Calculous Cholecystitis

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Calculous Cholecystitis A Case Study Presented to the Faculty, Ateneo de Davao Universi ty College of Nursing Submitted to: Daphny Grace Peneza, R.N., R.M., M.N. Clinical Instructor – Panelist for the Case Study Submitted by: Gino Gregor Palaca Marvin Rey Andrew Pepino Rio Remonde Kevin Melvin Roa Krystle Rustia BSN-3H-4a May 25, 2010

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Page 1: Calculous Cholecystitis

Calculous Cholecystitis

A Case StudyPresented to the Faculty,

Ateneo de Davao Universi tyCollege of Nursing

Submitted to:

Daphny Grace Peneza, R.N., R.M., M.N.Clinical Instructor – Panelist for the Case Study

Submitted by:Gino Gregor Palaca

Marvin Rey Andrew PepinoRio Remonde

Kevin Melvin RoaKrystle Rustia


May 25, 2010

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I. Introduction........................................................................................1

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

III. Patient’s Data......................................................................................6

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

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

VI. Developmental Data............................................................................17

VII. Physical Assessment............................................................................26

VIII. Anatomy and Physiology....................................................................34

IX. Etiology and Symptomatology...........................................................37

X. Pathophysiology..................................................................................47

XI. Doctor’s Order....................................................................................50

XII. Diagnostic Exam.................................................................................62

XIII. Drug Study..........................................................................................72

XIV. Procedural Report..............................................................................87

XV. Nursing Theories.................................................................................94

XVI. Nursing Care Plan..............................................................................100

XVII. Discharge Plan (M. E. T. H. O. D.) & Prognosis..............................123

XVIII. Recommendation................................................................................130

XIX. References............................................................................................133

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The Group 4-1 of section 3H, would like to acknowledge the contributions of the

following groups and individuals to the development of this case presentation.

To the Almighty God for blessing them with wisdom, competence and genuine

passion and giving them the strength to finish this presentation. The group dedicates to

Him the fruits of their hard-earned achievement.

To the staff of the Davao Medical School Foundation Hospital-3C for being

accommodating to the students and for giving them additional teachings during their

exposure in the said hospital. They have also been very willing to allow the students to

obtain records necessary for this presentation.

To their respected clinical instructor for this rotation, Daphny Grace Peneza,

R.N., R.M., M.N., for her support and guidance to the group. She has imparted

knowledge that would furthermore enhance the student’s understanding of their patient’s

case, thus making them ready to present this case presentation.

To their client, Meg, and her family, for being open and generous enough to

disclose personal information that would be helpful for this study. The group would also

like to thank them for their patience throughout the duration of the study and for giving

the group the opportunity to care for Selecta and apply what they have learned.

To the proponents’ respective family and friends for their prayers as well as their

financial support. They have also been a source of inspiration of the students.

To the members of this group for working hard and giving their efforts, time and

resources in conducting the study and for the completion of the written output.

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One of the body organs that we can live without is the gallbladder.

However, does this mean it is of no use to the body? The gallbladder is a pear-

shaped organ situated underneath the liver. Its function is to store bile and

release it as needed for digestion. Bile emulsifies the fats in food, breaking them

to small fragments so they can be further digested and absorbed in the small

intestine. If the gallbladder is not working as it should, the digestion of fats can be

seriously impaired.

One of the common gallbladder diseases is calculous cholecystitis.

Calculous cholecystitis is a condition wherein gallstones obstruct the gallbladder

outlet leading to poor drainage of bile. Trapped bile can irritate and inflame the

walls of the bladder, thus leading to inflammation. Calculous cholecystitis is the

cause of more than 90% of cases of acute cholecystitis (Feldman, Friedman &

Brandt, 2006). It affects women more often than men and is more likely to occur

at the age of 20-50 or over 60. Asians are also more prone to develop pigment

stones. Moreover, people who are obese and those who had had low fat diet are

at an increased risk for developing cholelithiasis. In the United States, it is

estimated that 6.3 million men and 14.2 million women aged 20 to74 had

gallbladder disease (Everhart, Khare, Hill, Maurer, 1999). In the Philippines, an

extrapolated prevalence of 5, 073, 040 people are affected by the disease

( Gallstones that do not cause symptoms

do not require treatment. However, if gallstones cause, disruptive, recurring

episodes of pain, surgical removal of the gallbladder is recommended.

Recently, the Group 3H-4a had a patient who was diagnosed with

symptomatic calculous cholecystitis and underwent laparoscopic

cholecystectomy. The group chose this case for they see it fit for their

perioperative concept. Rarely do they interact with patients who had minimally

invasive surgery. The proponents are hoping that through this case study, they

will be more knowledgeable and aware about such gallbladder disorder and the

surgical procedure done for the said disease. They are also interested to know

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the proper and necessary nursing management that will be given to a patient

affected by the disease. Moreover, they would also like to impart their learning to

their families and their community regarding the prevention and care if ever such

condition will arise in the scenario.

As nursing students, they are hoping that this study will help them become

more efficient and better nurses in the future. The student nurses also hope to

apply their learning in taking care not only of their patients but of themselves as


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General objective: Within 2 weeks exposure to various clinical areas, the group

should have been able to present a comprehensive case study which explains

the pathology, the treatment and the appropriate medical and nursing

management regarding the condition of their chosen client. The group also aims

to perform the necessary nursing interventions to help alleviate the patient’s

condition and improve her health.

Specific Objectives: The proponents also created certain aims that will help

them in achieving their general objectives. Within 2 weeks of exposure, the

proponents aim to:


Gather pertinent data regarding the past and present health history of the

patient through interview and assessment;

Draw the family genogram of the patient;

Define the complete diagnosis of the patient by directly citing it from three

different sources;

Ascertain the patient’s developmental status using the theories of Robert

Havighurst, Erik Erikson and Lawrence Kohlberg;

Conduct a thorough cephalocaudal assessment obtained from the client;

Review the anatomy and physiology of the organs affected in the patient’s


Present the etiology and symptomatology of the disease;

Trace the pathophysiology of the patient’s disease;

Obtain the doctor’s orders and make rationales for each order;

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Obtain, analyze and interpret laboratory and diagnostic procedures done

on the patient and include the normal and abnormal values and findings

for comparison, and the specific nursing responsibilities associated with

each diagnostic procedure;

Make drug studies on each drug given to the client, correlate them with

the disease process, explain why such drugs were ordered, and present

important interventions in administering the drug;

Identify three nursing theories that can be applied to the patient’s


Present specific, measurable, attainable, realistic, and time-bounded

nursing care plans for the patient;

Correlate the different nursing theories with the nursing care plans that are

presented in this case study;

Make a discharge plan for the patient with the use of M.E.T.H.O.D.;

Validate patient’s prognosis according to the following categories: onset of

illness, duration of illness, precipitating factors, willingness to take

medications and treatment, age, environmental factors and family support;

Broaden our scope of knowledge about the disease and the appropriate

Nursing Care for the patient with the disease;


Find a patient who will be the subject of their case presentation;

Render health teachings to the patient and her significant others to

promote health;

Provide care based on the various nursing care plans formulated by the

researchers and the patient herself;

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Share information about calculous cholecystitis and the factors that cause

the development of such disease and its complications;

Share how the disease affects those affected by it and the systems

involved in its occurrence;


Establish rapport with the patient and significant others;

Show genuine concern and willingness in serving the client;

Be aware of the client’s progress on the succeeding interactions;

Appropriately state the bibliography of all resources used in order to

prevent plagiarism and promote honesty.

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Client’s Code Name: Meg

Age: 38 years old

Gender: Female

Birth date: November 6, 1971

Address: Upper Sirib, Calinan Davao City

Nationality: Filipino

Religion (Denomination): Christian (Roman Catholic)

Civil Status: Married

Spouse: Bobong

Educational Attainment: 4th year high School

Occupation: House keeper

Height: 5ft 2inches

Weight: 62 kgs.

Health Insurance: Phil Care

Hospital: Davao Medical School Foundation (DMSF)

Vital Signs on Admission: BP: 130/80 mmHg PR: 79 bpm RR: 19 cpm

T: 37 ºC

Unit: 3C- 324-5

Chief Complaint: Pain at right upper quadrant

Admitting Physician: Dr. Walter Batucan

Admitting Diagnosis: Acute Cholelithiasis

Final diagnosis Calculous Cholecystitis

Surgical procedure Laparoscopic cholecystectomy


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A. Family Background

Meg is the second child among Mamang and Papang’s four

children. All children of Mamang were born through Normal Spontaneous

Vaginal Delivery without any complications. She delivered all her children

at their house with the help of “mananabang”. The family has been

residing in Sirib, Calinan Davao City since the marriage of Papang and

Mamang. Their home is near their farm.

The client, Meg has 3 siblings namely: Kenny (Male, deceased),

Luigi (Male, 30, married), and Dora (Female, 28, married). Meg graduated

high school and didn’t to proceed to college because she helped her

family tend their farm.

According to the patient, her father and mother are still alive and

they suffer from hypertension and diabetes. She said that the family

lineage of her mother also suffers from heart problems as well as kidney

problems. Two of her uncles on father’s side underwent surgery,

cholecystectomy, and had the same condition as Meg. Her older brother

died due to motorcycle accident. Luigi was diagnosed with hypertension

and Dora had a history of UTI. There was no one else in her immediate

family that suffered cholecystitis aside from Meg herself.

Meg got married to Bobong in the 1998. They were blessed with 3

children. Her 3 children were delivered through Normal Spontaneous

Vaginal Delivery, all were born in the Maternity clinic in Calinan. Her eldest

child is now studying in 4th grade. So far, none of her children suffer a

serious illness.

In terms of their expenses, Bobong is the one that provides money

for their daily expenses. Bobong is a Supervisor at DABCO and has a

wage of approximately 10,000 a month. Meg said that they budget the

money well for them to have food and to provide the necessary daily

needs and expenses. By helping tend to the 2 hectare farm of the patient’s

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parents, they also get their share. They plant coconut trees, bananas, and

pineapples in their farm.


The patient has sedentary lifestyle. When Meg stopped going to

school, she helped her mother with household chores. Right now, she is

busy taking care of Bobong and their 3 children. She is the one who

cooks, cleans the house, and does the laundry of the whole family.

Sometimes, she does gardening in their backyard. According to her, she

only works in the house, but still, she experiences fatigue from doing

household chores especially since she is the only one who does the


She reported that she doesn’t smoke, but her husband does; he

smokes almost one pack a day. Meg said that she drinks liquor very

seldom; she only consumes a half of glass or a glass of liquor


The family has good relationship. At night, they watch television

together and this serves as their bonding time. Occasionally, they gather

together with her relatives when there are fiestas, birthday celebrations

and other special occasions.

She is not so active in terms of social organizations such as GKK

(Gagmay’ng Kristohanong Katilingban), but she sometimes joins in the

events in their community like the fiesta. She sometimes goes to church

on Sundays together with her children.

Meg sleeps around 9:00 o’clock at night and wakes up around 5:00

o’clock in the morning to prepare things needed of her husband. She is

the one who cooks the “baon” of her husband for work.

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Meg said that she eats at least two times a day in small meals. She

said “naga-diet diet man ko kay tabaan nako sa akoang lawas, nagsugod

ko katong 36 years old pako, pero karong tuiga giundangan na nako ang

pagdiet-diet”. For breakfast she usually eats, “bulad”, “bagoong”,

“ginamos” and bread. Every morning, she always drinks coffee. In a day,

she can consume at least 3 cups of coffee. Her lunch and supper are

sometimes vegetables that are found in their backyard such as

“kamunggay”, “upo”, “okra”, “talong” and “tinangkong”. She is not fond of

eating pork and beef. She said that before, she limits herself from eating

fatty foods since she aimed to lose weight because she was afraid of

becoming obese. Also, she is so fond of drinking soft drinks. In a day she

can consume 4 glasses of coke. But she also drinks approximately 5-6

glasses of water. She also loves to eat salty foods, especially junk foods.

According to her, she has no allergy from any form of food.

B. Past Health History

Meg and her husband preferred to have artificial family planning than

natural family planning. She started using birth control pills since she was

36 years old.

She said that she is not sure if she completed her immunizations.

Her mother forgot already and the records were lost. They only avail of the

services of the health center very seldom. She said that their house was

far from the health center so they weren’t able to avail of all of the

services. She also experienced common illnesses such as cough, colds,

fever, measles and even chickenpox. They only treated it at home, since

her mother knows how to make use of different herbal medicines such as

kalabo, mayana, buyo, gabon, and tawa-tawa. Also, they sometimes

bought over-the-counter drugs such as paracetamol, Neozep, and

Medicol. With regards to how long she experienced those usual illnesses,

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she said “dili man jud ko maabtan ug simana sa akoang kalintura ug bisan


She experienced measles when she was a 1-year old and had

chickenpox when she was 10-year old. Meg had her menarche when she

was 11 years old.

Meg reported that she got pregnant with her 1st child at the age of 28;

unfortunately, she had miscarriage on the 1st week of pregnancy. She

was hospitalized at Robillo Hospital, Calinan Davao City. Completion

curettage was performed to her. Again, on her 3rd pregnancy, she had a

miscarriage and was hospitalized on the maternity clinic and underwent

completion curettage. She reported that in almost all her pregnancies, she

experienced an increased blood pressure, usually 140/90. After delivering

her third child at the age of 36, Bobong and Meg decided to make use of

family planning. Meg started to take birth control pills until now to prevent

unexpected pregnancy.

C. History of Present Illness

On the second week of December 2009, Meg felt mild pain at the right

upper quadrant of her abdomen. She neglected it thinking that it’s nothing

serious and might be just an episode of indigestion. After three days, the

pain went away. But after two weeks, pain recurred at a higher scale

(5/10). Because of this, she was forced to seek medical advice. She went

to Isaac T. Robillo Memorial Hospital Calinan, Davao City and was asked

to have ultrasound of the whole abdomen. After 2 days, the result was

released and they found out that there were stones in her gallbladder. She

was advised by the doctor to undergo surgery, cholecystectomy. However,

the patient resisted the doctor’s advice due to fear of surgery. She was

given medications as an alternative (the patient already forgot the name of

medications prescribed). She was instructed by the doctor to increase

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water intake and have a low fat diet, unfortunately, she wasn’t able to

follow the doctor’s order and still continued with her usual lifestyle.

Meg said that she still felt the pain after the check-up but she could still

tolerate it. She just took medications that were prescribed by the doctors

to alleviate the pain she felt.

Last May 5 this year, three days prior to admission, the patient again

experienced right upper quadrant pain which lasted until the present

condition. This was characterized to be progressive pain with a pain scale

of 8 out of 10. There was no radiation noted and no associated symptoms.

Two days prior to admission, pain recurred with a pain scale of 10 out of

10. This prompted Meg to seek consultation, hence, admission.

On May 8, 2010, the patient was admitted at Davao Medical School

Foundation at Surgical Ward, room 324 bed 5 under the service of Dr.

Batucan, with admitting diagnosis of Acute Cholelithiasis.

D. Effects/Expectations of Illness to Self/Family


When Meg knew about her condition that she needs to undergo

surgery, she didn’t know what to do. She was very worried about herself

because she has fear of not waking up after surgery. She feared having

complications of not having a gall bladder anymore.


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Also, she is worried about her 3 children, who still need care and

guidance from their mother. This made her decide not to go through with

the surgery before.

Meg wants to overcome her illness so that she can still spend time

with her family and friends. Furthermore, she said that she wants to be in

good condition as much as possible so that she can do her daily task in

everyday life for her family. The client is worried about her condition

because she has many plans in life together with her family.


Still, Meg is still hopeful to overcome her challenges in life. The

client still has faith in the Creator, and she continues to pray to Him. She

believes that everything will be alright with the help of the creator.

Also, her children were worried about their mother, who’s suffering

from such condition. Her husband, Bobong is trying his best to support his

wife. Bobong was worried about Meg because for him, it makes him suffer

seeing his wife suffering. In addition, their relatives are also extending

their care and prayers for Meg because they are worried and concerned

for her.

The client is also very thankful because her family, relatives and

friends are still there giving support to her for her fast recovery. They are

always there and look after her in the hospital and to aid her physically,

mentally, emotionally, and spiritually.

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Maternal Side Paternal Side

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Ana, , 70 Lala, K, 67

Lolo, K ,†

Jose, c, , D, 64

Mamita, †,

Lola, †, o

Papito, †

Papang, 62Po, c, 67Mamang, 60, DSis, , 64

Dora, 28, K

Kenny, a, †

- Female


#- age

- Heart problems


D- diabetic

K- Kidney problem

o- old age

c- cholelithiasis

a- accident

Meg, , c, 38

Bobong, 45,

Luigi, 30,

Bebe two, 7Bebe three, 2 Bebe one, 10

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Complete Diagnosis: Calculous Cholecystitis


Calculi, or gallstones, usually form in the gallbladder from the solid

constituents of bile; they vary greatly in size, shape and composition.

Source: Boyer, M. (2006). Brunner and Suddarth’s Textbook of Medical-

Surgical Nursing, 11th ed., p. 1347. Lippincott Williams & Wilkins.

Calculus (pl. calculi) is also called stone; an abnormal stone formed in

body tissues by accumulation of mineral salts. Calculi are usually found in

the biliary and urinary tracts.

Source: Retrieved

May 15, 2010.

Calculi (stones) can be divided into two groups—renal calculi and

gallstones. The majority of gallstones are composed principally of

cholesterol and other calcium salts.

Source: Iyengar, V. Elemental Analysis of Biological Systems: Biomedical,

Environmental, Compositional and Methodological Aspects of Trace

Elements, Vol. 1, p. 49.


Cholecystitis is the inflammation of the gallbladder. In more than 90% of

the cases, gallstones are present.

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


Inflammation of the gallbladder is called cholecystitis (chole = bile +cyst =

bladder + itis = inflammation)

Source: Crowley, L. (2010). An Introduction to Human Disease: Pathology

and Pathophysiology Correlations, 8th ed., p. 563. USA: Jones and Bartlett


Inflammation of the bladder which may be either acute or chronic. In an

acute cholecystitis, the blood flow to the gallbladder may become

compromised which in turn will cause problems with the filling and

emptying of the gallbladder. A stone may block the cystic duct which will

result in bile becoming trapped within the bladder due to inflammation

around the stone within the duct. Chronic cholecystitis occurs when there

have been recurrent episodes of blockage of cystic duct.

Source: Digiulio, M. & Jackson, D.(2007). Medical-Surgical Nursing

Demystified, p. 288. USA: McGraw-Hill.

Calculous Cholecystitis

Acute cholecystitis is inflammation of the gallbladder. There are two major

types of acute cholecystitis— calculous and acalculous. In calculous

cholecystitis, gallstones obstruct the gallbladder outlet leading to poor

drainage of bile. In physical exam, patients may exhibit Murphy’s sign—

right upper quadrant pain elicited by palpation under the right costal

margin when the patient inspires.

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Source: Ginsber, G. & Ahmad, N. (2006) The Clinician’s Guide to

Pancreaticobiliary Disorders, p. 121-123. USA: SLACK Incorporated.

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According to Taylor, Lillis, LeMone and Lynn (2008), growth and development are orderly and sequential as well as

continuous and complex. All humans experience the same growth patterns and developmental levels, but, because these

patterns and levels are individualized, a wide variation in biologic and behavioral changes is considered normal. Within

each developmental level, certain milestones can be identified; for example, the time the infant rolls over, crawls, walks, or

says his or her first words. Although growth and development occur in individual ways for different people, certain

generalizations can be made about the nature of human development for everyone.

Robert Havighurst’s Developmental Task Theory

Robert Havighurst believed that living and growing are based on learning, and that a person must continuously learn to

adjust to changing societal conditions. He described learned behaviors as developmental tasks that occur at certain

periods in life. Successful achievement leads to happiness and success in late tasks, whereas unsuccessful achievement

leads to unhappiness, societal disapproval, and difficulty in later tasks. The developmental tasks arise from maturation,

personal motives, and values that determine occupational and family choices, and civic responsibility. (Taylor, et al. 2008)

Stage Description Result Justification



In the middle years, men and women reach

the peak of their influence upon society, and

at the same time the society makes its

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maximum demands upon them for social and

civic responsibility. It is the period of life to

which they have looked forward during their

adolescence and early adulthood. And the

time passes so quickly during these full and

active middle years that most people arrive

at the end of middle age and the beginning of

later maturity with surprise and a sense of

having finished the journey while they were

still preparing to commence it.

Selecting a mate

Learning to live with a partner

Starting family

Rearing children


The patient married and started a

family last 1998. She is happy with her

husband since she receives care and

unconditional love from him. She works

together with her husband in taking

care of and rearing their children by

providing their physiological,

psychological, and emotional needs.

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Managing home

Getting started in occupation

Taking on civic responsibility



The patient has no job, however, she is

the one managing the house, by

cleaning, washing clothes, doing other

household chores and being a

peacemaker when trouble happens

among her children. She is the one

managing the house to have a

peaceful and organized home. Meg is

also responsible for budgeting their

money needed to sustain them in their

everyday living. She sees to it that her

husband’s salary is well budgeted and

not put into waste.

The patient is doing her responsibilities

as a Filipino citizen by following laws in

our country such as not throwing

garbage anywhere, and following traffic

rules. She is also a registered voter.

Patient verbalized that if she were not

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admitted in the hospital, she would

really vote in the 2010 Presidential

elections. She also pays taxes

(property tax and cedula) as part of her

responsibility as a citizen.

Erik Erikson’s Psychosocial Development Theory

Erikson emphasized developmental change throughout the human life span. In Erikson’s theory, eight stages of

development unfold as we go through the life span. Each stage consists of a crisis that must be faced. According to

Erikson, this crisis is not a catastrophe but a turning point of increased vulnerability and enhanced potential. The more an

individual resolves the crises successfully, the healthier development will be. It is patterned to the Psychosexual

Development of Sigmund Freud but more concentrated on what task and conflict should a person be able to manage in a

certain age group. That is termed psychosocial development. He described eight stage of development:

1. Infancy

2. Early childhood

3. Late childhood

4. School age

5. Adolescence

6. Young adulthood

7. Adulthood

8. Maturity

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Each stage signals a task that must be accomplished. The resolution of the task can be complete, partial, or


Stage Description Result Justification



25-65 years





vs. Self

absorption or




The significant task is to perpetuate

culture and transmit values of the

culture through the family (taming the

kids) and working to establish a stable

environment. Strength comes through

care of others and production of

something that contributes to the

betterment of society, which Erikson

calls generativity, so when a person is

in this stage, she often fear inactivity

and meaninglessness.

As the children leave home, or the

person’s relationships or goals

changes, she may be faced with major





As a wife and a mother of three children, she is

the one who inculcates values in the family

whom she acquired from her parents. She

makes sure that her children will be raised with

good attitude and as good Filipino Citizens.

As of now, her children are dependent and still

with them, she still doesn’t know what her

feelings will be when her children will leave

home someday. Today, she is busy taking care

of her children and her husband as those are the

responsibilities of a mother and wife.

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and Care

life changes—the mid-life crisis—and

struggle with finding new meanings

and purposes. If a person doesn't get

through this stage successfully, she

can becomes self-absorbed and


Significant relationships are within the

workplace, the community and the


Creativity, productivity, concern for

others or self-indulgence, self-

concern, lack of interests and


Kozier and Erbs, Fundamentals of

Nursing, Chap. 20, page 352


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Lawrence Kohlberg’s Levels of Moral Development

Lawrence Kohlberg outlined the different planes of moral adequacy, based on his continued interest in how

children would react to varying moral dilemmas. Kohlberg stated that ethical behavior was based on moral reasoning,

which in turn could be broken down into six specific developmental stages. The stages are progressive, in that it is highly

improbable for someone to regress backwards. Once a person acquires the functionalities of higher stages of moral

development, it will be difficult for him to lose these abilities and revert to lower levels of growth. Every stage follows

another, making it difficult for a person to jump forward and virtually skip an entire stage.

The levels and stages are as follows:

Level 1: Preconventional

Stage1: Punishment/obedience

Stage2: Instrumental/relativist

Level 2: Conventional

Stage3: Approval Seeking

Stage4: Law and order

Level 3: Postconventional

Stage5: Social Contract

Stage6: Universal-ethical

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Stage Description Result Justification




Stage 5:






At stage 5 social contract and

utilitarian orientation, correct

behavior is defined in terms of

society’s law. Laws can be

changed, however, to meet

society’s needs, while

maintaining respect for self and


Stage 6, universal ethical

principle orientation, represents

the person’s concern for

equality for all human beings,

guided by personal values and

standards regardless of those






She sees that most of the laws are correct and worth to

be followed. She said that she follows the rules of the

country and the city she lives in. She doesn’t want

nuisance in the society because she believes that to be

able to live in a serene place, people must maintain and

establish respect with themselves and then to others.

She knows about universal laws, specifically about

justice. She is concerning about justice, “malooy gyud ko

sa mga tao nga dili matagaan ug hustisya, labaw na ng

mga kabus” , as verbalized by the patient.

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set by society or laws. Justice

might be internalized at an

even higher level than society.

Few adults ever reach this

stage of development.

(Taylor et. al, 2008)

Page | 25

Page 29: Calculous Cholecystitis


Patient’s Name: Meg

Age: 38 yrs. old

Sex: Female

Admitting Diagnosis: Acute Cholelithiasis

Final Diagnosis: Calculous Cholecystitis

Chief Complaint: right upper quadrant pain

Date of Assessment: May 12, 2010

Time of Assessment: 4:00 pm

Location of Assessment: DMSF Hospital, 3C, Room 324-5

Vital Signs upon physical assessment:

I. General Survey

The patient was received lying on bed, awake, conscious, coherent,

afebrile and without IVF. She has three 0.5-cm long incisions at her epigastric

and right lower rib cage areas and a 1-cm incision under her umbilicus. Incision

site is dry and intact. Each incision is covered with dry and intact dressing.

Patient complains of pain on the incision site and rated this pain as 6 out of 10 in

the pain scale. She is oriented to time (verbalized it was late in the afternoon),

person (identified watcher correctly), place (verbalized she’s in the hospital) and

Page | 26

Temperature : 36.6 °C

Pulse Rate: 82 bpm

Respiratory Rate: 18 cpm

Blood Pressure: 130/80 mmHg

Page 30: Calculous Cholecystitis

reason for admission (stated that she was admitted due to right upper quadrant

abdominal pain). Patient is not in respiratory distress.

Patient appears appropriate for her stated age. She stands 5 feet and 2

inches tall and weighs 62 kg. Her body mass index (BMI) is 24.9 which is normal.

She has an endomorphic body type. Patient is in fair grooming as evidenced by

unsoiled t-shirt she is wearing, well-kept hair and clean linens and pillows.

However, it was noted that patient has halitosis. Nails were long but clean.

Through the course of the physical assessment, it was observed that the

patient is cooperative and has an accommodating attitude towards the student.

The patient is calm. Patient’s speech was audible, comprehensible and in

moderate pace.

II. Skin

Skin is fair in color, intact and with hairs, except in the palms, soles and

dorsa of the distal phalanges. Skin is dry and slightly warm upon palpation. It

returns quickly to its normal state when picked up between two fingers and

released. Skin texture is soft and fine while extensor surfaces such as the elbows

have coarser skin. The palms and the soles are calloused. No skin breaks

present aside from the incision sites on her abdomen. No edema present.

III. Hairs and Nails

Upon inspection, hair was noted to be black. It is thick, oily, straight, long

and well-kept. Hair is also evenly distributed as evidenced by absence of bald

spots. Dandruff or flaking was not present. Other infestations, such as lice, were

not noted. The color of scalp is lighter than the color of skin.

Nails on both hands and feet are long but clean. Nail polish was removed.

Client has a capillary refill time of 2 seconds. No clubbing of the nailbeds noted.

Page | 27

Page 31: Calculous Cholecystitis

IV. Head

Patient’s head is round and normocephalic in configuration with smooth

skull contour. There were no palpated masses, nodules, deformities or fractures.

Facial features are symmetric as evidenced by palpebral fissures being equal in

size and symmetric nasolabial folds. Facial movements are symmetrical and

patient is able to perform different kinds of expression effortlessly and without

any obstructions. Patient can move her head up and down and side to side. No

lesions noted on the face.

V. Eyes

Hairs of eyebrows are thick and evenly distributed. Eyebrows are

symmetrically aligned and there’s equal movement as evidenced by the patient’s

ability to elevate and lower the eyebrows. No edema, lesions, puffiness or

tenderness noted upon inspection and palpation of the periorbital area.

Eyelashes are equally distributed and curled slightly outward with no ectropion or

entropion. Eyelids’ surface is intact with no discharges and no discoloration but

with noted eye bags on the lower surface. No lid lag noted. Blink reflex is

present. Palpebral fissure is equal in both eyes. Bulbar conjunctiva is pale pink.

Cornea is transparent and without cloudiness. Sclera is anicteric. Eyeballs are

symmetrical with no bulging observed. Pupils were black in color, equally round,

3mm in size and reactive to light and accommodation. Pupils quickly constrict

when a penlight is shone towards the pupil from a lateral position. Iris is dark

brown in color.

Client has central and peripheral vision. She can see things on the side

of her eye, like the adjacent bed, even when looking straight ahead. Moreover,

pupils constrict when looking at near objects and dilate when looking at far

objects. During ocular motility testing, patient was asked to follow the examiner’s

Page | 28

Page 32: Calculous Cholecystitis

finger in the six cardinal fields of gaze. There was smooth, parallel movement of

eyes in all direction. Both eyes move in unison. No nystagmus noted. To test her

visual acuity, the students asked her to read their nameplates placed about 1 ½

feet away from her. She was able to correctly read the names without any

difficulty. Patient verbalized she doesn’t use any corrective aids. She also did not

report any vision difficulty or eye pain.

VI. Ears

The color of the patient’s ears is the same as her facial skin. The skin

behind the ear in the crevice is smooth and without breaks. The left and right

pinna are symmetrical and aligned with the inner canthus of the eye. Pinna

recoils after it is folded. Auricle is nontender upon palpation. Mastoid process is

smooth and hard and no tenderness or swelling noted. External canals have

minimal cerumen. No sanguinous discharges noted on the meatus. Patient was

able to hear a soft whisper equally in both ears. She can also hear normal voice

tones as evidenced by prompt responses to questions asked.

VII. Nose

It was noted that the nostrils were symmetrical and the nasal septum is

midline. There were no observed discharges draining from the client’s nose. Hair

is noted on the nares. Nares are patent since patient is able to breathe normally

on both nostrils without difficulty when one nose is closed with digital

compression and patient inhaled with mouth closed. No lesions on the external

nose structure were seen. There was no tenderness over the maxillary and

frontal sinuses upon palpation of the cheeks and supraorbital ridges. Client’s

gross smell was functional as she could identify the scent of alcohol.

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Page 33: Calculous Cholecystitis

VIII. Mouth

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

color and with no masses or congenital defect. Buccal mucosa was uniform pale

pink in color and moist. The patient’s gum was, moist, firm and pinkish in color.

No gum retraction or bleeding was noted. Teeth are of complete set. There are

no spaces in between teeth. Dental carries are evident in lower right and left

molar. Teeth are yellow in color. Patient has no dentures. Tongue is pink, moist,

slightly rough and has thin whitish color on the surface. It is also in central

position and moves freely. The base of tongue is smooth with prominent veins.

No tenderness, lesions or any unusualness noted. Soft palate is light pink in

color. On the other hand, hard palate is much lighter and more irregular in

texture. Uvula is positioned in midline of soft palate and rises when the patient

says “ah”. Tonsils are not inflamed. No ulcerations and exudates present. Patient

has no difficulty of masticating and swallowing. Halitosis was noted. Patient has

no speech disorders.

IX. Neck

Neck is symmetrical with no masses or unusual swelling upon

palpation. No jugular vein distention noted. Pulsation at carotid arteries is strong

and regular in rhythm. Range of motion is normal and no pain elicited upon

flexion, extension, and rotation of head. Thyroid is not enlarged upon palpation

with no nodules, masses or irregularities upon palpation. Thyroid also rises when

patient was asked to swallow. Trachea is symmetrical and in midline without

deviation. No lymph adenopathies appreciated. No torticollis present.

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Page 34: Calculous Cholecystitis

X. Breast

Breast is conical, symmetrical and skin color is lighter than exposed areas.

No lesions, redness, or edema and texture is even. No dimpling or retraction.

Nipples are in midline and everted pointing in the same direction. Areola and

nipples are dark brown in color and has no discharges, crusting and masses.

XI. Chest/Lungs

Chest skin integrity is good and intact. Patient has symmetrical chest wall

movement. Point of maximal impulse is at 5th intercostal space left midclavicular

line. Apical pulse is 84bpm. Patient has distinct heart sounds, with S1 louder than

S2; negative for murmurs. There were no noted deformities in the client’s

thoracic area. There are no bulges or retraction of the intercostal spaces.

Client’s respiratory rate is 18 cycles per minute. Patient did not complain of

chest pain or chest tightness. Guarding of the chest noted upon respiration due

to the proximity of the incision site to the diaphragm. Patient is not in respiratory

distress. Coughing episodes were also not observed. Vesicular breath sounds

are soft and low pitched. Her breathing is deep, regular and slow with a long

inspiratory phase and a short expiratory phase. With no adventitious sounds,

lungs are clear to auscultation and no crackles, wheezes or rubs. It was

observed that vocal fremitus is present both at the back and front of the chest

when the patient says “ninety-nine”.

XII. Abdomen

Abdomen is round. Color of skin in abdomen is slightly lighter than the

rest of the body. A 0.5-cm incision was noted at the subxyphoid area. Another

two 0.5-cm incisions are seen at her right lower rib cage. A 1-cm incision is also

present just below her umbilicus. All four incisions are covered with dry and intact

dressing. Patient complains of pain on the surgical site and verbalized,

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Page 35: Calculous Cholecystitis

“Nagangulngol tong gioperhan. Pwede makahingi ug tambal para sa sakit?”

Patient reported a pain scale of 6 out of 10. Aortic pulsations are not visible.

Umbilicus is midline and inverted. Symmetrical movement of abdomen upon

respiration was noted. Upon auscultation of the abdomen, it was noted that

patient has normal bowel sounds—high-pitched and occurred 16 times per

minute. Abdomen is soft and there is no point tenderness. Patient was on DAT

as ordered.

XIII. Back and Extremities

Peripheral pulse of the patient was symmetrical and regular in rhythm;

radial pulse is 82bpm. Patient has normal capillary refill of 2 seconds. The nails

were pinkish in color without cyanosis and clubbing. Patient is able to ambulate

freely. She was able to sit up on bed and perform range of motion on both upper

and lower extremities. However, it was noted that patient has guarded and slow

movement for she feels pain on her abdomen. Client’s grasping ability was

moderately strong on both hands. No edema or cyanosis was noted on both

upper and lower extremities. There is no swelling, tenderness or nodules

palpated on each joint. The shoulders, arms, elbows and forearms are free of

nodules, swelling, deformities and atrophy.

The skin at the back of the patient is uniform in color. Symmetrical

chest expansion with respirations noted. No spinal tenderness noted. There are

no skin breaks present. The back is also symmetrical with the spinal cord

aligning from the neck down to the buttocks. There were no deformities or

abnormalities on the bone such as scoliosis, osteoporosis and alike to be noted.

XIV. Genito-urinary

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

on the mons pubis. No vaginal bleeding or any other unusual discharges noted.

Page | 32

Page 36: Calculous Cholecystitis

Patient voids freely. She has no difficulty urinating and did not report dysuria.

She verbalized her urine is amber in color.

XV. Neurological

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

afebrile. Reflexes are normal and symmetrical bilaterally in both extremities.

Patient is oriented to person, place and time. She has a Glasgow coma scale of

15: 4 from eye opening, 5 for verbal resoponse and 6 for motor response. She is

also alert and attentive.

Page | 33

Page 37: Calculous Cholecystitis



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

the gallbladder measures approximately

8 cm in length and 4 cm in diameter when

fully distended. It is divided into three

sections: fundus, body, and neck. The neck

tapers and connects to the biliary tree via

the cystic duct, which then joins the common

hepatic duct to become the common bile

duct. Its function is to store and release bile,

a fluid made by the liver.

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Page 38: Calculous Cholecystitis


The cystic duct is the

short duct that joins the gall bladder to

the common bile duct. The cystic duct

varies from 2 to 3 cm in length and

terminates in the gallbladder.

Throughout its length, the cystic duct is

lined by a spiral mucosal elevation,

called the valvula spiralis (valve of

Heister) which is

a series of crescentic folds of mucous

membrane in the upper part of the cystic duct, arranged in a

somewhat spiral manner. Its length is variable and usually ranges from 2 to 4 cm.

The cystic duct is usually 2-3 mm wide. It can dilate in the presence of pathology

(stones or passed stones).

The duct and spiral folds contain muscle fibers responsive to

pharmacologic, hormonal, and neural stimuli. There is, however, no convincing

evidence of a discrete muscular sphincter within the duct. Although the cystic

duct is unlikely to play a major role in gallbladder filling and emptying, it appears

to function as more than a passive conduit. Coordinated, graded muscular

activity in the cystic duct in response to hormonal and neural stimuli may facilitate

gallbladder emptying. The principal function of the internal spiral folds that are

found in man may be to preserve patency of this narrow, tortuous tube rather

than to regulate bile flow. 


The main components of bile include contains water, cholesterol, fats, bile

salts, proteins, and bilirubin.

Page | 35

Page 39: Calculous Cholecystitis

Bile, is produced by hepatocytes in the liver and and then flows into

the common hepatic duct, which joins with the cystic duct from the gallbladder to

form the common bile duct. The common bile duct in turn joins with the

pancreatic duct to empty into the duodenum. If the sphincter of Oddi, a muscular

valve that controls the flow of digestive juices (bile and pancreatic juice) through

the ampulla of Vater into the second part of the duodenum, is closed, bile is

prevented from draining into the intestine and instead flows into the gallbladder,

where it is stored and concentrated to up to five times its original potency

between meals. This concentration occurs through the absorption of water and

small electrolytes, while retaining all the original organic molecules.

When food is released by the stomach into the duodenum in the form of

chyme, the duodenum releases cholecystokinin, which causes the gallbladder to

release the concentrated bile to complete digestion.

Bile helps to emulsify the fats in the food. Besides its digestive function,

bile serves also as the route of excretion for bilirubin, a byproduct of red blood

cells recycled by the liver.

The alkaline bile also has the function of neutralizing any excess stomach

acid before it enters the ileum, the final section of the small intestine. Bile salts

also act as bactericides, destroying many of the microbes that may be present in

the food.

In the absence of bile, fats become indigestible and are instead excreted

in feces, a condition called steatorrhea.

Page | 36

Page 40: Calculous Cholecystitis



Predisposing Factors

Present/ Absent

Rationale Justification

Female PRESENT Women between 20 and 60 years of

age are twice as likely to develop

gallstones as men.

Estrogen increases cholesterol

levels in bile and decrease

gallbladder movement, both of

which can lead to gallstones.


Harrison’s Principles of Internal Medicine,

Tenth Edition 1983 page 1822

Lippincott Williams and Wilkins Handbook

of Diseases Third Edition, page 184


The patient

is female.



ABSENT People with diabetes generally have

high levels of fatty acids called

triglycerides. These fatty acids

increase the risk of gallstones.


Harrison’s Principles of Internal Medicine,

Tenth Edition 1983 page 1823

The patient

is not


Page | 37

Page 41: Calculous Cholecystitis

Lippincott Williams and Wilkins Handbook

of Diseases Third Edition, page 184


(20-50; over

age 60)

PRESENT Many of the body’s systems and

protective mechanisms become less

efficient with age. Body systems and

processes become sluggish.


Harrison’s Principles of Internal Medicine,

Tenth Edition 1983 page 1823

Lippincott Williams and Wilkins Handbook

of Diseases Third Edition, page 184

The patient

is 38 years








PRESENT Native Americans have a genetic

predisposition to secrete high levels

of cholesterol in bile. In fact, they

have the highest rate of gallstones

in the United States. A majority of

Native American men have

gallstones by age 60. Mexican

American men and women of all

ages also have high rates of


Asians are more genetically

predisposed to having pigment

stones as compared to those living

in the Western countries

The patient

is Filipino.

She is


to having



Page | 38

Page 42: Calculous Cholecystitis


Lippincott Williams and Wilkins Handbook

of Diseases Third Edition, page 184


Precipitating Factors

Present/ Absent

Rationale Justification

PregnancyABSENT Excess estrogen from pregnancy,

hormone replacement therapy, or birth control pills appears to

increase cholesterol levels in bile and decrease gallbladder

movement, both of which can lead to gallstones.



The patient is not pregnant.

Rapid weight loss ABSENT As the body metabolizes fat during

rapid weight loss, it causes the liver to secrete extra cholesterol into

bile, which can cause gallstones.


Lippincott Williams and Wilkins Handbook of Diseases Third

Edition, page 184

No rapid weight loss

was noted by the patient.

Page | 39

Page 43: Calculous Cholecystitis

Obesity ABSENT The most likely reason is that obesity tends to reduce the amount of bile salts in bile, resulting in more cholesterol. Obesity also decreases

gallbladder emptying.


Harrison’s Principles of Internal Medicine, Tenth Edition 1983 page


Lippincott Williams and Wilkins Handbook of Diseases Third

Edition, page 184

The patient is not obese.

Fasting ABSENT Fasting decreases gallbladder movement, causing the bile to become overconcentrated with cholesterol, which can lead to



The patient doesn’t fast.

Hormone replacement therapy, or

birth control pills

PRESENT Excess estrogen from pregnancy, hormone replacement therapy, or

birth control pills appears to increase cholesterol levels in bile

and decrease gallbladder movement, both of which can lead

to gallstones.


Lippincott Williams and Wilkins

The patient has been on birth control pills since

she was 36 years old.

Page | 40

Page 44: Calculous Cholecystitis

Handbook of Diseases Third Edition, page 184

Low Fat Diet PRESENT Before dietary fat can be digested, it has to be emulsified. Bile is used for this purpose. The liver makes

bile continuously and stores it in the gall bladder until such time as it is

needed. However, if a low-fat diet is eaten, that bile remains in the gall


Gallstones are formed when the gall bladder is not emptied on a

regular basis. In people who continually resort to low-fat diets,

bile is stored for long periods in the gall bladder — and it stagnates. In time — and it is really quite a short time — a 'sludge' begins to form.


The patient avoids fatty



Signs and Present/ Rationale Justification

Page | 41

Page 45: Calculous Cholecystitis

Symptoms Absent

Right upper

quadrant pain

(may radiate

to right


shoulder, or



“biliary colic”

PRESENT Obstruction of ducts

connected to the gallbladder

will cause inflammation

produced by increased

intraluminal pressure and

distension of the



Harrison’s Principles of

Internal Medicine, Tenth

Edition 1983 page 1825

The patient

came into



of RUQ pain.

Fever (low


ABSENT Fever is a nonspecific

response that is mediated

by endogenous pyrogens

released from host cells in

response to infectious or

non-infections disorders. It

may be brought about by

prostaglandins released

during inflammation.

Source: Carol Mattson

Porth (2005.

Pathophysiology, Seventh

The patient

was not


Page | 42

Page 46: Calculous Cholecystitis

edition page 205)

Murphy's sign


interruption of



PRESENT Classically Murphy's sign is

tested for during

an abdominal examination;

it is performed by asking the

patient to breathe out and

then gently placing the hand

below the costal margin on

the right side at the mid-

clavicular line (the

approximate location of

the gallbladder). The patient

is then instructed to inspire

(breathe in). Normally,

during inspiration,

the abdominal contents are

pushed downward as

the diaphragm moves down

(and lungs expand). If the

patient stops breathing in

(as the gallbladder

is tender and, in moving

downward, comes in

contact with the examiner's

fingers) and winces with a

'catch' in breath, the test is

considered positive. A

positive test also requires

no pain on performing the

The patient

was positive

for the



Page | 43

Page 47: Calculous Cholecystitis

maneuver on the patient's

left hand side.




Nausea and


ABSENT Nausea and vomiting

sometimes occur with biliary

colic. The inflammation of

the gallbladder causes pain

and spasms of the

abdominal muscles which

may make one feel



Understanding Medical

Surgical Nursing by

Williams and Hopper page


The patient


complain of

nausea or






ABSENT Biliary obstruction causes

suppression of bile flow,

and regurgitation of

conjugated bilirubin into the

The patient’s

bilirubin was

not increased.

Page | 44

Page 48: Calculous Cholecystitis



Harrison’s Principles of

Internal Medicine, Tenth

Edition 1983 page 1829


SGPT and




an enzyme found mostly in

the liver but also in the

heart, the muscles, the

kidneys, the pancreas and

in red blood cells. High

elevations may be

associated with liver

disease or muscle trauma.

Elevations may also be

associated with a variety of

conditions including

myocardial infarction (heart

attack), pancreatitis, bile

duct obstruction and more.

Abnormalities of liver

enzymes including


are indicative of problems

such as Mirrizi syndrome, or

The patient’s

lab tests

reveal an

elevated level

of SGPT and



Page | 45

Page 49: Calculous Cholecystitis

a stone in the bile duct

causing infection/liver





Page | 46

Page 50: Calculous Cholecystitis

Page | 47


Predisposing Factors:

Female Age 38 Ethnicity Diabetes Mellitus

Precipitating Factors:

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

Bile stagnates in the gallbladder

Pigment solute precipitate as solid crystals

Crystals clump together and form stones


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

Bile stasis

Gallbladder contracts after intake of fat to release bile


Lumen is obstructed by stones

Page 51: Calculous Cholecystitis

Page | 48

If treated with:

If not treated

Good prognosis

Chemical reaction inside gallbladder triggers the release of inflammatory




Increased intraluminal pressure and distention

of the gallbladder

Inflammation of the gallbladder

Biliary Colic

(RUQ pain)

Murphy’s Sign

Fluids leak into gallbladder


Constriction of blood vessels

Continued increase in intraluminal pressure of gallbladder

Rupture of gallbladder

Spread of bile and indigenous microorganisms into peritoneal cavity

Continued lack of blood supply to gallbladder


Gangrene and empyema

Perforation of gallbladder

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

to medications

Page 52: Calculous Cholecystitis

Page | 49



Page 53: Calculous Cholecystitis


Date Order Rationale Remarks


@ 11pm

Admit under the care

of Dr. Batucan

Admitted under the care of

Dr. Batucan, a surgeon, for

his specialties on surgical

procedures (Laparoscopic



Patient was

placed in

ward 324

bed 5

Secure consent to


Consent is an agreement

between client and health

care provider to give proper

quality care. It is also to

protect the client from harmful

procedures and the institution

from law suits


Low fat diet Doctors were not sure

whether the gallstones are

either cholesterol or pigment

stones. Thus, this is done to

prevent any further damage

to the gallbladder.


Monitor VSqShift and


Monitoring vital signs is

important in order to note any

unusualities and to refer

these as follows.



CBC A complete blood count

(CBC) is a series of tests

used to evaluate the

composition and

concentration of the cellular


Page | 50

Page 54: Calculous Cholecystitis



components of blood. It

consists of the following tests:

red blood cell (RBC) count,

white blood cell (WBC) count,

and platelet count;

measurement of hemoglobin

and mean red cell volume;

classification of white blood

cells (WBC differential); and

calculation of hematocrit and

red blood cell

Platelet count is to determine

the number of platelets; If the

number of platelets is too low,

excessive bleeding can occur.

However, if the number of

platelets is too high, blood

clots can form (thrombosis),

which may obstruct blood


It is done to detect urinary

tract infection. It also

measures the level of

ketones, sugar, protein, blood

components and many other




Venoclysis: PNSS 1L

@ 100cc/hr

PNSS is an isotonic solution

to provide hydration since it

was found out that the

Done. IVF

infusing well

at right

Page | 51

Page 55: Calculous Cholecystitis

specific gravity for urine is in

the borderline (1.010). It is

also to provide electrolytes,

and as a medium for IVTT





Demerol 50mg IVTT

now then prn for

abdominal pain

HNBB (Hyoscine N-

Butyl Bromide) 20mg

1amp IVTT now

Acts as agonist at specific

opioid receptors in the CNS to

produce analgesia, euphoria,

sedation for relief of moderate

to severe pain

It's a competitive antagonist

of the actions of acetylcholine

and other muscarinic agonists

causing smooth muscle

relaxation indicated for her

abdominal pain



MHBR Moderate high back rest is to

elevate the upper portion of

the body to increase lung

expansion thus promoting gas

exchange. This is also to

prevent ascending infection

that could be caused by

possible rupture of the



Refer any

unusualities: severe

In order for the patient to be

assessed and evaluated


Page | 52

Page 56: Calculous Cholecystitis

abdominal pain,


properly and be managed




Start Cefoxitin

(Monowel) 1g IVTT


Cefoxitin inhibits synthesis of

bacterial cell wall causing cell

death which acts as a

perioperative prophylaxis for

surgical procedures. ANST or

after negative skin test is to

check whether the client is

not allergic to the antibiotic.

Done. Result

for skin test

is negative.


may be

given to the


For ultrasound

tomorrow morning

This is done to visualize

internal organs, to capture

their size, structure and any

pathological lesions with real

time tomographic images.

This is also to know the

condition of the gallbladder

whether it ruptured or not.

Not able to


Patient had



on May 11,


For total bilirubin,

Direct bilirubin,

Indirect bilirubin

Bilirubin is elvated if

hepatocytes are injured and

cannot metabolize or excrete


Increases in conjugated

bilirubin are highly specific for

disease of the liver or bile


Increase in unconjugated

bilirubin may be caused by

hepatic disease, cholestasis,


Results are


Page | 53

Page 57: Calculous Cholecystitis

Alkaline phosphatise

and hemolysis

High levels of alkaline

phosphatise indicates liver



(Serum glutamic




(Serum glutamic



SGPT is released into blood

when the liver or heart is

damaged; thus, this is to

determine liver function.

Elevation of this may possibly

mean liver problems

AST (aspartate

aminotransferase) or SGOT is

an enzyme found in high

amounts in heart muscle and

liver and skeletal muscle

cells. It is also found in lesser

amounts in other tissues.

Elevated levels may be

caused by liver or heart





results are


Done. SGOT

results are

also high

Schedule for


cholecystectomy on

Tuesday (4/11/10)


Lap Chole was to surgically

remove the gallbladder with

only a small incision.


Surgery was

done on

4/11/10 @


Secure consent/AC Patient has the right to be

consented in all procedures to

be done, and for legal


Page | 54

Page 58: Calculous Cholecystitis

purposes. Anesthesia

clearance is for the patient to

be evaluated whether he/she

is fit to undergo the operation.

It is also for the

anaesthesiologist to predict

the operative risk and the

appropriateness of the

anaesthesia to be induced

during operation.

Inform OR For the OR to know that such

case will be performed and to

prepare the necessary

instruments and room. This is

also to coordinate availability

of staff and surgeon


Refer In order for the patient to be

assessed and evaluated

properly and be managed





May have ultrasound

on Tuesday 5/11/10

This was to visualize internal

organs, to capture their size,

structure and any pathological

lesions with real time

tomographic images. It is also

to know whether the

gallbladder has ruptured or





retrieved on






ally normal

liver and

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Page 59: Calculous Cholecystitis




To reschedule OR

tomorrow from 2pm

to 4pm

To inform the OR that the

procedure will be moved from

2pm to 4pm


Patient had

her surgery

at 4pm of

May 11,




PNSS is an isotonic solution

for hydration and as a

medium for IVTT meds; KVO

was done since patient’s

hydration was good.


9:15pm Please facilitate AC AC is to assess patient’s rate

of survival and check for what

anesthetics is right for the

patient, making sure that the

patient isn’t allergic to the



For Lap Chole tom


This was to surgically remove

the gallbladder with only a

small incision. Patient can

undergo laparoscopic

cholecystectomy since

gallbladder has not ruptured

yet as seen on the ultrasound



For blood chem. and

Ultrasound tom

Blood tests are used to

determine physiological and

biochemical states, such as

disease, mineral content,

drug effectiveness, and organ


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9:30pm Pre-op orders:

NPO after light

breakfast (8am)

Assess VS prior to


General oral hygiene




Diazepam 10mg 1

tab 2am

NPO is to prevent peristalsis,

aspiration and injury during


as baseline data and to detect

any unusualities

Oral hygiene is the practice of

keeping the mouth clean and

healthy by brushing and

flossing to prevent tooth

decay and gum disease.

Intravenous solutions with

reduced saline concentrations

typically have dextrose added

to maintain a safe osmolality

while providing less sodium

chloride; to hydrate before

surgery in preparation for

disruption of homeostasis

Potentiates the effects of

GABA; Act in spinal cord and

at supraspinal sites to






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Ranitidine 150mg

1tab 2am

Vitamin K

produce skeletal muscle

relaxation; it is also used as

adjunct to General anesthesia

Inhibits basal gastric acid

secretion and gastric acid

secretion; patient was placed

on NPO

For the liver to activate

clotting factors such as

prothrombin, proconvertin,

thromboplasstin, and stuart






NPO NPO is to prevent peristalsis,

aspiration and injury to the GI

tract during surgery.


Post op orders:

To PACU then to


NPO for 4 hrs then

may have SD

Patient must first be stabilized

before transfer to the ward;

PACU is a place with

complete gadgets and staff

for emergency purposes after

post op.

Patient not yet fully conscious

due to anesthetics, thus this

is to prevent aspiration.



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Monitor VS q15 until

stable then q30 for

2hrs then q2


Etoricoxib 120mg PO


Tramadol 100mg

1tab 12mn

Demerol 50mg IVTT

Sultamicillin 375mg


Monitoring vital signs is to

detect any unusualities after

the operation.

Half life is 22hrs. Etoricoxib

blocks COX2 thus relieving

pain and inflammation.

Half life is 5-7hrs

Inhibits the reuptake of

norepinephrine and serotonin;

causes many effects similar

to opioids – analgesic

Half life is 3-5hrs

Causes analgesia, euphoria,

sedation; thus reducing pain

Inhibits synthesis of bacterial

cell wall causing cell death;

this was indicated due to

possible intra – abdominal







O2 inhalation @ 4pm

until fully awake

This ensures optimum

oxygenation of cells gearing

towards achieving balance or

homeostasis. Also this was

for optimum respiratory level;

prevents lung collapse.


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MHBR Moderate high back rest is to

elevate the upper portion of

the body to increase lung

expansion thus promoting gas



Deep breathing

exercises for 15mins


Post op exercise is indicated

To prevent lung collapse and

to eliminate anesthetic gases

introduced to the body




May have DAT Patient may eat anything as

long as it can’t harm her

current condition


Continue meds For the patient to complete

the medication regimen and

for continuity of care


Wound care Daily routine wound care is

indicated in order to promote

healing and/or prevent





MGH Patient may go home after

the doctor decides if

unusualities are absent


Home meds:

Etoricoxib 90mg PO


Tramadol 100mg ½

tab PO BID

Half life is 22hrs. Etoricoxib

blocks COX2 thus relieving

pain and inflammation.

Half life is 5-7hrs

Inhibits the reuptake of


Patient was


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Sultamicillin 375mg


norepinephrine and serotonin;

causes many effects similar

to opioids – analgesic

Inhibits synthesis of bacterial

cell wall causing cell death

C/D IVF Terminate IVF when IVF is

about 50cc



ff. up check at


Follow up check up is for the

patient to be assessed and

evaluated properly and be

managed accordingly.

Patient to

come back

at 5/18/10

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CBC – a determination of red and white blood cells per cubic millimeter of blood. It helps health professional check any

symptoms such as weakness, fatigue, or bruising. It also helps diagnose conditions such as anemia, infection and other


May 8, 2010

Test Normal Values

Result Remark Rationale Interpretation Nursing Responsibilities

Hemoglobin 115.0-


137.0 Normal Hemoglobin carries

oxygen to and removes

carbon dioxide from red

blood cells. It measures

total amount of

hemoglobin in the blood

Within normal


There is very little risk

associated with taking

blood from a vein in the

arm, although there is a

slight risk of infection

anytime the skin is

broken. Strict asepsis

should be observed

The patient may feel

discomfort when blood is

drawn from a vein.

Hematocrit 0.36-


0.42 Normal Hematocrit measures the

percentage of red blood

cells in the total blood


Within normal


RBC 4.2-6.1 4.47 Normal Measures the number o

RBCs per cubic millimeter

of the whole blood.

Within normal


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Bruising may occur at

the puncture site, or the

person may feel dizzy or

faint. Pressure should be

applied to the puncture

site until the bleeding

stops to reduce bruising.

Warm packs can also be

placed over the puncture

site to relieve discomfort

Instruct patient in dietary

sources of iron such as

red meat, organ meats,

clean green vegetable

and fortified grains

Protect the patient from

potential sources of

infection, monitor for

WBC 5.0-


14.1 High Determines the number of

circulating WBCs per cubic

millimeter of the whole


Elevated levels

may be caused by

acute infections –






colitis, etc.

Neutrophil 55-75 74 Normal Phagocytes engulfing

bacteria and cellular

debris. It prevents or limits

bacterial infections.

Within normal




20-35 21 Normal Cells present in the blood

and lymphatic tissue that

provide the main means of

immunity for the body.

There are three types of

lymphocytes: the natural

killer (NK), thymus-derived

lymphocytes (T cells), and

Within normal


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Page 67: Calculous Cholecystitis

bone marrow-derived

lymphocytes (B cells). NK

cells are found in the

blood, red bone marrow,

lymph nodes and spleen

and are able to destroy

many kinds of infected

body cells and tumor cells.

The T cells and B cells are

involved in specific

immune responses.

signs of infection.

Provide soft, bland diet

high in protein, vitamins,

and calories. Meticulous

hand washing and strict

asepsis are mandatory

Institute protective

isolation measures

immediately if there is

neutrophil disorder. Also

instruct the patient to

observe aseptic

technique and to take

caution most especially

if immunocompromised.

Inflammatory responses

involve more than one

body system. Monitor

the patient for worsening

Monocytes 2-10 4 Normal This type of granular

leukocyte functions in the

ingestion of bacteria and

other foreign particles

Within normal


Eosinophil 1-8 1 Normal Functions in allergic

responses and in resisting

infections. Eosinophils

mount on attack against

parasitic invaders by

attacking to their bodies

Within normal


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Page 68: Calculous Cholecystitis

and discharging toxic

molecules from their

cytoplasmic granules.

of the inflammatory

condition, particularly



Encourage patient to

rest between activities.

Encourage patient to

plan ahead and save

energy for the most

important activities.

Encourage patient to

void or stop activities

that make short of

breath or make heart

beat faster.

Encourage patient to Eat

a diet with adequate

protein and vitamins.

Drink plenty of non-

caffeinated and non-

Platelet 150.0-


278 Normal A test that direct count of

platelets in whole blood.

Platelets number from

100,000-500,000 per cubic

millimeter and are

important in triggering the

sequence of events that

leads to the formation of

blood clots.

Within normal


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alcoholic fluids.

Urinalysis - Urinalysis is a physical, microscopic, or chemical examination of the urine. It is done to detect urinary tract

infection. It also measures the level of ketones, sugar, protein, blood components and many other substances

May 8, 2010


Glucose Negative <50mg/dL Glucose is the type of sugar found in blood.

Normally there is very little or no glucose in urine.

When the blood sugar level is very high, as in

uncontrolled diabetes. Glucose can also be found in

urine when the kidneys are damaged or diseased.

Advise Patient to:

Wash hands to make

sure they are clean

before collecting the


If the collection cup

has a lid, remove it

carefully and set it

down with the inner

surface up. Do not

Protein Negative <30mg/dL Protein is normally not found in the urine. Fever,

hard exercise, pregnancy, and some diseases,

especially kidney disease, may cause protein to be

in the urine.

Bilirubin Negative <1mg/dL This is a substance formed by the breakdown of red

blood cells. If it is present, it often means the liver is

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damaged or that the flow of bile from the gallbladder

is blocked.touch the inside of the

cup with your fingers.

Clean the area around

your genitals.

Begin urinating into

the toilet or urinal.

Finish urinating into

the toilet or urinal.

Carefully replace and

tighten the lid on the

cup then return it to

the lab.

After the urine has

flowed for several

seconds, place the

collection cup into the

urine stream and

collect "midstream"

urine without stopping

your flow of urine.

Urobilinogen Normal <2mg/dL This is a substance formed by the breakdown of

bilirubin. Urobilinogen in urine can be a sign of liver

disease (cirrhosis, hepatitis) that the flow of bile

from the gallbladder is blocked.

pH 6 4.5-8 Urine pH is used to classify urine as either a dilute

acid or base solution. The lower the pH, the greater

the acidity of a solution; the higher the pH, the

greater the alkalinity. The glomerular filtrate of blood

is usually acidified by the kidneys from a pH of

approximately 7.4 to a pH of about 6 in the urine

Blood Negative <5-


Red blood cells in the urine may be caused by

kidney or bladder injury, kidney stones, a urinary

tract infection (UTI), inflammation of the kidneys

(glomerulonephritis), a kidney or bladder tumor, or

systemic lupus erythematosus (SLE).

Ketone Negative <5 mg/dL Ketones in the urine may mean a very serious

condition, diabetic ketoacidosis, is present. A diet

low in sugars and starches (carbohydrates),

starvation, or severe vomiting may also cause

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ketones to be in the urine.Do not touch the rim

of the cup to your

genital area. Do not

get toilet paper, pubic

hair, stool (feces),

menstrual blood, or

anything else in the

urine sample.

Nitrite Negative Negative Bacteria that cause a urinary tract infection (UTI)

make an enzyme that changes urinary nitrates to

nitrites. Nitrites in urine show a UTI is present.

Leukocytes 25 <25WBC/


Leukocyte esterase shows leukocytes in the urine.

WBCs in the urine may mean a UTI is present.

Clarity Clear Clear Urine is normally clear. Bacteria, blood, sperm,

crystals, or mucus can make urine look cloudy.



1.010 1.010-1.030 This checks the amount of substances in the urine.

It also shows how well the kidneys balance the

amount of water in urine. The higher the specific

gravity, the more solid material is in the urine.

Color Yellow Pale to dark


Many things affect urine color, including fluid

balance, diet, medicines, and diseases. How dark

or light the color is tells you how much water is in it.

Vitamin B supplements can turn urine bright yellow.

Some medicines, blackberries, beets, rhubarb, or

blood in the urine can turn urine red-brown.

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Blood Chemistry - A number of tests performed on blood serum (liquid portion of the blood). It determines certain

enzymes that may be present (including lactic dehydrogenase [LDH], certain kinase [CK], aspartate aminotransferase

[AST], and alanine aminotransferas [ALT]), serum glucose, hormones such as thyroid hormone and other substances

such as cholesterol and triglycerides. These tests provide valuable diagnostic cues.

May 9, 2010


Total Bilirubin 8.3 2.0 – 21.0 Normal It occurs when bilirubin production exceeds the liver's

excretory capacity. This may occur because (1) too

much bilirubin is being produced, (2) hepatocytes are

injured and cannot metabolize or excrete bilirubin, or

(3) the biliary tract is obstructed blocking the flow of

conjugated bilirubin into the intestine

Direct Bilirubin 0.9 0.0 – 3.4 Normal Increases in conjugated bilirubin are highly specific for

disease of the liver or bile ducts

Inderct Bilirubin 7.4 2.0 – 17.0 Normal Increase in unconjugated bilirubin may be caused by

hepatic disease, cholestasis, and hemolysis

SGPT 60.2 0.0 – 34.0 High SGPT is released into blood when the liver or heart is

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damaged; thus, this is to determine liver function.

SGOT 55.6 0.0 – 31.0 High SGOT is an enzyme found in high amounts in heart

muscle and liver and skeletal muscle cells. Elevated

levels may be caused by liver or heart disease



191 64 – 306 Normal When a person has evidence of liver disease , very

high ALP levels can tell the doctor that the person’s

bile ducts are somehow blocked

Medical sonography (ultrasonography) is an ultrasound-based diagnostic medical imaging technique used to visualize

muscles, tendons, and many internal organs, to capture their size, structure and any pathological lesions with real time

tomographic images. Ultrasound has been used by sonographers to image the human body for at least 50 years and has

become one of the most widely used diagnostic tools in modern medicine.

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12/28/10 Isaac T. Robillo Memorial Hospital


Non-obstructive cholelithiasis

Ultrasonically normal liver, intrahepatic ducts,

pancreas, spleen, aorta, paraaortic areas, kidneys

and urinary bladder

05/11/10 Davao Medical School Foundation



Sonographically normal liver and pancreas

Nursing Responsibilities:

Explain the procedure and purpose of the test

Provide a gown without snaps, and ask the patient to remove all jewelry

Take ultrasound if the patient’s bladder is fluid filled for better results

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Page 75: Calculous Cholecystitis


Generic Name: Meperidine Hydrochloride

Brand Name: DemerolClassification: Opioid agonist analgesicOrdered Dose: 50mg IVTT now then prn for abdominal pain Mode Of Action: Acts as agonist at specific opioid receptors in the CNS to

produce analgesia, euphoria, sedation; the receptors mediating these effects are thought to be the same with endorphins

Indications: Relief of moderate to severe acute pain.

Pre-op: Support for of anesthesia

Contraindications: Hypersensitivity to narcotics, diarrhea, asthma, COPD, respiratory depression, pregnancy, seizure, renal dysfunction

Drug Interactions: Potentiation of effects with barbiturate anesthetics Severe/fatal reactions with MAOIs Increased chances of respiratory depression,

hypotension, sedation, and coma with phenothiazinesSide Effect: Nausea, vomiting, loss of appetite, constipation, dizziness,

sedation, drowsiness, impaired visual acuityAdverse Effects: CNS: light-headedness, dizziness, sedation, euphoria,

dysphoria, delirium, insomnia, agitation, anxiety, fear, hallucinations, disorientation, mood changes, lethargy, weakness, headache, tremor

CV: peripheral circulatory collapse, tachycardia, bradycardia, arrhythmia, palpitations, hypertension, hypotension

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Dermatologic: pruritus, urticaria, bronchospasm, edema GI: nausea, vomiting, dry mouth, anorexia, constipation, GU: ureteral spasm, urinary retention, oliguria,

decreased libido MAJOR: respiratory depression, apnea, circulatory

depression, respiratory arrest, shock, cardiac arrest

Nursing Responsibilities:

Keep opioid antagonist and facilities readily available during parenteral administration

Use caution when injecting to patients with hypotension Reduce dosage of Demerol in patients receiving

phenothiazines or other tranquilizers Reassure that addiction is unlikely to occur Use Demerol with extreme caution in patient with renal

dysfunction Give only prescribed dosage Avoid alcohol, antihistamines, sedatives, tranquilizers Do not take left over medications for other disorders Keep out the reach of children Take Demerol with food, small frequent meals May use laxative if constipation occurs Avoid driving or doing activities that require alertness

because it could cause drowsiness and impaired visual activity.

Bibliography: 2005 Lippincott’s Nursing Drug

Generic Name: Hyoscine N-butyl Bromide

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Page 77: Calculous Cholecystitis

Brand Name: Buscopan

Classification: Gastro-intestinal antispasmodicOrdered Dose: 20mg 1amp IVTT nowMode Of Action: It's a competitive antagonist of the actions of acetylcholine

and other muscarinic agonists. Hyoscine works by relaxing the muscle that is found in the walls of the stomach, intestines and bile duct (gastrointestinal tract) and the reproductive organs and urinary tract (genitourinary tract)

Indications: This medication is used to relieve bladder or intestinal spasms.

Contraindications: Hypersensitivity to hyoscine butylbromide, Patients with prostatic enlargement, paralytic ileus or pyloric stenosis, ulcerative colitis, closed angle glaucoma

Drug Interactions: Anticholinergic agents Antihistamines Monoamine oxidase inhibitors Tricyclic antidepressants Competitively blocks prokinetic agents

Side Effect: Nausea, vomiting, loss of appetite, constipation, dry mouth, rash, itching, swelling of the hands or feet, trouble breathing, increased pulse, dizziness, diarrhea, vision problems, eye pain

Adverse Effects: CNS: light-headedness, dizziness, sedation, euphoria, dysphoria, delirium, insomnia, agitation, anxiety, fear, hallucinations, disorientation, mood changes, lethargy, weakness, headache, tremor

CV: peripheral circulatory collapse, tachycardia, bradycardia, arrhythmia, palpitations, hypertension, hypotension

Dermatologic: pruritus, urticaria, bronchospasm, edema GI: nausea, vomiting, dry mouth, anorexia, constipation, GU: ureteral spasm, urinary retention, oliguria,

decreased libido MAJOR: respiratory depression, apnea, circulatory

depression, respiratory arrest, shock, cardiac arrest

Nursing Responsibilities:

Inform patient that drug may cause blurred vision. Instruct patient to report if she experiences such symptom.

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Page 78: Calculous Cholecystitis

Assess for parkinsonism and Extra-pyramidal symptoms.

Assess for urinary hesitancy Assess for constipation. Caution patient to avoid alcohol because it may

increase CNS depression. As appropriate, review all other significant adverse

reactions and interactions Give only prescribed dosage Do not take left over medications for other disorders Keep out the reach of children

Bibliography: MIMS 113th edition 2007

Generic Name: Cefoxitin Sodium

Brand Name: Monowel

Classification: Antibiotic, Cephalosphorin (2nd gen)Ordered Dose: 1g IVTT q8 ANSTMode Of Action: Inhibits synthesis of bacterial cell wall causing cell death

Indications: Perioperative prophylaxis

Contraindications: Hypersensitivity to cephalosphorins and/or penicillinsDrug Interactions: Increased nephrotoxicity with aminoglycosides

Increased bleeding effects with anticoagulants

Side Effect: Stomach upset, nausea, vomiting, diarrheaAdverse Effects: CNS:, dizziness, lethargy, headache

CV: peripheral circulatory collapse, tachycardia, bradycardia, arrhythmia, palpitations, hypertension,

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Page 79: Calculous Cholecystitis

hypotension GI: nausea, vomiting, diarrhea, anorexia, abdominal

pain, psuedomembranous colitis GU: Nephrotoxicity Hematologic: bone marrow depression,

thrombocytopeniaNursing Responsibilities:

Culture infection before starting therapy Have vitamin K available in case of

hypoprothrombinemia Discontinue if hypersensitivity occurs Avoid alcohol while taking drug Take only prescribed dosage Complete antibiotic therapy, don’t skip doses Do not use extra medicine to make up the missed dose Do not use drug if you are allergic to penicillins and

cephalosporins Antibiotic medicines can cause diarrhea, which may be

a sign of a new infection. If you have diarrhea that is watery or has blood in it, call your doctor.

Store at room temperature away from moisture, heat, and light

If you get a skin rash, do not treat yourself.Bibliography: 2005 Lippincott’s Nursing Drug Guide

MIMS 113th edition

Generic Name: Diazepam

Brand Name: Valium

Classification: Benzodiazepine, skeletal muscle relaxantOrdered Dose: 10mg 1 tab 2am

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Page 80: Calculous Cholecystitis

Mode Of Action: Potentiates the effects of GABA; Act in spinal cord and at supraspinal sites to produce skeletal muscle relaxation

Indications: Relief of anxiety and tension; to lessen recall in patients prior to surgical procedures

Contraindications: Hypersensitivity to benzodiazepines, psychosis, shock, coma, alcoholic intoxication, pregnancy

Drug Interactions: Increased CNS depression with omperazole Increased effects of diazepam with cimetidine,

hormononal contraceptives Decreased effects with ranitidine

Side Effect: Drowsiness, dizziness, GI upset, difficulty concentrating, fatigue, nervousness, crying

Adverse Effects: CNS: drowsiness, sedation, depression, lethargy, fatigue, light headedness, disorientation, restlessness, tremor, stupor, psychomotor retardation, EPS, hallucinations, nasal congestion

CV: bradycardia, tachycardia, hypotension, hypertension, edema

Dependence: drug dependence Dermatologic: uticaria, pruritus, dermatitis GI: constipation, diarrhea, dry mouth, salivation,

nausea, anorexia, vomiting, hepatic dysfunction, jaundice

GU: incontinence, retention, change in libido, menstrual irregularities

Other: phlebitis and thrombosis at injection site, hiccups, fever, diaphoresis, pain at injection site

Nursing Responsibilities:

Carefully monitor pulse, respiration rate and blood pressure during administration

Keep addiction – prone patients under careful surveillance

Ensure ready access to bathroom if GI effects occur Provide small, frequent meals to prevent GI upset Establish safety precautions if CNS changes occur Monitor liver and kidney function, CBC during long term

therapy Taper dose gradually after long term therapy Discuss risk of fetal abnormalities with patients desiring

to become pregnant

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Page 81: Calculous Cholecystitis

Take drug exactly as prescribed Do not stop drug abruptly during long term therapy Caregiver should learn to assess seizures and monitor

patient Use of barrier contraceptive is advised while on this

drug Avoid alcohol, sleep inducing drugs

Bibliography: 2005 Lippincott’s Nursing Drug GuideMIMS 113th edition

Generic Name: Ranitidine Hydrochloride

Brand Name: Zantac

Classification: Histamine2 antagonistOrdered Dose: 150mg 1tab

Mode Of Action: Competitively inhibits action of histamine at histamine2 receptors of the parietal cells of the stomach, inhibiting basal gastric acid secretion and gastric acid secretion that is stimulated by food, insulin, histamine, cholinergic agonists, gastrin, and pentagastrin

Indications: Against ulcer brought about by NPO due to surgical procedure

Contraindications: Hypersensitivity to ranitidine, lactationDrug Interactions: Increased effects of warfarinSide Effect: Constipation, nausea, vomiting, breast enlargement,

impotence, headacheAdverse Effects: CNS: headache, malaise, dizziness, somnolence,

insomnia, vertigo CV: bradycardia, tachycardia, Dermatologic: rash, alopecia

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Page 82: Calculous Cholecystitis

GI: constipation, diarrhea, nausea, anorexia, vomiting, abdominal pain, hepatic dysfunction, jaundice

GU: gynecomastia, impotence Hematologic: leucopenia, granulocytopenia,

thrombocytopenia, pancytopenia Local: pain at IM site, local burning pain at injection site

Nursing Responsibilities:

Administer oral drug with meals and hs Decrease doses in renal and liver failure Provide concurrent antacid therapy to relieve pain Avoid cigarette smoking as it decreases

effectiveness Have regular medical follow-up to evaluate

response Adjust environment (lights, temp, noise) to prevent

headache Using ranitidine may increase your risk of

developing pneumonia Avoid drinking alcohol. It can increase the risk of

damage to your stomach If you think you have taken too much of this

medicine contact a poison control center or emergency room at once.

If you need to take an antacid you should take it at least 1 hour before or 1 hour after this medicine. This medicine will not be as effective if taken at the same time as an antacid.

If you get black, tarry stools or vomit up what looks like coffee grounds, call your doctor or health care professional at once. You may have a bleeding ulcer.

Bibliography: 2005 Lippincott’s Nursing Drug GuideMIMS 113th edition

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Generic Name: Phytonadione

Brand Name: Hema K

Classification: Fat soluble vitamin; antifibrinolytic agent Ordered Dose: 1amp now

Mode Of Action: Vitamin K is required for the liver to make factors that are necessary for blood to properly clot (coagulate), including factor II (prothrombin), factor VII (proconvertin), factor IX (thromboplastin component), and factor X (Stuart factor).

Indications: Preoperatively: to activate clotting factors to decrease chances of bleeding during surgical procedure

Contraindications: Hypersensitivity to benzyl alcohol, Drug Interactions: Coumarin and indanedione derivatives

Side Effect: No known side effects for this drug; bruising and bleeding are less likely to happen.

Adverse Effects: No known adverse effects reported

Nursing Responsibilities:

Instruct patient to take only prescribed order If a dose is missed, take as soon as remembered

unless almost time for the next dose Cooking does not destroy substantial amounts of

Vitamin K Caution patient to avoid IM injection and activities

leading to injury Patient should not drastically alter diet while taking

Vitamin K Use a soft toothbrush until coagulation effect is

corrected Advise patient to report any signs of

bleeding/bruising Patient should be advised not to take OTC drugs

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without advice of health care provider Advise patient to inform health care provider of

medication regimen prior to treatment or surgery Emphasize importance of frequent lab test to

monitor coagulation factors Source MIMS 113th edition 2007

Generic Name: Etoricoxib

Brand Name: Arcoxia

Classification: COX-2 Selective Inhibitor

Ordered Dose: 120mg PO 12mn

Mode Of Action: Arcoxia reduces pain and inflammation by blocking COX-2, an enzyme in the body.Arcoxia does not block COX-1, the enzyme involved in protecting the stomach from ulcers.Other anti-inflammatory medicines (NSAIDS) block both COX-1 and COX-2.Arcoxia relieves pain and inflammation with less risk of stomach ulcers compared to NSAID

Indications: relief of acute pain

Contraindications: Hypersensitivity to arcoxia and it’s ingredients such as etoricoxib

Drug Interactions: warfarin, a medicine used to prevent blood clots rifampicin, an antibiotic used to treat tuberculosis and

other infections water pills (diuretics) ACE inhibitors and angiotensin receptor blockers,

medicines used to lower high blood pressure or treat

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Page 85: Calculous Cholecystitis

heart failure lithium, a medicine used to treat a certain type of

depression birth control pills hormone replacement therapy methotrexate, a medicine used to suppress the immune


Side Effect: Nausea, vomiting, diarrhea, Headache, Rash, Blurred vision, Difficulty in sleeping, Muscle cramps, Fatigue

Adverse Effects: CNS: headache, malaise, dizziness, hallucinations, insomnia, vertigo, anxiety, drowsiness, confusion

CV: bradycardia, tachycardia, hypertension Dermatologic: rash, urticaria GI: constipation, diarrhea, nausea, anorexia, vomiting,

abdominal pain, hepatic dysfunction, jaundice GU: gynecomastia, impotence Hematologic: leucopenia, granulocytopenia,

thrombocytopenia, pancytopenia Local: pain at IM site, local burning pain at injection site

Nursing Responsibilities:

Take Arcoxia only when prescribed by your doctor.

For the relief of chronic musculoskeletal pain the recommended dose is 60 mg once a day.

If you have mild liver disease, you should not take more than 60 mg a day. If you have moderate liver disease, you should not take more than 60 mg every other day.

When taking the tablets, swallow them with a glass of water. Do not halve the tablet.

Take your Arcoxia at about the same time each day.

Taking Arcoxia at the same time each day will have the best effect. It will also help you remember when to take the dose.

It does not matter if you take Arcoxia before or after food.

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Do not use Arcoxia for longer than your doctor says. Do not take a double dose to make up for the dose that

you missed. If you get an infection while taking Arcoxia, tell your

doctor. Arcoxia may hide fever and may make you think, mistakenly, that you are better or that your infection is less serious than it might be.

Bibliography: MIMS 113th edition 2007

Generic Name: Tramadol hydrochloride

Brand Name: Ultram

Classification: Central acting analgesicOrdered Dose: 100mg 1tab PO Mode Of Action: Binds to mu-opioid receptors and inhibits the reuptake of

norepinephrine and serotonin; causes many effects similar to opioids but doesn’t cause respiratory depression

Indications: Relief of moderate to severe pain.

Contraindications: Hypersensitivity to tramadol or opioids or intoxication with alcohol, opioids, or psychoactive drugs

Drug Interactions: Decreased effectiveness with carbamezapine Increased risk of tramadol toxicity with MAOIs

Side Effect: Dizziness, sedation, drowsiness, impaired visual acuity, nausea, loss of appetite

Adverse Effects: CNS: sedation, dizziness, headache, confusion, dreaming, anxiety, seizures

CV: hypotension, tachycardia, bradycardia, Dermatologic: pruritus, urticaria, sweating, pallor GI: nausea, vomiting, dry mouth, flatulence,


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Other: potential for abuse, anaphylactoid reactionsNursing Responsibilities:

Control environment ( temp, light, noise) Limit use in patients with past or present history of

addiction or dependence to opioids Caution patient not to chew or crush tablet Keep opioid antagonist readily available in case of

emergency Instruct post-op patients that drug suppress cough

reflex Monitor bowel function and arrange laxatives for

constipation Institute safety precautions (side rails, assistive

device) Provide frequent, small meals if GI upset occurs Provide back rubs, positioning, and other non

pharmacological measures to alleviate pain Take drug exactly as prescribed Avoid alcohol, antihistamines, sedatives,

tranquilizers while taking this drug

Bibliography: 2005 Lippincott’s Nursing Drug Guide

Generic Name: Sultamicillin (ampicillin and sulbactam)

Brand Name: Unasyn

Classification: AntibioticOrdered Dose: 375mg tab PO TID

Mode Of Action: It acts through the inhibition of cell wall mucopeptide

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biosynthesis. Ampicillin has a broad spectrum of bactericidal activity against many gram-positiveand gram-negative aerobic and anaerobic bacteria. sulbactam in the UNASYN formulation effectively extends the antibioticspectrum of ampicillin to include many bacteria normally resistant to it and to other beta-lactamantibiotics.

Indications: Intra-Abdominal Infections caused by beta-lactamase producing strains of Escherichia coli, Klebsiella spp. (including K. pneumoniae*), Bacteroides spp. (including B. fragilis), and Enterobacter spp.

Contraindications: contraindicated in individuals with a history of hypersensitivity reactions to any of the penicillins.

Drug Interactions: allopurinol (Zyloprim); probenecid (Benemid); or an antibiotic such as amikacin (Amikin), gentamicin

(Garamycin), kanamycin (Kantrex), neomycin (Mycifradin, Neo-Fradin, Neo-Tab), netilmicin (Netromycin), streptomycin, tobramycin (Nebcin, Tobi).

Side Effect: Nausea, vomiting, stomach pain, bloating, gas, vaginal itching or discharge, headache, itching, swollen, black, or "hairy" tongue, thrush ;pain, swelling, or other irritation where the needle is placed.

Adverse Effects: CNS: lethargy, hallucinations, seizures GI: stomatitis, gastritis, nausea, vomiting, diarrhea,

abdominal pain, pseudomembranous colitis, nonspecific hepatitis

GU: proteinuria, oliguria, hematuria, pyuria Hematologic: anemia, thrombocytopenia, leukopenia,

neutropenia, prolonged bleeding time Hypersensitivity: rash, fever, wheezing, anaphylaxis Local: pain, phlebitis, thrombosis at injection site Other: superinfection, sodium overload, CHF

Nursing Responsibilities:

Culture infected area before beginning treatment Monitor serum electrolytes and cardiac status Do not use this medication if you are allergic to

ampicillin and sulbactam or to any other penicillin

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antibiotic Antibiotic medicines can cause diarrhea, which may be

a sign of a new infection. If you have diarrhea that is watery or has blood in it, call your doctor. Do not use any medicine to stop the diarrhea unless your doctor has told you to.

Use this medication for the entire length of time prescribed by your doctor. Your symptoms may get better before the infection is completely treated.

This medication can cause you to have unusual results with certain medical tests. Tell any doctor who treats you that you are using ampicillin and sulbactam.

Store ampicillin and sulbactam at room temperature away from moisture, heat, and light.

Provide small, frequent meals if GI upset occurs Do not use extra medicine to make up the missed dose. Seek emergency medical attention if you think you have

used too much of this medicine. If you get a skin rash, do not treat yourself.


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Date of operation: May 11, 2010

Time of Operation: 4:48 pm

Time Ended: 6:25 pm

Age: 38 years old

Diagnosis: Calculous Cholecystitis

Operation Performed: Laparoscopic Cholecystectomy

Type of Anesthesia: General Endotracheal Anesthesia

Name of Surgeon: Dr. Walter Batucan

Anesthesiologist: Dr. Lamanosa

Scrub Nurse: J. Dabon, R.N.

Circulating nurse: R. Napoles, R.N.

Procedural Report

A. Definition of Laparoscopic Cholecystectomy

The surgery to remove the gallbladder is called a cholecystectomy. The

gallbladder is removed through a 5 to 8 inch long incision, or cut, in the

abdomen. The cut is made just below the ribs on the right side and goes to just

below the waist. This is called open cholecystectomy.

A less invasive way to remove the gallbladder is called laparoscopic

cholecystectomy. This surgery uses a laparoscope (an instrument used to see

the inside of your body) to remove the gallbladder. It is performed through

several small incisions rather than through one large incision.

A laparoscope is a small, thin tube that is put into your body through a tiny

cut made just below the navel. The surgeon can then see the gallbladder on a

television screen and do the surgery with tools inserted in three other small cuts

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made in the right upper part of the abdomen. The gallbladder is then taken out

through one of the incisions.

B. Instrumentations

(4) folded towels(1) oral gastric tube(1) foley catheter(1) Veress needle(1) 5mm trocar/port(1) 10mm trocar/port(1)10mm right angle laparoscopic dissector(1) 5mm right angle dissector(1) Dolphin Nose Dissecting forceps(1) scoop

(1) Merlin dissector(1) suction irrigator(1) Bovie with spatula tip(1) endoscissors(1) cholangiogram catheter unit(1) aspirating needle(1) Laparoscope(4) metallic surgical clips(1) camera(1) light source cord(1) Bovie cord

C. Procedure

1. Placed on supine position, reverse trendelenburg

2. Administration of General Endotracheal Anesthesia (GETA)

3. Skin over surgical site is cleansed with antiseptic solution

4. Placement of drapes.

5. Three to four small

incisions is made in

the abdomen.

Carbon dioxide gas

is introduced into

the abdomen to

inflate the

abdominal cavity so

that the gallbladder

and surrounding

organs can be more easily visualized.

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6. The laparoscope is inserted through one of the incisions (usually at the

incision below the umbilicus) and instruments will be inserted through

the other incisions to remove the gallbladder.

7. When the procedure is completed, the laparoscope is removed.

8. The gallbladder is sent to the lab for examination

9. The skin incisions are closed with stitches or surgical staples.

10.A sterile bandage/dressing or adhesive strips is applied.

D. Nursing Responsibilities

Preoperative Phase

o Secure the informed consent for legal purposes and take note of

the following things:

1. The surgeon must provide a clear and simple explanation of

the surgical procedure.

2. The nurse may witness the patient’s signature.

4. If the patient needs additional information about the procedure,

nurse notifies the surgeon.

5. The nurse ascertains that the consent form has been signed

before administering psychoactive drugs.

6. No patient should be urged or coerced to sign an operative


7. Refusing to undergo a surgical procedure is a person’s legal

right and privilege.

o Assess for drug and alcohol abuse. Persons with history of

chronic alcoholism often suffer from malnutrition and other

systemic problems that increase the surgical risk.

o Assess the respiratory status. The goal for potential surgical

patients is optimal respiratory function.

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o Assess the cardiovascular status. The goal in preparing any

patient for surgery is to ensure a well functioning cardiovascular

system to meet the oxygen, fluid and nutritional needs.

o Assess the hepatic and renal functioning. Presurgical goal is

optimal function of the liver and urinary system to enhance

removal of medications.

o Assess the immune functioning. An important function of the

preoperative assessment is to determine the existence of


o Assess for the previous medication use. A medication history is

obtained from each patient because of the possibility of drug


o Make nursing diagnoses, and prepare nursing care plans to

address patient’s needs

o Teach deep-breathing, coughing and incentive Spiro meter to aid

the patient post operatively

o Encourage mobility and active body movement to avoid


o Teach cognitive coping strategies such as imagery, distraction

and optimistic self-recitation to reduce fear and anxiety

o Explain the activities that may occur inside the operating room to

reduce anxiety

o Inform the patient on the following to impart knowledge on the

part of the patient and to avoid delay in surgery due to


Scheduled date and time of the surgery and where to


What to bring such as insurance card, list of medications

and allergies

What to leave at home such as jewelry, watch, medications

and contact lenses

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What to wear which is loose-fitting, comfortable clothes

and flat shoes

take nothing by mouth for six to 12 hours before the


o Acquire and document patient’s vital signs for baseline data and

maintain the preoperative record

o Transport the patient to the presurgical area to prepare the patient

for surgery

o Attend to the family needs to reduce the anxiety felt by the family

o Make sure that preoperative checklist which contains the following

is accomplished:

Lab exam results in

OR services form accomplished

Patient is scheduled in OR

Anesthesiologist informed

Medicines in

Blood Typed and Matched

Field of Operation prepared

Sponged or bathed

Diet instruction given

Enema given

Make-up and nail polish removed

Jewelry removed

Oral hygiene given

Patient changed into patient’s gown

Indwelling catheter inserted

Pre-op meds given

Medicine for OR in

Intraoperative phase

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o Position the patient:

The patient is in a supine position reverse trendelenburg.

o Skin preparation

o Circulating nurse:

Manages the operating room

Protects patient’s safety and health by monitoring the

activities of the surgical team

Checks and verifies the consent form

Ensures fire safety precautions, cleanliness, proper

temperature, humidity and lighting of the operating room

Monitors safe functioning of the equipments

Coordinates with the surgical/ perioperative team and

monitors aseptic practices

Documents operating room surgical activities

Count all needles, sponges and instruments together with

the scrub nurse

o For the scrub nurse:

Setting up sterile tables

Assisting the surgeon and assistant surgeon, taking

care of tissue specimens

Count all needles, sponges and instruments together

with the circulating nurse

Postoperative Phase

o Assess patient : appraise air exchanges status & note skin color;

verify & identify operative status & surgeon performed; assess

neurological status (LOC)

o Perform safety checks – good body alignment, side rails and

maintain patent airway and cardiovascular stability

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o Medication

Analgesics are administered as prescribed for pain.

Antibiotics are administered to prevent infection.

o Surgical dressing is assessed periodically and reinforced when



Inform the patient about the importance of complying with

the prescribed medication.

Emphasize the proper dosage of the medications taken.

Educate the client about the importance of proper


Encourage the client to have the prescribed diet for her


Encourage to have early ambulation in order to promote

circulation and wound healing.

Instruct to do splinting while performing deep breathing

exercises to minimize pain.

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Virginia Henderson sees the nurse as concerned with both healthy and ill

individuals, acknowledges that nurses interact with clients even when recovery

may not be feasible, and mentions the teaching and advocacy roles of the

nurses. In 1955, Virginia Henderson devised her own definition as to create a

proper standard of what nursing should be, to ensure safe and competent care

for patients. Her famous definition of nursing states "The unique function of the

nurse is to assist the individual, sick or well, in the performance of those activities

contributing to health or its recovery (or to peaceful death) that he would perform

unaided if he had the necessary strength, will or knowledge, and to do this in

such a way as to help him gain independence as rapidly as possible". In this

definition of hers, she recognized the need to be clear about the functions of the

nurse and described the nurse's role as substitutive (doing for the person),

supplementary (helping the person), or complementary (working with the

person), with the goal of helping the person become as independent as possible.

Henderson conceptualizes the nurse’s role as assisting sick or

healthy individuals to gain independence in meeting 14 fundamental

needs which is: (1) breathing normally; (2) eating and drinking adequately;

(3) eliminating body wastes; (4) moving and maintaining a desirable

position; (5) sleeping and resting; (6) selecting suitable clothes; (7)

maintaining body temperature within normal range; (8) keeping the body

clean and well-groomed to protect the integument; (9) avoiding dangers in

the environment and avoiding injuring others; (10) communicating with

others in expressing emotions, needs, fears, or opinions; (11) worshipping

according to one’s faith; (12) working in such a way that one feels a sense

of accomplishment; (13) playing or participating in various forms of

recreation; and (14) learning, discovering, or satisfying the curiosity that

leads to normal development and health, and using available health

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facilities. When the patient was able to perform all the functions by him or

herself then the patient could be considered independent and no longer

required the aid of a nurse.

Virginia Henderson also believed that it was important that nursing

be based on evidence, and that research was a critical component of

improving nursing practice. She believed all nurses should have access to

literature on nursing and current nursing research to help better their

practices, and to this end, she worked to develop an index of nursing.

Virginia Henderson’s theory is one of the most valuable theories

that a student nurse has in his or her arsenal in providing care for the

clients. It provides student nurses a guide on what to focus on and on

giving priority on the care being provided to the client. The client was

admitted to Davao Medical School Foundation Hospital due to right upper

quadrant abdominal pain and was later diagnosed with Calculous

Cholecystitis. Employing this theory the student nurses noted that among

the 14 Fundamental Needs that Henderson laid out, eating and drinking

adequately and getting enough sleep and rest are given most priority.

Since the ability of the body to handle fat and other fat soluble substances

is impaired, following a diet which is specified for patients with Calculous

Cholecystitis is essential to improve the patient’s wellbeing. The diet

promoted by the student nurses to the client should be moderate in

calories and low in fat. This diet included High fiber foods (fresh fruits and

vegetables), Whole grains (such as whole wheat bread and oats) and lean

meat (such as chicken and fish). Supervising the client in her diet was

done by the student nurses in order for the client to improve her current

condition. Having enough rest and sleep is also important for the client in

order for her to reach optimum wellbeing. Having enough sleep periods

was encouraged to the client by the group. The client was made

comfortable and was placed in a stress free environment to minimize

stressors that might further compromise the client’s health.

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Ida Jean Orlando's theory was developed in the late 1950s from

observations she recorded between a nurse and patient. Her nursing process is

based on the manner in which all individuals act and that this process is used by

a nurse to meet a patient’s need for help; meeting this need improves the

patient’s behavior. The components of Orlando’s Nursing Process Theory are

(1.) patient behavior, (2.) nurse reaction, and (3.) nurse action. The nursing

process is set in motion by the patient’s behavior and all patient behavior, no

matter how significant, may represent a cry for help because the patient who

cannot resolve a need feels helpless, and the person’s behavior reflects this

feeling. Nurse reaction to a patient’s behavior forms the basis for determining

how a nurse acts; it consists of perception, thought, and feeling. The nurse’s first

experience with the patient’s behavior is through the senses; this perception

leads to thought, which evokes a feeling, and because these three parts occur

automatically and almost simultaneously a nurse must identify each part of the

reaction to help the patient. Nurse action is whatever the nurse says or does to

benefit the patient and when performing an action, the nurse is influenced by

stimuli related to the patient’s needs.

Orlando’s theory states that the function of the nurse is to find out and

meet the patient's immediate need for help and to use the nursing process

(nurse-patient interaction) to relieve a patient’s feelings of helplessness or


Given the client’s current medical status, the group utilized

Orlando’s theory as they provided care and did their work. Focusing on

the client’s verbal and non-verbal cues as focusing on the immediate

people surrounding her is essential in any medical situation for it may

indicate distress or danger in one form or another. The patient may have

concerns that she will not communicate with the people around her. These

concerns may be hazardous to the client’s wellbeing and may further

compromise her health. Orlando’s theory keeps the student nurses focus

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on the needs and concerns of the patient whether the client or her

significant others stated it or not. Learning how to interpret and validate

both verbal cues and non verbal cues is essential in any hospital situation

for not all cues is presented as it is. Therefore, the student nurses applied

Orlando’s theory to aid them in interpreting the actions and behaviors of

the patient. They also made sure to verify first what they’ve observed

before planning anything. The student nurses paid close attention to any

signs that may lead to distress that might threaten the patient’s life.

Application of the theory also helps the student nurse prepare and plan

the course of action towards the situation. This preparation leads to an

appropriate intervention by the nurse that might relieve the patient of her

distress or might even save the patient’s life.


Roy’s Adaptation theory views the client as an adaptive system

where the goal of nursing is to help the person adapt to changes in

physiological needs, self-concept, role function & interdependent relations

during health & illness. Roy believed that the need for nursing care arises

when the client cannot adapt to internal & external environmental


Callista Roy noted different stimuli that would affect a client’s adaptive

response, namely the focal stimuli, which constitute the greatest degree of

change impacting upon the person and is the stimulus most immediately

confronting the person, the contextual stimuli which are all other stimuli of the

person’s internal & external world that can be identified as having a positive or

negative influence on the situation, and the residual stimuli which are those

internal or external factors whose current effects are unclear. With that said,

Callista Roy theorized that there are four adaptive modes: (1.) Physiological

mode which represents physical response to environmental stimuli & primarily

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involves the regulator subsystem. The basic need is the physiologic integrity,

associated with oxygenation, nutrition, elimination, activity & rest and protection.

(2.) Self-concept mode which relates to the basic need for psychic integrity

(psychological & spiritual aspect)

a. Physical self – has components of body image & body sensation

b. Personal self – has components of self-consistency, self-ideal &

moral-ethical-spiritual self. (3.) Role function mode which identifies the patterns

of social interaction of the person in relation to others reflected by; (a.) primary

role which determines the majority of a person’s behavior & is defined by age,

sex and developmental stage. (b.) Secondary role - assumed to carry out the

tasks required by the stage of development & primary role.(c.) Tertiary role – are

temporary, freely chosen & may include activities related to hobby. (4.)

Interdependence mode – identifies patterns of human value, affection, love &


The proponents conceptualized that the patient’s well being

depends upon her ability to adapt to her current condition. Being able to

adapt to her illness may lead to a faster recovery. However failure to adapt

and cope up may lead to a decline in her health status. Therefore it is the

role of the student nurses to help the patient cope up with her ailment. Use

of Roy’s Adaptation Theory guided the student nurses that the goal of

nursing in this theory is the promotion of adaptive responses in relation to

the four adaptive modes. Nursing seeks to reduce ineffective responses &

promote adaptive responses as output behavior of the person. With that,

the proponents first identified the stressors, either in the client’s

environment or within the client herself, that cause distress to the patient’s

mental and emotional status. Having identified the said stressors, the

student nurses planned the action to be done and implemented it. One of

which is providing vital information about the patient’s current condition.

By providing the patient information, her false beliefs towards her ailments

may be reduced. Anxiety, which is the fear of the unknown, may also be

alleviated through giving the patient information. Aside from giving

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information, the proponents also listened and took notice of the patient’s

concerns about her admission to the hospital. By doing so, the student

nurses hope that any mental and emotional stress may be reduced. This

decrease in stressors hopefully will lead the patient to a faster recovery.

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1. Acute pain related to presence of surgical incision secondary to status post laparoscopic


2. Impaired skin integrity related to surgical procedure: laparoscopic cholecystectomy secondary to

calculous cholecystitis

3. Deficient knowledge regarding illness and treatment course related to lack of information presented.

4. Risk for infection related to presence of surgical incision.

5. Risk for imbalanced body temperature related to exposure to anesthesia secondary to status post

laparoscopic cholecystectomy.

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Patient’s Name: Meg Age: 38 years old

Chief Complaint: pain at the right upper quadrant of the abdomen Ward: 3C

Diagnosis: Calculous Cholecystitis

1. Acute pain related to presence of surgical incision secondary to status post laparoscopic cholecystectomy.

Date Cues Need Nursing Diagnosis Objective/Goal Nursing Interventions Evaluation





Subjective Cues:

Verbalized “Sakit

pa akong opera,

ngul-ngul pa.”

Objective Cues:

pain scale of 6 out

of 10 noted.

Grimaced face



behavior noted.









Acute pain related to

presence of surgical

incision secondary to

status post laparoscopic


R: Pain is a common

aftermath for every

surgery after the

anesthesia wore down.

Pain is recognized in two

different forms:

physiologic pain and

At the end of 3

hours nursing

intervention, the

patient will be able


1. Report a

decrease in pain

intensity to a

scale of 3 out of


2. Demonstrate


1. Monitor and assess

vital signs every 2 hours.

R: Vital signs are usually

altered in acute pain.

2. Administer analgesics

(e.g Tramadol) as


R: Tramadol is an

analgesic. It binds to

mu-opioid receptors and

inhibits the reuptake of


At the end of

rendering 3 hours


intervention, the

patient was able


1. Report pain as

relieved and

controlled as

evidenced by


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Slow and limited

movement of the

upper extremities

Patient is 1 day

post operative

0.5 mm incision

noted on the right

lower rib cage and

the subxyphoid

area; 10mm

incision below the


Incisions are

covered with dry

and intact


Vital Signs: T-

36.6°C; BP-

130/90; RR-18;

PR- 81.













clinical pain. Physiologic

pain comes and goes,

and is the result of

experiencing a high-

intensity sensation. It

often acts as a safety

mechanism to warn

individuals of danger

(e.g., a burn, animal

scratch, or broken

glass). Clinical pain, in

contrast, is marked by

hypersensitivity to

painful stimuli around a

localized site, and also is

felt in non-injured areas

nearby. When a patient

undergoes surgery,

tissues and nerve

endings are traumatized,

resulting in incision pain.


methods and/or

use of relaxation

skills and


activities, as

indicated, for



norepinephrine and

serotonin; causes many

effects similar to opioids

but doesn’t cause

respiratory depression. It

is for moderate to severe


3. Evaluate the

effectiveness of

analgesic at regular

intervals after each

administration, also

observing for any

signs and symptoms

of untoward effects

(e.g. respiratory

depression, nausea

and vomiting)

R: The analgesic dose

of client, “Dili

na man kaayo

siya sakit,

makaya na

man.” And

reported a

pain scale of 3

out of 10

2. Demonstrate



al methods

and/or use of


skills and


activities (e.g.



moderate high

back rest

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This trauma overloads

the pain receptors that

send messages to the

spinal cord, which


overstimulated. The

resultant central

sensitization is a type of

posttraumatic stress to

the spinal cord, which

interprets any

stimulation—painful or


unpleasant. That is why

a patient may feel pain

in movement or physical

touch in locations far

from the surgical site.


may not be adequate to

raise the client’s

pain threshold or may be

causing intolerable or

dangerous side

effects or both. Ongoing

evaluation will assist in

making necessary

adjustments for effective

pain management.

4. Monitor patient’s pain

at least every hour

while awake by the

use of the pain scale.

R: Allows evaluation of

the severity of the pain

felt by the patient. Pain

is a subjective

experience and only the

position; she




activities such

as talking with

her watcher)

Vital Signs: T-

36.4°C; BP-

120/90; RR-19;

PR- 84.

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patient can describe the

pain she’s feeling.

5. Instruct and

demonstrate use of

deep breathing

exercise. Also

instruct patient to do

splinting while doing

deep breathing


R: Deep breathing

increases oxygen in the

body and prevents

atelectasis. Deep

breathing exercise also


comfort.Splinting while

doing deep breathing is

to lessen the pain upon

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6. Position the patient

properly in bed.

Elevate head of bed.

Maintain anatomic


R: Alignment helps

prevent pain from

malposition and it

enhances comfort

7. Encourage

diversional activities


socialization with

others, mental


R: These highten ones

concentration upon

nonpainful stimuli to

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decrease one's

awareness and

experience of pain.

8. Provide rest periods

to facilitate comfort,

sleep, and relaxation

R: The patient's

experiences of pain may

become exaggerated as

the result of fatigue.

Adequate rest helps

provide comfort

9. Assist patient in

doing her activities of

daily living

R: Helps reduce pain

brought about by the

exertion of force

necessary to perform

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10.Encourage patient to

report pain as soon

as it starts and allow

her to verbalize pain

experienced or

describe the pain

she’s feeling.

R: Severe pain is more

difficult to control and

increases the client’s

anxiety and fatigue.

2. Impaired skin integrity related to surgery: laparoscopic cholecystectomy secondary to calculous cholecystitis.

Date Cues Need Nursing Diagnosis Objectives/Goals Nursing Interventions Evaluation


Subjective: N Impaired skin integrity related to surgery:

At the end of 2 days nursing intervention

1. Assess dressings/ wound every shift.

Goal Met

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9:00 pm

“Gioperahan ko diri sa tiyan,” as verbalized by the patient


-post laparoscopic cholecystectomy (2 hrs)

-disruption of the dermis, epidermis, and subcutaneous tissues.

-with 0.5 to 1 cm incisions at the epigastrium, right lower rib cage and below the umbilicus

















laparoscopic cholecystectomy secondary to calculous cholecystitis.


Laparoscopic cholecystectomy is a less invasive way to remove the bladder. It is performed through inserting a laparoscope just below the navel. Three additional ports are inserted by making three other incisions in the epigastrium and in the right upper quadrant of the abdomen.


Talamini, M. (2006). Advanced Therapy in

the patient will be able to:

1. Display improvement in wound healing as evidenced by intact incision site.

2. Remain free from infection as evidenced by normal vital signs and absence of purulent discharge.

3. Demonstrate behaviors/techniques to promote healing or prevent complications

Describe wounds and observe for changes.

®: Establishes comparative baseline providing opportunity for timely intervention.

2. Keep the incision site clean and dry, carefully dress wounds.

®: Keeping incision site clean and dry prevents infection; it also aids in the process of wound healing.

3. Encourage early ambulation. Assist patient in doing active and passive range of motion exercises.

®: Movement stimulates circulation and assists in the body’s natural process of repair.

5/12/10 @


At the end of 2 days nursing intervention, the patient was able to:

1. Maintain incision site and dressing intact and dry.

2. Remain free from infection as evidenced by normal vital signs (BP= 120/70; RR=18; PR=85; Temp=36.6) and absence of purulent discharge.


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-incisions covered with dry and intact dressing

-skin slightly warm to touch. Temperature: 36.8°C












Minimally Invasive Surgery, p. 179. USA: Decker Inc.

4. Monitor temperature every 4 hours.

®: Early recognition of developing infection enables rapid institution of treatment and prevention of further complications.

5. Place in semi-Fowler’s position or moderate high back rest.

®:Proper positioning decreases tension in the operative site and promotes healing.

6. Instruct to wear clean, dry, loose-fitting clothes, preferably cotton fabric

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

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

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infection. Loose clothing reduces pressure on compromised tissues, which may improve circulation/healing

7. Emphasize importance of adequate nutrition and fluid intake. Encourage patient to eat foods rich in protein, iron and vit. C.

®: Improved nutrition and hydration will improve skin condition. Protein and iron helps in repair of tissues. Vitamin C is important for immune system function and increases resistance to some pathogens.

8. Instruct the client in proper postoperative skin care. Teach client and her significant

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others the importance of proper hand washing.

®: This is to involve the patient in caring for skin, promoting comfort, and preventing infection or other complications. Proper washing of hands deter the spread of microorganisms.

9. Instruct the client to observe for signs and symptoms of complications such as elevated temperature, redness, warmth, swelling near the surgical incision, purulent discharge, or breakdown of sutures around the incision, and report to the physician.

®: Provides for prompt recognition of complications and facilitates prompt

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10. Administer antibiotics as indicated (sultamicillin)

®: May be given prophylactically or to treat specific infection and enhance healing.

3.Deficient knowledge regarding illness and treatment course related to lack of information presented.



Cues Need Nursing Diagnosis Objective/Goal Nursing Interventions Evaluation

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“Para asa

diay ni siya













g of














Knowledge deficit

regarding illness

and treatment

course related to

lack of information


R: Knowledge is

important especially

in health matters.

Deficiency in

knowledge might

affect the patient’s

health status. If

ever health issues

are taken for

granted, it may

result to


that could have

At the end of 2

hours nursing

intervention, the

patient will be

able to:

1. Verbalize

understanding of

disease process

and treatment.

2. Initiate


lifestyle changes

and participate in



1. Assess the patient’s

current knowledge of the

medications and other

doctor’s instructions and

nursing procedures and its

implications, the likelihood

of complications if these are

not followed, and the

likelihood of cure or disease

control. Specifically ask

about the physician’s

explanations and the

patient’s past experiences.

R: Adults learn best when

teaching builds on previous

knowledge or experience.

Assessing recall of the

physician’s explanations as

well as the patient’s past

Goal Met

At the end of 2

hours nursing

intervention, the

patient was able to:

1. Verbalize

kasabot nako karon

ngano ginahatagan

ko ug mga ing

aning tambal, para

pud malabanan ang

inpeksyon nako.”

2. Initiate necessary lifestyle changes and participate in treatment regimen and verbalized “ Sa sunod mag-iwas na gyud ko ug mga taba kayo nga

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been prevented if

the patient had

enough knowledge

regarding her

current health

status. Lack of

knowledge about

health may also

contribute to

occurrence of



Berman, A. et. al.

(2008) Kozier &

Erb’s Fundamental

of Nursing

Concepts, Process

and Practice 8th

Edition. Pearson

Prentice Hall,

experiences and exposure

to health information

provides an opportunity for

evaluating attitudes and the

accuracy and completeness

of knowledge.

2. Ask how much the

patient wants to know.

Consider patient’s

preference for information in

planning and teaching.

R: People vary in the

degree of detail they find

helpful. Those who cope

with a threatening

experience by avoiding it

generally want to know

relatively little about

impending experiences,

whereas those who cope by


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N volume Two,

Chapter 42, stress

and coping

learning as much as

possible about the

threatening experience want

to know a great deal.When

possible, supporting the

patient’s preferred learning

style shows respect for

individual differences.

3. Determine learning

needs. Consider needs

expressed by the patient

and family.

R: Learning needs

determine appropriate

content. Learning occurs

most rapidly when it’s

relevant to current needs.

Responding to expressed

needs displays sensitivity to

the patient’s and family’s

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concern. Identifying

predictable concerns and

responses and necessary

self-care activities helps the

nurse fulfill learning needs

of which the patient and

family may be unaware.

4. Present manageable

amounts of information at

any one time.

R: Too much information at

one time causes confusion.

They patient may lose sight

of key points.

5. Inform the patient about

indication of medication,

drug interaction and its side


R: Allows patient to be

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knowledgeable about

medication and avoid


6. Inform the patient about

the diet specific for her

condition (low fat, high fiber

foods; avoid spicy foods,

alcohol and caffeine)

R: A patient who has

recently had

a gallbladder removed may

suffer from diarrhea and

bloating after consuming

foods high in fat. Diarrhea

and bloating occur because

of two reasons. One reason

is that fat inside the

intestine absorbs more

water, causing stomach

upset. A second reason is

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that bacteria begins to

digest the fat within the

intestine and ultimately

produces gas. When a


with gallbladder problems

consumes spicy foods, ,

unpleasant side

effects such as gas

and heartburn can occur.

7. Provide simple

explanations, using easy-to-

understand terminology.

R: Medical and nursing

jargon distances the patient

and family members.

Intricate explanations may

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confuse or overwhelm them.

8. Discuss to the patient

and to the family the

importance of complying

with the medications and

other doctor’s orders.

R: This lets the patient be

aware of the significance of

the doctor’s instructions. It

also lets the patient know

the consequences which

might occur if instructions

weren’t followed. Knowing

the benefits of complying

with the instructions

encourages participation.

9. Ask for feedback.

R: The patient may initially

feel overwhelmed and

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insecure about learning

because of the magnitude,

urgency or unfamiliarity of

necessary adaptations to


10. Use review and

repetition judiciously,

considering individual


R: The unit environment

and the patient’s age may

contribute to a short

attention span and poor


11. During and after

teaching, determine what

learning has occurred.

R: Determining learning

accomplishment permits

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resolution of some learning

needs and provides

guidance for meeting


12. Provide information

about additional learning

resources, like the nearest

baranggay health center in

their area.

R: Patients should be

informed that there are

health services in the health

centers which are for free,

so as to persuade them to

avail it.

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1. Take medications as ordered.

2. Inform the patient to take medications on time or as directed for the full

course of therapy even if feeling better.

3. Inform the client about the adverse effects and possible side effects of

the medications.

4. Inform the client about the importance of taking prescribed medications

and the consequences of not following the treatment regimen.

5. Encourage the patient to report or inform the health team if any of these

side effects occur. Inform and explain to the client that other drugs that

he is taking will probably have effects with the medication given.

Moreover, emphasize the right time interval of these drugs to maximize

its effects and avoid further complications.

6. Provide information for better understanding regarding therapeutic



1. Promote regular light exercise and exercise as tolerated.

2. Encourage exercise in lower and upper extremities to promote good


3. Inform patient about proper exercise regimen to avoid injury.

4. Alternate rest periods with activity.

5. Encourage walking exercise.


1. Instruct the patient to continue drug therapy as ordered.

2. Inform the patient as well as family the dangers of non compliance to

treatment regimen.

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3. Discuss to the patient the complications and other problems that might

arise from the condition.

4. Inform the patient to exercise and do breathing exercises.

5. Instruct the patient to report to the health team promptly about any

changes on health condition.

6. Encourage patient to strictly comply with the doctor’s orders, especially

in taking prescribed medications.

7. Encourage the patient to have followed up visitations to the physician

after discharge.


1. Encourage patient to avoid strenuous activities.

2. Improving nutritional intake; meal planning is implemented with High

fiber moderate calorie, low fat and low salt as the primary goal.

3. Encourage to balance diet and intake of nutritious food such as

vegetables and lean meat, avoiding high fat foods.

4. Check with healthcare provider to evaluate progress of the condition.

5. Encourage to have adequate hydration. Water is the best source of fluid

that is needed by the body to maintain its function.

6. Instruct to avoid alcoholic beverages due to a compromised hepatic


7. Encourage to have a restful and quiet atmosphere at home.

8. Encourage patient to use relaxation skills when in pain.

9. Encourage patient to seek emotional and social support especially to

family and friends to promote strength and comfort.

10.Check the condition with a healthcare provider to evaluate progress of

the condition.


1. Remind patient on the arrangements to be made with the physician for

follow-up checkups.

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2. Follow-up check up regularly in order to monitor and properly manage

patient’s illness.

3. Inform to continue medication as ordered.

4. Instruct to have a follow-up check up or refer to the physician if the

patient is uncomfortable.

5. Instruct the patient and significant others to report for any irregularities.


1. The diet recommended for the client is High fiber moderate calorie, low

fat and low salt

2. Encourage patient to increase nutritious foods intake by eating fresh

fruits and vegetables, whole grain products, and lean meat.

3. Recommend to eat 5 or more servings of vegetables and fruits each day.

4. Encourage to choose whole grain foods instead of white flour and


5. Advise to try to limit meats that are high in fat and cut back on processed

meats like hot dogs and bacon.

6. Inform patient to avoid food such as salted, cured, smoked, or canned


7. Increase oral fluid intake. Hydration is needed by the body to transport

nutrients needed by the body.

8. Instruct to avoid drinking of alcoholic beverages as much as possible.

9. Encourage not to forget to get some type of light exercise because the

combination of good diet and regular exercise will help in the

maintenance of healthy weight and the feeling of more energetic.

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Good Fair Poor Justification

Onset of the


Signs and symptoms of her current illness

first appeared on the second week of

December 2009. After three days, the

pain disappeared. But after two weeks,

pain recurred in a higher scale of pain

(5/10). Because of this, she was forced to

seek medical advice and consult at

Robillo Memorial Hospital. On May 5,

2010, three days prior to admission, the

patient again experienced right upper

quadrant pain. This was characterized to

be progressive pain with a pain scale of 8

out of 10. There was no radiation noted

and no associated symptoms. Two days

prior to admission, pain recurred with a

pain scale of 10 out of 10. This prompted

Meg to seek consultation, hence,

admission. On May 8, 2010, the patient

was admitted at Davao Medical School

Foundation at Surgical Ward, room 324

bed 5 under the service of Dr. Batucan,

with admitting diagnosis of Acute

Cholelithiasis. Based on the data, the

onset of illness of the client first started

on December of 2009. Patient did not

comply with her doctor’s order to modify

her diet (low fat, high fiber) and this led to

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exacerbation of her illness. Because of

the patient’s onset of illness, the

proponents rated the area as fair.

Duration of


The client’s hepatic system has been

compromised since December 2009, 5

months before admission to DMSF

Hospital. Because of the span of the

illness of the client, the proponents rated

the Duration of Illness as fair.



The precipitating factors of Calculous

Cholecystitis present in the client were (1)

Hormone replacement therapy, or birth

control pills and (2) a Low Fat Diet. Given

that the client has a few of the

precipitating factors present and has

none of the much more serious

precipitating factors, the proponents rated

the Precipitating factors as good.


to take




Before she was brought to DMSF, she

had a consult first at the Robillo Hospital.

There, she was instructed to revise her

diet into a low fat, high fiber diet. She was

also instructed to drink lots of fluids.

However, patient was not able to comply

with this treatment plan and this later on

led to worsening of her condition. On the

positive note, she was later on able to

follow instructions about her treatment

regimen and cooperate with the health

care team when she was admitted at

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DMSF. Because of these reasons, the

proponents rated the Willingness to take

medications and treatment as fair.

Age ♠

Most of the body’s protective

mechanisms become less efficient with

age. Since the patient is 38 years old, the

proponents rated the age factor as fair.


al factors

The proponents rated the Environmental

factor as good for the reason that there is

nothing in her environment at home or at

work that can decrease her health status

and further compromise her wellbeing.



The client’s family is very supportive and

willing to comply with the therapy in order

for the patient to get well, even with their

financial problems. The patient also

stated that her family provides her with all

the emotional support she needs.

Members of her family frequently visit her

in the hospital and she is able to verbalize

any concern to them. Her husband is also

present and is able to provide her support

as she undergoes her current condition.


3 4 0


Poor:(0*1)/7 = 0/7

Fair: (4*2)/7= 8/7

Good: (3*3)/7= 9/7

Total: 17/7 or 2.42 (Good Prognosis)

*Scoring for General Prognosis: 1-1.6 = Poor Prognosis; 1.7-2.3 = Fair Prognosis; 2.4-3.0 = Good Prognosis

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Rationale for a Good Prognosis

The patient has a good chance of recuperating from her current ailment as

evidenced by the study done. The onset and duration of the illness, the

absence of the much more serious precipitating factors, her willingness to take

medication and treatment, and the support of the patient’s family made the

prognosis better, increasing the chance of her recovery from her current

ailment. The current status of her condition is very manageable and there is a

good chance that she can recover as long as she is determined enough to

achieve optimum well being. Therefore, according to the research and the

calculations done by the proponents, the patient has a very good chance of

recovering from her ailment.

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This case study about Calculous Cholecystitis gave the group more

information and knowledge in making an actual management for this kind of

problem. Thus, the members of the group have realized the need of promoting

and maintaining optimal health to both the patient and her significant others. With

these, the group would like to recommend the following.

To the client:

The patient’s participation and willingness to be assessed and comply with

the therapeutic regimen is needed for an effective management and prevention

of complications. The patient is encouraged to always reach for wellness, and be

cautious enough to know what her body needs and to recognize her limitations in

complying therapeutic regimen. Also, the patient is encouraged to follow the

discharge plan for the betterment of her condition while at home. She is also

recommended to have her regular follow-up checkups to evaluate her condition.

The patient is enlightened to be more open with her feelings regarding her

current condition, family problems and concerns about her health

To the client’s family:

The patient’s family plays an important role in the improvement of patient’s

condition because they are source of strength and inspiration to deal with the

disease. The family is encouraged to be sensitive enough to know the patient’s

need and weaknesses that they may be able to render their support and care. Just

with their presence and affection can help the patient feel that she is being loved

and that she can successfully surpass the challenges that are brought by her

illness. The feeling of being secured and accepted is what also the patient needs

to achieve optimal state of well being.

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To the community:

The community should also be sensitive with the client’s condition, not

treating her like she is incapable of doing her daily activities. They must still

respect the client even with the illness. They must also be understanding enough

and let the client feel security and acceptance. They should be more aware about

this kind of condition. More knowledge should be acquired by the community to

be able to know how to manage this kind of illness and how to prevent the

occurrence of the illness within the community.

To the government:

Budget for health must be increased so that patients would be able to

receive adequate amount of health services from government hospitals. They

should also disseminate vital information regarding illnesses that may affect the

body’s hepatic system. They should also make sure that people from far flung

areas have access to medical services. Being able to access even basic medical

attention may lead to a decrease in certain ailments of the genitourinary system.

To professional health workers:

Health care providers should be passionate about their job, giving proper

care and support to their clients. Health workers should be sensitive to the

client’s feelings and emotions. They should be open for conversation to know

what the client is feeling at the moment. They should also continue their work

even though they receive little or sometimes no salary at all, thinking that what

they’re doing is for humanitarian reasons.

To the College of Nursing:

They should provide more exposure to the students on a consistent area

to further increase their experience regarding the concept. They should also do

proper scheduling of duties so that students wouldn’t be stressed out with their

case presentations, clearing any scheduling matters with the students. They

should also make sure that the student nurses are respected and treated well by

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their superiors. Also, they should make sure that their students are safe while on

their duty, and if able, provide prophylactic treatment to avoid endangering the

lives of the students. The College of Nursing should be more sensitive to the

needs of the students and should be open to any comments or suggestions.

To the Student Nurses:

Give appropriate nursing care and follow out doctor’s order properly to

avoid any errors and give better care to the clients. Cooperation with the

healthcare team is also essential to provide better quality care. They should also

be honest in the data collecting done to the patient, putting in mind that they are

dealing lives. They should treat the client as a fellow human being giving quality

care and service. They must also research about the disease to enhance their

knowledge about it. They must also be updated with current updates that could

be beneficial to the nurse, the client and the rest of the healthcare team.

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Process and Practice 8th Edition. Pearson Prentice Hall, volume Two, Chapter

42, stress and coping

Boyer, M. (2006). Brunner and Suddarth’s Textbook of Medical-Surgical

Nursing, 11th ed.

Carol Mattson Porth (2005). Pathophysiology, Seventh edition.

Crowley, L. (2010). An Introduction to Human Disease: Pathology and

Pathophysiology Correlations, 8th ed., p. 563. USA: Jones and Bartlett


Digiulio, M. & Jackson, D.(2007). Medical-Surgical Nursing Demystified, p.

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Everhart, JE, Khare, M, Hill, M, Maurer, KR. Prevalence and ethnic

differences in gallbladder disease in the United States. Gastroenterology

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Ginsber, G. & Ahmad, N. (2006) The Clinician’s Guide to Pancreaticobiliary

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Harrison’s Principles of Internal Medicine, Tenth Edition 1983.

Iyengar, V. Elemental Analysis of Biological Systems: Biomedical,

Environmental, Compositional and Methodological Aspects of Trace

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Kozier and Erbs, Fundamentals of Nursing, Chap. 20, page 352

Lippincott Williams and Wilkins Handbook of Diseases Third Edition, page


MIMS 113th edition 2007

Talamini, M. (2006). Advanced Therapy in Minimally Invasive Surgery, p. 179.

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Taylor, Lillis, LeMone and Lynn (2008),Fundamentals of Nursing: The Art and

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