturation of bile cholesterol controlled in part by estrogens.

The formation of gallstones is a complex process that starts with bile, a fluid
composed mostly of water, bile salts, lecithin (a fat known as a phospholipid), and
 23

cholesterol. Most gallstones are formed from cholesterol. Bile is important for the
digestion of fat. It is first produced by the liver and then secreted through tiny channels
that eventually lead into a larger tube called the common bile duct, which leads to the
small intestine. Only a small amount of bile drains directly into the small intestine,
however. Most flows into the gallbladder through the cystic duct, which is a side branch
off the common bile duct. This system of ducts through which bile flows is called the biliary tree.
 24

VIII. PHYSICAL ASSESSMENT

General Assessment

Physical Assessment done at Ward 3-C of the Davao Medical School Foundation

(DMSF) Hospital, Davao City, 10:10 am of January 12, 2017 while patient was awake

and sitting on bed. The patient is 36 years old, weighing at 56.4 kilograms and a standing

height of 148cm. Arms and legs are proportionate to the body. Patient is responsive but

shows no signs of labored breathing. She was wearing appropriate clothing to compliment

with air-conditioned room. No sudden weight loss noted on patient despite strict

compliance of low-fat diet.

Vital Signs

• Temperature- 36.8 °C

• Pulse Rate- 85 bpm

• Respiratory Rate- 23 cpm

• BP : 110/90 mmHg

Pain

During assessment the client don’t show any signs of distress.

Skin, Hair, Nails Assessment

Skin color is brown. Lip membrane is slightly pale and dry. Nails are trimmed but

with dirt on its sides. No signs of Jaundice noted. Patient skin is slightly warm to touch

with a temperature of 36.8 °C. Client has good skin turgor. Client’s hair is black in color,

with some gray hair on forehead area and is medium in length. Her hair is evenly
 25

distributed throughout the body. The client’s nail plate is slightly pale. Capillary refill of 3

seconds noted.

Head, Neck, Regional Lymphatics Assessment

Head is normocephalic and symmetrical. Skull is smooth, non-tender, and without

masses or depressions. Scalp is shiny, intact, moist and lighter in color than complexion.

No scars, nits, dandruff, or infestations noted. No lesions, tenderness, nor masses noted

upon palpation. Shape of face is oval and symmetrical. No lumps and swelling,

tenderness noted. Forehead is symmetrical, and no rashes, scars, pimples, tenderness,

lumps, masses noted. Muscle of the neck is symmetrical with the head in central position.

Eye Assessment

Eyes are symmetrical and in line with each other. Eyeballs are semi-protruding but

with equal palpebral fissure. Eyebrows are symmetrically aligned and evenly distributed.

Equal eye movement noted. Eyelashes are black in color, equally distributed, and slightly

curled outward. The sclera appears slightly yellow in color and moist. No lesions noted.

Both conjunctivae are smooth, shiny, and pink in color. No swelling noted or tenderness

noted. The corneal surface is moist, shiny and transparent with no abnormal discharges

or cloudiness noted. The irises are dark brown in color. The pupils are black in color;

appears round, smooth, and of equal size. Pupils dilate at 3mm and constrict at 2mm. No

drooping, infections, tumors, lesions, and abnormal discharges noted in all areas of the

eyes.

Ears, Nose, Mouth and Throat Assessment

Both ears match the color of the rest of the patient’s skin. Ears are positioned

centrally and in proportion to the head. The top of the ear crosses the imaginary line
 26

drawn from the outer canthus of the eye to the occiput. There were no foreign bodies,

redness, drainage, deformities, nodules, tenderness or lesions noted.

Nose is located symmetrically in the midline of the face and is without swelling,

bleeding, lesions or masses. Runny nose was noted. No tenderness noted upon

palpation. Septum is at midline and without perforation, lesions or bleeding noted. No

evidence of swelling noted around the eyes.

Lip membranes are slightly pale and moist, without evidence of lesions or

inflammation taken place. Tongue is in the midline of the mouth. No swelling or bleeding

found. Teeth are off white in color, no dentures noted. Gums are pink, moist, and firm with

no signs of bleeding or swelling. Uvula is at midline. Tonsils are present and pink in color.

No inflammation noted.

Thorax and Lungs Assessment

Patient’s shoulders are of the same height. The scapulae are at the same height

bilaterally. No masses, tenderness. Respiratory rate is 23 breaths per minute. Shallow

respirations noted. Patient inhales and exhales through the nose. No chest indrawing

noted.

Abdomen Assessment

Abdomen contour is rounded and clean. Slight protruding appearance noted which

is normal. Diaphragm rises with inspiration and falls with expiration. Umbilicus is

depressed and beneath the abdominal surface. Skin immediately returns to normal shape

when slightly pinched, results to normal skin turgor. Incision wounds on the Right Upper

quadrant of theabdomen noted, as well as another in the umbilicus.

 27

Musculoskeletal System Assessment

Patient’s head is at midline and is perpendicular to the shoulders and pelvis. The

shoulder and hips are at level, and the arms hand freely from the shoulders. Right and

left shoulders are of the same level. No pain, stiffness, masses, and inflammation noted.

Mental Status

Patient is aware of his surroundings. She is responsive to the external stimuli and

able to communicate through writing and hand gestures.

Cardiovascular Assessement

No palpitations noted. No presence of chest pain noted. Cardiac Rate of 85 bpm

Sinus Rhythm.

Genito-Urinary Assessment

The patient refused for her genitals to be checked but reported she voids freely

without pain.
 28

IX. ETIOLOGY

The 5-F rule refers to risk factors for the development of cholelithiasis in the event of
upper abdominal pain:
 Fair: Caucasian Descent
 Food: Fatty Diet
 Female
 Fertile: one or more children
 Forty: age ≥40

Predisposing Factors

Factor Presence Rationale Justification

Descent Genetic Suscptibility of Cuacasian race

has higher percentage than of Asian.
(https://www.ncbi.nlm.nih.gov/pmc/articles
/PMC1422514/)

Gender X Females have a slightly higher risk than Patient is female

males
(Source:
http://www.medicalnewstoday.com/articles
/188993.php)

Fertile X Both estrogen and progesterone influence Patient has two

the digestive process a way that promotes offsprings. One
gallstone formation. Estrogen increases pregnancy of
cholesterol levels in the bile, while which was the time
progesterone makes the gallbladder empty her ultrasound
more slowly. finings revealed a
gallstone.
 29

(http://drmarinarose.com/digestion-and-
detoxification/why-women-are-at-higher-
risk-for-gallbladder-symptoms/)

Age Forty is an indicator of the premenopausal The patient is still

time for women, bringing on spikes of 36 years old.
estrogen levels.
(https://www.floridahospital.com/blog/4-fs-
gallbladder-disease)

Precipitating Factors

Factor Presenc Rationale Justification

e

Food X Fatty foods such as deep-fried foods, foods high Patient

in cholesterol and spicy foods can all trigger a admitted of
frequently
gallbladder attack and cause inflammation of the
eating foods
bile ducts, as well as Cholesterol accumulation, high infat
which then leads to Cholesterol-derived and
cholesterol
gallstones.
content, such
(https://www.livestrong.com/article/368910- as roasted
inflammation-of-the-gall-bladder-from-fatty-foods/) pig, and pork
soy stew.
 30

X. SYMPTOMATOLOGY

Because of the absence of specific symptoms, the disease is difficult to diagnose.

Chronic Cholecystitis is supported by a family history of Cholelithiasis, episodes of
jaundice, multiple births and obesity. Sometimes chronic Cholecystitis is indicated by
episodes of acute Cholecystitis or biliary colic attacks.

Signs & Presence Clinical Significance Justification

Symptoms

Right X The pain in the right side is most often Patient has
Upper associated with the pathology of the biliary tract been
Quadrant (stones, dyskinesia, inflammation - cholangitis, complaining
Abdominal Cholangiocholecystitis, Cholecystitis). In of RUQ
Pain addition to typical attacks of hepatic or biliary abdominal
radiating to colic, with bile duct disease, mild non-stiff pain pain,
the back. can be observed, not only in the right side, but radiating to
also in the epigastric region, often with her back, all
irradiation in the back and under the scapula, along, prior
as well as dyspeptic symptoms. to surgery.
(http://iliveok.com/health/pain-right-
side_105783i15965.html)

Fatty Food X Bile acid malabsorption (BAM) refers to the Patient’s GI

Intolerance presence of increased amounts of bile acids in functioning
the colon, resulting in symptoms. As bile acids was
are important in the absorption of fats, compromised
intolerance to fatty foods or even normal due to
amounts of dietary fat are often observed. Bile persistent
acids are produced in the liver and play a major intake of fatty
role in the absorption of dietary fats from the foods,
 31

Signs & Presence Clinical Significance Justification

Symptoms

small intestine. About 95% of bile acids are wherein LDL

actively reabsorbed in the lowest part of the results of the
small intestine and returned to the liver. About patient was
5% of bile acids normally reach the colon to be baseline-
excreted in the stool. Bile acid malabsorption high, as well
leads to increased amounts of bile acids in the as bile
colon, causing higher water content, raised gut sludge was
permeability, accelerated transport in the colon noted in the
and increased mucus secretion, amongst other 2014
effects. ultrasound
report.
(http://foodintolerances.org/intolerances/fat-
intolerance-bile-acid-malabsorption/)
 32

XI. PATHOPHYSIOLOGY

Predisposing Factors: Precipitating Factors:

 Gender: Female  Food: High-fat and High-
 Fertile: 2 offspring Cholesterol Diet

Supersaturation of cholesterol in the bile

Gallstone formation in the Gallbladder

Pressure Obstruction

Bile Stasis
- Decrease Fat
Emulsification:
fat intolerance
- Inflammation:
Irritation of gallbladder
Accumulation of Bile in Pain (RUQ)
lining mucosal surface
Liver - Leukocytosis

Mucus Hyper secretion

Cholecystitis

Prognosis
If not treated:
If Treated:  Empyema and Hydrops
 Laparospic  Gangrene and
Cholecystectomy Perforation
 Diet Management.  Fistula Formation and
 Antibiotic and Pain Gallstone Ileus
Management Therapy  Limey (Milk of Calcium)
Bile and Porcelain
Gallbladder
 33

XII. DOCTOR’S ORDER

Date and Time Orders Rationale Remarks

ordered

September 9,  Refer this patient for  The patient was  Patient was
2014 Laparoscopic diagnosed with referred in Dr.
3:20pm Cholecystectomy. Cholelithiasis and Lasala Gen.
Dr. Lasala needs to be Surgery.
referred to a
Surgeon for
management.

 The patient needs  Patient was

 Admit under combine to be confined prior admitted at DMSF
December 29, service with Dr. Lasala// to any surgery to ward 3-c on
2017 Dr. Derla be done on her, in January 10, 2018
Dr. Derla order to maintain at 1:00pm.
 Notify once admitted for and monitor her
surgery scheduling condition.

 In order to proceed  The patient was

with the surgery scheduled to
undergo
Laparoscopic
Cholecystectomy
on January 11,
2016 at 6am.
January 10,
2018  Please admit patient under  Low fat diet was
1:00pm the service of Dr. Derla ordered in order to  Patient was
Dr. Jonathan (IM-Gastro Digestive prevent further faithfully admitted
Narisma Endoscopy) build-up of under the service
 Secure consent to care, cholesterol stones of Dr. Derla
low fat diet in the gallbladder. (Gastro).
 Monitor Vital signs
 Venoclysis: PNSS 1Liter  To determine
@ 90cc.hr (Maintainance which treatment
Rate) protocols to follow,
 Laboratories/Diagnostics provide critical
-ECG information needed
-CBC with Platelet to make life-saving
-Creatinine decisions, and  Patient’s VS and
-Chest X-ray PA confirm feedback InO was taken
-Serum Electrolyte on treatments and recorded q4
(Na, K, Ca, Mg) performed. and undergo
-Blood type laboratory test.
 CBC- used to
 Medications: evaluate the overall
health and detect a
1. Omeprazole wide range of
40mg/amp 1 amp OD disorders, including
IVTT anemia, infection
 34

2. Ketorolac 30mg/amp and leukemia. It

1 amp, q8 (PRN) also measures
3. Hyoscine Butyl several
Bromide 10mg/amp 1 components and
amp q6 features of the
blood, including:
 Attach lab results to chart Red blood cells,  Labs attached to
 Will inform Dr. Derla about which carry chart. Done.
this admission oxygen.
 Will inform SPOD once in
room  Na, K, Crea- helps
 Monitor Input and output diagnose and/or
very shift. monitor kidney
 Watch out for unusualities disease.  Done
such as severe, jaundice,
and others, then refer  to screen for,
ASAP. diagnose, and
 Refer Accordingly monitor a range of
 Thank you conditions relating
to the bones, heart,
nerves, kidneys,
and teeth.
4:20pm  Please schedule patient  Patient was
Dr. Jonathan for laparoscopic  to find out how scheduled for
Narisma cholecystectomy many red blood surgery.
tomorrow @ 9:00am cells (RBCs) does
 Secure Anaesthesiologist the patient have.
Clearance
 Please inform  Help find the cause  Anaesthesiologist
Anaesthesiologist care of of common informed and
Dr. Mabunga symptoms such as a obtained
 For Cardio-Pulmonary cough, shortness of clearance.
Clearance car of Dr. breath, r chest pain.
Hernandez
 Refer accordingly
 Thank you!  Labs and
Diagnostic tests
are for obtaining
Anaesthesia Pre-op order: baseline data and  Pre-assessment
9:00pm  Pre-Assessment: assess for any done
Dr. De Chavez (-) Diabetes Mellitus unusualities prior
(-) Hypertension to surgery.  NPO done.
(-) Bile Acids
Hgb 138
 Thank you for this referral  IVF therapy
 NPO after midnight  This is for safety maintained.
 Record Vital signs en reasons. This
route to OR prevents stomach
 Increase IVF rate to contents from
120cc/hr (PLR 1L @ entering the lungs
120cc/hr) when having
 Medication: anaesthesia.
13. Omeprazole 40mg  Hydrate and avoid
IVTT @ 6am tom. patient of losing
14. Midazolam 15mg ½ electrolytes, while
tab @ 7am on NPO.
 35

 Void prior to taking

midazolam.
 Refer

Jan. 11, 2018  Post-op Orders  To prevent any  Done

12:50pm  Post-Laparoscopic dehydration and
Dr. Mabunga Cholecystectomy with fatigue after
lysis of adhesions surgery.
 General Liquids once
fully awake
 Soft diet post 6pm  To prevent emesis  Done
 Vital signs q15mins x and nausea after
1hr, q30min x 2hours, surgery.
and q4 hours.
 Continue IVF: PLR 1L  To closely monitor  Done
@ 120cc/hr any abnormalities
 Moderate High Back as anaesthesia
Rest fades-out.
 Oxygen Therapy @
2lpm via nasal canula  To encourage  Done
@ PACU proper breathing
 Medication: and oxygenation.
1. Ampi-Subactam 1.5grams
IVTT q8 hours x 2 dose,
after start
Sultamicillin750mg 1 tab
BID.
2. Parecoxib 40mg IVTT
@9pm, after start
Etoricoxib 90mg 1 tab
BID in the morning.
3. Nalbuphine 50mg IVTT q
8 hours PRN for
unbearable pain.
4. Refer

3:00pm  Continue present  Post-operation  Done

Dr. Derla management and vital patients have
signs monitoring tendencies to have
 Watch out for homeostatic
hypovolemia, severe imbalance due to
abdominal pain, and the post-
dyspnea. anaesthesia effect.
 Continue Antibiotics Hypovolemia may
 Will update Dr. Lasala occur due to blood
for patient’s Post-op loss upon surgery.
Status Severe abdominal
pain is due to the
incisions done on
7:30pm  Give metoclopramide the abdomen, and
(+) vomiting 1 ampule IVTT q8 RN dyspnea occurs
Dr. De Chavez for vomiting due to respiratory
compensation of
the body, due to
 36

lack of oxygen
supply.
January 12,  Encourage ambulation  For blood  Done
2018  Deep breathing exercises circulation and
10:00am 10x hourly for waking easily eradicate
hours only anaesthetic effects
 Continue Antibiotic in the body.
coverage
 Refer

10:20am  May go Home anytime

Dr. Lasala gastro-wise.

12:00pm  To start soft diet/ diet as  The momentum of  Done

Dr. Derla tolerated
 Discontinue IVF and
Parenteral medications
 Discontinue Omeprazole
 Start Arcoxia 120mg/tab, 1
tab OD PRN for pain.
 Multivitamins + Minerals
(Conzace) 1 capsule OD
 Tentative acceptance for
MGH in AM.
the Gastro-
intestinal system
has just started to
function prior to
anaesthesia, thus it
is vital to start
eating soft foods in
order to not upset
the GI tract.

1:00pm  MGH from Gastro-service

Dr. Lasala
 37

XIII. DIAGNOSTIC AND LABORATORY TESTS

TEST(S) PATIENT’S REFERENCE CLINAL SIGNIFICANCE

RESULT RANGE

Clinical
Chemistry
January 10,  3.80mmol/L  3.50- Potassium helps to move
2018 5.30 waste out of cells and
nutrients into cells. This
 Potassium electrolyte is essential to
proper muscle and nerve
function.

 Sodium  142.3  135.00-

mmol/L L 148.00 Sodium is both an
electrolyte and mineral. It
helps keep the water (the
amount of fluid inside and
outside the body's cells)
and electrolyte balance of
the body. Sodium is also
important in how nerves
and muscles work.
 38

Clinical Chemistry

 Calcium  1.17  1.13- 1.32  Calcium test is ordered to

mmol/L screen for, diagnose, and
monitor a range of
conditions relating to the
bones, heart, nerves,
kidneys, and teeth.

 Magnesium  0.82  0.74-

0.99

 Creatinine  65.21  0.48-90.0  Creatinine is a waste product

umol/L umol/L that forms
when creatine breaks
down. Creatine is found in
your muscle. Creatinine
levels in the blood can
provide your doctor with
information about how well
your kidneys are working.
Doctors measure the level of
creatinine in the blood to
check kidney function.
 39

Hematology

Blood Type:

B Rh Positive
 138.0 g/L  120.0- It measures the total
CBC + PLT 155.0 amount of the oxygen-
carrying protein in the
 Hemoglobin blood, which generally
reflects the number of
RBCs in the blood. It
usually mirrors RBC
results.
 Hematocrit  0.35  0.36- It measures the
0.48 percentage of a
person’s total blood
volume that consists of
RBCs. Usually mirrors
RBC results
 RBC Count  4.22  4.00- It is a count of the actual
x10^/uL 6.10 number of RBCs in a person’s
sample of blood. It indicates
that the patient is anemic. It
could be caused by trauma,
RBC destruction, nutritional
deficiency, bone marrow
disorder or damage, chronic
inflammatory disease, and
chronic kidney disease.
 WBC Count  7.06  5.0- It is a count or the total
X10^3/uL 10.0 number of WBCs in a
person’s sample of blood.
Patient is leukocytosis
Differential Count

 Neutrophil  56  55.00- It is also known as

75.00 granulocytes and the most
abundant type of WBC in
healthy adults.
 Lymphocytes  30  20-35 It is also known as
granulocytes and the most
abundant type of WBC in
healthy adults.
 40

 Monocytes  13 H  2-10 Monocyte level is normal.

This replenishes
macrophages under normal
state and it response to
inflammation signals.
 Eosinophils  0.02 L  0.02- Leukocyte with granules are
0.04 stained by the dye, eosin.
Eosinophils are believed to
function in allergic responses
and it resists in some
infections.
 Basophils  0  0-0.1 It is a type of WBC, with
coarse granules that stains
blue when exposed to a basic
dye. Basophils normally
constitute 1% or less of the
total WBC count but may
increase or decrease in
certain diseases.
 Platelet  424  150- It is the number of platelets in
Count x10^3/uL 400 a person’s sample of blood.
This can indicate whether the
patient is bleeding or not.
 MCV  86.70 fl  79.40- Mean Corpuscular Volume is a
94.80 measurement of the average
size of a single RBC. Indicates
RBCs are larger than normal
(macrocytic), for example in
anemia caused by vitamin B12
or folate deficiency,
myelodysplasia, liver disease,
hypothyroidism
 MCH  29.4 pg  260- Mean Corpuscular
32.20 Hemoglobin is a calculation of
the average amount of
hemoglobin inside a single
RBC. Mirrors MCV results;
macrocytic RBCs are large so
tend to have a higher MCH.
 MCHC  339 Mean Corpuscular
 320- Hemoglobin Concentration is
1/18/17 360 a calculation of the average
10:14 AM concentration of hemoglobin
inside a single RBC.
 41

TEST(S) PATIENT’S REFERENCE CLINAL

RESULT RANGE SIGNIFICANCE
Hematology

Blood type (ABO + Rh)

Blood type B To determine the
patient’s blood
type The test is
essential if the
patient needs a
blood transfusion or
are planning to
donate blood. Not
all blood types are
compatible, so it is
important to know
the blood group.
Receiving blood
that is incompatible
with the patient’s
blood type could
trigger a dangerous
immune response.
Blood type Rh Positive Rhesus (Rh) factor
is an inherited
protein found on
the surface of red
blood cells. If your
blood has the
1/18/17 protein, you're Rh
positive. If your
blood lacks the
protein, you're Rh
negative.
 42

TEST(S) PATIENT’S REFERENCE CLINAL SIGNIFICANCE

RESULT RANGE
Clinical
Chemistry
(Assessment of low-density lipoprotein
12/08/18 C (LDL-C) in patients with
ypertriglyceridemia, type III
Cholesterol 5.60 0 – 6.40 hyperlipoproteinemia/dysbetalipoprotei
mmol/L nemia, or when an accurate gold
standard determination of LDL-C is
required.

SGPT 40.4 0-42 U/L Serum glutamic pyruvic transaminase,

an enzyme that is normally present in
liver and heart cells. SGPT is released
into blood when the liver or heart are
damaged. The blood SGPT levels are
thus elevated with liver damage (for
example, from viral hepatitis) or with an
insult to the heart (for example, from a
heart attack). Some medications can
also raise SGPT levels. Also called
alanine aminotransferase (ALT).

TEST(S) PATIENT’S RESULT CLINAL SIGNIFICANCE

Clinical The liver is normal in size
Ultrasound
with smooth external
report Ultrasound is occasionally used in the
outine. It exhibits a normal
emergency department to expedite the
Date:
hypoecholic parenchymal
09/09/2014 care of people with right upper quadrant
echopattern. No focal solid
abdominal pain who may have
or cystic lesion
gallstones or Cholecystitis. Abdominal
demonstrated. Intrahepatic
 43

ducts are not dialted. ultrasound: Ultrasound produces

Thewidest anteroposterior pictures of the gallbladder and bile
diameter of the common
bile dict is about 3mm.

The gallbladder is
adequately distended ut
shos thickened walls
measuring up to 0.8 cm.
ducts. It shows signs of inflammation or
There is a 2.0 cm
indications that there is blockage of bile
shadowing echogenic focus
flow. Ultrasound is the most common
exhibit dependent mobility
test performed to evaluate gallbladder
within the gallbladder
abnormalities.
lumen. There are low level
echoes suspended within
the gallbladder lumen as
well.
The pancreas is normal in
size (head= 1.3cm, body=
1.3cm, AP=9.3cm) and
tissue echogencity. No
focal lesions noted here.
No enlarged lymph nodes
appreciated along the para-
aortic regions

The spleen is normal in size

There is no significant
disparity in the size, shape,
 44

location of the kidneys.

Both exhibitnormal
hypoechoic parenchyma
relative to the liver and
spleen.
Central echo-complexes
are intact. No Caleitasia
noted. The pelvocalyceal
system and ureters are not
dilated. No focal of diffuse
lesions.

Impression:

 Calculous
Cholecystitics with Bile
Sludge
 Sonographically
normal liver, biliary tree,
pancreas, kidneys, spleen,
aorta, para-aortic areas.

TEST(S) PATIENT’S RESULT CLINAL SIGNIFICANCE

Clinical The liver is normal in size
Ultrasound
and tissue attenuation. The
report Ultrasound is occasionally used in the
intrahepatic ducts are not
emergency department to expedite the
Date:
dilated. The widest
11/20/2014 care of people with right upper quadrant
diameter of the common
abdominal pain who may have
 45

bile duct is normal in gallstones or Cholecystitis. Abdominal

caliber. ultrasound: Ultrasound produces
pictures of the gallbladder and bile
The gallbladder is normal in ducts. It shows signs of inflammation or
size and configuration. No indications that there is blockage of bile
wall thickening, abnormal flow. Ultrasound is the most common
intraluminal echoes and test performed to evaluate gallbladder
calculi demonstrated. abnormalities.

The pancreas is normal in

size and parenchymal
echopattern, No focal
lesions noted.

Impression:

Sonographically Normal
Liver and Pancreas.

TEST(S) PATIENT’S RESULT CLINAL SIGNIFICANCE

Clinical The liver is normal in size
Ultrasound
with smooth external
report Ultrasound is occasionally used in the
outine. It exhibits a normal
emergency department to expedite the
Date:
hypoecholic parenchymal
12/09/2017 care of people with right upper quadrant
echopattern. No focal solid
abdominal pain who may have
or cystic lesion
gallstones or Cholecystitis. Abdominal
demonstrated. Intrahepatic
ultrasound: Ultrasound produces
ducts are not dialted.
pictures of the gallbladder and bile
Thewidest anteroposterior
ducts. It shows signs of inflammation or
indications that there is blockage of bile
 46

diameter of the common flow. Ultrasound is the most common

bile dict is about 3mm. test performed to evaluate gallbladder
abnormalities.

The gallbladder is
adequately distended ut
shos thickened walls
measuring up to 0.8 cm.
There is a 2.0 cm
shadowing echogenic focus
exhibit dependent mobility
within the gallbladder
lumen. There are low level
echoes suspended within
the gallbladder lumen as
well.
The pancreas is normal in
size (head= 1.3cm, body=
1.3cm, AP=9.3cm) and
tissue echogencity. No
focal lesions noted here.
No enlarged lymph nodes
appreciated along the para-
aortic regions

The spleen is normal in size

There is no significant
disparity in the size, shape,
location of the kidneys.
Both exhibitnormal
 47

hypoechoic parenchyma
relative to the liver and
spleen.
Central echo-complexes
are intact. No Caleitasia
noted. The pelvocalyceal
system and ureters are not
dilated. No focal of diffuse
lesions.

Impression:

 Consider
Cholecystolithiasis with
sludge ball and gallbladder
fossa cyst.
 Sonographically normal
liver, biliary tree, pancreas,
spleen, para-aortic
regions, kindeys, and
urinary bladder.
 48

XIV. SPECIAL PROCEDURES

Laparoscopic Cholecystectomy

Definition:

Laparoscopic cholecystectomy is a procedure in which the gallbladder is removed

by laparoscopic techniques. Laparoscopic surgery also referred to as minimally invasive
surgery describes the performance of surgical procedures with the assistance of a video
camera and several thin instruments.

During a laparoscopic surgical procedure, small incisions of up to half an inch are

made and plastic tubes called ports are placed through these incisions. The camera and
the instruments are then introduced through the ports which allow access to the inside of
the patient. The camera transmits an image of the organs inside the abdomen onto a
television monitor.The surgeon is not able to see directly into the patient without the
traditional large incision. The video camera becomes a surgeon’s eyes in laparoscopy
surgery, since the surgeon uses the image from the video camera positioned inside the
patient’s body to perform the procedure.

Procedures:

Step One: Creation of pneumoperitoneum as well as insertion of trocars.

Step Two: Separating of adhesions towards the gallbladder and the surrounding liver,
having exposure of the peritoneal fold in which the cystic duct as well as artery are
situated.

Step Three: Dissection as well as skeletonisation from the cystic duct as well as cystic
artery as well as occlusion and also division of these structures.

Step Four: Dissection and extraction of the gallbladder and closure of incisions.

When the telescope is inserted a fast inspection is done of the peritoneal cavity to exclude
obvious pathology and iatrogenic injury. The typical incisions for trocar insertion for
laparoscopic cholecystectomy are:
 49

 A 1 cm long infra-umbilical incision for that telescope trocar.

 A 5 mm incision within the right mid-axillary line about5 - 8 cm below the rib
margin.
 A 5 mm incision in the right mid-clavicular line about 2 cm. below the costal
margin.
 A 1 cm incision approximately in the junction of upper third minimizing 2/3rd of
the line between your xiphisternum and umbilicus.

XV. DRUG STUDY

Generic Name Omeprazole

Brand Names Prilosec

Classification Proton Pump Inhibitor

Dosage and 40mg/amp 1 amp OD IVTT

Frequency
Mechanism of Suppresses gastric acid secretion by specific inhibition of the
Action hydrogen potassium ATP as enzyme system at secretory
 50

surface of the gastric parietal cells; blocks the final step of acid
production.
Indication  GERD/maintenance of healing in erosive esophagitis.
Duodenal ulcers (with or without anti-infectives for
Helicobacter pylori). Short-term treatment of active benign
gastric ulcer. Pathologic hypersecretory conditions,
including Zollinger-Ellison syndrome. Reduction of risk of
GI bleeding in critically ill patients.
 OTC: heartburn occurring less than twice per week.

Contraindication  Hypersensitivity
 Pregnancy
 Lactation

Side Effects / CNS: dizziness, drowsiness, fatigue, headache, weakness

Adverse Effects CV: chest pain
GI: abdominal pain, diarrhea, flatulence, nausea, vomiting,
acid regurgitation, constipation
Derm: itching, rash
Misc: allergic reaction

Drug Interactions  Omeprazole is metabolized by the CYP450 enzyme

system and may compete with other agents metabolized by
this system. Decrease metabolism and may increase
effects of antifungal agents, diazepam, digoxin,
flurazepam, triazolam, cyclosporine, phenytoin, saquinavir,
tacrolimus, and warfarin.
 May decrease absorption of drugs requiring acid pH,
including ketoconazole, itraconazole, ampicillin, iron salts,
and digoxin. Has been used safely with antacids.
 May significantly decrease effects of atazanavir and
nelfinavir (concurrent use not recommended).
 May increase risk of bleeding with warfarin.
 May decrease the antiplatelet effects of clopidogrel.
Nursing  Assess patient routinely for epigastric or abdominal pain
Responsibilities
and frank or occult blood in the stool, emesis, or gastric
aspirate.
 Lab test Considerations: Monitor CBS with differential
periodically during therapy.
 51

 Lab test Considerations: Monitor urinalysis for hematuria

and proteinuria. Periodic liver function tests with
prolonged use.
 Report any changes in urinary elimination such as pain or
discomfort associated with urination, or blood in urine.
 Report severe diarrhea; drug may need to be
discontinued.
 Caution patient to swallow capsules whole not to open,
chew, or crush them
 Arrange for further evaluation of patient after 8 weeks of
therapy for gastro reflux disorders; not intended
for maintenance therapy
 Take the drug before meals.

Generic Name Ketorolac

Brand Names Toradol

Classification Antipyretic, NSAID

Dosage and
Frequency
30mg/amp 1 amp, q8 (PRN)
 52

Mechanism of Inhibits prostaglandin synthesis, producing peripherally mediated

Action analgesia. Also has antipyretic and anti-inflammatory properties.
Therapeutic Effect: Decreased pain

Indication Short-term management of moderately severe, acute pain

requiring opioid-level analgesia.

Contraindication  Hypersensitivity
 Cross-sensitivity with other NSAIDs may exist
 Pre- or perioperative use
 Known alcohol intolerance
 Use cautiously in:
1) History of GI bleeding
2) Renal impairment (dosage reduction may be required)
3) Cardiovascular disease

Side Effects /  Respiratory: rhinitis, hemoptysis, dyspnea

Adverse Effects
 GI: GI pain, diarrhea, vomiting, nausea
 CNS: dizziness, fatigue, insomnia, headache
 Hematologic: neutropenia, leukopenia, decreased Hgb or Hct,
bone marrow depression
 Dermatologic: sweating, dry mucous membrane, pruritus

Drug Drug: May increase methotrexate levels and toxicity; may

Interactions increase lithium levels and toxicity.

Herbal: Feverfew, garlic, ginger, ginkgo increased bleeding

potential.

Nursing Assessment & Drug Effects

Responsibilities
 Correct hypovolemia prior to administration of ketorolac.
 Lab tests: Periodic serum electrolytes and liver functions;
urinalysis (for hematuria and proteinuria) with long-term
use.
 Monitor urine output in older adults and patients with a
history of cardiac decompensation, renal impairment, heart
failure, or liver dysfunction as well as those taking diuretics.
Discontinuation of drug will return urine output to
pretreatment level.
 Monitor for S&S of GI distress or bleeding including nausea,
GI pain, diarrhea, melena, or hematemesis. GI ulceration
with perforation can occur anytime during treatment. Drug
 53

decreases platelet aggregation and thus may prolong

bleeding time.
 Monitor for fluid retention and edema in patients with a
history of CHF.

Patient & Family Education

 Watch for S&S of GI ulceration and bleeding (e.g., bloody

emesis, black tarry stools) during long-term therapy.
 Note: Possible CNS adverse effects (e.g., light-headedness,
dizziness, drowsiness).
 Do not drive or engage in potentially hazardous activities until
response to drug is known.
 Do not use other NSAIDs while taking this drug.
 Do not breast feed while taking this drug.

Generic Name Amlodipine

Brand Names Norvasc

Classification Antihypertensives; Calcium channel blockers

Dosage and 10mg/tab

Frequency Once a day
 54

Mechanism of Inhibits the transport of calcium into myocardial and vascular

Action smooth muscle cells, resulting in inhibition of excitation-
contraction coupling and subsequent contraction.

Therapeutic Effects: Systemic vasodilation resulting in

decreased blood pressure. Coronary vasodilation resulting in
decreased frequency and severity of attacks of angina.

Indication Alone or with other agents in the management of hypertension,

angina pectoris, and vasospastic angina.

Contraindication  Hypersensitivity
 Systolic Blood Pressure <90 mmHg
 Severe Hepatic Impairment
 Aortic Stenosis
 History of CHF
 Lactation

Side Effects / CNS: headache, dizziness, fatigue

Adverse Effects CV: peripheral edema, angina, bradycardia, hypotension,
palpitations
GI: gingival hyperplasia, nausea
Derm: flushing
Drug Interactions  Fentanyl
 Other hypertensives
 Nitrates
 Acute ingestion of Alcohol
 Quinidine
 NSAIDs
 Lithium
Nursing Assessment & Drug Effects
Responsibilities
 Monitor BP for therapeutic effectiveness. BP reduction
is greatest after peak levels of amlodipine are achieved
6–9 h following oral doses.
 Monitor for S&S of dose-related peripheral or facial
edema that may not be accompanied by weight gain;
rarely, severe edema may cause discontinuation of
drug.
 Monitor BP with postural changes. Report postural
hypotension. Monitor more frequently when additional
antihypertensives or diuretics are added.
 55

 Monitor heart rate; dose-related palpitations (more

common in women) may occur.

Patient & Family Education

 Report significant swelling of face or extremities.

 Take care to have support when standing & walking due to
possible dose-related light-headedness/dizziness.
 Report shortness of breath, palpitations, irregular
heartbeat, nausea, or constipation to physician.
 Do not breast feed while taking this drug without consulting
physician.

Generic Name Hyoscine-N-butylbromide (HNBB)

Brand Names Buscopan

Classification Antispasmodic; Anticholinergic

Dosage and 10mg/amp 1 amp q6

Frequency
Mechanism of Hyoscine-N-butylbromide (HNBB) acts by interfering with the
Action transmission of nerve impulses by acetylcholine in the
parasympathetic nervous system.

Buscopan exerts a spasmolytic action on the smooth muscle of the

gastrointestinal, biliary and urinary tracts. As a quaternary
ammonium derivative, hyoscine-N- butylbromide does not enter the
central nervous system. Therefore, anticholinergic side effects at the
 56

central nervous system do not occur. Peripheral anticholinergic

effects result from a ganglion-blocking action within the visceral
wall as well as from anti- muscarinic activity.

Indication Buscopan Tablets are indicated for the relief of spasm of the genito-
urinary tract or gastro- intestinal tract and for the symptomatic relief of
Irritable Bowel Syndrome
Contraindication  Buscopan Tablets should not be administered to patients
with myasthenia gravis, megacolon and narrow angle
glaucoma. In addition, they should not be given to patients
with a known hypersensitivity to hyoscine-N-butylbromide
or any other component of the product,

Side Effects / CNS: dizziness, anaphylactic reactions, anaphylactic shock,

Adverse Effects
increased ICP, disorientation, restlessness, irritability, dizziness,
drowsiness, headache, confusion, hallucination, delirium,
impaired memory
CV: hypotension, tachycardia, palpitations, flushing
GI: Dry mouth, constipation, nausea, epigastric distress
DERM: flushing, dyshidrosis
GU: Urinary retention, urinary hesitancy
Resp: dyspnea, bronchial plugging, depressed respiration
EENT: mydriasis, dilated pupils, blurred vision, photopobia,
increased intraocular pressure, difficulty of swallowing.

Drug Interactions  Potassium chloride

 Metoclopramide
 MAO inhibitors
 Beta-agonists
 Anticholinergics
 Antacids
 Droperidol

Nursing  Drug compatibility should be monitored closely in patients

Responsibilities requiring adjunctive therapy
 Avoid driving & operating machinery after parenteral
administration.
 Avoid strict heat
 57

 Raise side rails as a precaution because some patients

become temporarily excited or disoriented and some
develop amnesia or become drowsy.
 Reorient patient, as needed, Tolerance may develop
when therapy is prolonged
 Atropine-like toxicity may cause dose related adverse
reactions. Individual tolerance varies greatly
 Oerdose may cause curare-like effects, such as
respiratory paralysis. Keep emergency equipment
available.

Generic Name Ampi-Subactam

Brand Names B Unasyn

Classification Penicillins, Amino

Dosage and Frequency 1.5grams IVTT q8 hours x 2 dose
Mechanism of Action Short-acting parenteral benzodiazepine.
Mechanism of action unclear. Intensifies
activity of gamma-aminobenzoic acid
(GABA), a major inhibitory neurotransmitter
of the brain, by interfering with its reuptake
 58

and promoting its accumulation at neuronal

synapses. This calms the patient, relaxes
skeletal muscles, and in high doses
produces sleep.
Indication Susceptible skin and skin structure,
intraabdominal, gynecologic infections.
Contraindication Intolerance to benzodiazepines; acute
narrow-angle glaucoma; shock, coma;
acute alcohol intoxication; intraarterial
injection. Safety in pregnancy (category D),
labor and delivery, or lactation is not
established.
Side Effects / Adverse Effects CNS: Retrograde amnesia, headache,
euphoria, drowsiness, excessive
sedation, confusion.
CV: Hypotension. Special Senses:
Blurred vision, diplopia, nystagmus,
pinpoint pupils.
GI: Nausea, vomiting.
Respiratory: Coughing, laryngospasm
(rare), respiratory arrest.
Skin: Hives, swelling, burning, pain,
induration at injection site, tachypnea.
Body as a Whole: Hiccups, chills,
weaknessResp: dyspnea, bronchial
plugging, depressed respiration
EENT: mydriasis, dilated pupils,
blurred vision, photopobia, increased
intraocular pressure, difficulty of
swallowing.

Drug Interactions Drug: Alcohol, cns depressants,

anticonvulsants potentiate CNS
depression; cimetidine increases
midazolam plasma levels, increasing
its toxicity; may decrease
antiparkinsonism effects of levodopa;
 59

may increase phenytoin levels;

smoking decreases sedative and
antianxiety effects. Herbal: Kava-
kava, valerian may potentiate
sedatiodn.

Generic Name
Sultamicillin

Brand Names Ampicllin

Classification Anti-infectives
Dosage and Frequency 750mg 1 tab BID.

Mechanism of Action Description: Sultamicillin inhibits β-lactamases in penicillin-resistant

microorganisms and it acts against sensitive organisms during the stage of
active multiplication by inhibiting biosynthesis of cell wall mucopeptide.
Indication Upper & lower resp tract infections, UTI & pyelonephritis; bacterial
septicemia & pneumonia, intra-abdominal, gonococcal, skin, soft tissue,
bone & joint infections. Incidence of post-op wound infections undergoing
abdominal or pelvic surgery. Prophylaxis in termination of pregnancy or
cesarean.

Contraindication  Hypersensitivity,

Side Effects / Adverse Diarrhoea, nausea, vomitting, rashes, pruritus, blood dyscrasias,
Effects superinfections, dizziness, dyspnoea.
Potentially Fatal: Anaphylaxis.

Drug Interactions  Concurrent use increases risk of bleeding with warfarin and
methotrexate toxicity; decreases efficacy of oestrgen-containing oral
contraceptives. Excretion of ampicillin is reduced when used with
probencid.

Nursing Responsibilities  If your symptoms or health problems do not get better or if they
become worse, call your doctor.
 60

 Do not share your drugs with others and do not take anyone
else's drugs.
 Keep a list of all your drugs (prescription, natural products,
vitamins, OTC) with you. Give this list to your doctor.
 Talk with the doctor before starting any new drug, including
prescription or OTC, natural products, or vitamins.
 Keep all drugs in a safe place. Keep all drugs out of the reach of
children and pets.
 Check with your pharmacist about how to throw out unused
drugs.
 Some drugs may have another patient information leaflet. Check
with your pharmacist. If you have any questions about Unasyn
(ampicillin and sulbactam), please talk with your doctor, nurse,
pharmacist, or other health care provider.
 If you think there has been an overdose, call your poison control
center or get medical care right away. Be ready to tell or show
what was taken, how much, and when it happened.

Generic Name
Eterocoxib
 61

Brand Names Arcoxia

Classification Coxibs
Dosage and Frequency 1. 90mg 1 tab BID in the morning.

Mechanism of Action ARCOXIA belongs to a group of medicines called Coxibs. It works in a

similar way to traditional anti-inflammatory medicines, known as Non-
Steroidal Anti-Inflammatory Drugs (NSAIDs), by blocking the production of
substances that cause pain and inflammation. In clinical trials, ARCOXIA
has been shown to have a lower risk of serious side effects on the stomach
(for example, bleeding stomach ulcers) than NSAIDs. However taking
aspirin with ARCOXIA may reverse this benefit.
Indication Etoricoxib is indicated in adults and adolescents 16 years of age and older
for the symptomatic relief of osteoarthritis (OA), rheumatoid arthritis (RA),
ankylosing spondylitis, and the pain and signs of inflammation associated
with acute gouty arthritis.

Etoricoxib is indicated in adults and adolescents 16 years of age and older

for the short-term treatment of moderate pain associated with dental
surgery.
Contraindication  Upper gastrointestinal complications [perforations, ulcers or
bleedings (PUBs)], some of them resulting in fatal outcome, have
occurred in patients treated with etoricoxib.

 Caution is advised with treatment of patients most at risk of

developing a gastrointestinal complication with NSAIDs; the
 62

elderly, patients using any other NSAID or acetylsalicylic acid

concomitantly or patients with a prior history of gastrointestinal
disease, such as ulceration and GI bleeding.

 There is a further increase in the risk of gastrointestinal adverse

effects (gastrointestinal ulceration or other gastrointestinal
complications) when etoricoxib is taken concomitantly with
acetylsalicylic acid (even at low doses). A significant difference
in GI safety between selective COX-2 inhibitors + acetylsalicylic
acid vs. NSAIDs + acetylsalicylic acid has not been
demonstrated in longterm clinical trials

Side Effects / Adverse

Effects  feeling sick (nausea), vomiting
 heartburn, indigestion, uncomfortable feeling or pain in the
stomach
 diarrhoea
 swelling of the legs, ankles or feet
 high blood pressure
 dizziness
 headache
 allergic reactions including rash, itching and hives
 severe skin reactions, which may occur without warning
 taste alteration
 wheezing
 insomnia
 anxiety
 drowsiness
 mouth ulcers
 diarrhoea
 severe increase in blood pressure
 confusion
 hallucinations
 63

 platelets decreased
Drug Interactions Some medicines and Arcoxia may interfere with each other.
These include:

 warfarin, a medicine used to prevent blood clots

 rifampicin, an antibiotic used to treat tuberculosis and
other infections
 water pills (diuretics)
 ACE inhibitors and angiotensin receptor blockers,
medicines used to lower high blood pressure or treat
heart failure
 lithium, a medicine used to treat a certain type of
depression
 birth control pills
 hormone replacement therapy
 methotrexate, a medicine used to suppress the immune
system

Nursing Responsibilities Do not take ARCOXIA if:

 you have an allergy to ARCOXIA or any of the ingredients listed

at the end of this leaflet
 you have taken aspirin or other anti-inflammatory medicines
(commonly known as NSAIDs) before, which caused asthma,
pinkish itchy swellings on the skin (hives), runny nose, or other
allergic reactions
 you have had heart failure, a heart attack, chest pain (angina),
narrow or blocked arteries of the extremities (peripheral arterial
disease), a stroke or mini stroke (TIA or transient ischaemic
attack)
 you have had or are having major surgery on your heart or
arteries
 you have high blood pressure that has not been controlled by
treatment (check with your doctor or nurse if you are not sure
whether your blood pressure is adequately controlled)
 you have serious liver disease
 you have a current stomach ulcer or bleeding in your stomach or
intestines
 64

 you have serious kidney disease

Do not take ARCOXIA if:

 the packaging is torn or shows signs of tampering

 the expiry date on the pack has passed
 If you take this medicine after the expiry date has passed, it may
not work.

Nalbuphine

Generic Name

Brand Names Nubaine

Classification Opioid Analgesics

Dosage and 50mg IVTT q 8 hours PRN for unbearable pain
Frequency
Mechanism of Depresses pain impulse transmission at the spinal cord level
Action by interacting with opioid receptors
Indication Nalbuphine hydrochloride injection is indicated for the
management of moderate to pain severe enough to require an
opioid analgesic and for which alternative treatments are
inadequate. Nalbuphine hydrochloride can also be used as a
 65

supplement to balanced anesthesia, for preoperative and

postoperative analgesia, and for obstetrical analgesia during
labor and delivery.
Contraindication  Hypersensitivity to this product or parabens,
 addiction (opiate)
 Precautions: Pregnancy (B), breastfeeding, addictive
personality, increased intracranial pressure, MI (acute),
severe heart disease, respiratory depression, renal/hepatic
disease, bowel impaction,
 abrupt discontinuation
Side Effects / CNS Effects : Nervousness, depression, restlessness,
Adverse Effects crying, euphoria, floating, hostility, unusual dreams,
confusion, faintness, hallucinations, dysphoria, feeling of
heaviness, numbness, tingling, unreality. The incidence of
psychotomimetic effects, such as unreality,
depersonalization, delusions, dysphoria and hallucinations
has been shown to be less than that which occurs with
pentazocine.

Cardiovascular: Hypertension, hypotension, bradycardia,

tachycardia.

Gastrointestinal: Cramps, dyspepsia, bitter taste.

Respiratory: Depression, dyspnea, asthma.

Dermatologic: Itching, burning, urticaria.

Miscellaneous : Speech difficulty, urinary urgency, blurred

vision, flushing and warmth.
 66

Allergic Reactions : Anaphylactic/anaphylactoid and other

serious hypersensitivity

Drug Interactions  Increase: effects with other CNS depressants—alcohol,

opiates, sedative/hypnotics, antipsychotics, skeletal
muscle relaxants

Nursing Assess:
Responsibilities
• Pain: type, location, intensity before and 30-60 min
after administration; titrate upward with 25%-50% until
50% of pain reduced; need for pain medication by pain
sedation scoring, physical dependency

• Bowel status; constipation is common; may need

laxative or stool softener Withdrawal reactions in
opiate-dependent individuals: PE, vascular occlusion;
abscesses, ulcerations, nausea, vomiting, seizures;
low potential for dependence

• CNS changes: dizziness, drowsiness, hallucinations,

euphoria, LOC, pupil reaction

• Allergic reactions: rash, urticarial

• Respiratory dysfunction: respiratory depression,

character, rate,

rhythm; notify prescriber if respirations are ,10/min

Evaluate:
 67

• Therapeutic response: decrease in pain without

respiratory depression

Teach patient/family:

• To report any symptoms of CNS

 changes, allergic reactions

Generic Name Metoclopramide

Brand Names Apo-Metoclop, Emex, Maxeran, Metonia, Metozolv ODT,

Reglan

Classification Antiemetics

Dosage and 1 ampule IVTT q8 RN for vomiting

Frequency
Mechanism of Blocks dopamine receptors in chemoreceptor trigger zone of
Action the CNS. Stimulates motility of the upper GI tract and
accelerates gastric emptying.
Therapeutic effects: Decreased nausea and vomiting.
Decreased symptoms of gastric stasis. Easier passage of
nasogastric tube into small bowel.

Indication Prevention of chemotherapy-induced emesis. Treatment of

postsurgical and diabetic gastric stasis. Facilitation of small
bowel intubation in radiographic procedures. Management of
gastroesophageal reflux. Treatment and prevention of
postoperative nausea and vomiting when nasogastric
suctioning is undesirable.
 68

Unlabeled Use: Treatment of hiccups. Adjunct management

of migraine headaches.

Contraindication  Hypersensitivity
 Possible GI obstruction or hemorrhage
 History of seizure disorders
 Pheochromocytoma
 Parkinson’s Disease
 History of depression
 Diabetes
 Lactation

Side Effects / CNS: drowsiness, extrapyramidal reactions, restlessness,

Adverse Effects neuroleptic malignant syndrome, anxiety, depression,
irritability, tardive dyskinesia
CV: arrhythmias (supraventricular tachycardia, bradycardia),
hypertension, hypotension
GI: constipation, diarrhea, dry mouth, nausea
Endo: gynecomastia
Hemat: methemoglobinemia, neutropenia, leukopenia,
agranulocytosis

Drug Interactions  antidepressants

 antihistamines
 opioid analgesic
 sedative / hypnotics
 MAO inhibitors
 levodopa
 tacrolimus
 haloperidol
 phenothiazines
 anticholinergics
Nursing Assessment & Drug Effects
Responsibilities
 Assess patient for nausea, vomiting, abdominal
distention, and bowel sounds before and after
administration.
 Report immediately the onset of restlessness, involuntary
movements, facial grimacing, rigidity, or tremors.
Extrapyramidal symptoms are most likely to occur in
children, young adults, and the older adult and with high-
dose treatment of vomiting associated with cancer
chemotherapy. Symptoms can take months to regress.
 69

 Be aware that during early treatment period, serum

aldosterone may be elevated; after prolonged
administration periods, it returns to pretreatment level.
 Lab tests: Periodic serum electrolyte.
 Monitor for possible hypernatremia and hypokalemia
especially if patient has CHF or cirrhosis.
 Adverse reactions associated with increased serum
prolactin concentration (galactorrhea, menstrual
disorders, gynecomastia) usually disappear within a few
weeks or months after drug treatment is stopped.

Patient & Family Education

 Avoid driving and other potentially hazardous activities

for a few hours after drug administration.
 Avoid alcohol and other CNS depressants.
 Report S&S of acute dystonia, such as trembling hands
and facial grimacing, immediately.
 Do not breast feed while taking this drug without
consulting physician.

Generic Name Metoclopramide

Brand Names Apo-Metoclop, Emex, Maxeran, Metonia, Metozolv ODT,

Reglan
 70

Classification Antiemetics

Dosage and 1 ampule IVTT q8 RN for vomiting

Frequency
Mechanism of Blocks dopamine receptors in chemoreceptor trigger zone of
Action the CNS. Stimulates motility of the upper GI tract and
accelerates gastric emptying.
Therapeutic effects: Decreased nausea and vomiting.
Decreased symptoms of gastric stasis. Easier passage of
nasogastric tube into small bowel.

Indication Prevention of chemotherapy-induced emesis. Treatment of

postsurgical and diabetic gastric stasis. Facilitation of small
bowel intubation in radiographic procedures. Management of
gastroesophageal reflux. Treatment and prevention of
postoperative nausea and vomiting when nasogastric
suctioning is undesirable.

Unlabeled Use: Treatment of hiccups. Adjunct management

of migraine headaches.

Contraindication  Hypersensitivity
 Possible GI obstruction or hemorrhage
 History of seizure disorders
 Pheochromocytoma
 Parkinson’s Disease
 History of depression
 Diabetes
 Lactation

Side Effects / CNS: drowsiness, extrapyramidal reactions, restlessness,

Adverse Effects neuroleptic malignant syndrome, anxiety, depression,
irritability, tardive dyskinesia
CV: arrhythmias (supraventricular tachycardia, bradycardia),
hypertension, hypotension
GI: constipation, diarrhea, dry mouth, nausea
Endo: gynecomastia
Hemat: methemoglobinemia, neutropenia, leukopenia,
agranulocytosis

Drug Interactions  antidepressants

 antihistamines
 opioid analgesic
 71

 sedative / hypnotics
 MAO inhibitors
 levodopa
 tacrolimus
 haloperidol
 phenothiazines
 anticholinergics
Nursing Assessment & Drug Effects
Responsibilities
 Assess patient for nausea, vomiting, abdominal
distention, and bowel sounds before and after
administration.
 Report immediately the onset of restlessness, involuntary
movements, facial grimacing, rigidity, or tremors.
Extrapyramidal symptoms are most likely to occur in
children, young adults, and the older adult and with high-
dose treatment of vomiting associated with cancer
chemotherapy. Symptoms can take months to regress.
 Be aware that during early treatment period, serum
aldosterone may be elevated; after prolonged
administration periods, it returns to pretreatment level.
 Lab tests: Periodic serum electrolyte.
 Monitor for possible hypernatremia and hypokalemia
especially if patient has CHF or cirrhosis.
 Adverse reactions associated with increased serum
prolactin concentration (galactorrhea, menstrual
disorders, gynecomastia) usually disappear within a few
weeks or months after drug treatment is stopped.

Patient & Family Education

 Avoid driving and other potentially hazardous activities

for a few hours after drug administration.
 Avoid alcohol and other CNS depressants.
 Report S&S of acute dystonia, such as trembling hands
and facial grimacing, immediately.
 Do not breast feed while taking this drug without
consulting physician.
 72

Generic Name
Multivitamins + Minerals (Conzace) 1 capsule OD

Brand Names Conzace

Classification Multivitamins
Dosage and 1 capsule OD
Frequency
Mechanism of Contain fat-soluble vitamins (A, D, and E) and most water-
Action soluble vitamins (B-com-
plex vitamins B1,B2,B3,B5,B6,B12, vitamin C, biotin, and folic
acid). These vitamins are a diverse group of compounds
necessary for normal growth and development.
Many act as coenzymes or catalysts in numerous metabolic
processes. Liquid products do not contain folic acid.
Indication Treatment and prevention of vitamin deficiencies. Special
formulations are available for patients with particular needs,
including: Prenatal multiple vitamins (with larger doses of folic
acid), Preconceptional multiple vitamins,
Contraindication Contraindicated in:
 Hypersensitivity to preservatives, colorants, or additives,
in- cluding tartrazine, saccharin, and aspartame (oral
 73

forms); Some products contain alcohol and should be

avoided in patients with known intolerance.
Use Cautiously in:
 Patients with anemia of undetermined cause
Side Effects / Minor side effects include headache, upset stomach,
Adverse Effects unpleasant feeling inside the mouth and vomiting. These
effects should pass away with regular use of the drug. In case
the side effects become persistent stop using the medication
and consult a doctor.

In case of allergic reaction (symptoms includes skin rashes,

swelling of face, mouth throat and tongue, difficulty in breathing
and hives), stop administering Conzace Multivitamins and
seek immediate medical help.

Drug Interactions  Large amounts of vitamin B may interfere with the

beneficial effect of levodopa

Nursing  If symptoms or health problems do not get better or if

Responsibilities they become worse, call physician.
 Do not share drugs with others and do not take anyone
else's drugs.
 Keep a list of all drugs (prescription, natural products,
vitamins, OTC). Give this list to physician.
 Talk with the doctor before starting any new drug,
including prescription or OTC, natural products, or
vitamins.
 Some drugs may have another patient information
leaflet. Check with your pharmacist. If have any
questions about this medicine (multivitamins capsules
 74

and tablets), please talk with your doctor, nurse,

pharmacist, or other health care provider.
 If you think there has been an overdose, call your
poison control center or get medical care right away. Be
ready to tell or show what was taken, how much, and
when it happened.
 Encourage patient to comply with recommendations of
health care professional. Explain that the best source of
vitamins is a well-balanced diet with foods from the 4
basic food groups.
 Advise parents not to refer to chewable multivitamins for
children as candy.
 75

XVI. NURSING THEORIES

A.)The Roy Adaptation Model

By: Sister Callista Roy

First, consider the concept of a system as applied to an individual. Roy conceptualizes

the person in a holistic perspective. Individual aspects of parts act together to form a
unified being. Additionally, as living systems, persons are in constant interaction with their
environments. Between the system and the environment occurs an exchange of
information, matter, and energy. Characteristics of a system include inputs, outputs,
controls, and feedback.

Goal of nursing

The “promotion of adaptation in each of the four modes.”

1. Physiologic-physical mode: physical and chemical processes involved in the function

and activities of living organisms; the underlying need is physiologic integrity as seen in
the degree of wholeness achieved through adaptation to changes in needs. In groups,
this is the manner in which human systems manifest adaptation relative to basic operating
resources. The basic need of this mode is composed of the needs associated with
oxygenation, nutrition, elimination, activity and rest, and protection. The complex
processes of this mode are associated with the senses, fluid and electrolytes, neurologic
function, and endocrine function.
2. Self-concept-group identity mode: focuses on psychological and spiritual integrity and
a sense of unity, meaning, purposefulness in the universe.
3. Role function mode: refers to the roles that individuals occupy in society fulfilling the
need for social integrity; it is knowing who one is, in relation to others.
4. Interdependence mode: the close relationships of people and their purpose, structure
and development individually and in groups and the adaptation potential of these
relationships.
 76

APPLICATION:

The patient is currently experiencing physical and physiological problems. The

patient needs to adapt to the change especially to the fact that she will undergo recovery
and would not be able to easily move, especially when working as a teacher. In this case,
she has to adapt in ways of how to do her daily routine. In the second mode of the theory,
the patient should not lose hope in what is currently happening. She must not view herself
as a useless person because of the condition she has. Thus, she must show unity with
the people giving care with her in order to make her feel comfortable. In the third mode,
the patient knows that she is the one being treated and thus she has to cooperate to the
tasks implemented. Also, her current condition must not hinder her from doing things she
wants to do. She has to adapt to the changes done to her. In the last mode, significant
others should show that they will always be with the patient no matter what. All these
changes, the patient must adapt in order for her to achieve comfort.

B.)The Neuman Systems Model

by: Betty Neuman

The Neuman Systems Model views the client as an open system that responds to
stressors in the environment. The client variables are physiological, psychological,
sociocultural, developmental, and spiritual. The client system consists of a basic or core
structure that is protected by lines of resistance. The usual level of health is identified as
the normal line of defense that is protected by a flexible line of defense. Stressors are
intra-, inter-, and extrapersonal in nature and arise from the internal, external, and created
environments. When stressors break through the flexible line of defense, the system is
invaded and the lines of resistance are activated and the system is described as moving
into illness on a wellness-illness continuum. If adequate energy is available, the system
will be reconstituted with the normal line of defense restored at, below, or above its
previous level.

APPLICATION:
 77

The patient had been carrying gallstones in her body for almost 7 years already.
The patient has just had her surgery for gallstone removal. Currently, she has incision
wounds which are still fresh, thus first line of defense is then compromised. The patient
is open to infections with the condition she has. To prevent such infections, health
teachings regarding proper hygiene, proper management and care of the tracheostomy
tube should be given to the patient. Importance of compliance to the medicines should
also be emphasized in order to prevent further complications.

C.) Care, Cure and Core

The Three C’s of Lydia Hall

 The theory contains of three independent but interconnected circles:

1. the core,

2. the care and

3. the cure

 According to the theory, the core is the person or patient to whom nursing care is
directed and needed. The core has goals set by himself and not by any other person,
and that these goals need to be achieved.

 The core, in addition, behaved according to his feelings, and value system.

 The cure, on the other hand is the attention given to patients by the medical
professionals. The model explains that the cure circle is shared by the nurse with
other health professionals. These are the interventions or actions geared on treating
or “curing” the patient from whatever illness or disease he may be suffering from.

 The care circle explains the role of nurses, and focused on performing that noble task
of nurturing the patients, meaning the component of this model is the “motherly” care
provided by nurses, which may include limited to provision of comfort measures,
provision of patient teaching activities and helping the patient meet their needs where
help is needed.
 78

APPLICATION

The patient should set goals in order for her to achieve maximum comfort. As
student nurses, we must explain to the patient her current condition. In this way, the
patient herself will set goals in order for her to contribute in improving her health status.
Such goals that she can implement would be her hygiene and the proper care of the
tracheostomy tube. In the cure circle, we should we should emphasize the importance of
drug compliance to prevent further complication. In the care circle, we should implement
interventions necessary to the patient. We should also inform the significant others about
how important their roles to patient is. The health care team will not be present when the
patient is not in the hospital which means the significant others will take place in helping
the patient achieve maximum comfort. Their help is needed by the patient especially when
the patient is currently trying to adapt to the changes done.
 79

XVII. NURSING CARE PLANS

DAT CUES NSG DX NEED PLANNING INTERVENTION EVALUAT

E ION
01/12 Objective: Acute Pain related to P At the end of 8 1) Observe and document
/18 presence of incision hours of nursing location, severity (0–10 scale), and The
H
8:3 - Presence of three wounds on the surgical intervention. character of pain (steady, patient’s
Y
0am laparoscopic area of the abdomen. intermittent, colicky) perception
incision sites in the S -The patient will R – Assists in differentiating cause of pain
abdomen, well- Rationale: I lessen the pain of pain, and provides information lessened
dressed, with not The incision and C scale rate of 7/10 about disease progression and to 5/10
exudates and abdominal muscles A to 5/10 resolution, development of -Goal met
bleeding noted. may ache, especially complications, and effectiveness of
L
after long periods of -The patient will interventions. The
- Patient complained not show signs of patient did
standing. If one had a C
of Right Upper irritability and 2) Note response to medication, not
laparoscopic surgery, O
Quadrant uncomfortablene and report to physician if pain is anymore
Abdominal Pain you may feel pain from M ss. not being relieved. show
radiating to the any carbon dioxide gas R – Severe pain not relieved by signs of
F
back. still in your belly. This -The radiating routine measures may indicate face
O
pain may last for a few pain of the developing complications or need grimacing
R
- Pain scale of 7/10 days. It should feel a bit patient will be for further intervention. and
T alleviated. irritability (
better each day. In
- Grimmacing noted. performing 3) Promote bedrest, allowing
cholecystectomy, patient to assume position of
- Irritability and comfort.
surgical incision is
uneasiness noted. R – Bedrest in low-Fowler’s
done. By which, the
position reduces intra-abdominal
- Vital Signs of incision causes direct pressure; however, patient will
irritation to the nerve naturally assume least painful
- B/P: 120/90 endings by chemical position.
mediators released at

- Cardiac Rate: 95 the site such as
bradykinin. This
- Respiratoy Rate:30 irritation will send signal
to the cortex and
- Temperature:37.4
thalamus of the brain
thus producing pain
perception.
(https://www.hopkinsmedi
cine.org/healthlibrary/test
_procedures/gastroentero
logy/cholecystectomy_92,
P07689)
80
4) Use soft or cotton linens;
calamine lotion; cool or moist
compresses as indicated.
R – Reduces irritation and dryness
of the skin and itching sensation.
5) Administer medications as
prescribed:
- Ampi-Subactam 1.5grams
IVTT q8 hours x 2 dose, after
start Sultamicillin750mg 1 tab
BID.
- Parecoxib 40mg IVTT @9pm,
after start
- Etoricoxib 90mg 1 tab BID in
the morning.
- Nalbuphine 50mg IVTT q 8
hours PRN for unbearable
pain
R – Given to reduce severe pain.
Nuabaine is used with caution
because it may increase spasms
of the sphincter of Oddi, although
nitroglycerin may be given to
reduce morphine-induced spasms
if they occur.
6) Encourage use of relaxation
techniques. Provide diversional
activities.
R – Promotes rest, redirects
attention, may enhance coping.
7) warm compress on the patients
back.
 81

R – Alleviates pain in an area and

promotes good blood circulation
for healing and repair.

8) Make time to listen to and

maintain frequent contact with
patient.
R – Helpful in alleviating anxiety
and refocusing attention, which
can relieve pain.

9) Control environmental
temperature.
R – Cool surroundings aid in
minimizing dermal discomfort.

10) refer patient if none of the

interventions were effective
R- Referral to physician may help
seek proper medical management
to a patient who is in pain.
 82

DATE CUES NSG DX NEED PLANNING INTERVENTION EVALUATION

01-12- Objective: Impaired Skin At the end of 8 1) assist initial dressing and
18 Integrity related S hours of nursing change as indicated. Use
9:00am - Presence to disruption of A intervention strict aseptic techniques.
of three skin surface and F R – Protects incision wound
laparoscopic layer, as E from mechanical injury and The patient
evidenced by T contamination. Prevents enumerated
incision sites
presence of Y -the patient will be accumulation of fluids that different types
in the laparoscopic able to learn the may cause excoriation of wound care
abdomen, incision sites on A ideal managements
well-dressed, the right upper N management of 2) Gently remove tape (in and routine.
with not quadrant of the D having direction of hair growth) and -Goal Met
exudates and abdomen, and Cholecystectomy. dressings when changing.
bleeding the umbilicus. P R – Reduces risk of skin
R . The patient will trauma and disruption of The patient
noted.
R– O understand the wound. understood
- The Following a T importance of the rationale
patient laparoscopic E following the 3) Assess amounts and of the
complained of Cholecystectomy C orders of the characteristics of drainage. physicians
difficulty of Surgery would T physician on the R – Decreasing drainage order and
movement on often result to 3- I healing of the suggests evolution of complied on
bed and on 4 incisions O surgical wounds. healing process, whereas it.
ambulation wounds that N continued drainage or -Goal met
due to would be present presence of bloody or
presence of on the patient’s odoriferous exudate
the surgical right upper suggests complications.
wounds. quadrant of the
abdomen. 4) Elevate operative area
as appropriate.
R – Promotes venous
return and limits edema
formation.
 83

5) Caution patient not to

touch wound.
R – Prevents contamination
of wound.

6) Apply cold compress .R

– Reduces edema
formation that may cause
undue pressure on incision
during initial postoperative
period.

7) Use abdominal binder if

indicated.
R – Provides additional
support for high-risk
incisions (obese patient).

8) Monitor or maintain
dressings: hydrogel,
vacuum dressing.
R – May be used to hasten
healing in large, draining
wound/ fistula, to increase
patient comfort, and to
reduce frequency of
dressing changes. Also
allows drainage to be
measured more accurately
and analyzed for pH and
electrolyte content as
appropriate.
 84

9) Cleanse skin surface (if

needed) with diluted
hydrogen peroxide solution,
or running water and mild
soap after incision is sealed
R – Reduces skin
contaminants; aids in
removal of drainage or
exudate.

10)Advise patient ot eat

high-protein food such as
red meat and leafy-green
vegetables,
R – This would help in the
rebuilding of tissues
affected by the wound.

Given health teaching on

how to incision site cleaning
and caring….
 85

DATE CUES NSG DX NEED PLANNING INTERVENTION EVALUATION

1/12/18 Fatigue r/t generalized E 1) Assess the
11:00am Subjective: weakness secondary to N Short term: physical activity level
DMSF “Galuya Laparoscopic Cholecystectomy R and mobility of the Short term:
3C man ko ui, After 1 hour of patient.
E
unsa man Dereference: Nursing The patient
akong R intervention, - Take the resting understood
buhaton Post-op patients. usually is G the patient will pulse, blood the
para under bed rest for few days Y verbalize pressure, and importance of
maulian that may hinder them to their understanding respirations. having to
ani.” As usual activity. Presence of A on - Consider the rate, improve
verbalized surgical incision procedures N improvement rhythm, and quality tolerance of
by the causes the pt. to be reluctant in of preventing of the pulse. activity in
D
patient. doing personal activities, fatigability - If the signs are order to
because those may result in within his/ her normal, have the restore full
Objective: the stimulation of the nerve B limitation. patient perform the condition.
endings, during movement, A activity. Goal met.
>difficulty thus, increase pain sensation. L - Obtain the vital
turning A signs immediately
from one (https://nurseslabs.com/activity- N after activity
side to intolerance/) After 8 hours - Have the patient Long term:
C
another of nursing rest for 3 minutes The patient
noted E intervention, and then take the had
the pt. will vital signs again. participated in
> participate in the activities
generalized conditioning >Provides baseline and exercise
weakness activities and information for presented to
therapy to formulating nursing her, and did a
 86

>limited enhance goals during goal demonstration

ROM ability to setting. in front of the
perform nurse on duty.
>needs activities. 2) Investigate the Goal met.
assistance patient’s perception
when of causes of…..
moving
>Causative factors
>Vital sign may be temporary or
of: permanent as well as
physical or
T: 36.7 psychological.
P: 87 Determining the
R: 25 cause can help guide
BP: 120/70 the nurse during the
Oxygen nursing intervention.
sat: 95%
3) Assess the
patient’s nutritional
status. Advice soft
diet as indicated.
R> Adequate energy
reserves are needed
during activity.

4) monitor the
patient’s sleep
pattern and
the amount of sleep
achieved over the
past few days.
 87

>to gather baseline

data and compare it
with normal findings.
R> Sleep deprivation
and difficulties during
sleep can affect the
activity level of the
patient – these needs
to be addressed
before successful
activity progression
can be achieved.

5) Assess the need

for ambulation aids
(e.g., cane, walker)
for ADLs.
R>Assistive devices
enhance the mobility
of the patient by
helping him
overcome limitations.

6) Use portable pulse

oximetry to assess for
oxygen desaturation
during activity.
R>May determine the
use of supplemental
oxygen to help
compensate for the
 88

increased oxygen
demands during
physical activity.

7) Have the patient

perform the activity
more slowly, in a
longer time with more
rest or pauses, or
with assistance if
necessary.
R> Helps in
increasing the
tolerance for the
activity.

8) Gradually increase
activity with active
range-of-motion
exercises in bed,
increasing to sitting
and then standing.
R> Gradual
progression of the
activity prevents
overexertion.

9) Assist with ADLs

while avoiding patient
dependency.
R> Assisting the
patient with ADLs
allows conservation
 89

of energy. Carefully
balance provision of
assistance; facilitating
progressive
endurance will
ultimately enhance
the patient’s activity
tolerance and self-
esteem.

10) Provide emotional

support and positive
attitude regarding
abilities.
R> Patient may be
fearful of overexertion
and potential damage
to the heart.
Appropriate
supervision during
early efforts can
enhance confidence.
 90

DATE CUES NSG DX NEED PLANNING INTERVENTION EVALUATION

1/12/18 Objective: Risk for Deficient Fluid N After an 1) Monitor vital signs.
2:30pm -Vital signs of: Volume related to U hour, Assess mucous membranes,
DMSF BP: 110/70 Vomiting, as manifested T skin turgor, peripheral -The patient
3C T: 36.4 by post-operation R -The pulses, and capillary refill. does not feel
P: 95 anaesthesia I patient will R> Indicators of adequacy of nauseated
R: 30 complication.. T not be circulating volume, perfusion anymore, with
I feeling no traces of
-S/P R: Post-operative O nauseated, 2) Observe for signs of emesis on the
Cholecystectomy nausea and vomiting N and not bleeding: hematemesis, bed.
with lysis of (PONV) is a common A have the melena, petechiae, and Goal met.
adhesions. complication of surgery L urge to ecchymosis.
-Patient was and anaesthesia. vomit.. R> Prothrombin is reduced -The patient
under General Although it is rarely fatal, A and coagulation time did not go into
Endotracheal PONV is unpleasant and N -The prolonged when bile flow is a state of
Anesthesia associated with patient D patient will obstructed, increasing risk of dehydration.
(GETA) during discomfort, and not be bleeding or hemorrhage. Goal met.
the procedure. dissatisfaction with their M dehydrated
peri-operative care. E of 12- 3) Administer IV fluids Plain
-Vomiting noted, T 20cpm. Lactated Ringer’s Solution 1- The patient is
with fluid (https://www.pharmaceut A Liter Running at 120cc/hour now resting on
consistency and ical- B as indicated\ bed, with
greenish in color journal.com/learning/lear O R> Sodium chloride, anormal
ning-article/post- L potassium chloride, sodium respiration of
operative-nausea-and- I lactate and calcium (Lactated 14cpm.
vomiting/10030469.articl C Ringer's Solution) is a sterile Goal met.
e) solution used to replace fluids-
and electrolytes in patients
with unbalanced blood fluid,
 91

and it also is used for an

alkalizing agent.

4) Assess skin turgor and

oral mucous membranes for
signs of dehydration.
R> Signs of dehydration are
also detected through the
skin. Skin of elderly patients
losses elasticity, hence skin
turgor should be assessed
over the sternum or on the
inner thighs. Longitudinal
furrows may be noted along
the tongue.

5) Assess alteration in
mentation/sensorium
(confusion, agitation, slowed
responses)
R> Alteration in
mentation/sensorium may be
caused by abnormally high or
low glucose, electrolyte
abnormalities, acidosis,
decreased cerebral
perfusion, or developing
hypoxia. Impaired
consciousness can
predispose patient to
aspiration regardless of the
cause.

6) Assess color and amount

of urine. Report urine output
 92

less than 30 ml/hr for 2

consecutive hours.
R > A normal urine output is
considered normal not less
than 30ml/hour.
Concentrated urine denotes
fluid deficit.

7) Keep head of bed elevated

when feeding and at least a
half hour afterward.
R – Helps decrease risk of
aspiration.

8) Urge the patient to drink

prescribed amount of fluid.
R – Oral fluid replacement is
indicated for mild fluid deficit
and is a cost-effective
method for replacement
treatment. Older patients
have a decreased sense of
thirst and may need ongoing
reminders to drink. Being
creative in slecting fluid
sources (e.g., flavored
gelatin, frozen juice bars,
sports drink) can facilitate
fluid replacement. Oral
hydrating solutions (e.g.,
Rehydralyte) can be
considered as needed.
.

9) Position patient in high

back rest.
 93

R – alleviates the feeling of

nausea.

10) Give metoclopramide 1

ampule IVTT q8 RN for
vomiting as prescribed.
R>
Blocks dopamine receptors
in chemoreceptor trigger
zone of the CNS. Stimulates
motility of the upper GI tract
and accelerates gastric
emptying.
Therapeutic effects:
Decreased nausea and
vomiting. Decreased
symptoms of gastric stasis.
Easier passage of
nasogastric tube into small
bowel
 94

DATE CUES NSG DX NEED PLANNING INTERVE

As one NTION
1/12/18 Subjective: Risk for infection r/t Short-term: 1. Assess for the presence, the patient
3:00pm impaired primary defense existence of, and history of shall have
DMSF 3C “First time man as evidenced by incision After 1 hour of risk factors demonstra
nako na- wounds in the abdominal nursing R>These represent a break ted
operahan unya area due to Laparoscopic interventions, in the body’s normal first technique
dili pud ko Cholecystectomy. the patient will line of defense. s in
kabalo kung demonstrate reducing
pwede ba techniques in 2. Monitor white blood cell risk of
limpyuhan ang The patient is at risk of reducing risk (WBC) count having
lawas paghuman acquiring infection due to of having R> An increasing WBC infection.
ug operasyon.” the break in the continuity infection. count indicates the body’s Goal met.
As verbalized by of the first line defense efforts to combat
the patient. which is the skin. The pathogens
patient shall have Long-term: 3. Assess immunization status
undergone and history. The
cholecystectomy, thus After 8-hour of R> . People with patient
Objective: there is an incision and nursing incomplete immunizations shall have
suture made in the interventions, may not have sufficient achieved
- CBC as of abdomen. If there is a the patient will acquired active immunity. timely
1/10/18 breakage in the skin, the achieve timely 4. Maintain or teach asepsis wound
4:09pm pathogens will easily wound for dressing changes and healing,
WBC Count: invade the body’s system healing, be wound care, peripheral IV be free of
7.06 X10^3/uL thus increasing risk for free of and central venous purulent
(5.0- 10.0) infection. purulent management, and catheter drainage,
- Neutrophil: 56 drainage, and care and handling.tell and be
(55.00- 75.00) (https://nurseslabs.com/ch maintain patient to comply to afebrile.
- Lymphocytes: olecystectomy-nursing- normal level of antibiotic therapy as Goal met.
30 (20-35) care-plans/12/) body prophylaxis
- Monocytes 13 temperature. R> Aseptic technique
(2-10) decreases the changes of
- Eosinophils: transmitting or spreading
0.02 (0.02- pathogens to the patient.
0.04) Interrupting the
transmission of infection
 95

- Basophils: 0 (0- along the chain of infection

0.1) is an effective way to
prevent infection.
- Presence of 5. Teach the patient proper
three Hand washing Technique
laparoscopic with Antimicrobial soap
R> Friction and running
incision sites in
water effectively remove
the abdomen, microorganisms from
well-dressed, hands. Washing between
with not procedures reduces the risk
exudates and of transmitting pathogens
bleeding from one area of the body
noted. to another. Plain soap is
good at reducing bacterial
counts but antimicrobial
- Body soap is better, and alcohol-
Temperature based hand rubs are the
of 36.5 Celsuis best.

6. Encourage intake of
protein-rich and calorie-rich
foods.
R> Helps support the
immune system.
7. Encourage fluid intake of
2,000 to 3,000 mL of water
per day, unless
contraindicated. Tell patient
to comply to antibiotic
therapy as prophylaxis.
R> Fluids promote diluted
urine and frequent
emptying of bladder –
reducing the stasis of urine,
in turn, reduces risk for
 96

bladder infection or urinary

tract infection.
8. Teach the patient the
importance of avoiding
contact with individuals who
have infections.
R> avoiding contact with
individuals who have
infections or colds.
Other people can
spread infections or colds
to a susceptible patient
through direct contact,
contaminated objects, or
through air currents.
9. Demonstrate and allow
return demonstration of all
high-risk procedures that
the patient will do after
discharge, such as
dressing changes,
peripheral or central IV site
care.
R> The Patient need
opportunities to master new
skills to reduce risk for
infection.

10. If infection occurs, teach

the patient to take
antibiotics as prescribed.
Instruct patient to take the
full course of antibiotics
even if symptoms improve
or disappear.
 97

R> Antibiotics work best

when a constant blood level
is maintained which is done
when medications are
taken as prescribed. Not
completing the prescribed
antibiotic regimen can lead
to drug resistance in the
pathogen and reactivation
of symptoms.
 98

XVIII. PROGNOSIS

CRITERIA POOR 1 FAIR 2 GOOD 3

Age ✔

Emotional Status ✔

Compliance of ✔
Therapeutic
Regimen

Family support ✔

Environment ✔

Chances of ✔
Complication

Chances of ✔
Recurrence

Poor: 0x2=2 Range of values:

Fair: 5x3=15 Poor: 1.0-1.6
Good: 2x3=6 Fair: 1.7-2.3
Total= 21/7=3 (Good) Good: 2.4-3.0

Patient G.B.S. is 36 years old, diagnosed with Cholelithiasis resulting Cholecystitis

due to late and poor compliance of her physician’s referral. The result of her prognosis is
3 which is good. Upon interviewing, the patient was cooperative and approachable. The
husband of the patient is helping her whenever she needs help. The patient stays in an
environment wherein she can easily acquire medical consultation due to the free bus
ticket her husband acquires on his job. With the diagnosis of the patient, chances of
complication is high especially when it regards to her Digestive system. The diagnosis
has a chance of recurrence whether the patient will comply to such dietary regimen.
 99

XIX. DISCHARGE PLANS

Medications

 Discuss to the patient the indication, dosage, contraindication and side effects of all
given medications.
 Advise patient to keep a list of the medications given to her including the dosage and
purpose of taking the medicine. Advise to always bring the list with her especially
during follow-up visits.
 Encourage the patient to comply with all the medications.
 Emphasize the importance of complying all the medications given.
 Advise patient to contact her healthcare provider if she thinks the medications are not
helping.

Exercise

 Encourage patient to have adequate rest.

 Encourage patient to avoid stressful activities.
 Advise husband of patient to help her in some activities.

Treatment

 Advise patient to follow the orders given by the physician.

 Educate patient and significant others about the importance of drug compliance.

Hygiene

 Discuss the importance of proper hygiene.

 Encourage daily cleaning of the incision site to prevent infection.
 Advise significant others to maintain a clean and relaxing environment to prevent
acquiring infections.
 100

 Advise patient to perform daily oral care.

 Made the patient become aware of the possibilities of not performing hygiene.

Outpatient

 Advise patient to religiously follow the discharge plan.

 Encourage patient to have a follow-up check-up and discuss its importance
 Advise significant others to keep appointments with health care providers.
 Discuss the importance of maintenance of medications.

Diet

 Encourage patient to have a balanced diet.

 Encourage to eat three times a day and to not skip meals.
 Advised patient to eat food that are naturally rich in nutrients such as fruits and
vegetables.
 Discourage patient to eat unhealthy foods such as junk foods, high in cholesterol,
salty foods and etc.

Sexuality and spirituality

 Encourage patient to still engage and develop her spiritual aspect in life.
 Encourage patient to not lose faith and just keep on hoping for a better outcome.
 101

XX. RECOMMENDATIONS

Patient

I would like recommend the patient to avoid high in fat and cholesterol and low in

fiber diet. The patient’s weight must also be monitored and maintained based on the

patient’s required Body Mass Index. A full diet with fresh fruits and vegetables, whole

grains (whole-wheat bread, brown rice, oats, bran cereal), lean meat, poultry, fish, and

low-fat dairy products is encouraged. We would also suggest to include women who ate

at least one serving of peanuts a day, because based on a study (Watson, 2017) wherein

there is a 20% lower chance of their gallbladder problems compared to women who rarely

ate peanuts or peanut butter. We also recommend exercises to be instituted after incision

heals: flexion, extension, oblique, and lateral movement of head and neck. Regular ROM

exercises strengthen abdominal muscles, enhance circulation and healing process.

Review importance of rest and relaxation, avoiding stressful situations and emotional

outbursts. We encourage the use of loose-fitting scarves to cover scar, avoiding the use

of jewelry. This covers the incision without aggravating healing or precipitating infections

of suture line. And lastly, we advisethe patient to take the medications according to the

presribed dose and duration, and attend the follow up doctor’s appointment to ensure full

recovery.

Nursing Education

I recommend that case studies like this be continued to ensure greater hands on

and real life exposure to perception and coordination diseases. This will ensure that
 102

nursing students will have a collaborative and holistic experience in nursing. Moreover,

case studies will guarantee that nurses engage in lifelong learning. These case studies

will prepare me for advanced challenges and phases that I will encounter in hospitals in

the future. As a student nurse, we must not set limitations in seeking for new information.

I must have continuous effort to gain new knowledge and acquire new skills. Also, this a

form of educating myself about the current medical trends, diseases, nursing

management, and medical and surgical procedures. It is my hope to spread health

education no matter where I am.

Nursing Practice

As a student nurse of the Ateneo de Davao University, I pledge to provide the quality

healthcare for all people that we interact, especially the patients that we will meet in our

duties. I will demonstrate willingness and enthusiasm during our nursing practice. As an

aspiring nurse, I am called to provide care and services to our field of clinical experiences,

such as fully knowing and understanding the health teachings, nursing interventions, and

aftercare that we deliver to our clients. To my clinical instructors, it’s all hope that they

bestow their knowledge to me by giving more information about nursing practices and

guide us throughout. In addition, with heart in caring, I hope to improve and expand our

skills to its fullest potential.

Nursing Research

Making this case presentation and researching made a realization that there is still plenty

of things to learn. The nursing interventions, nursing care plan, and readings enhanced

our knowledge more and this kind of information can help improve nursing skills and know
 103

the appropriate interventions to implement. This experience has taught me that

researching is the key to have a better understanding of different diseases. Not only

establishing rapport to the patient and her family is a must in making this case

presentation successful; however, having a good grasp of the patient’s case is just as

important. It is a must to be updated with information so we will be able to understand the

rationale behind these new interventions, techniques, and procedures so that it can be

applied it to patients and let them have a faster recovery.

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XXI. BIBLIOGRAPHY

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