Calculous Cholecystitis

_________________________________________________________________

A Case Study Presented to the Faculty, Emilio Aguinaldo College-Manila College of Nursing and Midwifery

Submitted to:

Clinical Instructor Submitted by:

TABLE OF CONTENTS

I.

Introduction ................................................................................................ 1

II.

Objectives (General & Specific) ................................................................ 3

III.

Patients Data ............................................................................................. 5

IV.

Family Background and Health History ................................................... 7

V.

Definition of Complete Diagnosis ............................................................. 14

VI.

Physical Assessment................................................................................. 17

VII.

Anatomy and Physiology .......................................................................... 25

VIII.

Etiology and Symptomatology.................................................................. 28

IX.

Pathophysiology ........................................................................................ 38

X.

Review of Literature

XI.

Doctors Order ............................................................................................ 41

XII.

Diagnostic Exam ........................................................................................ 53

XIII.

Drug Study .................................................................................................. 63

XIV.

Nursing Care Plan ...................................................................................... 76

XV.

Discharge Plan (M. E. T. H. O. D.) & Prognosis ....................................... 98

XVI.

Recommendation ....................................................................................... 101

XVII.

References .................................................................................................. 103

ACKNOWLEDGMENT

The BSN-IV of Section-4 Goup-C, would like to acknowledge the contributions of the following groups and individuals to the development of this case presentation. To the Almighty God for blessing them with wisdom, competence and genuine passion and giving them the strength to finish this presentation. The group dedicates to Him the fruits of their hard-earned achievement. To the staff of the Medical Center Manila 8th Main for being accommodating to the students and for giving them additional teachings during their exposure in the said hospital. They have also been very willing to allow the students to obtain records necessary for this presentation. To their respected clinical instructor for this rotation, R.N., R.M., M.N., for her support and guidance to the group. She has imparted knowledge that would furthermore enhance the students understanding of their patients case, thus making them ready to present this case presentation. To their client, V.Q and her family, for being open and generous enough to

disclose personal information that would be helpful for this study. The group would also like to thank them for their patience throughout the duration of the study and for giving the group the opportunity to care for Selecta and apply what they have learned. To the proponents respective family and friends for their prayers as well as their financial support. They have also been a source of inspiration of the students. To the members of this group for working hard and giving their efforts, time and resources in conducting the study and for the completion of the written output.

INTRODUCTION One of the body organs that we can live without is the gallbladder. However, does this mean it is of no use to the body? The gallbladder is a pearshaped organ situated underneath the liver. Its function is to store bile and release it as needed for digestion. Bile emulsifies the fats in food, breaking them to small fragments so they can be further digested and absorbed in the small intestine. If the gallbladder is not working as it should, the digestion of fats can be seriously impaired. One of the common gallbladder diseases is calculous cholecystitis. Calculous cholecystitis is a condition wherein gallstones obstruct the gallbladder outlet leading to poor drainage of bile. Trapped bile can irritate and inflame the walls of the bladder, thus leading to inflammation. Calculous cholecystitis is the cause of more than 90% of cases of acute cholecystitis (Feldman, Friedman & Brandt, 2006). It affects women more often than men and is more likely to occur at the age of 20-50 or over 60. Asians are also more prone to develop pigment stones. Moreover, people who are obese and those who had had low fat diet are at an increased risk for developing cholelithiasis. In the United States, it is estimated that 6.3 million men and 14.2 million women aged 20 to74 had gallbladder disease (Everhart, Khare, Hill, Maurer, 1999). In the Philippines, an extrapolated prevalence of 5, 073, 040 people are affected by the disease (http://digestive.niddk.nih.gov/statistics). Gallstones that do not cause symptoms do not require treatment. However, if gallstones cause, disruptive, recurring episodes of pain, surgical removal of the gallbladder is recommended. Recently, the Group- C had a patient who was diagnosed with symptomatic calculous cholecystitis and underwent laparoscopic

cholecystectomy. The group chose this case for they see it fit for their perioperative concept. Rarely do they interact with patients who had minimally invasive surgery. The proponents are hoping that through this case study, they will be more knowledgeable and aware about such gallbladder disorder and the surgical procedure done for the said disease. They are also interested to know
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the proper and necessary nursing management that will be given to a patient affected by the disease. Moreover, they would also like to impart their learning to their families and their community regarding the prevention and care if ever such condition will arise in the scenario. As nursing students, they are hoping that this study will help them become more efficient and better nurses in the future. The student nurses also hope to apply their learning in taking care not only of their patients but of themselves as well.

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OBJECTIVES General objective: Within 4 weeks exposure to Medical Center Manila 8th Main, the group should have been able to present a comprehensive case study which explains the pathology, the treatment and the appropriate medical and nursing management regarding the condition of their chosen client. The group also aims to perform the necessary nursing interventions to help alleviate the patients condition and improve her health. Specific Objectives: The proponents also created certain aims that will help them in achieving their general objectives. Within 4 weeks of exposure, the proponents aim to: Cognitive:  Gather pertinent data regarding the past and present health history of the patient through interview and assessment;  Draw the family genogram of the patient;  Define the complete diagnosis of the patient by directly citing it from three different sources;  Conduct a thorough cephalocaudal assessment obtained from the client;  Review the anatomy and physiology of the organs affected in the patients disease;  Present the etiology and symptomatology of the disease;  Trace the pathophysiology of the patients disease;  Obtain the doctors orders and make rationales for each order;  Obtain, analyze and interpret laboratory and diagnostic procedures done on the patient and include the normal and abnormal values and findings for comparison, and the specific nursing responsibilities associated with each diagnostic procedure;
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 Make drug studies on each drug given to the client, correlate them with the disease process, explain why such drugs were ordered, and present important interventions in administering the drug;  Present specific, measurable, attainable, realistic, and time-bounded nursing care plans for the patient;  Make a discharge plan for the patient with the use of M.E.T.H.O.D.;  Broaden our scope of knowledge about the disease and the appropriate Nursing Care for the patient with the disease; Psychomotor:  Find a patient who will be the subject of their case presentation;  Render health teachings to the patient and her significant others to promote health;  Provide care based on the various nursing care plans formulated by the researchers and the patient herself;  Share information about calculous cholecystitis and the factors that cause the development of such disease and its complications;  Share how the disease affects those affected by it and the systems involved in its occurrence; Affective:  Establish rapport with the patient and significant others;  Show genuine concern and willingness in serving the client;  Be aware of the clients progress on the succeeding interactions;  Appropriately state the bibliography of all resources used in order to prevent plagiarism and promote honesty.

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PATIENTS DATA Clients Code Name: Age: Gender: Birth date: Address: Nationality: Religion (Denomination): Civil Status: Spouse: Educational Attainment: Occupation: Height: Weight: Health Insurance: V.Q. 38 years old Female November 6, 1971 Sampaloc, Manila Filipino Christian (Roman Catholic) Married Bobong College Graduate Government Employee 5ft 2inches 62 kgs. Philhealth Care

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Hospital: Vital Signs on Admission:

Medical Center Manila BP: 130/80 mmHg PR: 79 bpm RR: 19 cpm T: 37 C

Date of Admission: Room No. Chief Complaint: Admitting Physician: Admitting Diagnosis: Final diagnosis Surgical procedure

July 22, 2011 815 Pain at right upper quadrant Dr. Fojas Acute Cholelithiasis Calculous Cholecystitis Laparoscopic cholecystectomy

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FAMILY BACKGROUND AND HEALTH HISTORY A. Family Background V.Q is the second child among the four children. All children of Mamang were born through Normal Spontaneous Vaginal Delivery without any complications. She delivered all her children at the hospital .The family have been residing in Sampaloc, Manila since the marriage of their parents. The client, V.Q has 3 siblings namely: Kenny (Male, deceased), Luigi (Male, 30, married), and Dora (Female, 28, married). Shes a college graduate. She is a government employee for almost 15 years. According to the patient, her father and mother are still alive and they suffer from hypertension and diabetes. She said that the family lineage of her mother also suffers from heart problems as well as kidney problems. Two of her uncles on fathers side underwent surgery, cholecystectomy, and had the same condition as V.Q. Her older brother died due to motorcycle accident. Luigi was diagnosed with hypertension and Dora had a history of UTI. There was no one else in her immediate family that suffered cholecystitis aside from V.Q herself. V.Q got married to Bobong in the 1998. They were blessed with 3 children. Her 3 children were delivered through Normal Spontaneous Vaginal Delivery, all were born in the Maternity clinic. Her eldest child is now studying in 4th grade. So far, none of her children suffer a serious illness. In terms of their expenses, both of them provide money for their daily expenses. Bobong is a Supervisor in one of the companies in Metro Manila and has a wage of approximately 15,000 a month. V.Q said that they budget the money well for them to have food and to provide the necessary daily needs and expenses.
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Lifestyle The patient has an vigorous lifestyle. Right now, she is busy working and taking care of her family. She is the one who cooks, cleans the house, and does the laundry of the whole family. Sometimes, she does gardening in their backyard. According to her, she experiences fatigue from doing household chores especially since she is the only one who does the laundry. She reported that she doesnt smoke, but her husband does; he smokes almost one pack a day. V.Q said that she drinks liquor very seldom; she only consumes a half of glass or a glass of liquor occasionally. The family has good relationship. At night, they watch television together and this serves as their bonding time. Occasionally, they gather together with her relatives when there are fiestas, birthday celebrations and other special occasions. She is not so active in terms of social organizations but she sometimes joins in the events in their community like the fiesta. She sometimes goes to church on Sundays together with her children. V.Q sleeps around 9:00 oclock at night and wakes up around 5:00 oclock in the morning to prepare things needed of her husband. She is the one who cooks the baon of her husband for work. V.Q said that she eats at least two times a day in small meals. She said nagda-diet kasi ako kasi feeling ko mataba na ako. It started when I was 36 years old pero nag stop din ako last year. For breakfast she usually eats bread. Every morning, she always drinks coffee. In a day, she can consume at least 3 cups of coffee. Her lunch and supper are sometimes vegetables .She is not fond of eating pork and beef. She said that before, she limits herself from eating fatty foods since she aimed to
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lose weight because she was afraid of becoming obese. Also, she is so fond of drinking soft drinks. In a day she can consume 4 glasses of coke. But she also drinks approximately 5-6 glasses of water. She also loves to eat salty foods, especially junk foods, daing, bagoong. According to her, she has no allergy from any form of food.

B. Past Health History V.Q and her husband preferred to have artificial family planning than natural family planning. She started using birth control pills since she was 36 years old. She said that she is not sure if she completed her immunizations. Her mother forgot already and the records were lost. They only avail of the services of the health center very seldom. She said that their house was far from the health center so they werent able to avail of all of the services. She also experienced common illnesses such as cough, colds, fever, measles and even chickenpox. They only treated it at home; they bought over-the-counter drugs such as paracetamol, Neozep, and Medicol. She experienced measles when she was a 1-year old and had chickenpox when she was 10-year old. Meg had her menarche when she was 11 years old. V.Q reported that she got pregnant with her 1st child at the age of 28; unfortunately, she had miscarriage on the 1st week of pregnancy. She was hospitalized at Manila Doctors Hospital. Completion curettage was performed to her. Again, on her 3rd pregnancy, she had a miscarriage and was hospitalized on the maternity clinic and underwent completion curettage. She reported that in almost all her pregnancies, she experienced an increased blood pressure, usually 140/90. After delivering her third child at the age of 36, Bobong and V.Q decided to make use of
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family planning. V.Q started to take birth control pills until now to prevent unexpected pregnancy.

C. History of Present Illness On the second week of January 2011, V.Q felt mild pain at the right upper quadrant of her abdomen. She neglected it thinking that its nothing serious and might be just an episode of indigestion. After three days, the pain went away. But after two weeks, pain recurred at a higher scale (5/10). Because of this, she was forced to seek medical advice. She went to Manila Doctors Hospital and was asked to have ultrasound of the whole abdomen. After 2 days, the result was released and they found out that there were stones in her gallbladder. She was advised by the doctor to undergo surgery, cholecystectomy. However, the patient resisted the doctors advice due to fear of surgery. She was given medications as an alternative (the patient already forgot the name of medications prescribed). She was instructed by the doctor to increase water intake and have a low fat diet, unfortunately, she wasnt able to follow the doctors order and still continued with her usual lifestyle. V.Q said that she still felt the pain after the check-up but she could still tolerate it. She just took medications that were prescribed by the doctors to alleviate the pain she felt. Last July 19 this year, three days prior to admission, the patient again experienced right upper quadrant pain which lasted until the present condition. This was characterized to be progressive pain with a pain scale of 8 out of 10. There was no radiation noted and no associated symptoms. Two days prior to admission, pain recurred with a pain scale of 10 out of 10. This prompted V.Q to seek consultation, hence, admission.

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On July 22, the patient was admitted at Medical Center Manila 8th Main Room 815 under the service of Dr. Fojas, with admitting diagnosis of Acute Cholelithiasis.

D. Effects/Expectations of Illness to Self/Family

Biological: When V.Q knew about her condition that she needs to undergo surgery, she didnt know what to do. She was very worried about herself because she has fear of not waking up after surgery. She feared having complications of not having a gall bladder anymore.

Psychosocial: Also, she is worried about her 3 children, who still need care and guidance from their mother. This made her decide not to go through with the surgery before. V.Q wants to overcome her illness so that she can still spend time with her family and friends. Furthermore, she said that she wants to be in good condition as much as possible so that she can do her daily task in everyday life for her family. The client is worried about her condition because she has many plans in life together with her family.

Spiritual: Still, V.Q is still hopeful to overcome her challenges in life. The client still has faith in the Creator, and she continues to pray to Him. She believes that everything will be alright with the help of the creator.
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Also, her children were worried about their mother, whos suffering from such condition. Her husband, Bobong is trying his best to support his wife. Bobong was worried about V.Q because for him, it makes him suffer seeing his wife suffering. In addition, their relatives are also extending their care and prayers for V.Q because they are worried and concerned for her. The client is also very thankful because her family, relatives and friends are still there giving support to her for her fast recovery. They are always there and look after her in the hospital and to aid her physically, mentally, emotionally, and spiritually.

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Genogram

Maternal
Lolo, K ,

Side
Lola, , o

Paternal Side
Mamita, , Papito,

<

Ana, <,
70

Lala, K,

67

Sis, <,
64

Mama, 60, D

Po, c, 67

Jose, c, <, D,
64

Papa, 62<

- Female -Male #- age <- Heart problems -deceased D- diabetic K- Kidney problem o- old age c- cholelithiasis a- accident
Bebe three, 2 Dora, 28, K

Kenny, a, Luigi, 30, <

V.Q, <, Bobong, 45,

<

c, 38

Bebe two, 7

Bebe one, 10

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DEFINITION OF COMPLETE DIAGNOSIS Complete Diagnosis: Calculous Cholecystitis

Calculous

Calculi, or gallstones, usually form in the gallbladder from the solid constituents of bile; they vary greatly in size, shape and composition.

Source: Boyer, M. (2006). Brunner and Suddarths Textbook of MedicalSurgical Nursing, 11th ed., p. 1347. Lippincott Williams & Wilkins.

Calculus (pl. calculi) is also called stone; an abnormal stone formed in body tissues by accumulation of mineral salts. Calculi are usually found in the biliary and urinary tracts.

Source: http://medical-dictionary.thefreedictionary.com/calculi. Retrieved May 15, 2010. Calculi (stones) can be divided into two groupsrenal calculi and gallstones. The majority of gallstones are composed principally of cholesterol and other calcium salts.

Source: Iyengar, V. Elemental Analysis of Biological Systems: Biomedical, Environmental, Compositional and Methodological Aspects of Trace Elements, Vol. 1, p. 49.

Cholecystitis

Cholecystitis is the inflammation of the gallbladder. In more than 90% of the cases, gallstones are present.

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Source: White, L. Foundations of Nursing: Caring for the Whole Person, p. 832.

Inflammation of the gallbladder is called cholecystitis (chole = bile +cyst = bladder + itis = inflammation)

Source: Crowley, L. (2010). An Introduction to Human Disease: Pathology and Pathophysiology Correlations, 8th ed., p. 563. USA: Jones and Bartlett Publishers. Inflammation of the bladder which may be either acute or chronic. In an

acute cholecystitis, the blood flow to the gallbladder may become compromised which in turn will cause problems with the filling and emptying of the gallbladder. A stone may block the cystic duct which will result in bile becoming trapped within the bladder due to inflammation around the stone within the duct. Chronic cholecystitis occurs when there have been recurrent episodes of blockage of cystic duct.

Source: Digiulio, M. & Jackson, D.(2007). Medical-Surgical Nursing Demystified, p. 288. USA: McGraw-Hill.

Calculous Cholecystitis

Acute cholecystitis is inflammation of the gallbladder. There are two major types of acute cholecystitis calculous and acalculous. In calculous cholecystitis, gallstones obstruct the gallbladder outlet leading to poor drainage of bile. In physical exam, patients may exhibit Murphys sign right upper quadrant pain elicited by palpation under the right costal margin when the patient inspires.

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Source: Ginsber, G. & Ahmad, N. (2006) The Clinicians Guide to Pancreaticobiliary Disorders, p. 121-123. USA: SLACK Incorporated.

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PHYSICAL ASSESSMENT Patients Name: V.Q. Age: 38 yrs. old Sex: Female Admitting Diagnosis: Acute Cholelithiasis Final Diagnosis: Calculous Cholecystitis Chief Complaint: right upper quadrant pain Date of Assessment: July 27, 2010 Time of Assessment: 11:00 am Location of Assessment: Medical Center Manila 8th Main Room Number: 815 Vital Signs upon physical assessment: Temperature : Pulse Rate: Respiratory Rate: Blood Pressure: 36.6 C 82 bpm 18 cpm 130/80 mmHg

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I. General Survey The patient was received lying on bed, awake, conscious, coherent, a febrile and without IVF. She has three 0.5-cm long incisions at her epigastric and right lower rib cage areas and a 1-cm incision under her umbilicus. Incision site is dry and intact. Each incision is covered with dry and intact dressing. Patient complains of pain on the incision site and rated this pain as 6 out of 10 in the pain scale. She is oriented to time (verbalized it was late in the morning), person (identified watcher correctly), place (verbalized shes in the hospital) and reason for admission (stated that she was admitted due to right upper quadrant abdominal pain). Patient is not in respiratory distress. Patient appears appropriate for her stated age. She stands 5 feet and 2 inches tall and weighs 62 kg. Her body mass index (BMI) is 24.9 which is normal. She has an endomorphic body type. Patient is in fair grooming as evidenced by unsoiled t-shirt she is wearing, well-kept hair and clean linens and pillows. However, it was noted that patient has halitosis. Nails were long but clean. Through the course of the physical assessment, it was observed that the patient is cooperative and has an accommodating attitude towards the student. The patient is calm. Patients speech was audible, comprehensible and in moderate pace.

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II. Skin Skin is fair in color, intact and with hairs, except in the palms, soles and dorsa of the distal phalanges. Skin is dry and slightly warm upon palpation. It returns quickly to its normal state when picked up between two fingers and released. Skin texture is soft and fine while extensor surfaces such as the elbows have coarser skin. The palms and the soles are calloused. No skin breaks present aside from the incision sites on her abdomen. No edema present.

III. Hairs and Nails Upon inspection, hair was noted to be black. It is thick, oily, straight, long and well-kept. Hair is also evenly distributed as evidenced by absence of bald spots. Dandruff or flaking was not present. Other infestations, such as lice, were not noted. The color of scalp is lighter than the color of skin. Nails on both hands and feet are long but clean. Nail polish was removed. Client has a capillary refill time of 2 seconds. No clubbing of the nailbeds noted.

IV. Head Patients head is round and normocephalic in configuration with smooth skull contour. There were no palpated masses, nodules, deformities or fractures. Facial features are symmetric as evidenced by palpebral fissures being equal in size and symmetric nasolabial folds. Facial movements are symmetrical and patient is able to perform different kinds of expression effortlessly and without any obstructions. Patient can move her head up and down and side to side. No lesions noted on the face.

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V. Eyes Hairs of eyebrows are thick and evenly distributed. Eyebrows are symmetrically aligned and theres equal movement as evidenced by the patients ability to elevate and lower the eyebrows. No edema, lesions, puffiness or tenderness noted upon inspection and palpation of the periorbital area. Eyelashes are equally distributed and curled slightly outward with no ectropion or entropion. Eyelids surface is intact with no discharges and no discoloration but with noted eye bags on the lower surface. No lid lag noted. Blink reflex is present. Palpebral fissure is equal in both eyes. Bulbar conjunctiva is pale pink. Cornea is transparent and without cloudiness. Sclera is anicteric. Eyeballs are symmetrical with no bulging observed. Pupils were black in color, equally round, 3mm in size and reactive to light and accommodation. Pupils quickly constrict when a penlight is shone towards the pupil from a lateral position. Iris is dark brown in color. Client has central and peripheral vision. She can see things on the side of her eye, like the adjacent bed, even when looking straight ahead. Moreover, pupils constrict when looking at near objects and dilate when looking at far objects. During ocular motility testing, patient was asked to follow the examiners finger in the six cardinal fields of gaze. There was smooth, parallel movement of eyes in all direction. Both eyes move in unison. No nystagmus noted. To test her visual acuity, the students asked her to read their nameplates placed about 1 feet away from her. She was able to correctly read the names without any difficulty. Patient verbalized she doesnt use any corrective aids. She also did not report any vision difficulty or eye pain.

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VI. Ears The color of the patients ears is the same as her facial skin. The skin behind the ear in the crevice is smooth and without breaks. The left and right pinna are symmetrical and aligned with the inner canthus of the eye. Pinna recoils after it is folded. Auricle is nontender upon palpation. Mastoid process is smooth and hard and no tenderness or swelling noted. External canals have minimal cerumen. No sanguinous discharges noted on the meatus. Patient was able to hear a soft whisper equally in both ears. She can also hear normal voice tones as evidenced by prompt responses to questions asked.

VII. Nose It was noted that the nostrils were symmetrical and the nasal septum is midline. There were no observed discharges draining from the clients nose. Hair is noted on the nares. Nares are patent since patient is able to breathe normally on both nostrils without difficulty when one nose is closed with digital compression and patient inhaled with mouth closed. No lesions on the external nose structure were seen. There was no tenderness over the maxillary and frontal sinuses upon palpation of the cheeks and supraorbital ridges. Clients gross smell was functional as she could identify the scent of alcohol.

VIII.

Mouth Mouth is proportional and symmetrical. Lips are cracked, dry, pink in

color and with no masses or congenital defect. Buccal mucosa was uniform pale pink in color and moist. The patients gum was, moist, firm and pinkish in color. No gum retraction or bleeding was noted. Teeth are of complete set. There are no spaces in between teeth. Dental carries are evident in lower right and left molar. Teeth are yellow in color. Patient has no dentures. Tongue is pink, moist, slightly rough and has thin whitish color on the surface. It is also in central position and moves freely. The base of tongue is smooth with prominent veins.
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No tenderness, lesions or any unusualness noted. Soft palate is light pink in color. On the other hand, hard palate is much lighter and more irregular in texture. Uvula is positioned in midline of soft palate and rises when the patient says ah. Tonsils are not inflamed. No ulcerations and exudates present. Patient has no difficulty of masticating and swallowing. Halitosis was noted. Patient has no speech disorders.

IX.

Neck Neck is symmetrical with no masses or unusual swelling upon

palpation. No jugular vein distention noted. Pulsation at carotid arteries is strong and regular in rhythm. Range of motion is normal and no pain elicited upon flexion, extension, and rotation of head. Thyroid is not enlarged upon palpation with no nodules, masses or irregularities upon palpation. Thyroid also rises when patient was asked to swallow. Trachea is symmetrical and in midline without deviation. No lymph adenopathies appreciated. No torticollis present.

X. Breast Breast is conical, symmetrical and skin color is lighter than exposed areas. No lesions, redness, or edema and texture is even. No dimpling or retraction. Nipples are in midline and everted pointing in the same direction. Areola and nipples are dark brown in color and has no discharges, crusting and masses.

XI. Chest/Lungs Chest skin integrity is good and intact. Patient has symmetrical chest wall movement. Point of maximal impulse is at 5th intercostal space left midclavicular line. Apical pulse is 84bpm. Patient has distinct heart sounds, with S1 louder than S2; negative for murmurs. There were no noted deformities in the clients thoracic area. There are no bulges or retraction of the intercostal spaces.
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Clients respiratory rate is 18 cycles per minute. Patient did not complain of chest pain or chest tightness. Guarding of the chest noted upon respiration due to the proximity of the incision site to the diaphragm. Patient is not in respiratory distress. Coughing episodes were also not observed. Vesicular breath sounds are soft and low pitched. Her breathing is deep, regular and slow with a long inspiratory phase and a short expiratory phase. With no adventitious sounds, lungs are clear to auscultation and no crackles, wheezes or rubs. It was observed that vocal fremitus is present both at the back and front of the chest when the patient says ninety-nine.

XII. Abdomen Abdomen is round. Color of skin in abdomen is slightly lighter than the rest of the body. A 0.5-cm incision was noted at the subxyphoid area. Another two 0.5-cm incisions are seen at her right lower rib cage. A 1-cm incision is also present just below her umbilicus. All four incisions are covered with dry and intact dressing. Patient reported a pain scale of 6 out of 10. Aortic pulsations are not visible. Umbilicus is midline and inverted. Symmetrical movement of abdomen upon respiration was noted. Upon auscultation of the abdomen, it was noted that patient has normal bowel soundshigh-pitched and occurred 16 times per minute. Abdomen is soft and there is no point tenderness. Patient was on DAT as ordered.

XIII. Back and Extremities Peripheral pulse of the patient was symmetrical and regular in rhythm; radial pulse is 82bpm. Patient has normal capillary refill of 2 seconds. The nails were pinkish in color without cyanosis and clubbing. Patient is able to ambulate freely. She was able to sit up on bed and perform range of motion on both upper and lower extremities. However, it was noted that patient has guarded and slow
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movement for she feels pain on her abdomen. Clients grasping ability was moderately strong on both hands. No edema or cyanosis was noted on both upper and lower extremities. There is no swelling, tenderness or nodules palpated on each joint. The shoulders, arms, elbows and forearms are free of nodules, swelling, deformities and atrophy. The skin at the back of the patient is uniform in color. Symmetrical chest expansion with respirations noted. No spinal tenderness noted. There are no skin breaks present. The back is also symmetrical with the spinal cord aligning from the neck down to the buttocks. There were no deformities or abnormalities on the bone such as scoliosis, osteoporosis and alike to be noted.

XIV.

Genito-urinary Pubic hair is present, thick in each strand, curly and equally distributed

on the mons pubis. No vaginal bleeding or any other unusual discharges noted. Patient voids freely. She has no difficulty urinating and did not report dysuria. She verbalized her urine is amber in color.

XV.

Neurological Patient was received lying on bed, awake, conscious, coherent and

afebrile. Reflexes are normal and symmetrical bilaterally in both extremities. Patient is oriented to person, place and time. She has a Glasgow coma scale of 15: 4 from eye opening, 5 for verbal response and 6 for motor response. She is also alert and attentive.

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ANATOMY AND PHYSIOLOGY

GALLBLADDER The gallbladder is a hollow organ that sits just beneath the liver. In adults, the gallbladder measures approximately

8 cm in length and 4 cm in diameter when fully distended. It is divided into three sections: fundus, body, and neck. The neck tapers and connects to the biliary tree via the cystic duct, which then joins the common hepatic duct to become the common bile duct. Its function is to store and release bile, a fluid made by the liver.

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CYSTIC DUCT The cystic duct is the

short duct that joins the gall bladder to the common bile duct. The cystic duct varies from 2 to 3 cm in length and terminates in the gallbladder.

Throughout its length, the cystic duct is lined by a spiral mucosal elevation, called the valvula spiralis (valve of Heister) which is

a series of crescentic folds of mucous membrane in the upper part of the cystic duct, arranged in a

somewhat spiral manner. Its length is variable and usually ranges from 2 to 4 cm. The cystic duct is usually 2-3 mm wide. It can dilate in the presence of pathology (stones or passed stones). The duct and spiral folds contain muscle fibers responsive to pharmacologic, hormonal, and neural stimuli. There is, however, no convincing evidence of a discrete muscular sphincter within the duct. Although the cystic duct is unlikely to play a major role in gallbladder filling and emptying, it appears to function as more than a passive conduit. Coordinated, graded muscular activity in the cystic duct in response to hormonal and neural stimuli may facilitate gallbladder emptying. The principal function of the internal spiral folds that are found in man may be to preserve patency of this narrow, tortuous tube rather than to regulate bile flow.

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BILE The main components of bile include contains water, cholesterol, fats, bile salts, proteins, and bilirubin. Bile, is produced by hepatocytes in the liver and and then flows into the common hepatic duct, which joins with the cystic duct from the gallbladder to form the common bile duct. The common bile duct in turn joins with the pancreatic duct to empty into the duodenum. If the sphincter of Oddi, a muscular valve that controls the flow of digestive juices (bile and pancreatic juice) through the ampulla of Vater into the second part of the duodenum, is closed, bile is prevented from draining into the intestine and instead flows into the gallbladder, where it is stored and concentrated to up to five times its original potency between meals. This concentration occurs through the absorption of water and small electrolytes, while retaining all the original organic molecules. When food is released by the stomach into the duodenum in the form of chyme, the duodenum releases cholecystokinin, which causes the gallbladder to release the concentrated bile to complete digestion. Bile helps to emulsify the fats in the food. Besides its digestive function, bile serves also as the route of excretion for bilirubin, a byproduct of red blood cells recycled by the liver. The alkaline bile also has the function of neutralizing any excess stomach acid before it enters the ileum, the final section of the small intestine. Bile salts also act as bactericides, destroying many of the microbes that may be present in the food. In the absence of bile, fats become indigestible and are instead excreted in feces, a condition called steatorrhea.

Page | 27

ETIOLOGY AND SYMPTOMATOLOGY Etiology Predisposing Factors Present/ Absent Rationale Justification

Female

PRESENT Women between 20 and 60 years of age are twice as likely to develop gallstones as men. Estrogen increases cholesterol levels in bile and decrease gallbladder movement, both of which can lead to gallstones.
Sources: Harrisons Principles of Internal Medicine, Tenth Edition 1983 page 1822 Lippincott Williams and Wilkins Handbook of Diseases Third Edition, page 184 http://www.diabetesmonitor.com/learningcenter/gallstones.htm

The patient is female.

Diabetes mellitus

ABSENT

People with diabetes generally have high levels of fatty acids called triglycerides. These fatty acids increase the risk of gallstones.
Sources: Harrisons Principles of Internal Medicine,

The patient is not diabetic.

Page | 28

Tenth Edition 1983 page 1823 Lippincott Williams and Wilkins Handbook of Diseases Third Edition, page 184

Age (20-50; over age 60)

PRESENT

Many of the bodys systems and protective mechanisms become less efficient with age. Body systems and processes become sluggish.
Sources: Harrisons Principles of Internal Medicine, Tenth Edition 1983 page 1823 Lippincott Williams and Wilkins Handbook of Diseases Third Edition, page 184

The patient is 38 years old.

Ethnicity (Native American, Mexican American) (Asian)

PRESENT

Native Americans have a genetic predisposition to secrete high levels of cholesterol in bile. In fact, they have the highest rate of gallstones in the United States. A majority of Native American men have gallstones by age 60. Mexican American men and women of all ages also have high rates of gallstones. Asians are more genetically predisposed to having pigment stones as compared to those living

The patient is Filipino. She is predisposed to having pigment stones.

Page | 29

in the Western countries

Sources: Lippincott Williams and Wilkins Handbook of Diseases Third Edition, page 184 http://www.diabetesmonitor.com/learningcenter/gallstones.htm

Precipitating Factors Pregnancy

Present/ Absent

Rationale

Justification

ABSENT

Excess estrogen from pregnancy, hormone replacement therapy, or birth control pills appears to increase cholesterol levels in bile and decrease gallbladder movement, both of which can lead to gallstones. Source: http://www.fbhc.org/Patients/Modul es/gallstns.cfm

The patient is not pregnant.

Rapid weight loss

ABSENT

As the body metabolizes fat during rapid weight loss, it causes the liver to secrete extra cholesterol into bile, which can cause gallstones. Sources: Lippincott Williams and Wilkins Handbook of Diseases Third Edition, page 184 http://www.fbhc.org/Patients/Modul es/gallstns.cfm

No rapid weight loss was noted by the patient.

Page | 30

Obesity

ABSENT

The most likely reason is that obesity tends to reduce the amount of bile salts in bile, resulting in more cholesterol. Obesity also decreases gallbladder emptying. Sources: Harrisons Principles of Internal Medicine, Tenth Edition 1983 page 1823 Lippincott Williams and Wilkins Handbook of Diseases Third Edition, page 184 http://www.fbhc.org/Patients/Modul es/gallstns.cfm

The patient is not obese.

Fasting

ABSENT

Fasting decreases gallbladder movement, causing the bile to become overconcentrated with cholesterol, which can lead to gallstones. Source: http://www.diabetesmonitor.com/lea rning-center/gallstones.htm

The patient doesnt fast.

Hormone replacement therapy, or birth control pills

PRESENT

Excess estrogen from pregnancy, hormone replacement therapy, or birth control pills appears to increase cholesterol levels in bile and decrease gallbladder movement, both of which can lead to gallstones.

The patient has been on birth control pills since she was 36 years old.

Page | 31

Source: Lippincott Williams and Wilkins Handbook of Diseases Third Edition, page 184 http://www.diabetesmonitor.com/lea rning-center/gallstones.htm

Low Fat Diet

PRESENT

Before dietary fat can be digested, it has to be emulsified. Bile is used for this purpose. The liver makes bile continuously and stores it in the gall bladder until such time as it is needed. However, if a low-fat diet is eaten, that bile remains in the gall bladder. Gallstones are formed when the gall bladder is not emptied on a regular basis. In people who continually resort to low-fat diets, bile is stored for long periods in the gall bladder and it stagnates. In time and it is really quite a short time a 'sludge' begins to form.

The patient avoids fatty foods.

Source: http://www.secondopinions.co.uk/gallstones.html

Page | 32

Symptomatology Signs and Symptoms Present/ Absent Rationale Justification

Right upper quadrant pain (may radiate to right scapula, shoulder, or interscapular area) biliary colic

PRESENT

patient ducts The into connected to the gallbladder came Obstruction of will cause inflammation DMSF by increased complaining

produced

intraluminal pressure and of RUQ pain. distension gallbladder. Sources: Harrisons Principles of Internal Medicine, Tenth Edition 1983 page 1825 of the

Fever (low grade)

ABSENT

patient nonspecific The not response that is mediated was by endogenous pyrogens febrile. Fever is a released from host cells in response to infectious or non-infections disorders. It may be brought about by prostaglandins released

during inflammation. Source: Carol Mattson

Page | 33

Porth (2005. Pathophysiology, Seventh edition page 205)

Murphy's sign (abrupt interruption of deep inspiration)

PRESENT

Classically Murphy's sign is The tested for during was

patient positive

the an abdominal examination; for it is performed by asking the Murphys patient to breathe out and Sign. then gently placing the hand below the costal margin on the right side at the midclavicular line approximate location (the of

the gallbladder). The patient is then instructed to inspire (breathe during in). Normally, inspiration,

the abdominal contents are pushed downward as

the diaphragm moves down (and lungs expand). If the patient stops breathing in (as the gallbladder in moving in

is tender and, downward,

comes

contact with the examiner's fingers) and winces with a 'catch' in breath, the test is

Page | 34

considered

positive.

positive test also requires no pain on performing the maneuver on the patient's left hand side. Source: http://www.turnerwhite.com/pdf/hp_nov00_m urphy.pdf

Nausea and vomiting

ABSENT

Nausea

and

vomiting The

patient

sometimes occur with biliary didnt colic. The inflammation of complain the gallbladder causes pain nausea and spasms of the vomiting. of or

abdominal muscles which may make one feel

nauseated. Source: Understanding Surgical Medical by

Nursing

Williams and Hopper page 742

Mildly elevated

ABSENT

Biliary obstruction causes The patients suppression of bile flow, bilirubin was

Page | 35

serum bilirubin

and

regurgitation

of not increased.

conjugated bilirubin into the bloodstream. Sources: Harrisons Principles of Internal Medicine, Tenth Edition 1983 page 1829

Elevated SGPT and SGOT enzymes

PRESENT

SGOT (AST) and (ALT) is The patients an enzyme found mostly in lab the liver but also in the reveal heart, the muscles, tests an

the elevated level

kidneys, the pancreas and of SGPT and in red blood cells. High SGOT elevations associated may with be enzymes. liver

disease or muscle trauma. Elevations may also be

associated with a variety of conditions including

myocardial infarction (heart attack), pancreatitis, bile duct obstruction and more. Abnormalities enzymes of liver

including

Page | 36

AST/SGOT and ALT/SGPT are indicative of problems such as Mirrizi syndrome, or a stone in the bile duct causing inflammation. Sources http://my.diabetovalens.com /apollo/sgot.asp infection/liver

Page | 37

PATHOPHYSIOLOGY ________________________________________________________________
Precipitating Factors:
Predisposing Factors:

y
y y y y Female Age 38 Ethnicity Diabetes Mellitus

y y y y y
Bile stagnates in the gallbladder Pigment solute precipitate as solid crystals

Birth control pills Low Fat Diet Pregnancy Rapid weight loss Obesity fasting

Crystals clump together and form stones Gallstones

Gallbladder contracts after intake of fat to release bile

Upon contraction, a stone is moved and becomes impacted on the cystic duct

CHOLELITHIASIS

Lumen is obstructed by stones

Bile stasis

Page | 38

Chemical reaction inside gallbladder triggers the release of inflammatory enzymes (Prostaglandins)

Fluids leak into gallbladder

Inflammation of the gallbladder

Edema

Increased intraluminal pressure and distention of the gallbladder

Biliary Colic (RUQ pain)

Constriction of blood vessels

Murphy s Sign

ACUTE CHOLECYSTITIS
If not treated If treated with: Continued lack of blood supply to gallbladder Continued increase in intraluminal pressure of gallbladder

Surgery, proper diet (low fat, high fiber), compliance to medications

Necrosis Rupture of gallbladder

Good prognosis

Gangrene and empyema Spread of bile indigenous microorganisms peritoneal cavity and into

Perforation of gallbladder

Page | 39

Sepsis

Death

Page | 40

DOCTORS ORDER Date 07/22/11 Order Low fat diet Rationale Doctors were not sure whether the gallstones are either cholesterol or pigment stones. Thus, this is done to prevent any further damage to the gallbladder. Monitor VSqShift and record Monitoring vital signs is important in order to note any unusualities and to refer these as follows. Labs: A complete blood count (CBC) is a series of tests CBC used to evaluate the composition and concentration of the cellular components of blood. It consists of the following tests: red blood cell (RBC) count, white blood cell (WBC) count, and platelet count; measurement of hemoglobin and mean red cell volume; classification of white blood cells (WBC differential); and calculation of hematocrit and red blood cell Done Done Remarks Done

Platelet count is to determine

Page | 41

the number of platelets; If the Platelet number of platelets is too low, excessive bleeding can occur. However, if the number of platelets is too high, blood clots can form (thrombosis), which may obstruct blood vessels. Done

It is done to detect urinary tract infection. It also Urinalysis measures the level of ketones, sugar, protein, blood components and many other substances Venoclysis: PNSS 1L @ 100cc/hr PNSS is an isotonic solution to provide hydration since it was found out that the specific gravity for urine is in the borderline (1.010). It is also to provide electrolytes, and as a medium for IVTT meds Done. IVF infusing well at right metacarpal vein. Done

Meds:

Demerol 50mg IVTT now then prn for abdominal pain

Acts as agonist at specific opioid receptors in the CNS to produce analgesia, euphoria, sedation for relief of moderate to severe pain

Given

Page | 42

HNBB (Hyoscine NButyl Bromide) 20mg 1amp IVTT now

It's a competitive antagonist of the actions of acetylcholine and other muscarinic agonists causing smooth muscle relaxation indicated for her abdominal pain

Given

MHBR

Moderate high back rest is to elevate the upper portion of the body to increase lung expansion thus promoting gas exchange. This is also to prevent ascending infection that could be caused by possible rupture of the gallbladder.

Done

Refer any unusualities: severe abdominal pain, vomiting 7/23/11 Start Cefoxitin (Monowel) 1g IVTT q8 ANST

In order for the patient to be assessed and evaluated properly and be managed accordingly. Cefoxitin inhibits synthesis of bacterial cell wall causing cell death which acts as a perioperative prophylaxis for surgical procedures. ANST or after negative skin test is to check whether the client is not allergic to the antibiotic.

Done

Done. Result for skin test is negative. Cefoxitin may be given to the patient.

Page | 43

For ultrasound tomorrow morning

This is done to visualize internal organs, to capture their size, structure and any pathological lesions with real time tomographic images. This is also to know the condition of the gallbladder whether it ruptured or not.

Not able to comply. Patient had her ultrasound on May 11, 2010.

For total bilirubin,

Bilirubin is elvated if hepatocytes are injured and cannot metabolize or excrete bilirubin

Done. Results are normal

Direct bilirubin,

Increases in conjugated bilirubin are highly specific for disease of the liver or bile ducts

Indirect bilirubin

Increase in unconjugated bilirubin may be caused by hepatic disease, cholestasis, and hemolysis

Alkaline phosphatise

High levels of alkaline phosphatise indicates liver disease

SGPT (Serum glutamic pyruvic transaminase)

SGPT is released into blood when the liver or heart is damaged; thus, this is to determine liver function. Elevation of this may possibly

Done. Patients SGPT results are high

Page | 44

mean liver problems AST (aspartate aminotransferase) or SGOT is an enzyme found in high amounts in heart muscle and liver and skeletal muscle cells. It is also found in lesser amounts in other tissues. Elevated levels may be caused by liver or heart disease

SGOT (Serum glutamic oxaloacetic transaminase)

Done. SGOT results are also high

Schedule for laparoscopic cholecystectomy on Tuesday (4/11/10) 2pm Secure consent/AC

Lap Chole was to surgically remove the gallbladder with only a small incision.

Done. Surgery was done on 4/11/10 @ 4pm

Patient has the right to be consented in all procedures to be done, and for legal purposes. Anesthesia clearance is for the patient to be evaluated whether he/she is fit to undergo the operation. It is also for the anaesthesiologist to predict the operative risk and the appropriateness of the anaesthesia to be induced

Done.

Page | 45

during operation. Inform OR For the OR to know that such case will be performed and to prepare the necessary instruments and room. This is also to coordinate availability of staff and surgeon Refer In order for the patient to be assessed and evaluated properly and be managed accordingly. 07/24/11 May have ultrasound on Tuesday 5/11/10 This was to visualize internal organs, to capture their size, Done. Ultrasound Done Done

structure and any pathological result lesions with real time tomographic images. It is also to know whether the gallbladder has ruptured or not. retrieved on 5/11/10. Impression: Cholelithiasi s; Sonographic ally normal liver and pancreas 07/25/10 To reschedule OR tomorrow from 9am to 11am To inform the OR that the procedure will be moved from 9pm to 11am Done. Patient had her surgery at 11am of July 26, 2011 IVF TF: PNSS 1L @ KVO PNSS is an isotonic solution for hydration and as a
Page | 46

Done

medium for IVTT meds; KVO was done since patients hydration was good. Please facilitate AC AC is to assess patients rate of survival and check for what anesthetics is right for the patient, making sure that the patient isnt allergic to the anesthetic For Lap Chole tom 4pm This was to surgically remove the gallbladder with only a small incision. Patient can undergo laparoscopic cholecystectomy since gallbladder has not ruptured yet as seen on the ultrasound result. For blood chem. and Ultrasound tom Blood tests are used to determine physiological and biochemical states, such as disease, mineral content, drug effectiveness, and organ function. Pre-op orders: Done. Done. Done

NPO after light breakfast (8am)

NPO is to prevent peristalsis, aspiration and injury during surgery

Done

Assess VS prior to OR

as baseline data and to detect Done any unusualities

Page | 47

General oral hygiene

Oral hygiene is the practice of keeping the mouth clean and healthy by brushing and flossing to prevent tooth decay and gum disease.

Done

IVF: D5NSS 1L @ 120cc/hr

Intravenous solutions with reduced saline concentrations typically have dextrose added to maintain a safe osmolality while providing less sodium chloride; to hydrate before surgery in preparation for disruption of homeostasis

Done

Meds:

Diazepam 10mg 1 tab 2am

Potentiates the effects of GABA; Act in spinal cord and at supraspinal sites to produce skeletal muscle relaxation; it is also used as adjunct to General anesthesia

Given

Given Ranitidine 150mg 1tab 2am Inhibits basal gastric acid secretion and gastric acid secretion; patient was placed on NPO

Page | 48

Vitamin K

For the liver to activate clotting factors such as prothrombin, proconvertin, thromboplasstin, and stuart factor.

Given

07/26/11

NPO

NPO is to prevent peristalsis, aspiration and injury to the GI tract during surgery.

Done

Post op orders:

To PACU then to room

Patient must first be stabilized Done before transfer to the ward; PACU is a place with complete gadgets and staff for emergency purposes after post op.

NPO for 4 hrs then may have SD

Patient not yet fully conscious due to anesthetics, thus this is to prevent aspiration.

Done

Monitor VS q15 until stable then q30 for 2hrs then q2

Monitoring vital signs is to detect any unusualities after the operation.

Done

Meds:

Etoricoxib 120mg PO 12mn

Half life is 22hrs. Etoricoxib blocks COX2 thus relieving pain and inflammation.

Given

Page | 49

Tramadol 100mg 1tab 12mn

Half life is 5-7hrs Inhibits the reuptake of norepinephrine and serotonin; causes many effects similar to opioids analgesic

Given

Demerol 50mg IVTT

Half life is 3-5hrs Causes analgesia, euphoria, sedation; thus reducing pain

Given

Sultamicillin 375mg PO TID

Inhibits synthesis of bacterial cell wall causing cell death; this was indicated due to possible intra abdominal infections

Given

O2 inhalation @ 4pm until fully awake

This ensures optimum oxygenation of cells gearing towards achieving balance or homeostasis. Also this was for optimum respiratory level; prevents lung collapse.

Done

MHBR

Moderate high back rest is to elevate the upper portion of the body to increase lung expansion thus promoting gas exchange.

Done

Deep breathing exercises for 15mins TID

Post op exercise is indicated To prevent lung collapse and to eliminate anesthetic gases introduced to the body

Done

Page | 50

07/27/10

May have DAT

Patient may eat anything as long as it cant harm her current condition

Done.

Continue meds

For the patient to complete the medication regimen and for continuity of care

Done

Wound care

Daily routine wound care is indicated in order to promote healing and/or prevent infection

Done

07/28/10

MGH

Patient may go home after the doctor decides if unusualities are absent

Done

Home meds:

Etoricoxib 90mg PO BID

Half life is 22hrs. Etoricoxib blocks COX2 thus relieving pain and inflammation.

Done. Patient was informed

Tramadol 100mg tab PO BID

Half life is 5-7hrs Inhibits the reuptake of norepinephrine and serotonin; causes many effects similar to opioids analgesic

Sultamicillin 375mg PO BID

Inhibits synthesis of bacterial cell wall causing cell death

Page | 51

C/D IVF

Terminate IVF when IVF is about 50cc

IVF discontinued Patient to come back at 08/02/11

ff. up check at 08/02/11

Follow up check up is for the patient to be assessed and evaluated properly and be managed accordingly.

Page | 52

DIAGNOSTIC EXAM CBC a determination of red and white blood cells per cubic millimeter of blood. It helps health professional check any symptoms such as weakness, fatigue, or bruising. It also helps diagnose conditions such as anemia, infection and other disorders Test Hemoglobin Normal Result Remark Rationale Values 115.0- 137.0 Normal Hemoglobin carries 155.0 oxygen to and removes carbon dioxide from red blood cells. It measures total amount of hemoglobin in the blood Hematocrit 0.360.52 0.42 Normal Hematocrit measures the percentage of red blood cells in the total blood volume RBC 4.2-6.1 4.47 Normal Measures the number o RBCs per cubic millimeter of the whole blood. WBC 5.014.1 High Determines the number of Elevated levels
Page | 53

Interpretation Within normal range

Nursing Responsibilities There is very little risk associated with taking blood from a vein in the arm, although there is a slight risk of infection anytime the skin is

Within normal range

broken. Strict asepsis should be observed

The patient may feel Within normal range discomfort when blood is drawn from a vein.

Bruising may occur at

10.0

circulating WBCs per cubic millimeter of the whole blood.

may be caused by the puncture site, or the acute infections tuberculosis, pneumonia, meningitis, tonsillitis, appendicitis, colitis, etc. person may feel dizzy or faint. Pressure should be applied to the puncture site until the bleeding stops to reduce bruising. Warm packs can also be placed over the puncture site to relieve discomfort

Neutrophil

55-75

74

Normal

Phagocytes engulfing bacteria and cellular debris. It prevents or limits bacterial infections.

Within normal levels.

Instruct patient in dietary sources of iron such as Within normal range red meat, organ meats, clean green vegetable and fortified grains

Lymphocytes

20-35

21

Normal

Cells present in the blood and lymphatic tissue that provide the main means of immunity for the body. There are three types of lymphocytes: the natural killer (NK), thymus-derived lymphocytes (T cells), and

Protect the patient from potential sources of infection, monitor for signs of infection.

Page | 54

bone marrow-derived lymphocytes (B cells). NK cells are found in the blood, red bone marrow, lymph nodes and spleen and are able to destroy many kinds of infected body cells and tumor cells. The T cells and B cells are involved in specific immune responses. Monocytes 2-10 4 Normal This type of granular leukocyte functions in the ingestion of bacteria and other foreign particles Eosinophil 1-8 1 Normal Functions in allergic responses and in resisting infections. Eosinophils mount on attack against parasitic invaders by Within normal range Within normal range

Provide soft, bland diet high in protein, vitamins, and calories. Meticulous hand washing and strict asepsis are mandatory

Institute isolation

protective measures

immediately if there is neutrophil disorder. Also instruct the patient to observe aseptic

technique and to take caution most especially if immunocompromised. Inflammatory responses involve more than one body system. Monitor

the patient for worsening of the inflammatory

Page | 55

attacking to their bodies and discharging toxic molecules from their cytoplasmic granules. Platelet 150.0400.0 278 Normal A test that direct count of platelets in whole blood. Platelets number from 100,000-500,000 per cubic millimeter and are important in triggering the sequence of events that leads to the formation of blood clots. Within normal range

condition, respiratory compromised.

particularly

Encourage patient to rest between activities. Encourage patient to plan ahead and save energy for the most important activities. Encourage patient to void or stop activities that make short of breath or make heart beat faster. Encourage patient to Eat a diet with adequate

Page | 56

protein and vitamins. Drink plenty of noncaffeinated and nonalcoholic fluids.

Page | 57

Urinalysis - Urinalysis is a physical, microscopic, or chemical examination of the urine. It is done to detect urinary tract infection. It also measures the level of ketones, sugar, protein, blood components and many other substances TEST Glucose RESULT Negative NORMAL <50mg/dL CLINICAL SIGNIFICANCE Glucose is the type of sugar found in blood. Normally there is very little or no glucose in urine. When the blood sugar level is very high, as in uncontrolled diabetes. Glucose can also be found in urine when the kidneys are damaged or diseased. Protein Negative <30mg/dL Protein is normally not found in the urine. Fever, hard exercise, pregnancy, and some diseases, especially kidney disease, may cause protein to be in the urine. Bilirubin Negative <1mg/dL This is a substance formed by the breakdown of red blood cells. If it is present, it often means the liver is damaged or that the flow of bile from the gallbladder is blocked. Urobilinogen Normal <2mg/dL This is a substance formed by the breakdown of bilirubin. Urobilinogen in urine can be a sign of liver disease (cirrhosis, hepatitis) that the flow of bile from the gallbladder is blocked.
Page | 58

NURSING RESPONSIBILITIES Advise Patient to: Wash hands to make sure they are clean before collecting the urine. If the collection cup has a lid, remove it carefully and set it down with the inner surface up. Do not touch the inside of the cup with your fingers. Clean the area around your genitals.

pH

4.5-8

Urine pH is used to classify urine as either a dilute Begin urinating into acid or base solution. The lower the pH, the greater the toilet or urinal. the acidity of a solution; the higher the pH, the greater the alkalinity. The glomerular filtrate of blood is usually acidified by the kidneys from a pH of approximately 7.4 to a pH of about 6 in the urine Finish urinating into the toilet or urinal. Carefully replace and tighten the lid on the cup then return it to the lab. After the urine has flowed for several seconds, place the collection cup into the urine stream and collect "midstream" urine without stopping your flow of urine. Do not touch the rim

Blood

Negative

<510RBC/mL

Red blood cells in the urine may be caused by kidney or bladder injury, kidney stones, a urinary tract infection (UTI), inflammation of the kidneys (glomerulonephritis), a kidney or bladder tumor, or systemic lupus erythematosus (SLE).

Ketone

Negative

<5 mg/dL

Ketones in the urine may mean a very serious condition, diabetic ketoacidosis, is present. A diet low in sugars and starches (carbohydrates), starvation, or severe vomiting may also cause ketones to be in the urine.

Nitrite

Negative

Negative

Bacteria that cause a urinary tract infection (UTI) make an enzyme that changes urinary nitrates to nitrites. Nitrites in urine show a UTI is present.

Leukocytes

25

<25WBC/m

Leukocyte esterase shows leukocytes in the urine.

Page | 59

L Clarity Clear Clear

WBCs in the urine may mean a UTI is present. Urine is normally clear. Bacteria, blood, sperm, crystals, or mucus can make urine look cloudy.

of the cup to your genital area. Do not get toilet paper, pubic hair, stool (feces), menstrual blood, or anything else in the urine sample.

Specific gravity

1.010

1.010-1.030

This checks the amount of substances in the urine. It also shows how well the kidneys balance the amount of water in urine. The higher the specific gravity, the more solid material is in the urine.

Color

Yellow

Pale to dark yellow

Many things affect urine color, including fluid balance, diet, medicines, and diseases. How dark or light the color is tells you how much water is in it. Vitamin B supplements can turn urine bright yellow. Some medicines, blackberries, beets, rhubarb, or blood in the urine can turn urine red-brown.

Page | 60

Blood Chemistry - A number of tests performed on blood serum (liquid portion of the blood). It determines certain enzymes that may be present (including lactic dehydrogenase [LDH], certain kinase [CK], aspartate aminotransferase [AST], and alanine aminotransferas [ALT]), serum glucose, hormones such as thyroid hormone and other substances such as cholesterol and triglycerides. These tests provide valuable diagnostic cues.

TEST Total Bilirubin

RESULT 8.3

REFERENCE 2.0 21.0

REMARK Normal

RATIONALE It occurs when bilirubin production exceeds the liver's excretory capacity. This may occur because (1) too much bilirubin is being produced, (2) hepatocytes are injured and cannot metabolize or excrete bilirubin, or (3) the biliary tract is obstructed blocking the flow of conjugated bilirubin into the intestine

Direct Bilirubin

0.9

0.0 3.4

Normal

Increases in conjugated bilirubin are highly specific for disease of the liver or bile ducts

Inderct Bilirubin

7.4

2.0 17.0

Normal

Increase in unconjugated bilirubin may be caused by hepatic disease, cholestasis, and hemolysis

SGPT

60.2

0.0 34.0

High

SGPT is released into blood when the liver or heart is

Page | 61

damaged; thus, this is to determine liver function. SGOT 55.6 0.0 31.0 High SGOT is an enzyme found in high amounts in heart muscle and liver and skeletal muscle cells. Elevated levels may be caused by liver or heart disease

Alkaline Phosphate

191

64 306

Normal

When a person has evidence of liver disease , very high ALP levels can tell the doctor that the persons bile ducts are somehow blocked

Page | 62

DRUG STUDY

Generic Name:

Meperidine Hydrochloride

Brand Name: Classification: Ordered Dose: Mode Of Action:

Indications:

Demerol Opioid agonist analgesic 50mg IVTT now then prn for abdominal pain Acts as agonist at specific opioid receptors in the CNS to produce analgesia, euphoria, sedation; the receptors mediating these effects are thought to be the same with endorphins Relief of moderate to severe acute pain. Pre-op: Support for of anesthesia

Contraindications: Hypersensitivity to narcotics, diarrhea, asthma, COPD, respiratory depression, pregnancy, seizure, renal dysfunction Drug Interactions:  Potentiation of effects with barbiturate anesthetics  Severe/fatal reactions with MAOIs  Increased chances of respiratory depression, hypotension, sedation, and coma with phenothiazines Side Effect: Adverse Effects: Nausea, vomiting, loss of appetite, constipation, dizziness, sedation, drowsiness, impaired visual acuity  CNS: light-headedness, dizziness, sedation, euphoria, dysphoria, delirium, insomnia, agitation, anxiety, fear, hallucinations, disorientation, mood changes, lethargy, weakness, headache, tremor  CV: peripheral circulatory collapse, tachycardia, bradycardia, arrhythmia, palpitations, hypertension, hypotension  Dermatologic: pruritus, urticaria, bronchospasm, edema  GI: nausea, vomiting, dry mouth, anorexia, constipation,  GU: ureteral spasm, urinary retention, oliguria, decreased libido  MAJOR: respiratory depression, apnea, circulatory depression, respiratory arrest, shock, cardiac arrest

Page | 63

Nursing Responsibilities:

Bibliography:

 Keep opioid antagonist and facilities readily available during parenteral administration  Use caution when injecting to patients with hypotension  Reduce dosage of Demerol in patients receiving phenothiazines or other tranquilizers  Reassure that addiction is unlikely to occur  Use Demerol with extreme caution in patient with renal dysfunction  Give only prescribed dosage  Avoid alcohol, antihistamines, sedatives, tranquilizers  Do not take left over medications for other disorders  Keep out the reach of children  Take Demerol with food, small frequent meals  May use laxative if constipation occurs  Avoid driving or doing activities that require alertness because it could cause drowsiness and impaired visual activity. 2005 Lippincotts Nursing Drug Guide www.drugs.com/demerol.html www.rxlist.com/demerol-drug.htm

Generic Name:

Hyoscine N-butyl Bromide

Buscopan Gastro-intestinal antispasmodic 20mg 1amp IVTT now It's a competitive antagonist of the actions of acetylcholine and other muscarinic agonists. Hyoscine works by relaxing the muscle that is found in the walls of the stomach, intestines and bile duct (gastrointestinal tract) and the reproductive organs and urinary tract (genitourinary tract) Indications: This medication is used to relieve bladder or intestinal spasms. Contraindications: Hypersensitivity to hyoscine butylbromide, Patients with prostatic enlargement, paralytic ileus or pyloric stenosis, ulcerative colitis, closed angle glaucoma Brand Name: Classification: Ordered Dose: Mode Of Action:

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Drug Interactions:

    

Anticholinergic agents Antihistamines Monoamine oxidase inhibitors Tricyclic antidepressants Competitively blocks prokinetic agents

Side Effect:

Adverse Effects:

Nausea, vomiting, loss of appetite, constipation, dry mouth, rash, itching, swelling of the hands or feet, trouble breathing, increased pulse, dizziness, diarrhea, vision problems, eye pain  CNS: light-headedness, dizziness, sedation, euphoria, dysphoria, delirium, insomnia, agitation, anxiety, fear, hallucinations, disorientation, mood changes, lethargy, weakness, headache, tremor  CV: peripheral circulatory collapse, tachycardia, bradycardia, arrhythmia, palpitations, hypertension, hypotension  Dermatologic: pruritus, urticaria, bronchospasm, edema  GI: nausea, vomiting, dry mouth, anorexia, constipation,  GU: ureteral spasm, urinary retention, oliguria, decreased libido  MAJOR: respiratory depression, apnea, circulatory depression, respiratory arrest, shock, cardiac arrest  Inform patient that drug may cause blurred vision. Instruct patient to report if she experiences such symptom.  Assess for parkinsonism and Extra-pyramidal symptoms.  Assess for urinary hesitancy  Assess for constipation.  Caution patient to avoid alcohol because it may increase CNS depression.  As appropriate, review all other significant adverse reactions and interactions  Give only prescribed dosage  Do not take left over medications for other disorders  Keep out the reach of children

Nursing Responsibilities:

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Bibliography:

MIMS 113th edition 2007 http://home.intekom.com/pharm/quatrom/q-hyosc.html http://www.medicinenet.com/hyoscine_butylbromideoral/page2.htm http://www.netdoctor.co.uk/medicines/100000395.html

Generic Name:

Cefoxitin Sodium

Brand Name: Classification: Ordered Dose: Mode Of Action: Indications:

Monowel Antibiotic, Cephalosphorin (2nd gen) 1g IVTT q8 ANST Inhibits synthesis of bacterial cell wall causing cell death Perioperative prophylaxis

Contraindications: Hypersensitivity to cephalosphorins and/or penicillins Drug Interactions:  Increased nephrotoxicity with aminoglycosides  Increased bleeding effects with anticoagulants Side Effect: Stomach upset, nausea, vomiting, diarrhea Adverse Effects:  CNS:, dizziness, lethargy, headache  CV: peripheral circulatory collapse, tachycardia, bradycardia, arrhythmia, palpitations, hypertension, hypotension  GI: nausea, vomiting, diarrhea, anorexia, abdominal pain, psuedomembranous colitis  GU: Nephrotoxicity  Hematologic: bone marrow depression, thrombocytopenia Nursing  Culture infection before starting therapy Responsibilities:  Have vitamin K available in case of hypoprothrombinemia  Discontinue if hypersensitivity occurs  Avoid alcohol while taking drug  Take only prescribed dosage  Complete antibiotic therapy, dont skip doses  Do not use extra medicine to make up the missed dose  Do not use drug if you are allergic to penicillins and cephalosporins  Antibiotic medicines can cause diarrhea, which may be
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Bibliography:

a sign of a new infection. If you have diarrhea that is watery or has blood in it, call your doctor.  Store at room temperature away from moisture, heat, and light  If you get a skin rash, do not treat yourself. 2005 Lippincotts Nursing Drug Guide MIMS 113th edition 2007 www.drugs.com/cdi/cefoxitin.html www.revolutionhealth.com/drugs-treatments/cefoxitin

Generic Name:

Diazepam

Brand Name: Classification: Ordered Dose: Mode Of Action: Indications:

Valium Benzodiazepine, skeletal muscle relaxant 10mg 1 tab 2am Potentiates the effects of GABA; Act in spinal cord and at supraspinal sites to produce skeletal muscle relaxation Relief of anxiety and tension; to lessen recall in patients prior to surgical procedures

Contraindications: Hypersensitivity to benzodiazepines, psychosis, shock, coma, alcoholic intoxication, pregnancy Drug Interactions:  Increased CNS depression with omperazole  Increased effects of diazepam with cimetidine, hormononal contraceptives  Decreased effects with ranitidine Side Effect: Adverse Effects: Drowsiness, dizziness, GI upset, difficulty concentrating, fatigue, nervousness, crying  CNS: drowsiness, sedation, depression, lethargy, fatigue, light headedness, disorientation, restlessness, tremor, stupor, psychomotor retardation, EPS, hallucinations, nasal congestion  CV: bradycardia, tachycardia, hypotension, hypertension, edema  Dependence: drug dependence  Dermatologic: uticaria, pruritus, dermatitis  GI: constipation, diarrhea, dry mouth, salivation,
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Nursing Responsibilities:

Bibliography:

nausea, anorexia, vomiting, hepatic dysfunction, jaundice  GU: incontinence, retention, change in libido, menstrual irregularities  Other: phlebitis and thrombosis at injection site, hiccups, fever, diaphoresis, pain at injection site  Carefully monitor pulse, respiration rate and blood pressure during administration  Keep addiction prone patients under careful surveillance  Ensure ready access to bathroom if GI effects occur  Provide small, frequent meals to prevent GI upset  Establish safety precautions if CNS changes occur  Monitor liver and kidney function, CBC during long term therapy  Taper dose gradually after long term therapy  Discuss risk of fetal abnormalities with patients desiring to become pregnant  Take drug exactly as prescribed  Do not stop drug abruptly during long term therapy  Caregiver should learn to assess seizures and monitor patient  Use of barrier contraceptive is advised while on this drug  Avoid alcohol, sleep inducing drugs 2005 Lippincotts Nursing Drug Guide MIMS 113th edition 2007 www.drugs.com/valium.html www.medicinenet.com/diazepam/article.htm

Generic Name:

Ranitidine Hydrochloride

Brand Name: Classification: Ordered Dose:

Zantac Histamine2 antagonist 150mg 1tab

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Competitively inhibits action of histamine at histamine2 receptors of the parietal cells of the stomach, inhibiting basal gastric acid secretion and gastric acid secretion that is stimulated by food, insulin, histamine, cholinergic agonists, gastrin, and pentagastrin Indications: Against ulcer brought about by NPO due to surgical procedure Contraindications: Hypersensitivity to ranitidine, lactation Drug Interactions: Increased effects of warfarin Side Effect: Constipation, nausea, vomiting, breast enlargement, impotence, headache Adverse Effects:  CNS: headache, malaise, dizziness, somnolence, insomnia, vertigo  CV: bradycardia, tachycardia,  Dermatologic: rash, alopecia  GI: constipation, diarrhea, nausea, anorexia, vomiting, abdominal pain, hepatic dysfunction, jaundice  GU: gynecomastia, impotence  Hematologic: leucopenia, granulocytopenia, thrombocytopenia, pancytopenia  Local: pain at IM site, local burning pain at injection site Mode Of Action: Nursing Responsibilities:          Administer oral drug with meals and hs Decrease doses in renal and liver failure Provide concurrent antacid therapy to relieve pain Avoid cigarette smoking as it decreases effectiveness Have regular medical follow-up to evaluate response Adjust environment (lights, temp, noise) to prevent headache Using ranitidine may increase your risk of developing pneumonia Avoid drinking alcohol. It can increase the risk of damage to your stomach If you think you have taken too much of this medicine contact a poison control center or emergency room at once. If you need to take an antacid you should take it at least 1 hour before or 1 hour after this medicine.
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This medicine will not be as effective if taken at the same time as an antacid.  If you get black, tarry stools or vomit up what looks like coffee grounds, call your doctor or health care professional at once. You may have a bleeding ulcer.

Generic Name:

Phytonadione

Brand Name: Classification: Ordered Dose: Mode Of Action:

Hema K Fat soluble vitamin; antifibrinolytic agent 1amp now Vitamin K is required for the liver to make factors that are necessary for blood to properly clot (coagulate), including factor II (prothrombin), factor VII (proconvertin), factor IX (thromboplastin component), and factor X (Stuart factor). Preoperatively: to activate clotting factors to decrease chances of bleeding during surgical procedure

Indications:

Contraindications: Hypersensitivity to benzyl alcohol, Drug Interactions: Coumarin and indanedione derivatives Side Effect: Adverse Effects: Nursing Responsibilities: No known side effects for this drug; bruising and bleeding are less likely to happen. No known adverse effects reported  Instruct patient to take only prescribed order  If a dose is missed, take as soon as remembered unless almost time for the next dose  Cooking does not destroy substantial amounts of Vitamin K  Caution patient to avoid IM injection and activities leading to injury  Patient should not drastically alter diet while taking Vitamin K  Use a soft toothbrush until coagulation effect is corrected  Advise patient to report any signs of bleeding/bruising
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Source

 Patient should be advised not to take OTC drugs without advice of health care provider  Advise patient to inform health care provider of medication regimen prior to treatment or surgery  Emphasize importance of frequent lab test to monitor coagulation factors MIMS 113th edition 2007 http://www.nlm.nih.gov/medlineplus/druginfo/natural/patien t-vitamink.html http://www.drugs.com/enc/vitamin-k.html

Generic Name: Brand Name: Classification: Ordered Dose: Mode Of Action:

Etoricoxib Arcoxia COX-2 Selective Inhibitor 120mg PO 12mn Arcoxia reduces pain and inflammation by blocking COX-2, an enzyme in the body.Arcoxia does not block COX-1, the enzyme involved in protecting the stomach from ulcers.Other anti-inflammatory medicines (NSAIDS) block both COX-1 and COX-2.Arcoxia relieves pain and inflammation with less risk of stomach ulcers compared to NSAID relief of acute pain

Indications:

Contraindications: Hypersensitivity to arcoxia and its ingredients such as etoricoxib Drug Interactions:  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
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 methotrexate, a medicine used to suppress the immune system

Side Effect: Adverse Effects:

Nausea, vomiting, diarrhea, Headache, Rash, Blurred vision, Difficulty in sleeping, Muscle cramps, Fatigue  CNS: headache, malaise, dizziness, hallucinations, insomnia, vertigo, anxiety, drowsiness, confusion  CV: bradycardia, tachycardia, hypertension  Dermatologic: rash, urticaria  GI: constipation, diarrhea, nausea, anorexia, vomiting, abdominal pain, hepatic dysfunction, jaundice  GU: gynecomastia, impotence  Hematologic: leucopenia, granulocytopenia, thrombocytopenia, pancytopenia  Local: pain at IM site, local burning pain at injection site  Take Arcoxia only when prescribed by your doctor.  For the relief of chronic musculoskeletal pain the recommended dose is 60 mg once a day.  If you have mild liver disease, you should not take more than 60 mg a day. If you have moderate liver disease, you should not take more than 60 mg every other day.  When taking the tablets, swallow them with a glass of water. Do not halve the tablet.  Take your Arcoxia at about the same time each day.  Taking Arcoxia at the same time each day will have the best effect. It will also help you remember when to take the dose.  It does not matter if you take Arcoxia before or after food.  Do not use Arcoxia for longer than your doctor says.  Do not take a double dose to make up for the dose that you missed.  If you get an infection while taking Arcoxia, tell your doctor. Arcoxia may hide fever and may make you think, mistakenly, that you are better or that your infection is less serious than it might be.

Nursing Responsibilities:

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Generic Name:

Tramadol hydrochloride

Brand Name: Classification: Ordered Dose: Mode Of Action:

Ultram Central acting analgesic 100mg 1tab PO Binds to mu-opioid receptors and inhibits the reuptake of norepinephrine and serotonin; causes many effects similar to opioids but doesnt cause respiratory depression Relief of moderate to severe pain.

Indications:

Contraindications: Hypersensitivity to tramadol or opioids or intoxication with alcohol, opioids, or psychoactive drugs Drug Interactions:  Decreased effectiveness with carbamezapine  Increased risk of tramadol toxicity with MAOIs Side Effect: Dizziness, sedation, drowsiness, impaired visual acuity, nausea, loss of appetite Adverse Effects:  CNS: sedation, dizziness, headache, confusion, dreaming, anxiety, seizures  CV: hypotension, tachycardia, bradycardia,  Dermatologic: pruritus, urticaria, sweating, pallor  GI: nausea, vomiting, dry mouth, flatulence, constipation,  Other: potential for abuse, anaphylactoid reactions Nursing  Control environment ( temp, light, noise) Responsibilities:  Limit use in patients with past or present history of addiction or dependence to opioids  Caution patient not to chew or crush tablet  Keep opioid antagonist readily available in case of emergency  Instruct post-op patients that drug suppress cough reflex  Monitor bowel function and arrange laxatives for constipation  Institute safety precautions (side rails, assistive device)  Provide frequent, small meals if GI upset occurs  Provide back rubs, positioning, and other non pharmacological measures to alleviate pain  Take drug exactly as prescribed
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 Avoid alcohol, antihistamines, sedatives, tranquilizers while taking this drug

Generic Name:

Sultamicillin (ampicillin and sulbactam)

Brand Name: Classification: Ordered Dose: Mode Of Action:

Unasyn Antibiotic 375mg tab PO TID

It acts through the inhibition of cell wall mucopeptide biosynthesis. Ampicillin has a broad spectrum of bactericidal activity against many gram-positive and gram-negative aerobic and anaerobic bacteria. sulbactam in the UNASYN formulation effectively extends the antibiotic spectrum of ampicillin to include many bacteria normally resistant to it and to other beta-lactam antibiotics. Indications: Intra-Abdominal Infections caused by beta-lactamase producing strains of Escherichia coli, Klebsiella spp. (including K. pneumoniae*), Bacteroides spp. (including B. fragilis), and Enterobacter spp. Contraindications: contraindicated in individuals with a history of hypersensitivity reactions to any of the penicillins. Drug Interactions:  allopurinol (Zyloprim);  probenecid (Benemid); or  an antibiotic such as amikacin (Amikin), gentamicin (Garamycin), kanamycin (Kantrex), neomycin (Mycifradin, Neo-Fradin, Neo-Tab), netilmicin (Netromycin), streptomycin, tobramycin (Nebcin, Tobi). Side Effect: Nausea, vomiting, stomach pain, bloating, gas, vaginal itching or discharge, headache, itching, swollen, black, or "hairy" tongue, thrush ;pain, swelling, or other irritation where the needle is placed.  CNS: lethargy, hallucinations, seizures  GI: stomatitis, gastritis, nausea, vomiting, diarrhea, abdominal pain, pseudomembranous colitis,
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Adverse Effects:

     Nursing Responsibilities:

nonspecific hepatitis GU: proteinuria, oliguria, hematuria, pyuria Hematologic: anemia, thrombocytopenia, leukopenia, neutropenia, prolonged bleeding time Hypersensitivity: rash, fever, wheezing, anaphylaxis Local: pain, phlebitis, thrombosis at injection site Other: superinfection, sodium overload, CHF

 Culture infected area before beginning treatment  Monitor serum electrolytes and cardiac status  Do not use this medication if you are allergic to ampicillin and sulbactam or to any other penicillin antibiotic  Antibiotic medicines can cause diarrhea, which may be a sign of a new infection. If you have diarrhea that is watery or has blood in it, call your doctor. Do not use any medicine to stop the diarrhea unless your doctor has told you to.  Use this medication for the entire length of time prescribed by your doctor. Your symptoms may get better before the infection is completely treated.  This medication can cause you to have unusual results with certain medical tests. Tell any doctor who treats you that you are using ampicillin and sulbactam.  Store ampicillin and sulbactam at room temperature away from moisture, heat, and light.  Provide small, frequent meals if GI upset occurs  Do not use extra medicine to make up the missed dose.  Seek emergency medical attention if you think you have used too much of this medicine.  If you get a skin rash, do not treat yourself.

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NURSING CARE PLAN

1. Acute pain related to presence of surgical incision secondary to status post laparoscopic cholecystectomy. 2. Impaired skin integrity related to surgical procedure: laparoscopic cholecystectomy secondary to calculous cholecystitis 3. Deficient knowledge regarding illness and treatment course related to lack of information presented. 4. Risk for infection related to presence of surgical incision. 5. Risk for imbalanced body temperature related to exposure to anesthesia secondary to status post laparoscopic cholecystectomy.

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NURSING CARE PLAN Patients Name: V.Q Chief Complaint: Pain at the right upper quadrant of the abdomen Diagnosis: Calculous Cholecystitis Age: 38 years old Ward: MCM 8th Main Room No. 815

1. Acute pain related to presence of surgical incision secondary to status post laparoscopic cholecystectomy. Cues Subjective Cues: y Verbalized Masakit pa yun opera ko, kumikirot pa sa sakit. Objective Cues: Nursing Diagnosis Acute pain related to presence of surgical incision secondary to status post laparoscopic cholecystectomy. R: Pain is a common aftermath for every surgery after the y pain scale of 6 out anesthesia wore down. Pain is recognized in two of 10 noted ( 1 is the lowest; 10 is the different forms: physiologic pain and highest) Objective/Goal At the end of 3 hours nursing intervention, the patient will be able to: 1. Report a decrease in pain intensity to a scale of 3 out of 10. 2. Demonstrate non 2. Administer analgesics (e.g Tramadol) as ordered. R: Tramadol is an analgesic. It binds to mu-opioid receptors and inhibits the reuptake of Nursing Interventions 1. Monitor and assess vital signs every 2 hours. R: Vital signs are usually altered in acute pain. Evaluation GOAL MET At the end of rendering 3 hours nursing intervention, the patient was able to: 1. Report pain as relieved and controlled as evidenced by verbalization
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y Grimaced face noted. y Guarding behavior noted. y Slow and limited movement of the upper extremities y Patient is 1 day post operative. y Vital Signs: T36.6C; BP- 130/90; RR-18; PR- 81.

clinical pain. Physiologic pain comes and goes, and is the result of experiencing a highintensity sensation. It often acts as a safety mechanism to warn individuals of danger (e.g., a burn, animal scratch, or broken glass). Clinical pain, in contrast, is marked by hypersensitivity to painful stimuli around a localized site, and also is felt in non-injured areas nearby. When a patient undergoes surgery, tissues and nerve endings are traumatized, resulting in incision pain.

pharmacological methods and/or use of relaxation skills and diversional activities, as indicated, for individual situation.

norepinephrine and serotonin; causes many effects similar to opioids but doesnt cause respiratory depression. It is for moderate to severe pain.

of client, Hindi na masyadong masakit yung affected area, medyo tolerable na And reported

3. Evaluate the effectiveness of analgesic at regular intervals after each administration, also observing for any signs and symptoms of untoward effects (e.g. respiratory depression, nausea and vomiting)

a pain scale of 3 out of 10 2. Demonstrate non pharmacologic al methods and/or use of relaxation skills and diversional activities (e.g. patient

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This trauma overloads the pain receptors that send messages to the spinal cord, which becomes overstimulated. The resultant central sensitization is a type of posttraumatic stress to the spinal cord, which interprets any stimulationpainful or otherwiseas unpleasant. That is why a patient may feel pain in movement or physical touch in locations far from the surgical site.

R: The analgesic dose may not be adequate to raise the clients pain threshold or may be causing intolerable or dangerous side effects or both. Ongoing evaluation will assist in making necessary adjustments for effective pain management.

maintained moderate high back rest position; she also performed diversional activities such as talking with her watcher) Vital Signs: T36.4C; BP-

4. Monitor patients pain 120/90; RR-19; at least every hour while awake by the use of the pain scale. R: Allows evaluation of the severity of the pain felt by the patient. Pain is a subjective PR- 84.

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experience and only the Source: http://www.surgeryencyc lopedia.com/Pa-St/PostSurgical-Pain.html 5. Instruct and demonstrate use of deep breathing exercise. Also instruct patient to do splinting while doing deep breathing exercises. R: Deep breathing increases oxygen in the body and prevents atelectasis. Deep breathing exercise also provides comfort.Splinting while doing deep breathing is patient can describe the pain shes feeling.

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to lessen the pain upon respiration.

6. Position the patient properly in bed. Elevate head of bed. Maintain anatomic alignment R: Alignment helps prevent pain from malposition and it enhances comfort

7. Encourage diversional activities (TV/radio, socialization with others, mental imaging). R: These highten ones

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concentration upon nonpainful stimuli to decrease one's awareness and experience of pain.

8. Provide rest periods to facilitate comfort, sleep, and relaxation R: The patient's experiences of pain may become exaggerated as the result of fatigue. Adequate rest helps provide comfort

9. Assist patient in doing her activities of daily living R: Helps reduce pain

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brought about by the exertion of force necessary to perform activities

10. Encourage patient to report pain as soon as it starts and allow her to verbalize pain experienced or describe the pain shes feeling. R: Severe pain is more difficult to control and increases the clients anxiety and fatigue.

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2. Impaired skin integrity related to surgery: laparoscopic cholecystectomy secondary to calculous cholecystitis. Assessment Subjective: Inoperahan ako ditto sa may tiyan, as verbalized by the patient Diagnosis Impaired skin integrity related to surgery: laparoscopic cholecystectomy secondary to calculous cholecystitis. Planning At the end of 2 days nursing intervention the patient will be able to: 1. Display improvement in wound healing as evidenced by intact incision site. 2. Remain free from infection as evidenced by normal vital signs and absence of purulent discharge. Nursing Interventions 1. Assess dressings/ wound every shift. Describe wounds and observe for changes. : Establishes comparative baseline providing opportunity for timely intervention. 2. Keep the incision site clean and dry, carefully dress wounds. : Keeping incision site clean and dry prevents infection; it also aids in the process of wound healing. 3. Encourage early ambulation. Assist patient in doing active and passive range of motion exercises. : Movement stimulates circulation and assists in Evaluation At the end of 2 days nursing intervention, the patient was able to: 1. Maintain incision site and dressing intact and dry. 2. Remain free from infection as evidenced by normal vital signs (BP= 120/70; RR=18; PR=85; Temp=36.6) and absence of purulent discharge.

Objective: y post laparoscopic cholecystectomy (2 hrs) Disruption of the dermis, epidermis, and subcutaneous tissues. with 0.5 to 1 cm incisions at the epigastrium, right lower rib cage and below the Rationale: Laparoscopic cholecystectomy is a less invasive way to remove the bladder. It is performed through inserting a laparoscope just below the navel. Three additional ports are inserted by

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umbilicus incisions covered with dry and intact dressing skin slightly warm to touch. Temperature: 36.8C

making three other incisions in the epigastrium and in the right upper quadrant of the abdomen. Source: Talamini, M. (2006). Advanced Therapy in Minimally Invasive Surgery, p. 179. USA: Decker Inc.

3. Demonstrate behaviors/technique s to promote healing or prevent complications

the bodys natural process of repair. 4. Monitor temperature every 4 hours. : Early recognition of developing infection enables rapid institution of treatment and prevention of further complications. 5. Place in semi-Fowlers position or moderate high back rest. : Proper positioning decreases tension in the operative site and promotes healing. 6. Instruct to wear clean, dry, loose-fitting clothes, preferably cotton fabric : Skin friction caused by stiff or rough clothes leads to irritation of fragile skin and increases risk for infection. Loose clothing reduces pressure on

3.Demonstrate behaviors/techni ques to promote healing or prevent complications (e.g patient washes hands after using the comfort room, eats a balanced diet, and takes antibiotic medication (sultamicillin) as ordered)

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compromised tissues, which may improve circulation/healing 7. Emphasize importance of adequate nutrition and fluid intake. Encourage patient to eat foods rich in protein, iron and vit. C. : Improved nutrition and hydration will improve skin condition. Protein and iron helps in repair of tissues. Vitamin C is important for immune system function and increases resistance to some pathogens.

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8. Instruct the client in proper postoperative skin care. Teach client and her significant others the importance of proper hand washing. : This is to involve the patient in caring for skin, promoting comfort, and preventing infection or other complications. Proper washing of hands deter the spread of microorganisms.

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9. Instruct the client to observe for signs and symptoms of complications such as elevated temperature, redness, warmth, swelling near the surgical incision, purulent discharge, or breakdown of sutures around the incision, and report to the physician. : Provides for prompt recognition of complications and facilitates prompt treatment. 10. Administer antibiotics as prescribed by the physician (sultamicillin) : May be given prophylactically or to treat specific infection and enhance healing.

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3. Deficient knowledge regarding illness and treatment course related to lack of information presented. Asessment Subjective cues: y Verbalized: Para saan yang gamut nay an (holds sultamicillin tablet)? Objective cues: y Frequent questioning y Incorrect verbal feedback regarding understanding Diagnosis Knowledge deficit regarding illness and treatment course related to lack of information presented. Planning At the end of 2 hours nursing intervention, the patient will be able to: 1. Verbalize understanding of disease process and treatment. 2. Initiate necessary lifestyle changes and participate in treatment regimen. Nursing Interventions 1. Assess the patients current knowledge of the medications and other doctors instructions and nursing procedures and its implications, the likelihood of complications if these are not followed, and the likelihood of cure or disease control. Specifically ask about the physicians explanations and the patients past experiences. R: Adults learn best when teaching builds on previous knowledge or experience. Assessing recall of the physicians explanations as
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Evaluation At the end of 2 hours of nursing intervention, the patient was able to: 1. VerbalizeNaiintind ihan ko na kung bakit binibigyan ako nang ganitong gamut para malabanan ko yung inpeksyon. 2. Initiate necessary lifestyle changes and participate in treatment regimen and verbalized Sa susunod iiwasan ko na kumain nang matatabang pagkain.

R: Knowledge is important especially in health matters. Deficiency in knowledge might affect the patients health status. If ever health issues are

of treatment regimen.

taken for granted, it may result to disorders/diseas es that could have been prevented if the patient had enough knowledge regarding her current health status. Lack of knowledge about health may also contribute to occurrence of anxiety.

well as the patients past experiences and exposure to health information provides an opportunity for evaluating attitudes and the accuracy and completeness of knowledge. 2. Ask how much the patient wants to know. Consider patients preference for information in planning and teaching. R: People vary in the degree of detail they find helpful. Those who cope with a threatening experience by avoiding it generally want to know

GOAL MET

Source:

relatively little about

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Berman, A. et. al. (2008) Kozier & Erbs Fundamental of Nursing Concepts, Process and Practice 8th Edition. Pearson Prentice Hall, volume Two, Chapter 42, stress and coping

impending experiences, whereas those who cope by learning as much as possible about the threatening experience want to know a great deal. When possible, supporting the patients preferred learning style shows respect for individual differences. 3. Determine learning needs. Consider needs expressed by the patient and family. R: Learning needs determine appropriate content. Learning occurs most rapidly when its relevant to current needs.

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Responding to expressed needs displays sensitivity to the patients and familys concern. Identifying predictable concerns and responses and necessary self-care activities helps the nurse fulfill learning needs of which the patient and family may be unaware. 4. Present manageable amounts of information at any one time. R: Too much information at one time causes confusion. They patient may lose sight of key points. 5. Inform the patient about indication of medication,
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drug interaction and its side effects R: Allows patient to be knowledgeable about medication and avoid misconceptions. 6. Inform the patient about the diet specific for her condition (low fat, high fiber foods; avoid spicy foods, alcohol and caffeine) R: A patient who has recently had a gallbladder removed may suffer from diarrhea and bloating after consuming foods high in fat. Diarrhea and bloating occur because of two reasons. One reason
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is that fat inside the intestine absorbs more water, causing stomach upset. A second reason is that bacteria begins to digest the fat within the intestine and ultimately produces gas. When a person with gallbladder problems consumes spicy foods, , unpleasant side effects such as gas and heartburn can occur. 7. Provide simple explanations, using easy-tounderstand terminology. R: Medical and nursing jargon distances the patient

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and family members. Intricate explanations may confuse or overwhelm them. 8. Discuss to the patient and to the family the importance of complying with the medications and other doctors orders. R: This lets the patient be aware of the significance of the doctors instructions. It also lets the patient know the consequences which might occur if instructions werent followed. Knowing the benefits of complying with the instructions encourages participation.

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9. Ask for feedback. R: The patient may initially feel overwhelmed and insecure about learning because of the magnitude, urgency or unfamiliarity of necessary adaptations to illness. 10. Use review and repetition judiciously, considering individual factors. R: The unit environment and the patients age may contribute to a short attention span and poor retention.

11. During and after

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teaching, determine what learning has occurred. R: Determining learning accomplishment permits resolution of some learning needs and provides guidance for meeting others. 12. Provide information about additional learning resources, like the nearest baranggay health center in their area. R: Patients should be informed that there are health services in the health centers which are for free, so as to persuade them to avail it.

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DISCHARGE PLAN (M.E.T.H.O.D.)

I.

MEDICATION 1. Take medications as ordered. 2. Inform the patient to take medications on time or as directed for the full course of therapy even if feeling better. 3. Inform the client about the adverse effects and possible side effects of the medications. 4. Inform the client about the importance of taking prescribed medications and the consequences of not following the treatment regimen. 5. Encourage the patient to report or inform the health team if any of these side effects occur. Inform and explain to the client that other drugs that he is taking will probably have effects with the medication given. Moreover, emphasize the right time interval of these drugs to maximize its effects and avoid further complications. 6. Provide information for better understanding regarding therapeutic regimen.

II.

EXERCISE 1. Promote regular light exercise and exercise as tolerated. 2. Encourage exercise in lower and upper extremities to promote good circulation. 3. Inform patient about proper exercise regimen to avoid injury. 4. Alternate rest periods with activity. 5. Encourage walking exercise.

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III.

TREATMENT 1. Instruct the patient to continue drug therapy as ordered. 2. Inform the patient as well as family the dangers of non compliance to treatment regimen. 3. Discuss to the patient the complications and other problems that might arise from the condition. 4. Inform the patient to exercise and do breathing exercises. 5. Instruct the patient to report to the health team promptly about any changes on health condition. 6. Encourage patient to strictly comply with the doctors orders, especially in taking prescribed medications. 7. Encourage the patient to have followed up visitations to the physician after discharge.

IV.

HEALTH TEACHINGS 1. Encourage patient to avoid strenuous activities. 2. Improving nutritional intake; meal planning is implemented with High fiber moderate calorie, low fat and low salt as the primary goal. 3. Encourage to balance diet and intake of nutritious food such as vegetables and lean meat, avoiding high fat foods. 4. Check with healthcare provider to evaluate progress of the condition. 5. Encourage to have adequate hydration. Water is the best source of fluid that is needed by the body to maintain its function. 6. Instruct to avoid alcoholic beverages due to a compromised hepatic system. 7. Encourage to have a restful and quiet atmosphere at home. 8. Encourage patient to use relaxation skills when in pain. 9. Encourage patient to seek emotional and social support especially to family and friends to promote strength and comfort. 10. Check the condition with a healthcare provider to evaluate progress of the condition.
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V.

OUTPATIENT 1. Remind patient on the arrangements to be made with the physician for follow-up checkups. 2. Follow-up check up regularly in order to monitor and properly manage patients illness. 3. Inform to continue medication as ordered. 4. Instruct to have a follow-up check up or refer to the physician if the patient is uncomfortable. 5. Instruct the patient and significant others to report for any irregularities.

VI.

DIET 1. The diet recommended for the client is High fiber moderate calorie, low fat and low salt 2. Encourage patient to increase nutritious foods intake by eating fresh fruits and vegetables, whole grain products, and lean meat. 3. Recommend to eat 5 or more servings of vegetables and fruits each day. 4. Encourage to choose whole grain foods instead of white flour and sugars. 5. Advise to try to limit meats that are high in fat and cut back on processed meats like hot dogs and bacon. 6. Inform patient to avoid food such as salted, cured, smoked, or canned meat. 7. Increase oral fluid intake. Hydration is needed by the body to transport nutrients needed by the body. 8. Instruct to avoid drinking of alcoholic beverages as much as possible. 9. Encourage not to forget to get some type of light exercise because the combination of good diet and regular exercise will help in the maintenance of healthy weight and the feeling of more energetic.

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RECOMMENDATION This case study about Calculous Cholecystitis gave the group more information and knowledge in making an actual management for this kind of problem. Thus, the members of the group have realized the need of promoting and maintaining optimal health to both the patient and her significant others. With these, the group would like to recommend the following. To the client: The patients participation and willingness to be assessed and comply with the therapeutic regimen is needed for an effective management and prevention of complications. The patient is encouraged to always reach for wellness, and be cautious enough to know what her body needs and to recognize her limitations in complying therapeutic regimen. Also, the patient is encouraged to follow the discharge plan for the betterment of her condition while at home. She is also recommended to have her regular follow-up checkups to evaluate her condition. The patient is enlightened to be more open with her feelings regarding her current condition, family problems and concerns about her health To the clients family: The patients family plays an important role in the improvement of patients condition because they are source of strength and inspiration to deal with the disease. The family is encouraged to be sensitive enough to know the patients need and weaknesses that they may be able to render their support and care. Just with their presence and affection can help the patient feel that she is being loved and that she can successfully surpass the challenges that are brought by her illness. The feeling of being secured and accepted is what also the patient needs to achieve optimal state of well being.

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To the Student Nurses: Give appropriate nursing care and follow out doctors order properly to avoid any errors and give better care to the clients. Cooperation with the healthcare team is also essential to provide better quality care. They should also be honest in the data collecting done to the patient, putting in mind that they are dealing lives. They should treat the client as a fellow human being giving quality care and service. They must also research about the disease to enhance their knowledge about it. They must also be updated with current updates that could be beneficial to the nurse, the client and the rest of the healthcare team.

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REFERENCES  Berman, A. et. al. (2008) Kozier & Erbs Fundamental of Nursing Concepts, Process and Practice 8th Edition. Pearson Prentice Hall, volume Two, Chapter 42, stress and coping  Boyer, M. (2006). Brunner and Suddarths Textbook of Medical-Surgical Nursing, 11th ed.  Carol Mattson Porth (2005). Pathophysiology, Seventh edition.  Crowley, L. (2010). An Introduction to Human Disease: Pathology and Pathophysiology Correlations, 8th ed., p. 563. USA: Jones and Bartlett Publishers.  Digiulio, M. & Jackson, D.(2007). Medical-Surgical Nursing Demystified, p. 288. USA: McGraw-Hill.  Everhart, JE, Khare, M, Hill, M, Maurer, KR. Prevalence and ethnic differences in gallbladder disease in the United States. Gastroenterology 1999; 117:632.  Ginsber, G. & Ahmad, N. (2006) The Clinicians Guide to Pancreaticobiliary Disorders, p. 121-123. USA: SLACK Incorporated.  Harrisons Principles of Internal Medicine, Tenth Edition 1983.  Iyengar, V. Elemental Analysis and of Biological Systems: Aspects Biomedical, of Trace Environmental, Compositional Methodological

Elements, Vol. 1, p. 49.  Kozier and Erbs, Fundamentals of Nursing, Chap. 20, page 352  Lippincott Williams and Wilkins Handbook of Diseases Third Edition, page 184  MIMS 113th edition 2007  Talamini, M. (2006). Advanced Therapy in Minimally Invasive Surgery, p. 179. USA: Decker Inc.  Taylor, Lillis, LeMone and Lynn (2008),Fundamentals of Nursing: The Art and Science of Nursing Care, 6th edition.  Understanding Medical Surgical Nursing by Williams and Hopper page 742  White, L. Foundations of Nursing: Caring for the Whole Person, p. 832.
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 http://arcoxia-side-effects.com/  http://digestive.niddk.nih.gov/statistics  http://home.intekom.com/pharm/quatrom/q-hyosc.html  http://medical-dictionary.thefreedictionary.com/calculi  http://www.diabetesmonitor.com/learning-center/gallstones.htm  http://www.drugs.com/arcoxia.html  http://www.drugs.com/enc/vitamin-k.html  http://www.drugs.com/mtm/ampicillin-and-sulbactam.html  http://www.drugs.com/ultram.html  http://www.healthline.com/goldcontent/ranitidine  http://www.learningplaceonline.com/stages/organize/Erikson.htm  http://www.medicinenet.com/hyoscine_butylbromide-oral/page2.htm  http://www.medicinenet.com/tramadol/article.htm  http://www.netdoctor.co.uk/medicines/100000395.html  http://www.nlm.nih.gov/medlineplus/druginfo/natural/patient-vitamink.html  http://www.pfizer.com/files/products/uspi_unasyn.pdf  http://www.rxlist.com/unasyn-drug.htm  http://www.turner-white.com/pdf/hp_nov00_murphy.pdf  http://www.webmd.com/drugs/drug-11276-Ultram+Oral.aspx  www.drugs.com/valium.html  www.medicinenet.com/diazepam/article.htm  www.medicinenet.com/ranitidine/article.htm  www.revolutionhealth.com/drugs-treatments/cefoxitin  www.rxlist.com/zantac-

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