I.

INTRODUCTION

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-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-Very low calorie diets, prolonged fasting, and low-fiber/highcholesterol/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.

II.

NURSING ASSESSMENT A. Personal History

Mr. Aproniano Castro is a 56 year old male, a Filipino citizen who resides at Pulong Santol, Porac Pampanga. He was born on January 22, 1950 at Pulong Santol, his religious affiliation is Roman Catholic and he is married to Mrs. Brigida M. Castro. He is a jeepney driver bound in Porac-Angeles route. He is also the president of their jeepney’s association. Mr. Castro usually works for 10 to 12 hours a day usually around 7am to 7 pm. He always sleeps around 9 in the evening and wakes up at 6 in the morning. His wife was the one who prepares him the breakfast and the snack. He has day-offs but uses this day in working as the president of the jeepney association. He usually eats instant food and love eating foods which has condiment like “patis”, vinegar and soy sauce. He also love eating vegetable salads and fatty salty food. He is not also choosy on the food he eats because he really eat a lots. He seldom drinks alcohol and smoke. Regarding the finances about health he is using his wife’s PHILHEALTH card to compensate the finances needed. Family Health and Illness History B. Family Health and Illness History According to Mr. Castro that the familial disease he knows that they have in their family was the hypertension that is on his father’s side. His father died because of heart attack and her mother died of natural cause. He also added that cholecystitis is prone to their family, because of one of his siblings also had acquired this disease. C. History of Past and Present Illness This is the second time Mr. Castro been admitted into this hospital (Porac District Hospital). On his first admission into this hospital he had undergone throidectomy operation, which is almost 3 years ago. He had not experience any accident and injuries, even though his job is prone to accident particularly vehicular accident. He also added that he had an ashtma when he was 7 years old that lasts when he is 21 years old, his ashtma just stopped when he start drinking alcohol beverages as he said.

As for his present illness, he was admitted into this hospital because of cholecystitis, he was admitted last February 13, 2006. He was been diagnosed with cholecystitis with multiple cholelithiasis a month prior to admission due to severe epigastric pain and weight loss and was advised to remove his gallbladder. He just did not have his cholecystectomy done immediately due to financial problem. When the money needed for his operation was enough he then goes to Porac District Hospital last February 13, 2005 for his operation. He was diagnosed and surgically operated by Dr. Serrano.According to Mr. Castro. Upon admission he had undergone some laboratory examination such as UTZ, Chest X-ray, U/A, CBC, FBS, BUN,Creatinine and ECG. His initial medication were H2bloc and Cefuroxime. D. Physical Examination Physical Assessment done by the attending physician reveals that patient is; • afebrile • with pink palpebral conjunctiva • (-) cyanosis • (+) NABS • non tender abdomen Vital Signs upon admission (February 13, 2006) BP- 130/90 RR-19 PR-84 Temp-36.5 oC Physical Assessment done by the student reveals that patient is; • afebrile • with pink palpebral conjunctiva • (+) dry lips • (+) paleness • (+) dryskin • decreased skin turgor • (-) bowel movement • (-) weakness Vital Signs taken and recorded as of February 15, 2006 are as follows; BP- 140/90 PR- 85 RR- 21

Temp- 36.4 oC

III.

ANATOMY AND PHYSIOLOGY

Gallbladder, muscular organ that serves as a reservoir for bile, present in most

vertebrates. In humans, it is a pear-shaped membranous sac on the undersurface of the right lobe of the liver just below the lower ribs. It is generally about 7.5 cm (about 3 in) long and 2.5 cm (1 in) in diameter at its thickest part; it has a capacity varying from 1 to 1.5 fluid ounces. The body (corpus) and neck (collum) of the gallbladder extend backward, upward, and to the left. The wide end (fundus) points downward and forward, sometimes extending slightly beyond the edge of the liver. Structurally, the gallbladder consists of an outer peritoneal coat (tunica serosa); a middle coat of fibrous tissue and unstriped muscle (tunica muscularis); and an inner mucous membrane coat (tunica mucosa). The function of the gallbladder is to store bile, secreted by the liver and transmitted from that organ via the cystic and hepatic ducts, until it is needed in the digestive process. The gallbladder, when functioning normally, empties through the biliary ducts into the duodenum to aid digestion by promoting peristalsis and absorption, preventing putrefaction, and emulsifying fat. Digestion of fat occurs mainly in the small intestine, by pancreatic enzymes called lipases. The purpose of bile is to; help the Lipases to Work, by emulsifying fat into smaller droplets to increase access for the enzymes, Enable intake of fat, including fat-soluble vitamins: Vitamin A, D, E, and K, rid the body of surpluses and metabolic wastes Cholesterol and Bilirubin.

IV. PATHOPHYSIOLOGY Risk factorHeredity Obesity Rapid Weight Loss, through diet or surgery Age Over 60

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 Sharp pain in the right part of abdomen

Jaundice

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

V.

DIAGNOSTIC AND LABORATORY PROCEDURE 1. Complete Blood Count (CBC) This is to determine blood components and the response to

inflammatory process and streptococcal infection. Date Ordered: February 13, 2006 Date Result In: February 13, 2006 Results: WBC RBC Lymphocyte Conclusion: WBC is slightly elevated based on the normal value of 4.3-10 g/l which confirms the presence of infection. 2. Fasting Blood Sugar This is to measure the blood glucose levels. Date Ordered: February 13, 2006 Date Result In: February 13, 2006 Results: 94.8 mg/dl Conclusion: The result is within normal range based on the normal value of < 126 mg/dl. 10.9 g/l 5.5 g/l 27

3. Creatinine This is the indicator of the renal function Date Ordered: February 13, 2006 Date Result In: February 13, 2006 Results: 1.0 mg/dl Conclusions: The result is within normal range based on the normal value of 0.60-1.7 mg/dl. 4. BUN This is an indicator of renal function and perfusion, dietary intake of CHON and the level of protein metabolism Date Ordered: February 13, 2006 Date Result In: February 13, 2006 Results: 10.7 Mg/dl Conclusions: The result is within normal range based on the normal value of mg/dl. 5. Urinalysis Urinalysis yields a large amount of information about possible disorders of the kidney and lower urinary tract, and systematic disorders that alter urine composition. Urinalysis data include color, specific gravity, pH, and the presence of protein, RBC’s, WBC’s, bacteria, Leukocyte, esterase, bilirubin,glucose, ketones, casts and crystals.

Date Ordered: February 10, 2006 Date Result In: February 10, 2006 Results: Color- yellow Specific Gravity- 0.010 Sugar/ Albumin- negative Pus cells- 0.1 hpf Conclusions: The results are normal but there is a presence of pus cells in the urine which means that there is also the presence of infection.

VI.

Patients Care a. Nursing Care Plan

Preoperative NCP 1. Acute Pain Cues S � O - pain scale of 7/10 - difficulty in moving as manifested by facial grimaces - (+) pallor - (+) muscle guarding - RR- 30 - BP- 140/90 Nursing Diagnosis Acute pain related to inflammation and distortion of the gallbladder as evidenced by verbal reports of pain. Scientific Explanations Due to the presence of stones in the gallbladder it causes some obstruction in the cystic duct which in turn causes a sharp acute pain on the right part of the abdomen. Nursing Interventions After 4 hours 1. Observe and of nursing document intervention the location, patient will severity (0–10 report relieve scale), of pain. and character of pain (e.g., steady, intermittent, colicky). 2. Promote bedrest, allowing patient to assume position of comfort. Objectives Rationale Evaluation

- Assists in Is there a change differentiating cause on the patients; of pain, and provides a. Pain information about scale disease b. RR progression/resolution, c. BP development of d. Reports complications, and of pain effectiveness of e. Facial interventions. expressi ons. - Bedrest in lowFowler’s position reduces intraabdominal pressure; however, patient will naturally assume least painful position. - Cool surroundings

3. Control

environmental temperature. 4. Encourage use of relaxation techniques, e.g., guided imagery, visualization, deep-breathing exercises. Provide diversional activities. 5. Make time to listen to and maintain frequent contact with patient. 6. Administer analgesics as indicated

aid in minimizing dermal discomfort. - Promotes rest, redirects attention, may enhance coping.

- Helpful in alleviating anxiety and refocusing attention, which can relieve pain. - Relief of pain facilitates cooperation with other therapeutic interventions,

2. Fluid Volume deficient Cues S � O (+) pallor (+) body weakness (+) vomiting with poor skin turgor (+) dry skin (+) dry mouth Nursing Diagnosis Fluid Volume Deficient related to vomiting Scientific Explanations Because of vomiting excessive losses through normal routes occur thus causes Fluid Volume Deficient Objectives After series of NI the pt. will maintain adequate fluid volume as evidenced by moist mucous membranes and good skin turgor, Nursing Interventions 1. Maintain accurate record of I&O, noting output less than Intake, increased urine specific gravity. Assess skin/mucous membranes, peripheral pulses, and capillary refill. 2. Perform frequent oral hygiene Rationale - Provides information about fluid status/circulating volume and replacement needs. Evaluation Is there still the presence of; a. vomiting b. dry skin c. dry mouth d. poor skin turgor e. body weakness

- Decreases dryness of oral mucous membranes; reduces risk of oral bleeding. - Skin and mucous membranes are dry, with decreased

3. Provide skin and mouth care

4. Increase fluid intake 5. Ascertain patient’s beverage preferences, and set up a 24hr schedule for fluid intake. Encourage foods with high fluid content. 6. Administer antiemetics, e.g., prochlorperazine (Compazine) as ordered by the physician.

elasticity, because of vasoconstriction and reduced intracellular water. - promotes hydration. - Relieves thirst and discomfort of dry mucous membranes and augments parenteral replacement.

- Reduces nausea and prevents vomiting.

Post-operative NCP 3. Knowledge Deficit Cues S “pwede bang maulit ang sakit ko” as verbalized by the patient O Frequently asking question about his condition, treatment and diet With worried gaze Nursing Diagnosis Deficient knowledge related to condition, prognosis, treatment, self-care, and discharge needs Scientific Explanations There is this presence of knowledge deficit due to some unfamiliar information that causes some confusion to the client that needs to be discussed. Nursing Interventions After an hour 1. Provide of nurse-patient explanations interaction the of/reasons for test patient will procedures and Verbalize preparation understanding needed. of disease process, 2. Review prognosis, and disease potential process/prognosis. complications. Discuss hospitalization and prospective treatment as indicated. Encourage questions, expression of concern. 3. Review drug regimen, possible side effects. Objectives Rationale - Information can decrease anxiety, thereby reducing sympathetic stimulation. - Provides knowledge base from which patient can make informed choices. Effective communication and support at this time can diminish anxiety and promote healing. Evaluation Does the patient understands and could recall all the teachings given? Is there a significant changes that occur on the patients knowledge regarding; disease condition diet treatment medication self-care needs

-

-

a. b. c. d. e.

- Gallstones often recur, necessitating long-term therapy. - Prevents/limits

4. Instruct patient to avoid food/fluids high in fats (e.g., whole milk, ice cream, butter, fried foods, nuts, gravies, pork), gas producers (e.g., cabbage, beans, onions, carbonated beverages), or gastric irritants (e.g., spicy foods, caffeine, citrus).

recurrence of gallbladder attacks.

- Promotes gas 5. Suggest patient formation, which can limit gum increase gastric chewing, sucking distension/discomfort. on straw/hard candy, or smoking.

b. Drug Study Name of Drug GN: H2Bloc (Pepcidine) BN: Famotidine Date Ordered 02-13-06 Route/ Action Dosage and Frequency PO - Anti-ulcer 20 mg tab at - competitively bedtime inhibits action of histamine on the H2 at receptor sites of parietal cells, decreasing gastric acid secretion Indication -for short term treatment of duodenal ulcer Adverse Reaction - headache, dizziness, malaise, dry mouth Nursing Consideration 1. Check for doctor’s order 2. not to be given in patients hypersensitive to drugs 3. Inform the patient about the possible side effect of the drug 4. Instruct patient to take drug with food 5. Advised patient to take drug once daily usually at bed time 6. Advise patient to report abdominal pain or blood in stools or is vomiting. 1. Check for doctor’s order 2. Perform ANST prior to admission 3. Should not be given if positive skin test 4. Slow IV push 5. Inform the patient about the possible side effect of the drug 6. Advise patient to report any discomfort on the IV insertion site

GN: Cefuroxime BN: Zinacef

02-13-06

IV 750 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

Name of Drug GN: Clomipramine HCl BN: Placil

Date Ordered 02-13-06

Route/ Action Dosage and Frequency PO - Anti10 mg tab, depressants at 6 am

Indication - for depression and chronic pain

Adverse Reaction - headache, dizziness, malaise, dry mouth

Nursing Consideration 1. Check for doctor’s order 2. not to be given in patients hypersensitive to drugs 3. Inform the patient about the possible side effect of the drug

GN: Gentamicin Dulfate BN: Genticin

02-14-06

IV 80 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 order 2. Perform ANST prior to admission 3. Should not be given if positive skin test 4. Slow IV push 5. Inform the patient about the possible side effect of the drug 6. Advise patient to report any discomfort on the IV insertion site 7. Monitor urine output, specific gravity, U/A, BUN and creatinine levels

Name of Drug

Date Ordered

GN: Ampicillin 02-14-06 BN: Omnipen

Route/ Action Dosage and Frequency IV - Anti-infective 1 g amp, - inhibits every 80 protein synthesis

Indication - endocarditis prophylaxis for GI or GU procedure or surgery

Adverse Reaction - Nausea and Vomiting, headache, dizziness

Nursing Consideration 1. Check for doctor’s order 2. Perform ANST prior to admission 3. Should not be given if positive skin test 4. Slow IV push 5. Inform the patient about the possible side effect of the drug 6. Advise patient to report any discomfort on the IV insertion site

GN: MgSO4

02-14-06

IV 0.03% 7ml every 120

-anti-convulsant -replaces magnesium and maintains magnesium level

- magnesium supplementation

- drowsiness, hypotension

1. Use parenteral magnesium with extreme caution in patients with impaired renal function 2. Test knee jerk and patellar reflexes before each additional dose 3. check magnesium level after repeated doses 4. Monitor fluid intake and output 5. Monitor renal function

Name of Drug GN: Ketorolac Tromethamine BN: Toradol

Date Ordered 02-14-06

Route/ Action Dosage and Frequency IV - Anti30 mg amp, inflammatory every 60 - inhibits prostaglandin synthesis

Indication - short term management of moderately severe, acute pain

Adverse Reaction - dizziness, sedation, headache, flatulence, nausea and vomiting

Nursing Consideration 1. Check for doctor’s order 2. Perform ANST prior to admission 3. Should not be given if positive skin test 4. Slow IV push 5. Inform the patient about the possible side effect of the drug 6. Advise patient to report any discomfort on the IV insertion site

Anesthetic drug Name of Drug GN: Lidocaine HCl Date Ordered 02-14-06 Route IV Action Anesthetic drugs Adverse Reaction -lethargy, hypotension Nursing Consideration 1. Monitor BP, PR, and RR before and after giving the medication 2. Monitor patient for toxicity

c. Medical/ Surgical Management 1. Chest X-ray- this is used to rule out respiratory causes of referred pain. 2. Intake and Output- I&O measurement provide an other means of assessing fluid balance. This data provide insight into the cause of imbalance such as decrease fluid intake or increase fluid loss. These measurement are not that accurate as body weight, however, because of relative risk of errors in recording. 3. Electrocardiogram- The ECG is an essential tool in evaluating cardiac rhythm. Electrocardiography detects and amplifies the very small electrical potential changes between different points on the surface of the body as a myocardial cell depolarize and repolarize, causing the heart to contract. 4. O2 Inhalation- Oxygen therapies are used to provide more oxygen to the body into order to promote healing and health. 5. Intravenous Rehydration- when the fluid loss is severe or life threatening, intravenous (IV) fluids are used for replacement. 6. ultrasound (Also called sonography.) - a diagnostic imaging technique which uses high-frequency sound waves to create an image of the internal organs. Ultrasounds are used to view internal organs of the abdomen such as the liver spleen, and kidneys and to assess blood flow through various vessels. 7. hepatobiliary scintigraphy - an imaging technique of the liver, bile ducts, gallbladder, and upper part of the small intestine. 8. cholangiography - x-ray examination of the bile ducts using an intravenous (IV) dye (contrast). 9. percutaneous transhepatic cholangiography (PTC) - a needle is introduced through the skin and into the liver where the dye (contrast) is deposited and the bile duct structures can be viewed by x-ray.

10. endoscopic retrograde cholangiopancreatography (ERCP) - a procedure that allows the physician to diagnose and treat problems in the liver, gallbladder, bile ducts, and pancreas. The procedure combines x-ray and the use of an endoscope. A long, flexible, lighted tube. The scope is guided through the patient

�s mouth

and throat, then through the esophagus, stomach, and duodenum. The physician can examine the inside of these organs and detect any abnormalities. A tube is then passed through the scope, and a dye is injected which will allow the internal organs to appear on an x-ray. 11. computed tomography scan (CT or CAT scan) - a diagnostic imaging procedure using a combination of x-rays and computer technology to produce cross-sectional images (often called slices), both horizontally and vertically, of the body. A CT scan shows detailed images of any part of the body, including the bones, muscles, fat, and organs. CT scans are more detailed than general x-rays. 12. Cholecystectomy- removal of the gallbladder. This procedure may be performed to treat chronic or acute cholecystitis, with or without cholelithiasis, to remove a malignancy or to remove polyps. 13. Cholecystotomy- the establishment of an opening into the gallbladder to allow drainage of the organ and removal of stones. A tube is then placed in the gallbladder to established external drainage. This is performed when the patient cannot tolerate cholecystectomy. 14. Choledochoscopy- the insertion of a choledoscope into the common bile duct in order to directly visualize stones and facilitate their extraction.

VII.

Clients Daily Progress DAYS ADMISSION 2/13/06 * * BP- 130/90 PR- 84 RR- 19 Temp- 36.5 oC * * * * * * * * * * * * * DAY 2 2/14/16 * * * BP- 140/90 PR- 82 RR- 21 Temp- 36.2 oC BP- 140/90 PR- 85 RR- 21 Temp- 36.4 oC * BP- 130/90 PR- 83 RR- 20 Temp- 36.1 oC DAY 3 2/15/16 DISCHARGE 2/16/06

Nursing Problem Acute pain Fluid Volume Deficient Knowledge Deficit Vital Signs

Dx & Lab Procedures CBC U/A FBS BUN Creatinine Medical & Surgical Management Chest X-ray 12-L ECG O2 inhalation D5LRS, 1Lx 30-31 gtts/min D5NM, 1Lx 30-31 gtts/min Drugs H2 Bloc

Cefuroxime Ketorolac Ampicillin Gentamicin MgSO4 Lidocaine Placil Diet NPO Clear liquid Soft Diet DAT Activity & Exercise FOB Sit on Bed Ambulation as Tolerated

*

* *

* * * * * * * *

* * * * * * *

* * * * * *

* First started and indicates the duration it was done and taken.

VIII. M

DISCHARGE PLANNING 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 T H foods

-

Instructed the patient to do exercise as tolerated such as walking Instructed the patient to continue the medication 1. Encouraged patient to increase fluid intake 2. Encouraged patient to eat foods rich in Vitamin and Nutritious 3. Encourage patient to avoid salty and fatty foods 4. Encourage patient to have enough rest

O D and

-

Instructed to come back for follow-up check-up on February 23, 2006, Thursday. Advised the patient to a diet as tolerated but preferably avoiding salty fatty foods.

IX. Conclusion Our patient, Mr. Aproniano Castro has a chief complaint of epigastric pain. He was admitted in Porac District Hospital and he was diagnosed of having a cholecystitis with multiple cholelithiasis based on the diagnostic procedure conducted in him like the CBC, U/A, 12-L ECG, FBS, BUN, Crea, X-ray and UTZ. Due to the result the surgeon decided for a surgery to remove the gallbladder which is known as the cholecystectomy. We are happy to say that most of our group mates witness the operation. The following day we were given the chance to visit and assess our patient’s condition. Fortunately, the patient had recovered at once he is no longer complaining of epigastric pain. What he was complaining is if he could already eat his food for he is on a liquid diet! And of course the pain of his operative site which is just normal for several days after undergoing the operation. Since cholecystitis is the inflammation of the gall bladder which is usually accompanied by gallstones or cholelithiasis these gallstones may block the way of toxic substances that really needs to go out, but due to this blockage this toxic substances are not then being expelled and are just being stored in the bladder for a period of time. This then causes inflammation of the gallbladder. The treatment usually done is the cholecystectomy. In order to lower the risk of having this kind of condition each and every one of us must be conscious in our diet. We should try to avoid foods which are rich in salt and fats, especially those foods which contains many seasonings. Though there is a saying that ”Mas masarap pag bawal” which always pertains to the food were eating we should still be conscious on our health especially if we want to live longer and also to avoid those life-threatening diseases which not only shorten our life but causes us some financial problem. Remember also the saying “Mahal ang magkasakit”. Just like on what our patient had experience he still has to collect money for the operation he had underwent causing them to have debt with different persons. Let us not enjoy ourselves with the delicious food were eating that is rich in salts and fats but we should enjoy living because we have a healthy condition.

X. BIBLIOGRAPHY Books Joyce M. Black,PhD, RN, CPSN, CWCN & Jane Hokanson Hawks, DNSc, RN, BC, “Medical- Surgical Nursing” 7th edition, pg.1302-1314. Nursing 2004 Drug Handbook, 24th edition Doenges, Moorhouse, & Murr,” Nurse’s pocket guide” 9th edition. Online Resources www.facs.org http://tjsamson.client.web-health.com/webhealth/topics/GeneralHealth/generalhealthsub/generalhealth/liver&gallbladder/what_gall bladder.html http://www.emedicine.com/emerg/topic97.htm http://www.emedicine.com/radio/topic163.htm http://www.healthsystem.virginia.edu/uvahealth/adult_liver/chole.cfm http://www.emedicine.com/EMERG/topic98.htm Microsoft Encarta 2004 Nursing Care Plan Content CD-ROM