Acute Calculous Cholecystitis

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Transcript of Acute Calculous Cholecystitis

BULACAN STATE UNIVERSITYCITY OF MALOLOS, BULACAN

COLLEGE OF NURSING

OSPITAL NG GUIGUINTO (MEDICAL WARD)

A CASE STUDY ABOUT

ACUTE CALCULOUS CHOLECYSTITIS

SUDBMITTED BY:

LACAS, JOHN PHILIP REYES, FIONA NOELLE(BSN III-D GROUP 3)

SUBMITTED TO:

MR. ROGIE ABALLOS, R.N(CLINICAL INSTRACTOR)

NURSING ASSESSMENTA. BIOGRAPHIC DATANAME ADDRESS AGE BIRTH DATE GENDER RELIGION RACE STATUS OCCUPATION SOURCE OF HEALTH FINANCING DATE OF ADMISSION ADMITTING DIAGNOSIS FINAL DIAGNOSIS : Wilhelmina Boday : # 422 Narey Street, Rocka Village, Tabe, Guiguinto, Bulacan : 48 Years Old : November 02, 1960 : Female : Roman Catholic : Asian : Married : Businesswoman : Herself : September 21, 2009 (12:50pm) : RUQ Abdominal Pain : Acute Calculous Cholecystitis

B. CHIEFT COMPLAINT The patient complains of RUQ abdominal pain which is happened for almost 2 weeks, according to her.

C. HISTORY OF PRESENT ILLNES According to her, she often experience RUQ abdominal pain for almost how many years. First, she thought that the pain which she felt is caused by a hyperacidity attack and try to manage it by taking Aluminum Hydroxide (Kremil S) an antacid drug. As time past by the abdominal pain became severe and even an antacid drug cannot relieved the symptoms. Then she decided to consult a doctor, which is last January 2009. According to her the doctor gave her Omeprazole (Prisolec) a Proton Pump Inhibitor which work to stop acid secretion of the stomach. Then it works and it can now relieve the abdominal pain which she felt. After few months, this September of the same year, the abdominal pain came back and became more sever with a pain scale of 7/10. Then last Sept. 21, 2009, they decided to bring her in Ospital Ng Guiguinto and seek for some medical explanation. The doctor said she have gallstone and she will be going to undergo a surgery which is Cholecystectomy. D. PAST HISTORY OF ILLNESS According to her, she was complete in different immunization offered at that time. She already has Mumps and Varicella; do not have any known food or drug allergies: and have not suffered from any minor or major injury when she was a child.E. FAMILY HISTORY OF ILLNESS

According to her, besides in having Cholecystitis, she also has Hypertension & Diabetes Mellitus Type 1. Her father has Hypertension as well as her 2 siblings: her Mother died with unknown cause; the uncle in her mother side also has Diabetes Mellitus. And there is no family history of Osteoarthritis, Malignant Neoplasia and Cholecystisis.

GENOGRAM

N

/AN

/A

N

/A

N

/A

N

/AN

72 /A

N

/AN

N

/A69N

/A

/A

5250 48

37

MALE FEMALE

PATIENT HYPERTENSION

ALIVE AND WELL DECEASED

N

/A

NOT AVAILABLE CHOLECYSTITIS

DIABETES MELLITUS

F. DEVELOPMENTAL TASK

NAME: WILHELMINA BODAY AGE: 48 YEARS OLD HOSPITAL: OSPITAL NG GUIGUINTO (MEDICAL WARD) DATE: 09-24-09

THEORY

ERIK ERIKSON THEORY OF PSYCHOSOCIAL DEVELOPMENT

SIGMUND FREUD THEORY OF PSYCHOSEXUAL DEVELOPMENT

JEAN PIAGET THEORY OF COGNITIVE DEVELOPMENT

LAWRENCE KOHLBERG THEORY OF MORAL DEVELOPMENT

JAMES FOWLER THEORY OF FAITH DEVELOPMENT

UNIVERSALIZING FAITH STAGE MIDDLE ADULTHOODPSYCHOLOGICAL CRISIS: GENERATIVITY VS STAGNATION RELATED ELEMENT IN SOCIETY: PREPARING, EDUCATING & GIVING SOCIAL INVOVEMENT FOR THE NEXT GENERATION.

GENITAL STAGE

FORMAL OPERATIONS

POST CONVENTIONAL

DEFINITION

Generativity is the concern of establishing and guiding the next generation. Socially-

True maturity requires the timing of aggressive and sexual urges, allowing their to released their

The person at this stage can think abstractive.

An individual reaches this stage acts out universal principles based upon the equality and worth of all

Unitive view of reality and enlightenment.

valued work and disciplines are expressions of generativity. Simply having or wanting children does not in and of itself achieve generativity

repress feeling in a more social and acceptable manner.

human beings.

EXPLANATION

Our pt. has feeling of generativity because she already have established and guided her children by giving a good life and education.

She has a healthy sex life and does not suffering from any sexual problem.

Our pt. accepts opinions from other. She responds correctly and appropriate to situation and questions. The pt. has relevance of thought and good insight in organization of vital event in her life.

She can decide accurately and relevant to situation. And have a good moral insight in her life.

The religion of our pt. is Roman Catholic; there is no problem in terms of faith and devotion to God.

FUNCTIONAL HEALTH PATTERN

PRIOR HOSPITALIZATION

DURING HOSPITALIZATION

HEALTH PERCEPTION & HEALTH MANAGEMENT PATTERN NUTRITIONAL METABOLIC PATTERN

She believed in herbal medication like Lagundi Leaves extract in treating cough and Guava Leaves extract as an effective anti-microbial agent; she also go to faith healers like Manghihilot as a primary source of health remedies if they experience unserious medical problems. 3 DAYS FOOD RECALLFOOD DATE SEPT. 18, 2009 SEPT. 19, 2009 SEPT. 20, 2009BREAKFAST LUNCH DINNER BREAKFAST

When I ask her if she can follow what doctor & nurse advices them, she verbalized sa abot ng aking makakaya,kailangan kong sundin ang mga gusting ipagawa ng doctor, kasi para rin ito sa kabutihan ko The patient also experienced hyperthermia (38.2). 3 DAYS FOOD RECALL

FLUIDLUNCH DINNER

FOOD DATE SEPT. 22, 2009BREAKFAST LUNCH DINNER

FLUIDBREAKFAST LUNCH DINNER

N/A N/A N/A

N/A N/A N/A

N/A N/A N/A

N/A N/A N/A

N/A N/A N/A

N/A N/A N/A

3 Bread

Sinigang na Baboy, 1 Cup of Rice, 1 piece of Banana Ginisang Gulay, 1 Cup of Rice NPO

Chapsuey, 1Cup of Rice

1 Glass of Water

2-3 Glasess of Water

2 Glasess of Water

Shes taking vitamins, specifically Ascorbic Acid continuously, she eats mostly fishes & meat, she is fun of eating food rich in seasoning and drinking cola most of the time, and not experienced weight lost lately. There is no skin problem noted. There are 3 missing molars and there is no problem in wound healing.

SEPT. 23, 2009

1 Piece of Egg, 1 Cup of rice 1 Serving of Mami

Sinigang na Isada, 1 Cup of Rice NPO

1 Glass of Water

1-2 Glass of Water NPO

1-2 Glass of Water NPO

SEPT.24, 2009

1 Glass of Water

During hospitalization she cannot eat what her want. And there is sudden decreased in

appetite.ELIMINATION PATTERN FECAL-URINARY ELIMINATION PATTERN FECAL-URINARY ELIMINATION PATTERN

CATEGORY 1. URINATON

FREQUENCY COLOR/CONSISTENCY- 5 to 8 as estimated - Depends upon the weather 2 Straw

DEVIATIONNone

CATEGORY

FREQUENCY

COLOR/CONSISTENCYStraw

DEVIATIONNone

1. URINATON

3

2. DEFECATIONACTIVITY-EXERCISE PATTERN

Brown/Formed

None

2. DEFECATION

1

Brown/Hard

Constipation

She considered household chores as a form of exercise. O Feeding O Bathing O Dressing O Toileting O Shopping O Home Maintenance O Bed Mobility O General Mobility Level O - Independent Level I - With help from others Level II - With equipment Level III - With help from others & equipment Level IV - Dependent

There is no form of exercise upon admittance to hospital. I Feeding N/A Bathing I Dressing I Toileting N /A Shopping N/A Home Maintenance I Bed Mobility II General Mobility Level O - Independent Level I - With help from others Level II - With equipment Level III - With help from others & equipment Level IV Dependent During hospitalization, she only sleeps for about 5 hours each night in intermittent manner, because of environmental factor (sudden changed in environment) & physiological factor (RUQ Abdominal Pain).

SLEEP-REST PATTERN

Prior hospitalization, she sleep for approximately 7 hours each night from 10pm to 5 am, there is no sleep problem noted, she take naps every afternoon, more often from 2pm to 3pm, all in all the total no. of sleep is 8 hours in every 24 hours, the form of relaxation is thru watching her favorite TV program, chatting with her family or sometimes her friends & reading news clippings. No hearing and eye problems. According to her, she often experience tip of the tongue phenomenon together with slight confusion.

COGNITIVE PERCEPTUAL PATTERN

Still no change.

SELF PERCEPTION SELF CONCEPT PATTERN

She is satisfied with her physical appearance; lately she felt easily tired. There is no major problem in her self as a whole, according to hers he easily felt angry to those people whose are liars and do not know how to return dept of gratitudes.

Still no change.

ROLE RELATIONSHIP PATTERN

She is already married, with 3children. They are 5 in the family. She and Her husband are responsible for most of the health decision in their family. And these factors made their family as Nuclear in membership and Egalitarian in authority. There is no major family problem encountered lately, and if there is a problem they handle it by means of having open forums. There is no problem in her community interaction & there is no feeling of isolation from others.

Still no change.

SEXUALLY REPRODUCTIVE PATTERN

She is sexually active; formerly shes using Oral contraceptive Pills as a form of f