TABLE OF CONTENTS

I. IntroductionA. objectives

General objectivesSpecific objectives

II. Patient’s data

A. Vital InformationB. Family backgroundC. History of Past illnessD. History of Present illnessE. Effects & Expectations of illness to self & FamilyF. Genogram

III. Physical Assessment

IV. Textbook Discussiona. Complete Diagnosisb. Anatomy and physiologyc. Etiology and Symptomatologyd. Pathophysiology

V. Diagnostic Results

VI. Summary of Doctor’s Order

VII. Drug study

VIII. Nursing care plan

IX. Prognosis

X. Bibliography

INTRODUCTION

.This is the case of 20 year old boy who was admitted last December 2, 20011 at around 1:27 AM at Allah Valley Medical Specialists Center Incorporated with the chief complaint of abdominal pain with the admitting diagnosis of hydrops of gallbladder under the service of Dr. PJ.

Acalculous cholecystitis is related to conditions associated with biliary stasis, including debilitation, major surgery, severe trauma, sepsis, long-term total parenteral nutrition (TPN), and prolonged fasting. Other causes of acalculous cholecystitis include cardiac events; sickle cell disease; Salmonella infections; diabetes mellitus; and cytomegalovirus, cryptosporidiosis, or microsporidiosis infections in patients with AIDS.

An 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.

This case study aims to provide information that may help the reader to understand the occurrence and manifestations of the disease including proper care and management.

OBJECTIVES OF THE STUDY

GENERAL OBJECTIVESAfter thorough reading, the reader will be able to impart adequate knowledge and skills

about acute Cholecystitis. And discuss correctly all the related information about the disease.

SPECIFIC OBJECTIVES:

After two hours of reading, the listeners will be able to:

1. Know the important information regarding patient’s data.2. Know the result of the assessment done to the patient.3. Define comprehensively the complete diagnosis of the client.4. Discuss briefly the anatomy and physiology involved in the disease.5. Trace schematically the pathophysiology of Acute Cholecystitis.6. Enumerate the predisposing factors and precipitating factors of the disease.7. Identify the prioritized possible nursing diagnosis of the patient.8. Identify the Drugs that the physician orders for the wellness of the patient. 9. Discuss the mechanism and effects of the medication to the patient.

VITAL INFORMATION

PATIENT’S NAME : AAGE : 12 years oldSEX : Female ADDRESS : Purok 11 Talisay Lake Sebu South CotabatoDATE OF BIRTH : March 6, 1997PLACE OF BIRTH : Lake Sebu

RELIGION : Roman Catholic CIVIL STATUS : Child CITIZENSHIP : Filipino TRIBE : Ilonggo OCCUPATION : N/A EDUCATIONAL ATTAINMENT: Grade VI DATE ADMITTED : July 17,2009 TIME ADMITTED : 1:29 PM ADMITTING PHYSICIAN : Dr. Jake Albaño

ADMITTING DIAGNOSIS : Epigastric Pain CHIEF COMPLAINTS : Epigastric pain OPERATION PERFORMED : Cholicystectomy NAME OF INSTITUTION : Allah Valley Medical Specialists Center Incorporated

Father : BAGE : 33 Years oldOCCUPATION : FarmingEDUCATIONAL ATTAINMENT : Second Year High SchoolRELIGION : R. Catholic

TRIBE : Ilonggo

MOTHER : CAGE : 30 Years oldOCCUPATION : HousewifeEDUCATIONAL ATTAINMENT : High School GraduateRELIGION : R. CatholicTRIBE : Ilonggo

Siblings

NAME AGE SEX

1. AA 9 Female2. BB 2 Male

SOURCE OF INFORMATION

Patient Patient’s chart Patient’s Mother and Father

SOURCE OF MEDICAL FINANCING

Philhealth

PHYSICAL ASSESSMENT

GENERAL SURVEY Received lying on bed, awake with D5LR1L @ 20 gtts/min hooked at right metacarpal

vein, infusing well, patent and intact. The patient is physically ill with uneasy condition. She looks anxious and in pain.HEADInspection:

The patients head is proportional to the patient’s body size and round in shape. No lesions and deformities noted on the contrary dandruff was noted on her scalp. She has a long black hair with gray hair noted that is distributed evenly.

Palpation:No tenderness noted as well as masses.

FACEInspection:

The patient face is symmetric. Her skin is brown in complexion; some moles are noted.

PalpationThere is no masses and tenderness noted.

EYES Inspection:

The eye is straight and in normal position. Eyebrow is black in color and evenly distributed eyelids able to close completely. Eyelashes directed outward and intact. Eyeballs are symmetric and able to move in six cardinal movements. Pupils are equal in size, round in shape and reacts to light and accommodation. Conjunctiva is pale and moist. Sclera is anecteric, the cornea is clear and transparent, iris is black in color. Lacrimal system have enough moist.

NOSE Inspection:

The external nose is symmetrical and align at the center, mucosa is moist, nasal septum is intact, straight at the midline, no lesions and deformities.Palpation:

There is no tenderness noted.EARS Inspection:

External ear is clear, no deformities and lesion noted. She can hear whispered words within 1 foot apart. Auricle has no deformities.

Palpation:No tenderness and masses noted.

.LIPS AND MOUTHInspection

The patient’s lips appear to be dry and slightly pale. The tongue is moist, mobile, and pink in color and position in the midline. No dentures noted with incomplete set of teeth. Gums and mucosa is pink, have enough moist and no lesion noted. Tonsils are not inflamed; uvula is bell in shape, pink in color and at the midline.

NECKInspection

Has coordinated movement and no discomfort noted.Palpation

Lymph nodes at the neck are not palpable.

ABDOMENInspection

Incision noted on the right upper quadrant with sterile dressing noted.Palpation

Pain is felt during palpation.

EXTREMETIESInspection

The extremities are proportionate to the trunk, skin is brown in complexion. Positive ROM noted on both upper and lower extremities. She has no difficulties in performing flexion and extension. Muscle has equal strength, able to grasp properly but dominant hand has more force than her non dominant hand. Palpation

No edema noted on both extremities, patient sensation is present. Pulsation is present at the radial and dorsalis pedis.

SKIN Inspection

Patient appearspale, skin is dry. Good skin turgor noted. There is no lesions noted and her hair is evenly distributed.Palpation

No masses and tenderness noted. Afebrile noted during palpation.

NAILSInspection

Patient nail is pink in color/ her finger nails are uncut and not well trimmed specifically at his toe nails. Capillary refill return within 3 seconds after being pressed.

REVIEW OF SYSTEMS

GENERAL:

The patient said that he never experienced fever prior toadmission. He denies of experiencing weight loss.

SKIN: The patient denies any rashes and skin allergies.

HEAD:The patient verbalized that “nagasakit ang ulo ko kis-a” he also said that he doesn't

experienced any head injury and she never observed tenderness.

EYES: The patient denies any eye problem.NOSE: The patient said that he also has no allergies to any odor. He denies of having sinus problem and he has no problem in term of his sense of smell.THROAT:

Patient denies any throat problem.

RESPIRATORY:Patient denies any difficulty of breathing. he denies of having chest pain and hemoptysis.

CARDIOVASCULAR: The patient said that he has no problems in her heart,

GASTROINTESTINAL: The patient denies of any problem in his GI problems.

GENITOURINARY:

He said that he has a problem in urination. And she voids 5-6 times a day. He admits that his gallbladder was inflamed.

MUSCULOSKELETAL:He denies of having problems in moving. He states that he is a little bit weak because of pain.

PSYCHIATRIC: He denies difficulty of sleeping.

Textbook Discussion

Cholecystitis- is the inflammation of the gallbladder. The obstruction increases the pressure within the

gallbladder leading to ischemia of the gallbladder wall and mucosa. The ischemia can lead to necrosis and perforation of the gallbladder wall.

Acute Cholecystitis Usually begins with an attack of biliary colic. The pain involves the entire Right Upper Quadrant (RUQ), and may radiate to the back, right scapula, or shoulder. Movement or deep breathing may aggravate the pain. The pain usually lasts longer than the biliary colic, continuing for 12 to 18 hours. Anorexia, nausea and vomiting are common. Fever often is present, and may be accompanied by chills. The RUQ is tender to palpation.

Chronic Cholecystitis May result from repeated bouts of acute Cholecystitis or from persistent irritation of the gallbladder wall by stones. Bacteria may be present in the bile as well and often is asymptomatic.

Complications of Cholecystitis include empyema, a collection of infected fluid within the gallbladder; gangrene and perforation with resulting peritonitis or abscess formation; formation of fistula into an adjacent organ; or obstruction of the small intestine by a large gallstone.

Diagnostic tests

Serum bilirubin is measured. Elevated direct bilirubin may indicate obstructed bile flow in the biliary duct system.Complete blood count (CBC) may indicate infection and inflammationif the WBC is elevated.Serum amylase and lipase are measured to identify possible pancreatitis related to common duct obstruction.Abdominal X-ray may show gallstones with high calcium content.Ultrasonography of the gallbladder is a noninvasive exam that can accurately diagnose cholelithiasis.Gsllbladder scans use as an intravenous radioactive solution that is rapidly extracted from the blood and excreted into the biliary treeto diagnose cystic duct obstruction.

Source: Medical- Surgical Nursing (critical thinking in client care)

P. Lemone & K. Burke; 3rd edition; page 574-575

Cholecystitis

- Acute inflammation of the gallbladder causes pain, tenderness, and rigidity of the upper right abdomen that may radiate to the midsternal area or right shoulder and is associated with nausea, vomiting and the usual signs of an acute inflammation. An empyema of the gallbladder develops if the gallbladder becomes filled with purulent fluid.

- Calculous Cholecystitis is the cause of more than 90% of cases of acute Cholecystitis, a gallbladder stone obstructs bile outfow. Bile remaining in the gallbladder initiates a chemical; autolysis and edema occur; and the blood vessels in the gallbladder are compressed, compromising its vascular supply. Gangrene of the gallbladder with perforation may result. Bacteria play a minor role in acute choolecystitis; however, secondary infection of bile with Escherichia coli and other enteric organisms occur in about 60% of patients.

Source: Brunner & Suddarth’s textbook of Medical-Surgical Nursing Volume 2; 10th edition ; S. Smeltzer & B. Bare; page 1126

Cholecystitis

- is inflammation of the gall bladder. Cholecystitis is often caused by cholelithiasis (the presence of choleliths, or gallstones, in the gallbladder), with choleliths most commonly blocking the cystic duct directly. This leads to inspissation of bile, bile stasis, and secondary infection by gut organisms, predominantly E coli and Bacteroides species.

The gallbladder's wall becomes inflamed. Extreme cases may result in necrosis and rupture. Inflammation often spreads to its outer covering, thus irritating surrounding structures such as the diaphragm and bowel.

Less commonly, in debilitated and trauma patients, the gallbladder may become inflamed and infected in the absence of cholelithiasis, and is known as acute acalculous cholecystitis.

Stones in the gallbladder may not cause obstruction and the accompanying acute attack. The patient might develop a chronic, low-level inflammation which leads to a chronic cholecystitis, where the gallbladder is fibrotic and calcified.

Symptoms

Cholecystitis usually presents as a pain in the right upper quadrant. This is usually a constant, severe pain. The pain may be felt to 'refer' to the right flank or right scapular region at first.

This is usually accompanied by a low grade fever, vomiting and nausea.

More severe symptoms such as high fever, shock and jaundice indicate the development of complications such as abscess formation, perforation or ascending cholangitis. Another complication, gallstone ileus, occurs if the gallbladder perforates and forms a fistula with the nearby small bowel, leading to symptoms of intestinal obstruction.

Chronic cholecystitis manifests with non-specific symptoms such as nausea, vague abdominal pain, belching, & diarrhea.

Diagnosis

Cholecystitis is usually diagnosed by a history of the above symptoms, as well examination findings:

fever (usually low grade in uncomplicated cases) tender right upper quadrant +/- Murphy's sign

Source: http://en.wikipedia.org/wiki/Cholecystitis

Cholecystitis

is inflammation of the gallbladder, a small organ near the liver that plays a part in digesting food. Normally, fluid called bile passes out of the gallbladder on its way to the small intestine. If the flow of bile is blocked, it builds up inside the gallbladder, causing swelling, pain, and possible infection.

Causes of cholecystitis

A gallstone stuck in the cystic duct, a tube that carries bile from the gallbladder, is most often the cause of sudden (acute) cholecystitis. The gallstone blocks fluid from passing out of the gallbladder. This results in an irritated and swollen gallbladder. Infection or trauma, such as an injury from a car accident, can also cause cholecystitis.

Acute acalculous cholecystitis, though rare, is most often seen in critically ill people in hospital intensive care units. In these cases there are no gallstones. Complications from another severe illness, such as HIV or diabetes, cause the swelling.

Long-term (chronic) cholecystitis is another form of cholecystitis. It occurs when the gallbladder remains swollen over time, causing the walls of the gallbladder to become thick and hard.

Symptoms

The most common symptom of cholecystitis is pain in your upper right abdomen that can sometimes move around to your back or right shoulder blade. Other symptoms include:

Nausea or vomiting. Tenderness in the right abdomen. Fever. Pain that gets worse during a deep breath. Pain for more than 6 hours, particularly after meals.

Older people may not have fever or pain. Their only symptom may be a tender area in the abdomen.

Diagnosis:

Diagnosing cholecystitis begins when you describe your symptoms to your doctor. A physical exam follows. Your doctor will carefully feel your right upper abdomen looking for tenderness. You may have blood drawn and an ultrasound, a test that uses sound waves to create a picture of your gallbladder. Ultrasound may reveal gallstones, thickening of the gallbladder wall, extra fluid, and other signs of cholecystitis. This test also allows doctors to check the size and shape of your gallbladder.

You could also have a gallbladder scan, a nuclear scanning test that checks how well your gallbladder is working. It can also help find blockage in the tubes (bile ducts) that lead from the liver to the gallbladder and small intestine (duodenum).

TreatmentTreatment for cholecystitis will depend on your symptoms and your general health. People who have gallstones but don't have any symptoms may need no treatment. For mild cases, treatment includes bowel rest, fluids and antibiotics given through a vein, and pain medicine.

The main treatment for acute cholecystitis is surgery to remove the gallbladder (cholecystectomy). Often this surgery can be done through small incisions in the abdomen (laparoscopic cholecystectomy), though sometimes it requires a more extensive operation. Your doctor may try to reduce swelling and irritation in the gallbladder before removing it. Occasionally acute cholecystitis is caused by one or more gallstones becoming stuck in the main tube leading to the intestine, called the common bile duct. Treatment may involve an endoscopic procedure (endoscopic retrograde cholangiopancreatography, or ERCP) to remove the stones in the common bile duct before the gallbladder is removed.

In rare cases of chronic cholecystitis, you may also receive medicine that dissolves gallstones over a period of time.

Source: http://www.webmd.com/digestive-disorders/tc/cholecystitis-overview

ANATOMY AND PHYSIOLOGY

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 gallbladder to the common hepatic duct to form the common bile duct.

The common bile duct then joins the pancreatic duct, and enters through the hepatopancreatic ampulla at the major duodenal papilla.[2][3]

The fundus of the gallbladder is the part farthest from the duct, located by the lower border of the liver [4]. 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.

Function

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.

Vertebrates have gallbladders, but invertebrates don't. This is because vertebrates eat in boluses while invertebrates are constantly eating. To digest a large bolus of food requires a large amount of digestive secretions, hence the presence of a gallbladder.

Etiology

Predisposing Factor Rationale Remarks

AgeThe incidence of Cholecystitis increases with age. Patient is 20 years old therefore it is present.

Present

Sex

Gallstone are 2.3 times more frequent in females than in males, resulting in a higher incidence in females.Patient is male.

Present

Heredity

Indian and Scandinavian people have the highest prevalence of Cholecystitis. In United state white people have a highest prevalence than black people.Patient is Asian, hence not present.

Not Present

Precipitating FactorsLifestyle Excessive cholesterol

intake combined with a sedentary lifestyle increases the incidence of Cholecystitis. Patient is fond of extra fatty foods and meat.

Present

ObesityPersons who are obese have higher risk in developing Cholecystitis because of the accumulation of fatty deposits that can obstruct the gallbladder.

Not Present

Symptomatology

Predisposing Factor Rationale

Pain in the RUQ This is due to the location of the gallbladder which is at the right quadrant.http://www.merck.com/mmhe/sec10/ch140/ch140c.html

Present

Low grade feverThis is due to the inflammatory process that is happening to the body as a defense mechanism..http://www.merck.com/mmhe/sec10/ch140/ch140c.html

Present

Nausea This is due to the irritation in the gastrointestinal area.http://www.merck.com/mmhe/sec10/ch140/ch140c.html

present

Tenderness in the abdomen This is due to the inflammation of an organ which is situated at the abdomen.http://www.merck.com/mmhe/sec10/ch140/ch140c.html

present

Loss of appetite This symptom may not be present always but according to some sources this can be happen to older person.http://www.merck.com/mmhe/sec10/ch140/ch140c.html

present

weakness This is just present to older persons.http://www.merck.com/mmhe/sec10/ch140/ch140c.html

present

PATHOPHYSIOLOGY

Predisposing Factors Precipitating Factors

Age (20 year old) LifestyleSex (Male)Race

Obstruction of the cystic duct

Distention of the gallbladder

Impaired venous and lymphatic drainage

Proliferation of bacteria occurs

Localized cellular irritation

Ischemia

\ Inflamed gallbladder

Empyema will occur

If Treated: If not Treated:

>MEDICAL MANAGEMENT: >May result to more Medication for s/sx depends severe complications

on the physician prescription.

>SURGICAL MANAGEMENT:-Laparoscopic Cholecystectomy further bile duct - Cholecystectomy with obstructioncommon bile duct combination.-Choledochostomy

>NURSING MANAGEMENT: Enzyme bile duct -Health teaching especially obstruction

on the diet (low fats and low salts diet)

Pancreatic enzymesRegurgitation

Hospitalization

Pancreatitis Recovery

Hemorrhage WELLNESS

Coma

DEATH

NOTRE NAME OF TACURONG COLLEGECity of Tacurong

DRUG STUDYName of the Patient: A Attending Physician: Dr. Jake Albaño Diagnosis: Post-op Cholecystectomy Prepared by: Gallega and Lelim Section: BSN 4Date: July 19, 2009 Checked by: Date:

NAME DRUG ACTION SIDE EFFECT CONTRAINDICATION NURSING RESPONSIBILITIES

Generic:Tramadol

Brand:Ultram

Classification:Opioids Analgesic

MODE OF ADMINISTRATION

Route:IVTT ANST (-)

Dosage:50mg

Time:q 8

Mechanisms of Action:Unknown. A centrally acting synthetic analgesic compound not chemically related to opiates. Thought to bind to opioids receptor and inhibit reuptake of norepinephrine and serotonin.

Bibliography: Nursing Drug Handbook 2005, Page 405, 406

Indication;Moderate to moderately severe pain

CNS: Dizziness, vertigo headache, malaise, sleep disorderCV: vasolidationEENT: visual disturbanceGI: nausea, constipation, vomiting dyspepsia, dry mouth, diarrhea, abdominal pain, anorexia, flatulence.GU: urine retention, urinary frequency, proteinuria.Musculoskeletal: hypertonicSkinL pruritus, diaphoresis rash.

ADVERSE EFFECT

CNS: CNS stimulation, asthenia, anxiety, confusion coordination disturbance euphoria, nervousness, seizureRespiratory: Respiratory depression.

Contraindicated in the patient hypersensitivity to drug or other opioid breastfeeding woman, and in those with acute intoxification from alcohol, hypnotics centrally acting analgesic, opioids or psychotropic drug. Serious hypersensitivity reaction can occur, usually after the first dose. Patient with history of anaphylaxis to codeine and other opioids may be at an increase risk.

SPECIAL PRECAUTION

Use cautiously in patient at risk for seizures or respiratory depression, in patient with increased intracronial pressure or head injury, acute abdominal coordination or renal or hepatic impairment; or in patient with physical dependence an opioids.

DRUG INTERACTION

Drug-DrugCarbomazepine: May increased tramadol metaboism, patients

1. Consider the patients 10 rightsR: to ensure proper administration of drug

and most of all to avoid mistakes.2. Practice proper hand washing

R: Hand washing deters the spread of microorganism thus preventing nosocomial infections.

3. Reassess patient level of pain at least 30 minutes after administering.R: to assess patients conditions and

effectiveness of drug4. Assess the breathing pattern of the

patientR: Assessing the respiratory rate of the

patient is important to prevent respiratory depression and have immediate actions.

5. Monitor bowel and bladder function, anticipate the need for laxativesR: Monitoring these function will aide the

patient if he/she as feeling of constipation.6. For better analgesic effects, give drug

before onset of intense painR: Giving the drug this way will minimize

effect of intense pain thus promoting comfort to the client.

7. Monitor patient for drug dependenceR: Drug can produce dependence similar to

that of codiene and dextropropoxyphene and thus potential for abuse.

8. Educate the patient about the purpose

receiving long term carbamazephine therapy at up to 800mg daily may need up to twice the recommended dose of tremadol.

and administration of drugR: doing this will relieve patients anxiety,

making them aware and facilitate cooperation

9. Instruct patient to rest afterR: resting promotes relaxation and comfort to

the patient 10. Assess the patient sleep pattern before

giving the drug.R: Sleep disturbance its one of the side

effect of tramadol by doing this proper intervention and action should be done.

NAME DRUG ACTION SIDE EFFECT CONTRAINDICATION NURSING RESPONSIBILITIES

Generic:Ampicillin

Brand:Ampicin

Classification:Antibiotics

MODE OF ADMINISTRATION

Route:IVTT ANST (-)

Dosage:1 grm

Time:q 8

Mechanisms of Action:Inhibits cell wall synthesis during bacterial multiplication

Bibliography: Nursing Drug Handbook 2005, Page 78, 80

Indication;Respiratory tract or skin structure infections.

CNS: anxiety, dizziness and fatigueCV: thrombophlebitis GI: nausea, and vomiting abdominal pain, diarrhea, gastritisGU: vaginitisSkin: Pain at the injection site

ADVERSE EFFECT

CNS: Lethargy, hallucination, agitation, seizures, depression.CV: vein irritationGI: diarrhea, glossitis, stomatisis, enterocolitis and black hairy tongue.GU: Interstitial nephiritis, nephropathyHematologic: Anemia thrombocytopenia, eosinophilia.

Contraindicated in patient hypersensitivity to drug

SPECIAL PRECAUTION

Use cautiously in patient with other drug allergies because of possible cross-sensitivity and in those with mononucleosis because of high risk of maculopopular rash.

DRUG INTERACTION

Drug-DrugHormonal contraceptives: may decrease hormonal contraceptive effectiveness.

1. Consider the patients 10 rightsR: considering this will ensure that the

medication is given correctly and most all avoid unnecessary mistakes.

2. Explain to the client about the administration of the drugR: Explaining this to the client facilitate

awareness and cooperation 3. Practice proper hand washing first

R: Proper hand washing deters the spread of microorganisms and transferring of microorganism to the patient

4. Administer the drug right away after being preparedR: to promote sterility and effectives of the drugs

5. Conduct skin testing firstR: Skin testing is important to avoid allergic

reaction6. Give the drug 10-15 minutes

R: Giving the drug at the right span of time will prevent pain at injection site. vein irritation thus promoting comfort

7. Instruct patient to rest after administration and raise side rails R: Lethergy, hallucination, dizziness and

agitation may occur swallowing patient to rest and raising side raise promotes comfort and further injury.

8. Watch sign and symptoms of hypersensitivity such as sythematous, maculopopular rash, urticaria and snaphylaxis. R: This factors will indicate adverse reaction to

the drug.9. Advise patient to report discomfort at injection

siteR: For immediate management and action, for

comfort measures.10. At home instruct patient to take drug 1 to 2 hours

before or 2 to 3 hours after mealR: to prevent GI irritation

NOTRE NAME OF TACURONG COLLEGE

City of Tacurong

Name of the Patient: A Attending Physician: Dr. Jake Albaño Diagnosis: Post-op Cholecystectomy Prepared by: Gallega and Lelim Section: BSN 4Date: July 19, 2009 Checked by: Date:

DRUG STUDY

NAME DRUG ACTION SIDE EFFECT CONTRAINDICATION NURSING RESPONSIBILITIES Generic:Ranitidine

Brand:Zantac

Classification:Anti-ulcer drug

MODE OF ADMINISTRATION

Route:IVTT

Dosage:40mg

Time:q 8

Mechanisms of Action:Potent anti-ulcer drug that competitively and reversibly inhibits histamine action at H2 receptor sites parietal cells decreasing gastric acid secretions.

Bibliography: Nursing Drug Handbook 2005, Page 712, 713

Indication;Duodenal and gastric ulcer

CNS: vertigo, malaise headacheEENT: blurred visionHepatic: Jaundice Others: burning and itching at injection site.

ADVERSE EFFECT

Anaphylaxis, angio edema

Contraindicated in patient hypersensitivity to drug and those with acute prophyria

SPECIAL PRECAUTION

Use cautiously in patient with hepatic dysfunctions

DRUG INTERACTION

Drug-DrugAntacids: May interfere with

1. Before giving the drug, Practice Proper hand washingR: proper hand washing will reduce presence

of microorganism in your hands, thus it will prevent another complication to your pt.

2. Check the patency of the IV tube, before reducing the medicine.R: checking the patency of the IV tube will

facilitate easy administration of the drug thus reducing discomfort to the patient

3. Administer the medicine once it has been prepared.R: Administering the drug after preparing will

reduce incidence of mistake and ensuring the sterility and effectiveness of the medication

4. Assess patient for abdominal pain, advice to report blood and stoolR: These factors may indicate internal bleeding

5. Give the medication slowly about 10-15 minutesR: burning and itching at the injection site,

usually the complains of the patient, therefore give it slowly to prevent it.

6. Before giving the drug, educate first the patient about the purpose of it.R: Giving information to the patient will

facilitate cooperation and relieve their

ramitidine absorption stragger doses, if possible.Diazepam: may decreased absorption of diazepam monitor patient closely.

anxiety. 7. Instruct patient to rest after taking the drug

R: Having the patient to rest will promote relaxation and comfort.

8. Instruct patient to report any unusualitiesR: Instructing our patient to report unusualities

will help us to provide proper and prompt treatment

9. Before giving the drug asses if the patient has taken a meal.R: Assessing if the patient has taken any food,

because the drug works better when the stomach is empty.

NAME DRUG ACTION SIDE EFFECT CONTRAINDICATION NURSING RESPONSIBILITIES Generic:Gentamycin

Brand:Garamycin

Classification:Anti infectives

MODE OF ADMINISTRATION

Route:IVTT

Mechanisms of Action:Generally bactericidal, inhibits protein synthesis by binding directly to the 305 ribosomal sbmit.

Bibliography: Nursing Drug Handbook 2005, Page 67, 70

CNS: fever, headache, lethargy, confusion, dizziness, numbness, vertigo, ataxiaCV: hypotensionEENT: blurred vision, tirnitus GI: vomiting, nauseaGU: possible increase in urinary excretion of cast.Skin: rash, urticaria, pruritus, pian in the injection site.

ADVERSE EFFECT

Contraindicated to patient hypersensitivity to drug and other aminoglycosides

SPECIAL PRECAUTION

Use cautiously in neonates, infants, elderly patient and patient with impaired renal function or neuromuscular disorder.

1. Conduct skin testing as orderedR: conducting skin testing before giving the drugs

will help prevent allergies for their complication to the patient and will know what treatment to give.

2. Practice proper hand washing before giving the drugR: proper hand washing will prevent transfer of

microorganism from 1 patient to another3. Evaluate patients hearing before and during

therapy R: to notify the physician if the patient complains

of tinitus, vertigo or hearing loss4. Weight patient and review renal function studies

R: Reviewing those important data is essential because the drug will possibly increase urinary excretion of cast

Dosage:800mg

Time:q 8

Indication;To prevent endocarditis for GI or GU procedure or surgery

CNS: encephalorathy seizuresGU: nephrotoxicity Hematologic: leukofenia, thrombocytopenia, agranulocytosisRespiratory: apneaOthers: Anaphylaxis

DRUG INTERACTION

Drug-DrugAcyclovir, comphotericin B cephalosporins, cisplatin, methroxfluane, vancomycin other aminosylosides. May increase ototoxicity and nephrotoxicity monitoy hearing and renal function test results.

5. Instruct patient to report any unusualities R: Unusualities happens any time after drug

administration, so instructing the pt. to do so will help prevent further complication

6. provide bedpan or empty bucket at the patients bedsideR: providing bedpan or empty bucket will help

because once the patient experience vomiting, just give it to the patient so the she bed of the patient will not be messy

7. Raise the side rails of the patients bedR: Once the patient has taken the drug, advise

reaction occurs, like dizziness, vertigo, blurred vision and lethargy occurs, so patient safety should be practiced.

8. Monitor vital signs q 4 or as ordered.R: Monitoring vital signs of the patient is essential

because this drug can cause hyptension.9. Instruct patient to rest

R: resting will help minimize the side effects of the drug

10. Monitor patients breathing pattern R: assessing the breathing pattern

NAME DRUG ACTION SIDE EFFECT CONTRAINDICATION NURSING RESPONSIBILITIES Generic:Ketorolac

Brand:Toradol

Classification:NSAID

MODE OF ADMINISTRATION

Route:IVTT

Dosage:30mg

Time:q 8

Mechanisms of Action:Unknown. Produces anti-inflammatory analgesic and antipyretic effects possibly by inhibiting prostaglandin synthesis

Bibliography: Nursing Drug Handbook 2005, Page 369, 371

Indication;Short term management of moderately severe, acute pain.

CNS: drowsiness, sedation, dizziness, headacheCV: edema, hypertension palpitation GI: nausea, dyspepsia GI pain, diarrhea, peptic ulceration on vomiting constipation, flatulence, stomatitis Skin: pruritus, rash diaphoresisOthers: pain at injection site

ADVERSE EFFECT

CV: Arhytmias Hematologic adhesion, purpura, prolongned bleeding time

Parethesia

Contraindicated in patients hypersensitive to drug and in those with active peptic ulcer disease, recent GI bleeding or perforation advance renal impairment, cerebrovascular bleeding, hemorrhagic diathesis or incomplete hemostasis, and in those at risk for renal impairment from volume defection or at risk for bleeding

SPECIAL PRECAUTION

Use cautiously in patient with hepatic or renal impairment or cardiac decomposition

DRUG INTERACTION

Drug-DrugAce inhibitor: May cause renal impairment, particular in volume depleted patients avoid using together in volume depleted patient

1. Conduct skin testing before drug administrationR: Conducting skin testing before giving the drug

will prevent allergic reaction, this granting the patient safety.

2. Assess the client if he had peptic ulcer or GI bleeding before or prior to admissionR: Assessing these factor to the client will be

essential because ketorolac is contraindicated to patient who has this factor because it prolonged the bleeding time, therefore patient is a risk for bleeding

3. Give the drug 10-15 minutesR: Burning and pain at injection site, usually the

complains of the client, therefore give the drug slowly to avoid the situations

4. Before administration, check first if there is a bad flowR: Checking if there is a back flow is important

because it provide sterility and comfort to the client

5. Monitor patients vital signs q 4 or as ordered specially the blood pressure, before and after R: Monitoring this is very important to know if

patient, hypertensive, because ketorolac can cause hypertension

6. Raise the rails after giving to drugR: drowsiness, sedation and headache, dizziness

might occur for raising the side rails will prevent patient from falling thus preventing further injuries

7. Instruct patient to increase fluid intakeR: Taking this drug can cause renal impairment,

maintaining hydration will prevent this8. Instruct the watcher to report any unusualities

R: for immediate action and management9. Before giving the drug, carefully observe patient

with coagulopathis R;prevent platelet aggregation

NURSING CARE PLANASSESSMENT NEEDS NURSING

DIAGNOSISGOAL/OBJECTIVE NURSING

INTERVENTIONSRATIONALE EVALUATION

Date: 07-21-098AMSubjective data:“Masakit pa ang tahi ate.”Pain scale of 7 out of 10.

Objective data: Conscious Weak Dry lips Facial

grimacing Pallor noted Right lower

quadrant tenderness noted

Guarding of the stomach

V/S:BP-100/70 mmHgT-37 ºCP-80bpmR-25 cpm

COGNITIVE

PERCEPTUAL

PATTERN

Pain acute r/t inflammatory process as evidenced by facial grimacing and guarding of the site of pain

RATIONALE Unpleasant sensory and emotional experience arising from actual or potential tissue damage or described in terms of such damage.

General Objective:To promote optimal activity; exercise rest and sleep.

Specific Objectives:After 2h of NSG intervention patient will be able to:

Report pain is controlled.

Demonstrates use of relaxation techniques and divisional activities.

1. Observe and document location, severity and characteristics of pain.2. Note response to meds and report to physician if pain is not being relieved.3. Promote bed rest, allowing patent to costume position of comfort.4. Use of soft/cotton linens; cool/moist compress is indicated.5. Control environmental temperature.6. Encourage use of relaxation techniques; guided imagery, visualization7. Make time to listen and maintain frequent contact with patient.8. Administer medication as ordered like paracetamol.

~Assists in differentiating cause of pain and provides information about disease progression.~Severe pain not relieved by routine meaning may indicate developing complications.~Bed rest in low-fowlers position reduces intra-abdominal pressure.

Reduced irritation/dryness of the skin and itching sensation.~Cool surroundings, and in minimizing dermal comforts. ~promotes rest, redirects attention; may enhance coping.

~Helpful in alleviating anxiety and refocusing attention which can relieve pain..To treat infectious process, reducing inflammation.

Date: 7-21-093PMGoal partially met pt. reported pain is controlled.

ASSESSMENT NEEDS NURSING DIAGNOSIS

GOAL/OBJECTIVE NURSINGINTERVENTIONS

RATIONALE EVALUATION

Date:07-21-098AM Subjective data:“Ano gale ni siya ate,bakit nagkaganito.”As verbalized.

Objective data: Pallor noted Yellowish eyeball Weakness noted Decreased appetite

noted Apprehension Dark color urine Facial grimacing

COGNITIVE

PERCEP

Knowledge deficit regarding the condition r/t lack of information as manifested by apprehension. RATIONALEAbsence of deficiency of cognitive information related to specific topic.

General Objective:To recognize the physiologic response of the body to the disease conditions.

Specific Objectives:After 2h of NSG intervention patient will be able to:

Verbalize understanding of the disease process,

1. stablished rapport to the patient.

2. Monitor the vital signs of the pt.

3. Provide explanation for the test procedures or any preparation needed.

4. Discuss hospitalization and

~Establishing rapport will gain trust and cooperation of the pt.~V/S will serve as the baseline data and will be in comparing abnormal findings.~Information aim to decrease anxiety ,thereby reducing sympathetic stimulation

~Provides knowledge base on which pt. can make informed

Date: 7-21-093PM

Goal partially met, the pt understand her situation but needs more instructions.

Pallor notedV/S:BP-100/70 mmHgT-37 ºCP-80bpmR-25 cpm

TUAL

PATTERN

treatment and prognosis

Initiate necessary changes in treatment regimen.

prospective treatment as indicated.

5. Discuss weight reduction program as indicated.

6. Instruct pt. to avoid food or fluids high in fats, gas produces or gastric irritants.

7. Review s/sx requiring medical intervention.

8. Recommended resting in semi-fowlers position after meals.

9. Suggest pt. to limit gum chewing sucking on straw or candy or smoking.

10. Discuss avoidance of aspirin- containing products, forceful blowing of noise, straining.

choices. Effective communication can diminish anxiety and promote healing.~Obesity is a risk factor associated with Cholecystitis and weight loss is beneficial~Prevents or limits recurrence of gallbladder attacks.

~Indicative of progression of disease process or development of complication requiring further intervention.~Promotes flow of bile and general relaxation during initial digestive process.~Promotes gas formation, which can increase gastric distention or discomfort.~Reduces risk of bleeding related to changes in coagulation in time, mucosal irritation and trauma.

NURSING CARE PLAN

ASSESSMENT NEEDS NURSING DIAGNOSIS

GOAL/OBJECTIVE NURSINGINTERVENTIONS

RATIONALE EVALUATION

Date: 07-21-09 N General Date: 7-21-09

8AM

Subjective data:“No verbal cues”

Objective data: Pallor noted Yellowish

eyeball Weakness

noted Decreased

appetite noted

V/SBP-100/70 mmHgT-37 ºCP-80bpmR-25 cpm

UTRIONAL

METABOLIC

PATTERNBY:GORDON

Risk for altered nutrition less than body requirements r/t impaired digestion as evidenced by decreased appetite.RATIONALE This is an intake of nutrients insufficient to meet metabolic needs.

Objective:To promote / maintain proper nutrition.

Specific Objectives:After 2h of NSG intervention patient will be able to:

Demonstrate progression toward desired weight.

Maintain weight as appropriate to self.

1. Establish rapport to the pt.

2. Monitor V/S as appropriate as possible.3. Assess for abdominal distention, frequent guarding and reluctant to move.4. Weigh the pt. as indicated.

5. Consult with the pt. about like or dislike in food.

6. Provide a pleasant atmosphere at meal time; remove noxious stimuli.7. Provide oral hygiene before meals.8. Offer effervescent drinks with meals if tolerated.

9. Ambulate and increase activity as tolerated.

~Establishing rapport will gain trust and cooperation of the pt.~This may determine the condition of the pt.

~Nonverbal signs of discomfort associated with impaired digestion and Gas pain.

~It monitor effectiveness of dietary plan.~Involving the pt. in planning enables pt. to have a sense of control and encourage eating.~Using in promoting appetite or reducing nausea.

~A clean mouth enhances appetite.

~May lessen nausea and relieve gas. It may be contraindicated if beverage causes gas function or gastric discomfort.~Helpful in expulsions of flatus, reduction of abdominal distention/contributes to overall recovery and sense of well being and decreases possibility of secondary

3PM

Goal partially met, the patient demonstrates willingness to maintain nutrition.

10. Provide TPN as indicated

problems related to immobility.~Alternate feeling of may be required depending in the degree of gallbladder involvement and need for prolonged gastric rest.

BIBLIOGRAPHY

*Black, JM., J.H., Keene, AM ., Med-Surg Nsg.,clinical management for positive outcomes 6th edition vol.2

*Lippincott, Wilkins and Williams; springhouse nurses drug handbook 2007 8th edition

*Doenges , W. Moorehouse and Murr , nurses pocket guide, 10th edition F.A Davis Company, philadelphua, Pennsylvania @ 2006

*Ignatavicius and Workman, medical sorsical nursing critical nking for collaborative care 5th edition vol. 2 @ 2006

* Medical- Surgical Nursing (critical thinking in client care)P. Lemone & K. Burke; 3rd edition; page 574-575

* Brunner & Suddarth’s textbook of Medical-Surgical Nursing Volume 2; 10th edition; S. Smeltzer & B. Bare; page

1126

*http://en.wikipedia.org/wiki/Cholecystitis

*http://www.webmd.com/digestive-disorders/tc/cholecystitis-overview