St Anne College Lucena Inc.

Diversion Rd. Bry Gulang Gulang, Lucena city

College of Nursing

IN PARTIAL FULFILLMENT OF OUR REQUIREMENTS

IN

RELATED LEARNING EXPERIENCE (105)

CASE STUDY ABOUT ACUTE CHOLECYSTITIS

Presented to:

Mr. Clark Joy Barias R.N. MAN R.L.E Coordinator

Presented by:

DOLLY JOY SALOMES

BSN IV A

March 5, 2010

I Patient profile

Biographical Data

Name: Mr. X

Age: 46 years old

Sex: Male

Nationality: Filipino

Date of Birth: August 28, 1962

Place of Birth: General Santos City

Civil Status: Married

Address: Lucban Quezon

Religion: Christianity (Roman Catholic)

Educational attainment: High School Graduate

Occupation: Driver

Admitting Date and Time: January 8 at 10:40 am

Case Number: 083981

Attending Physician: Dr. Emmanuel Yap

II History

A, Nursing history

I chief complain: Right upper quadrant pain

II admitting diagnoses: Cholecystitis T/C Cholelithiasis

III physical Examination

Hair, head and face: Skull size was normocephalic. Skull and face were symmetrical with an equal distribution of hair. Hair was black in color with fair amount of white and gray strands, short, dry, and fine. There was no dandruff or infestation present. No lesions, lacerations, tenderness, masses and depressions noted. The forehead was furrowed with wrinkles. Face portrayed emotions with symmetrical movements. No masses or involuntary movement. The face was round, with no edema, lesions, discolorations present

Eyes: Pupils are equal and round reactive to light and accommodation (PERRLA)

Nose: The nose was symmetrical with no deformities, skin lesions, massses present. Nasal septum is intact and in midline. No nasal flaring was observed. No discharges were present. No tenderness in his sinuses upon palpation.

Ears: Ears were symmetrical with same size bilaterally and color consistent with face. Pinnas were free from lesions, masses, swelling, redness, tenderness, and discharges and were in line with the eyes. External canals were clear with no cerumen seen. No inflammation, masses, discharges and foreign bodies noted. Gross hearing acuity was good. No pain on the mastoid process was reported upon palpation.

Mouth and Throat: Mouth was proportional and symmetrical. Lips were rust colored and were dry

with no presence of ulcerations, sores or lesions. Teeth were yellowish in color with some dental caries noted. Right upper first premolar tooth was absent. Tongue was in central position and moves freely with no swelling or ulcerations observed. Gag reflex was present as evidenced by patient swallowing. Tonsils were not inflamed. Halitosis was also noted.

Neck and Lymph nodes: Neck was symmetrical with no masses or swelling noted. No jugular vein distention was noted. Range of motion was normal and moves easily without discomfort upon rotation, flexion, extension and hyperextension. Thyroid was not enlarged has no nodules, masses, and irregularities upon palpation. Trachea is symmetrical and in midline without deviation.

Skin: Skin was warm to touch, slightly dry, rough, and with good skin turgot. Neither jaundice nor cyanosis observed. Papules on the face observed, with nevi noted on the right side of the nose. Patient was not cyanotic. No bruises or discolorations observed. No edema noted.

Nails:Pink nail bed and trimmed

Thorax and Lungs: No thorax deformity observed. Respiratory rate was 21 cycles per minute with

regular breathing pattern. Symmetrical chest expansion was observed during respiration. No use of accessory muscles during breathing observed. Chest wall was intact; no tenderness and masses noted. Uniform temperature also noted. No adventitious breath sounds heard upon auscultation. No cough present.

Cardiovascular: With cardiac rate of 75 beats per minute with a regular rhythm. No abnormal

beats, palpitations, thrills or murmurs present upon auscultation.

Axilla:No assessment done

Abdomen: Abdomen was slighty enlarged and globular when patient was in supine position; with slightly soaked, intact dressing on the right upper quadrant. Pulsations

were not visible. The abdomen had hypoactive bowel sounds of two bowel sounds per minute.

Extremities:Symmetrical shoulder movement observed during respiration. Spine was

located at the midline with no discrepancies noted. Shoulders, arms, elbows and forearms were free from nodules, deformities and atrophy. Range of motion was not limited. Neither pallor nor bone enlargements were noted upon inspection of the upper extremities. Upper extremities were not edematous. Radial and brachial pulses were present. Hip joint and thighs were symmetrical with no deformities present. No edema noted at both legs. No inflammation noted in the lower extremities. Range of motion was active and not limited.

IV final diagnoses. Acute cholecystitis

B, Present Health history

Symptom (PTA)

Pt prior to admission, Mr X experienced right upper quadrant pain associated with a sense of bloatedness, without nausea and vomiting. The pain was tolerable so he did not seek medical attention yet. He said he also had an increased level of pain tolerance so he also didn’t mind to take any pain relievers. Until three days prior to admission, patient had severe right upper quadrant pain, which was said to be intolerable. Moreover, when pressure is applied on the RUQ of the abdomen, pain is elicited. He had also lost his appetite because of the pain. His scleras were also slightly icteric during admission and he was positive with Murphy’s sign. So he sought consultation at Out-Patient Department- Emergency Room at Tayabas Community Hospital. Ultrasound revealed cholecystitis, so patient was advised admission and operation.

C, Past Health History

I Hospitalization

Mr. x experienced common illness such as colds, cough, and fever during his childhood. He also had chicken pox during his childhood. However, he could not recall at what age he got the disease and as well as the management of his chicken pox.

Two years ago (2007), he was admitted to Davao Medical Center due to loss of consciousness. Prior to that, he was experiencing palpitations, and pain on the suboccipital area (nape) associated with headache. He had blood pressure of 180/100 as he could remember during the VS taking at the emergency room. And his diagnosed with hypertension.

II Surgical management

None

III allergies

None

D family Health History

Mr. X is the eldest among Mr. Dad‘s and Mrs. Mom‘s two children. But his younger sister Anna died of car accident at the age of six years old; He grew up at General Santos City where the relatives of his mother live. When Mr. X was a first year high school, his parents got separated because of third party. He lived with his mother and Mrs. Mom’s live-in partner at Davao City, while his father returned to Leyte where his other relatives live. With his mother’s second family, he had another two siblings, Step-brod and Step-sis. Step-brod died at the age of 18 because of suicide. He had suicide because of altered mental status due to shabu use. Today, Step-sis has her own family at Leyte.

Because Mr. X had been away from the relatives of his father, he does not know any significant disease they have or had. He doesn’t also know the causes of deaths of his grandmother and grandfather on the paternal side. On the other hand, what he only knows is that the eldest sister of her mother has hypertension, and that his grandfather on the maternal side died of hypertension.

Grandmother unknown

Father Mother

Grandfather Hypertension

Patient X . Hypertension and cholo

Younger sister Anna died of car accident at age of six years

Step-brod died at the age of 18 because of suicide.

Grandfather unknwon

Grandmother

IV Nutrition

A 24 hrs food result (PTA)

Meal Type and amount of food usually taken Breakfast I cup of rice and fried egg Morning snack Coke and sandwich Lunch 2 cap of rice and sinegang Dinner 2 cap of rice and adobong baboy

B Regular Routine of diet (weekly)

Monday Tuesday Wednesday Thursday Friday Saturday Sunday

Breakfast I cup of rice, 1 cup of coffee and hotdog

I cup of rice, 1 cup of coffee and tocino

I cup of rice, 1 cup of coffee and fried egg

I cup of rice, 1 cup of coffee and fried chicken

I cup of rice, 1 cup of coffee. Corne beef

I cup of rice, 1 cup of coffee and maling

I cup of rice, 1 cup of coffee and

Lunch 2cup of rice and sinegang na baboy

2 cup of rice and adobong manok

2 cup of rice and pinangat

2 cup of rice and langkang gulay

2 cup of rice and monggo

2 cup of rice and sisig

2cup of rice andkalderita

Dinner I cup of rice andLangka gulay

I cup of rice and Fried chicken

I cup of rice and maling

I cup of rice and corne beef

I cup of rice andSinegang

I cup of rice and tinola

I cup of rice and pansit

Food likes; all kinds of adobong Cheese curls; boy Bawang Allergies ; none

C Intake and output

Frequency Problem difficulty Usual remedy

Bowel movement Twice a day None none

Urination 4* a day None Morning

D habits

Playing computer games, basketball, and cooking foods

V Disease Entity

A Definition

Cholecystitis is an inflammation of the gallbladder wall and nearby abdominal lining. Cholecystitis is usually caused by a gallstone in the cystic duct, the duct that connects the gallbladder to the hepatic duct. The presence of gallstones in the gallbladder is called cholelithiasis. Cholelithiasis is the pathologic state of stones or calculi within the gallbladder lumen. A common digestive disorder worldwide, the annual overall cost of cholelithiasis is approximately $5 billion in the United States, where 75-80% of gallstones are of the cholesterol type, and approximately 10-25% of gallstones are bilirubinate of either black or brown pigment. In Asia, pigmented stones predominate, although recent studies have shown an increase in cholesterol stones in the Far East.

Gallstones are crystalline structures formed by concretion (hardening) or accretion (adherence of particles, accumulation) of normal or abnormal bile constituents. According to various theories, there are four possible explanations for stone formation. First, bile may undergo a change in composition. Second, gallbladder stasis may lead to bile stasis. Third, infection may predispose a person to stone formation. Fourth, genetics and demography can affect stone formation.

Risk factors associated with development of gallstones include heredity, obesity, rapid weight loss, through diet or surgery, age over 60, Native American or Mexican American racial makeup, female gender where gallbladder disease is more common in women than in men. Women with high estrogen levels, as a result of pregnancy, hormone replacement therapy, or the use of birth control pills, are at particularly high risk for gallstone formation. Diet with very low calorie diets, prolonged fasting, and low-fiber/high-cholesterol/high-starch diets all may contribute to gallstone formation.

Sometimes, persons with gallbladder disease have few or no symptoms. Others, however, will eventually develop one or more of the following symptoms; (1) Frequent bouts of indigestion, especially after eating fatty or greasy foods, or certain vegetables such as cabbage, radishes, or pickles, (2) Nausea and bloating (3) Attacks of sharp pains in the upper right part of the abdomen. This pain occurs when a gallstone causes a blockage that prevents the gallbladder from emptying (usually by obstructing the cystic duct). (4) Jaundice (yellowing of the skin) may occur if a gallstone becomes stuck in the common bile duct, which leads into the intestine blocking the flow of bile from both the gallbladder and the liver. This is a serious complication and usually requires immediate treatment.

The only treatment that cures gallbladder disease is surgical removal of the gallbladder, called cholecystectomy. Generally, when stones are present and causing symptoms, or when the gallbladder is infected and inflamed, removal of the organ is usually necessary. When the gallbladder is removed, the surgeon may examine the bile ducts, sometimes with X-rays, and remove any stones that may be lodged there. The ducts are not removed so that the liver can continue to secrete bile into the intestine. Most patients experience no further symptoms after cholecystectomy. However, mild residual symptoms can occur, which can usually be controlled with a special diet and medication.

B Etiology

When the outflow of bile from the gallbladder is obstructed, it becomes distended. This distension causes a compromise of blood flow and lymphatic drainage. This eventually leads to mucosal ischemia and finally necrosis. In 2000, the ability of endotoxin to cause necrosis, hemorrhage, areas of fibrin deposition, and extensive mucosal loss was demonstrated. Later, endotoxin was shown to have the capacity to abolish the gallbladder’s ability to contract in response to cholecystokinin (CCK), worsening gallbladder stasis and accelerating the process of infection. (Bile cultures are often positive for bacteria, but bacterial proliferation may be a more appropriate description of the overall process.)

C Epidemiology

FrequencyAn estimated 10-20% of Americans have gallstones, and as many as one third of these people develop acute cholecystitis. Cholecystectomy for either recurrent biliary colic or acute cholecystitis is the most common major surgical procedure performed by general surgeons, resulting in approximately 500,000 operations annually.

Cholelithiasis, the major risk factor for cholecystitis, has an increased prevalence among people of Scandinavian descent, Pima Indians, and Hispanic populations, whereas cholelithiasis is less common among individuals from sub-Saharan Africa and Asia.

Mortality/MorbidityMost patients with acute cholecystitis have a complete remission within 1-4 days. However, 25-30% of patients either require surgery or develop some complication. Patients with acalculous cholecystitis have a mortality rate ranging from 10-50%, which far exceeds the expected 4% mortality rate observed in patients with calculous cholecystitis. Emphysematous cholecystitis has a mortality rate approaching 15%. Perforation occurs in 10-15% of cases.

RacePima Indian and Scandinavian people have the highest prevalence of cholelithiasis and, consequently, cholecystitis. Populations at the lowest risk reside in sub-Saharan Africa and Asia. In the United States, white people have a higher prevalence than black people.

SexGallstones are 2-3 times more frequent in females than in males, resulting in a higher incidence of calculous cholecystitis in females. Elevated progesterone levels during pregnancy may cause biliary stasis, resulting in higher rates of gallbladder disease in pregnant females. Acalculous cholecystitis is observed more often in elderly men.

AgeThe incidence of cholecystitis increases with age. The physiologic explanation for the increasing incidence of gallstone disease in the elderly population is unclear. The increased incidence in elderly men has been linked to changing androgen-to-estrogen

ratios

D Anatomy of Origin

HEPATOBILLARY

LIVER

A.

A. Location and size of the liver- largest gland in the body, weighs approximately 1.5 kg; lies under the diaphragm; occupies most of the right hypochondrium and part of the epigastrium.

B. Liver lobes and lobules- two lobes separated by the falciform ligament1. Left lobe- forms about one sixth of the liver2. Right lobe- forms about five sixths of the liver; divides into right lobe proper,

caudate lobe, and quadrate lobe3. Hepatic lobules- anatomical units of the liver; small branch of hepatic vein

extends through the center of each lobuleC. Bile ducts

1. Small bile ducts form right and left hepatic ducts2. Right and left hepatic ducts immediately join to form one hepatic duct3. Hepatic duct merges with cystic duct to form the common bile duct, which

opens into the duodenumD. Functions of the liver

1. Glucose Metabolism-after a meal, glucose is taken up from the portal venous blood by the liver and converted into glycogen (glycogenesis), which is stored in the hepatocytes. Glycogen is converted back to glucose (glycogenolysis) and release as needed into the blood stream to maintain normal level of the blood glucose.

-glucose can be synthesized by the liver through the process gluconeogenesis

2. Ammonia Conversion-use of amino acids from protein for gluconeogenesis result in the formation of ammonia as a by product. Liver converts ammonia to urea

3. Protein Metabolism-Liver synthesizes almost all of the plasma protein including albumin, alpha and beta globulins, blood clotting factors plasma lipoproteins

4. Fat Metabolism-Fatty acid can be broken down for the production of energy and production of ketone bodies

5. Vitamin and Iron Storage-stores vitamin A, D, E, K

6. Drug Metabolism7. Bile Formation

-bile is formed by the hepatocytes

-composed of water, electrolytes such as sodium, potassium, calcium, chloride, bicarbonate, lecithin, fatty acids, cholesterol, bile salts

-collected and stored in the gallbladder and emptied in the intestine when needed for digestion

a. Lecithin and bile salts emulsify fats by encasing them in shells to form tiny spheres called micelles

b. Sodium bicarbonate increases pH for optimum enzyme functionc. Cholesterol, products of detoxification, and bile pigments (e.g. bilirubin)

are wastes products excreted by the liver and eventually eliminated in the feces

GALLBLADDER

The gallbladder (or cholecyst, sometimes gall bladder) is a small organ whose function in the body is to harbor bile and aid in the digestive process.

Anatomy The cystic duct connects the gall bladder to the common hepatic duct to form the

common bile duct. The common bile romero duct then joins the pancreatic duct, and enters through the

hepatopancreatic ampulla at the major duodenal papilla. The fundus of the gallbladder is the part farthest from the duct, located by the lower

border of the liver. It is at the same level as the transpyloric plane.

Microscopic anatomy

The different layers of the gallbladder are as follows: The gallbladder has a simple columnar epithelial lining characterized by recesses

called Aschoff's recesses, which are pouches inside the lining. Under the epithelium there is a layer of connective tissue (lamina propria). Beneath the connective tissue is a wall of smooth muscle (muscularis externa) that

contracts in response to cholecystokinin, a peptide hormone secreted by the duodenum.

There is essentially no submucosa separating the connective tissue from serosa and adventitia.

Size and Location of the Gallbladder

The gallbladder is a hollow, pear-shaped sac from 7 to 10 cm (3-4 inches) long and 3 cm broad at its widest point. It consists of a fundus, body and neck. It can hold 30 to 50 ml of bile. It lies on the undersurface of the liver’s right lobe and is attached there by areolar connective tissue.

Structure of the Gallbladder

Serous, muscular, and mucous layers compose the wall of the gallbladder. The mucosal lining is arranged in folds called rugae, similar in structure to those of the stomach.

Function of the Gallbladder

The gallbladder stores bile that enters it by way of the hepatic and cystic ducts. During this time the gallbladder concentrates bile fivefold to tenfold. Then later, when digestion occurs in the stomach and intestines, the gallbladder contracts, ejecting the concentrated bile into the duodenum. Jaundice a yellow discoloration of the skin and mucosa, results when obstruction of bile flow into the duodenum occurs. Bile is thereby denied its normal exit from the body in the feces. Instead, it is absorbed into the blood, and an excess of bile pigments with a yellow hue enters the blood and is deposited in the tissues.

The gallbladder stores about 50 mL (1.7 US fluid ounces / 1.8 Imperial fluid ounces) of bile, which is released when food containing fat enters the digestive tract, stimulating the secretion of cholecystokinin (CCK). The bile, produced in the liver, emulsifies fats and neutralizes acids in partly digested food.

After being stored in the gallbladder the bile becomes more concentrated than when it left the liver, increasing its potency and intensifying its effect on fats. Most digestion occurs in the duodenum.BILIRUBIN PRODUCTION AND ELIMINATION

Bilirubin is the substance that gives bile its color. It is formed from senescent red blood cells. In the process of degradation, the hemoglobin from the red blood cell is broken down from biliverdin, which is rapidly converted to free bilirubin thru biliverdin reductase. Free bilirubin, which is not soluble in plasma, is transported in the blood attached to plasma albumin. Even when it is bound to albumin, this bilirubin is still called free bilirubin. As it passes through the liver, free bilirubin is released from its albumin carrier molecule and moved into the hepatocytes. Inside the hepatocytes, free bilirubin is converted to conjugated bilrubin thru glucoronyl transferase, making it soluble to bile. Conjugated bilirubin is secreted as a constituents of bile, and in this form, it passes through the bile ducts into the small intestine. In the intestine, approximately one half of the bilirubin is converted into a higly soluble substance called urobilinogen by the intestinal flora. Urobilinogen is either absorbed into the portal circulation or excreted in the feces. Most of the urobilinogen that is absorbed is returned to the liver to be re-excreted into the bile. A small amount of urobilinogen, approximately 5% is absorbed into the general circulation and then excreted by the kidney

VI Pathophysilogy

Risk factor

Heredity Obesity Rapid Weight Loss, through diet or surgery Age Over 60 Female Gender Diet-Very low calorie diets, prolonged fasting, and

low-fiber/high-cholesterol/high-starch diets.

Bile must become supersaturated with

cholesterol and calcium

The solute precipitate from solution as solid crystals

Crystals must come together and fuse to form stones

Gallstones

Obstruction of the cystic duct and common bile duct

Jaundice Sharp pain in the right part of abdomen

Distention of the gall bladder

Venous and lymphatic drainage is impaired

Proliferation of bacteria

Localized cellular irritation or infiltration

or both take place

Areas of ischemia may occur

Inflammation of gall bladder

CHOLECYSTITIS

Cholecystotomy

The operation of making an opening in the gall bladder, as for the removal of a gallstone.

Cause of Fever

VII management

A Medical Management

Abdominal Ultrasound is an imaging procedure used to examine the internal organs of the abdomen, including the liver, gallbladder, spleen, pancreas, and kidneys. The blood vessels that lead to some of these organs can also be looked at with ultrasound.

The procedure usually takes less than 30 minutes.

cholecystectomy is performed to treat cholelithiasis and cholecystitis. In cholelithiasis, gallstones of varying shapes and sizes form from the solid components of bile. The presence of stones, often referred to as gallbladder disease, may produce symptoms of excruciating right upper

abdominal pain radiating to the right shoulder. The gallbladder may become the site of acute infection and

Surgical Incision

Disruption of skin, tissue and muscle integrity

Stimulation of sensory nerve endings

Pain

Destruction of skin layers

Impaired Skin integrity

Broken skin and traumatized tissue

Destruction of Skin Layers

Increased risk for environmental exposure to

pathogens

Risk for Infection

Broken Skin and traumatized tissue

inflammation, resulting in symptoms of upper right abdominal pain, nausea and vomiting. This condition is referred to as cholecystitis. The surgical removal of the gallbladder can provide relief of these symptoms

B Nursing Management

All care that is given and observations made regarding the patient (e.g., condition of skin preoperatively) must be documented in the operative record for continuity of care and for medicolegal reasons.

The nurse conveys to the patient that he will act as the patient’s advocate by speaking for him while the patient is in surgery.

Assess health factors that affects the patient preoperatively: nutritional status, drug or alcohol use, cardiovascular status, hepatic and renal function, endocrine function, immune function, previous medication use, psychosocial factors, as well as the spiritual and cultural beliefs.

When the circulator reviews patient allergies with the patient, he ascertains that the patient has no history of allergy to radiopaque dye.

Inform the patient of the scheduled date and time of the surgery and where to report Instruct what to bring (insurance card, list of meds & allergies) Check the chart for patient’s sensitivities and allergies e.g. allergy to iodine.

Document allergies noted preprocedure and document alternative used. Instruct what to leave at home such as jewelry, watch, medications and contact

lenses Instruct what to wear ( loose fitting, comfortable clothes and flat shoes) Remind the patient not to eat or drink if directed The patient may have fear and anxiety regarding the surgical procedure and the

unfamiliar environment. Explain nursing procedures before performing them and the sequence of perioperative events.

Assess and document patient’s anxiety level and level of knowledge regarding the intended procedure. Clarify misconceptions by answering the patient’s questions in a knowledgeable manner and refer questions to the surgeon as necessary.

Decrease fear Teach deep-breathing, coughing or incentive spirometer Provide emotional support to the patient regarding feelings of altered body image by

providing the patient an opportunity to express her feelings. Respect cultural, spiritual and religious beliefs

Notify your physician to report any of the following:

fever and/or chills

redness, swelling, or bleeding or other drainage from the incision site(s)

increased pain around the incision site(s)

abdominal pain, cramping, or swelling

pain behind the breast

VIII laboratory/ diagnoses procedure

A Blood Analysis

DIAGNOSTIC NORMAL RESULT

ACTUAL RESULT

NURSING

IMPLICATION

NSG. RESPONSIBILITY

WBC 5.0-10.0 12.9 g/l slightly elevated indicates infection

>Instruct patient to increase intake of Vitamin C and increase fluid intake

>Administer antibiotic as ordered

Lymph # 3.0-4.0 1.6x1069/L High-indicates stress, pain and acute systemic infection

>Instruct patient to increase intake of Vitamin C and increase fluid intake

>Monitor signs of infection such as elevated Body Temp.

>Administer antibiotic as ordered

Mid # 0.1-0.9 0.7x10^9/L Normal

Gran # 5.0-7.0 8.0 g/l Slightly elevated indicates infection

>Monitor signs of infection such as elevated Body Temp.

>Administer antibiotic as ordered

HGB 120-160 131g/L Normal

RBC 4.04-5.48 4.99x10^12/L Normal

B Urinalysis

NORMAL ACTUAL Implication Nursing Responsibility

COLOR Light or pale Yellow

Light Yellow Normal

CHARACTER Clear Slightly turbid Abnormal Instruct patient to increase fluid intake

ALBUMIN (-) (-) Normal

REACTION 4.6-8 6.5 pH Normal

SPECIFIC GRAVITY

1.010-1.025 1.010 Normal

PUS CELL 0 2-4 Slightly elevated

presence of infection

Instruct patient to increase fluid intake

Administer antibiotic as ordered

SQUAMOUS (-) (+) Abnormal Instruct patient to increase fluid intake

Administer antibiotic as ordered

BACTERIA (-) (+) Abnormal Instruct patient to increase fluid intake

Instruct patient to increase intake of Vitamin C

Administer antibiotic as ordered

X Discharge Plan.

M - Instructed the patient to continue medication as ordered

1. Cephalexin 500 mg cap 3 x day (8am-1pm-8pm) for 1 week

2. Mefenamic Acid 500 mg cap 3 x day (am-1pm-8pm) for 1 week

E - Instructed the patient to do exercise as tolerated such as walking

T - Instructed the patient to continue the medication

H - 1. Encouraged patient to increase fluid intake

2. Encouraged patient to eat foods rich in Vitamin and Nutritious foods

3. Encourage patient to avoid salty and fatty foods

4. Encourage patient to have enough rest

O - Instructed to come back for follow-up check-up on January 15, 2010, Friday.

Remind patients that regular check-ups are important to ensure that the patient

condition is constantly monitored by the doctor. If any of the following symptoms

are noted, he should contact his doctor: any of the wounds start to bleed

any of the wounds become more

painful, red, inflamed or swollen

the abdomen swells

pain is not relieved by the prescribed painkillers

a fever develops.

These could be signs of an infection that may need to be treated with antibiotics

D - Advised the patient to a diet as tolerated but preferably avoiding salty and

fatty foods.

1, Acute pain r/t disruption of skin, tissue and muscle integrity secondary to Surgical incision

ASSESSMENT NURSINGDIAGNOSIS

PLAN NURSINGINTERVENTION

RATIONALE EVALUATION

Subjective “masakit ang sugat ko" as verbalized by the patient

Objective with pain

scale of 5/10

with facial grimaces

weak appearance

guarding behavior

V/S:T: 36.2 °CP: 69 bpmR: 19 cpmBP: 120/80 mmHg

Acute pain r/t disruption of skin, tissue and muscle integrity secondary to Surgical incision(Cholecystotomy )

Cholecystotomy

↓Surgical Incision

↓Disruption of

skin, tissue and muscle integrity

↓Stimulation of sensory nerve

endings↓

Pain

After 8 hrs of nursing intervention the patient will report that her pain is lessen from a pain scale of 5/10 to 1/10.

Assess location, characteristic, onset, duration, frequency , quality and severity of pain

Note location of surgical incision

Perform assessment each time pain occurs, note and investigate changes from previous reports

Monitor V/S Provide quiet environment

and encourage adequate rest period

Encourage use of relaxation technique and diversional activities

Provide additional comfort measures such as back rub, changing patient’s position, change linen as necessary

Administer analgesic as ordered

To assess the etiology or precipitating factors

As this can influence the amount of post-op experience

To rule out worsening of underlying condition or development of complication

V/S are usually altered in acute pain

To prevent fatigue

To encourage sense of control and improve coping activities/helps control or alleviate pain

To relieve general discomfort

To maintain acceptable level of pain

Goal met:Patient reported that her pain was lessened from a pain scale of 5/10 to 1/10 after 8 hours of nursing intervention.

2, Acute Pain, r/t disruption of skin, tissue and muscle integrity secondary to Surgical incision

ASSESSMENT NURSINGDIAGNOSIS

PLAN NURSINGINTERVENTION

RATIONALE EVALUATION

Subjective ” masakit ang sugat ko pag gumaglaw ako’ as verbalized by the patientObjective Facial grimace

upon moving patient puts her

hand above surgical incision when moving

Slowed movement weak appearance Inability to

ambulate or walk without assistance from others

T: 36.2 °CP: 69 bpmR: 19 cpmBP: 120/80 mmHg

Acute Pain, r/t disruption of skin, tissue and muscle integrity secondary to Surgical incision(Cholecystotomy)

Cholecystotomy↓

Surgical Incision↓

Disruption of skin, tissue and muscle

integrity↓

Stimulation of sensory nerve

endings↓

Pain

After 8 hrs of nursing intervention the patient will report that her pain is lessen from a pain scale of 5/10 to 1/10.

Assess location, characteristic, onset, duration, frequency , quality and severity of pain

Note location of surgical incision

Perform assessment each time pain occurs, note and investigate changes from previous reports

Monitor V/S

Provide quiet environment and encourage adequate rest period

Encourage use of relaxation technique and diversional

To assess the etiology or precipitating factors

As this can influence the amount of post-op experience

To rule out worsening of underlying condition or development of complication

V/S are usually altered in acute pain

To prevent fatigue

To encourage sense of control and improve coping

Goal met:Patient reported that her pain was lessened from a pain scale of 5/10 to 1/10 after 8 hours of nursing intervention.

activities

Provide additional comfort measures such as back rub, changing patient’s position, change linen as necessary

Administer analgesic as ordered

Instruct patient’s significant others to help patient divert pain into other things

activities/helps control or alleviate pain

To relieve general discomfort

To maintain acceptable level of pain

3, Impaired Skin Integrity r/t disrupted skin layers secondary to surgical incision

ASSESSMENT NURSINGDIAGNOSIS

ANALYSIS PLAN NURSINGINTERVENTION

RATIONALE EVALUATION

Subjective ”Medyo na ngangate tong sugat ko” as verbalized by the patient

Objective disrupted

skin layers wound area

is warm to touch

(+)slight swelling at

the incision site

V/S:T: 36.2 °CP: 69 bpmR: 19 cpmBP: 120/80 mmHg

Impaired Skin Integrity r/t disrupted skin layers secondary to surgical incision

Cholecystotomy↓

Surgical Incision↓

Destruction of skin layers

↓Broken skin and

traumatized tissue↓

Impaired Skin integrity

After 8 hrs of nursing intervention the patient will avoid scratching at the incision site

Inspect/assess incision site for redness, swelling or signs of evisceration

Keep the incision site clean and dry, carefully change the dressing

Regularly clean the wound aseptically

Minimize skin irritation

Instruct patient to increase intake of foods rich in protein, minerals and vitamins

Assess for presence or absence of local wound infection

Redness or swelling indicates wound infection

To assist body’s natural process of infectio

To promote healing and prevent infection

Preventing skin irritation eliminates a potential source of microorganism entry

They aid in skin healing

Provides for early detection of developing infectious process

Goal Met (-) Scratching on the incision site after 8hours of nursing intervention.

Instruct patient to have adequate rest and sleep

Teach and assist the client in the following:

supporting the surgical site when moving

Splinting the area when coughing, sneezing, or vomiting

Administer antibiotic as ordered

Instruct patient’s significant others the proper way of caring wound

Adequate rest and sleep helps in faster healing and recovery

A wound typically requires 3 weeks for strong scar formation. Stress on the suture line before this occurs can cause disruption

To prevent infection and promote healing

To promote healing and prevent infection

4. Risk for infection related to presence of surgical incision

ASSESSMENT NURSINGDIAGNOSIS

PLAN NURSINGINTERVENTION

RATIONALE EVALUATION

S/O: “Surgical incision at right upper quadrant” as verbalized by the patient

Objective disrupted skin

layers wound area is

warm to touch

(+)slight swelling at

the incision site

WBC is slightly elevated,12

V/S:T: 36.2 °CP: 69 bpmR: 19 cpmBP: 120/80 mmHg

Risk for infection related to presence of surgical incision

Surgical Procedure

(Cholecystotomy)

↓Surgical Incision

↓Destruction of Skin Layers

↓Broken Skin and

traumatized tissue↓

Increased risk for environmental

exposure to pathogens

↓Risk for Infection

After 8 hours of nursing intervention the occurrence of infection will be prevented as evidenced by no s/sx of infection will appear like diaphoresis, chills, abdominal pain and fever.

Monitor vital signs. Note onset of fever, chills, diaphoresis, changes in mentation, and complaints of increasing abdominal pain.

Practice good hand washing and aseptic wound care.

Inspect incision and dressings. Note characteristics of drainage from wound.

Administer antibiotics

Suggestive of presence of infection/ developing sepsis, abscess or peritonitis.

Reduce risk of spread of bacteria

Provides early detection of developing infectious process and monitor resolution of pre-existing peritonitis.

May be given prophylactically or to reduce number of multiplying microorganisms in the presence of infection to decrease spread and seeding of the abdominal cavity.

Goal Met :after 8hours of nursing intervention (-) chills, (-)

diaphoresis (-) report of

increasing abdominal pain

afebrile with a body temp of 36.9°C

Use sterile gloves for wound care. Practice aseptic technique.

. Instructed to maintain clean dry clothes preferably cotton fabr

Cleanse incision site with povidone iodine.

Instruct client not to wet incision site.

Prevents invasion of bacteria or microorganisms at site and eventually prevents possible infection

Skin friction caused by stiff or rough clothes leads to irritation of fragile skin and increases risk for infection.

Disinfects site and prevents multiplication of microorganisms which may cause infection.

Microorganisms thrive at damp areas and makes it conducive for replication.

5. Anxiety related to Surgical incision.

Assessment Nursing Diagnosis

Plan Nursing Interventions Rationale Evaluation

Subjective Natakot ako sa operasyon baka kong anu ang mag yari sa akin.

Objective

Restlessness Reports of uncertainty and being scared

T: 36.2 °CP: 69 bpmR: 19 cpmBP: 120/80 mmHg

Anxiety related to upcoming surgical operation.

Inflammation of gall bladder

CHOLECYSTITIS

surgical operation

(Cholecystotomy)

Anxiety to scheduled surgical operation

Within my 4 hour care, the client will be able to:

1.Verbalize awareness of feelings of anxiety and health ways to deal with them.

2. Report anxiety is reduced to a manageable level.

Be available to the patient. Maintain frequent contacts with the patient/SO. Be available for listening and talking as needed

Identify patient’s perception of the threat represented by the situation

Encourage patient to acknowledge reality of stress without denial or reassurance that everything will be alright. Provide information about measures being taken to correct or alleviate condition.

Assist SO to respond in a positive manner to patient and situation

Establishes rapport, promotes expression of feelings. Demonstrates concern and willingness to help. Helpful in discussing sensitive subjects

Helps recognition of extent of anxiety and identification of measures that may be helpful for the individual.

Helps patient to accept what is happening and reduce level of anxiety. False reassurance is not helpful, because neither nurse nor patient knows the final outcome. Information can provide reassurance/ help reduce fear of the unknown.

Promotes reduction of anxiety to see others remaining calm. Because anxiety is contagious, if SO/ staff exhibit their anxiety, the patient’s coping abilities can be adversely

Review coping mechanisms used in the past such as recognizing or asking for help.

Acknowledge feelings as they are expressed.

Identify ways in which patient can get help when needed such as calling the attention of the members of the health team.

Provide as much order and predictability as possible in scheduling care or activities, visitors.

Instruct mental imagery or relaxation methods such as imaging a pleasant place, use of music, slow breathing and meditation.

. Use therapeutic touch

affected. Provides opportunity to build

on resources the patient and So may have available.

Often acknowledging feelings will enable patient to deal more appropriately with situation.

Provides assurance that staff and students is available for assistance and support.

Helps patient anticipate and prepare for difficult treatments or movements, as well as look forward to pleasant occurrences.

Promotes the release of endorphins and aids in developing internal locus of control, reducing anxiety. May enhance coping skills, allowing body to go about its work of healing

Aids in meeting basic human need, decreasing sense of

to help patient remain calm.

isolation and assisting the patient to feel less anxious.

C. PHARMACOLOGIC

Name of Drug Route/ Dosage and Frequency

Action Indication Adverse Reaction NURSING RESPONSIBILITY Pharmacokinetics

GN: H2Bloc (Pepcidine)

BN:Famotidine

PO20 mg tab at bedtime

- Anti-ulcer- competitively inhibits action of histamine on the H2 at receptor sites of parietal cells, decreasing gastric acid secretion

-for short term treatment of duodenal ulcer

- headache, dizziness, malaise, dry mouth

1. Check for doctor’s order2. Know the 10 Rights in drug

administration3. not to be given in patients

hypersensitive to drugs4. Inform the patient about the

possible side effect of the drug5. Instruct patient to take drug

with food6. Advised patient to take drug

once daily usually at bed time7. Advise patient to report

abdominal pain or blood in stools or is vomiting.

45% Absorbed after oral and IM administration.

GN: Cefuroxime

BN: Zinacef

IV750 mg every 8o prior to OR (30 to 60 minutes before)

- anti-infective- a 2nd generation cephalosporin that inhibits cell-wall synthesis, promoting osmotic instability

- perioperative prophylaxis

- Nausea and Vomiting 1. Check for doctor’s order2. Know the 10 Rights in drug

administration3. Perform ANST prior to

admission4. Should not be given if positive

skin test5. Slow IV push6. Inform the patient about the

possible side effect of the drug7. Advise patient to report any

discomfort on the IV insertion site

Approximately 50% of serum cefuroxime is bound to protein. Serum pharmacokinetic parameters for CEFTIN Tablets and CEFTIN for Oral. absorbed from the gastrointestinal tract and rapidly hydrolyzed by nonspecific esterases in the intestinal mucosa and blood to cefuroxime.

GN: Clomipramine HCl

BN: Placil

PO10 mg tab, at 6 am

- Anti-depressants - for depression and chronic pain

- headache, dizziness, malaise, dry mouth

1. Check for doctor’s order2. Know the 10 Rights in drug

administration

3. not to be given in patients hypersensitive to drugs

4. Inform the patient about the possible side effect of the drug

GN: Gentamicin Dulfate

BN: Genticin

IV80 mg amp, every 80

- Anti-infective- inhibits protein synthesis

- endocarditis prophylaxis for GI or GU procedure or surgery

- Nausea and Vomiting, headache, dizziness

1. Check for doctor’s order2. Know the 10 Rights in drug

administration3. Perform ANST prior to

admission

Gentamicin, the level in the blood decays exponentially. The way this works is that the kidneys are always