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IntroductionCholecystitis is an inflammation of the gallbladder wall and nearby abdominal lining. Cholecystitis is usually caused by a gallstone in the cystic duct, the duct that connects the gall bladder to the hepatic duct. The presence of gallstones in the gallbladder is called cholelithiasis. Cholelithiasis is the pathologic state of stones or calculi within the gallbladder lumen. A common digestive disorder worldwide, the annual overall cost of cholelithiasis is approximately $5 billion in the United States, where 75-80% of gallstones are of the cholesterol type, and approximately 10-25% of gallstones are bilirubinate of either black or brown pigment. In Asia, pigmented stones predominate, although recent studies have shown an increase in cholesterol stones in the Far East. Gallstones are crystalline structures formed by concretion (hardening) or accretion(adherenceofparticles,accumulation)ofnormalorabnormalbileconstituents. According to various theories, there are four possible explanations for stone formation. First, bile may undergo a change in composition.Second, gallbladder stasis may leadtobile stasis.Third, infectionmay predisposea personto stoneformation.Fourth, genetics and demography canaffect stone formationRisk factors associated with development of gallstones include heredity, Obesity, rapid weight loss, through diet or surgery, age over 60, Native American or Mexican American racial makeup, female gender-gallbladder disease is more common in women than in men. Women with high estrogen levels, as a result of pregnancy, hormone replacement therapy, or the use of birth control pills, are at particularly high risk for gallstone formation, Diet-Very low calorie diets, prolonged fasting, and low-fiber /high-cholesterol/high-starch diets all may contribute to gallstone formation.Sometimes, persons with gallbladder disease have few or no symptoms. Others, however, will eventually develop one or more of the following symptoms;

(1) Frequent bouts of indigestion, especially after eating fatty or greasy foods, or certain vegetables such as cabbage, radishes, or pickles,

(2) Nausea and bloating

(3) Attacks of sharp pains in the upper right part of the abdomen. This pain occurs when a gallstone causes a blockage that prevents the gallbladder from emptying (usually by obstructing the cystic duct).(4) Jaundice (yellowing of the skin) may occur if a gallstone becomes stuck in the common bile duct, which leads into the intestine blocking the flow of bile from both the gall bladder and the liver. This is a serious complication and usually requires immediate treatment. The only treatment that cures gallbladder disease is surgical removal of the gall bladder, called cholecystectomy. Generally, when stones are present and causing symptoms, or when the gallbladder is infected and inflamed, removal of the organ is usually necessary. When the gallbladder is removed, the surgeon may examine the bile ducts, sometimes with X rays, and remove any stones that may be lodged there. The ducts are not removed so that the liver can continue to secrete bile into the intestine. Most patients experience no further symptoms after cholecystectomy. However, mild residual symptoms can occur, which can usually be controlled with a special diet and medication.ASSESSMENTPATIENTS PROFILEName: Patient Confidentiality Ob La Di, Od Di Da JonesAge: 66 years oldAddress: Purok Kalipayan,Barangay Washington, S.C.Religion: Roman CatholicCivil Status: MarriedAdmitting Diagnosis: Acute CholecystitisDate of Admission: March 17, 2015 , 2:18 AMMedical history CHIEF COMPLAINT- FeverHISTORY OF PRESENT ILLNESS- Patient have had pain in the hypogastic region prior to admission ranging from light to severe, with dynamic intervals in a day, up to 3-6 occurrences. PAST MEDICAL HISTORY-This is the second time Mr. Jones been admitted. With a previous admission of stomaches, in relation to diarrhea. Have had experienced Hypertension and colds.SOCIAL and personal history ETHNIC BACKGROUND- CLIENTS POSITION IN THE FAMILY- Stronghold provider with the current household, Father of 5TYPE OF RESIDENCY- Owned NATURE OF PRESENT OCCUPATION- Active Church Member (KofC); Board Executive (DepEd)Gordons Typology of Health Pattern HEALTH PERCEPTION HEALTH MANAGEMENT- Once he has an illness, he opts to visit the local health unit for check-ups and prefers medications such as losartan, omeprazole NUTRITIONAL METABOLIC PATTERNHis water intake is usually 4-6 times a day, he is very picky with what he eats, he opts to eat what he wants at his own time and own pace.ELIMINATION PATTERN- He usually defecates once a day, but upon admission, he has had trouble with defecation, sometimes frequent, yet watery stools are present and sometimes scarcely (skips a day) ending up with hard stools. He urinates about a glass (345 mL), five times a day. Gordons Typology of Health Pattern SLEEP REST PATTERN - He sleeps for about 6 8 hours, naps for 2-3 hours COPING STRESS TOLERANCE PATTERN- He is not troubled with his condition. He has his wife as his go-to person for comfort and assistance COGNITIVE PERCEPTUAL PATTERN- Patient can understand but sometimes unable to comprehend, the wife intervenes. Patient also is assertive with what he believes in. He is firm and tends to outrule others opinion about his condition.

PHYSICAL ASSESSMENT VITAL SIGNSTEMPERATURE: 36.5OcPULSE RATE: 76 bpmRESPIRATORY RATE: 28 cpmB/P: 140/70 mmHg

PHYSICAL ASSESSMENTAPPEARANCE:Body Build: Proportionate, Stocky body builtHygiene and Grooming: Poor Hygiene (bathing); Body and Breath Odor: Unpleasant body odor; minimal oral odor MENTAL STATUS:Level of Consciousness: AlertAffect/Mood: His affect changes from Agitated to Extremely Jubilant. Mood shifting is slightly odd and attitude is eccentric. Speech: Coherent, Intellectual (speaks in the English language)PHYSICAL ASSESSMENTSKIN:Color: Unevenly Brown (tan/samon color in the neck and facial part)Integrity: Intact; No signs of any breakageMoisture: Dry, rough and flaky skinSkin Turgor: NormalHAIR:Color: Black (dominant) and Grey (roots and 1/4 of strands)Thickness: Thin and Smooth hairPHYSICAL ASSESSMENTNAILS:Shape: Normal; symmetricalTexture: Smooth and glossyNailbed color: Pale pinkish tingeCapillary Refill: NormalSize: SymmetricalDirtyEYES:Color: Yellow (Jaundice)Hollowness: Sunken PHYSICAL ASSESSMENTFACE:Symmetry of Movements: SymmetricalPUPILS:Color: BrownShape: CircularSymmetry: Symmetrical

PHYSICAL ASSESSMENTAURICLESColor, symmetry, size, and position: Normal and symmetricalTexture, elasticity, tenderness: Firm and not tenderEar canal and tympanic membrane: NormalSkin lesions: No skin lesionsPus or blood: No pus or blood

NOSE: Nasal Discharges: None

CBCRESULTNORMAL VALUESRED BLOOD CELL4.84.5-5.2 x 10HEMOGLOBIN13.813.5-17.5HEMATOCRIT42.340-52WHITE BLOOD CELL16.84.5-10.5 x 10PLATELET305150-400MCV88.880-99.9MCH2927-31MCHC32.733-37RDW13116-137MPV6.577.13BLOOD CHEMISTRYRESULTNORMAL VALUESINDICATIONALKALINE PHOSPHATASE19453-128ABNORMALALT/SGPT523-41ABNORMALAST/SGOT352-37NORMALGLUCOSE (FBS)127.270-105ABNORMALCREATININE0.770.70-1.30NORMALCHOLESTEROL143140-220NORMALTRIGLYCERIDES13440-200NORMALHDL-CHOLESTEROL2530-75ABNORMALLDL CHOLESTEROL92.20-130NORMALFECALYSIS: No Ova or Parasite SeenANATOMY and PHYSIOLOGYGallbladder, muscular organ that serves as a reservoir for bile, present in most vertebrates. In humans, it is a pear-shaped membranous sac on the undersurface of theright lobe of the liver just below the lower ribs. It is generally about 7.5 cm (about 3 in)long and 2.5 cm (1 in) in diameter at its thickest part; it has a capacity varying from 1 to1.5 fluid ounces.THE GALLBLADDER

The body (corpus) and neck (collum) of the gallbladder extend backward, upward, and to the left. The wide end (fundus) points downward and forward, sometimes extending slightly beyond the edge of the liver. Structurally, the gallbladder consists of an outer peritoneal coat (tunica serosa); a middle coat of fibrous tissue and unstriped muscle (tunica muscularis); and an inner mucous membrane coat (tunica mucosa).The function of the gallbladder is to store bile, secreted by the liver and transmitted from that organ via the cystic and hepatic ducts, until it is needed in the digestive process. The gallbladder, when functioning normally, empties through the biliary ducts into the duodenum to aid digestion by promoting peristalsis and absorption, preventing putrefaction, and emulsifying fat. Digestion of fat occurs mainly in the small intestine, by pancreatic enzymes called lipases. The purpose of bile is to; help the Lipases to Work, by emulsifying fat into smaller droplets to increase access for the enzymes, Enable intake of fat, including fat-soluble vitamins: Vitamin A, D, E, and K, rid the body of surpluses and metabolic wastes Cholesterol and Bilirubin.

NURSING CARE PLANASSESSMENTPatient Confidentiality Jones was admitted on March 17, 2015, with a chief complaint of fever (low grade). Upon assessment of Patients past and present history, patient claims that he is a healthy and active man, usually smokes occasionally and drinks alcohol in a casual setting. Patient demands of foods that are acidic despite being instructed of NPO. Upon occurrence of condition, he expressed pan-oy, yet on the day of the assessment, he expressed that he is feeling well, even expressing it with a mischievous smirk. At 8AM of March 19, 2015, he was referred for ultrasound at Miranda Family HospitalASSESSMENTResults were still disclosed. Received patient on bed with 1L of PLR, set to 20 gtts/min, inserted at left hand.

Patient had lots of queries about his current condition. States his misconceptions about his condition and does not diligently follow through instructions and does his own ways.

Patient has slight pallor, dry skin, dry mouth and slight body malaise, V/S are at normal ranges and breathing is normal.PHYSICAL ASSESSMENT VITAL SIGNSTEMPERATURE: 36.5OcPULSE RATE: 76 bpmRESPIRATORY RATE: 28 cpmB/P: 140/70 mmHg

DESIRED OUTCOMESNURSING INTERVENTIONSRATIONALEAfter an hour of nurse-patient interaction the patient will Verbalize understanding of disease process, prognosis, and potential complications Provide explanations of/reasons for test procedures and preparation needed.

2. Review disease process/prognosis. Discuss hospitalization and prospective treatment as indicated. Encourage questions, expression of concern.

3. Review drug regimen, possible side effectsInformation can decrease anxiety, thereby reducing sympathetic stimulation

Provides knowledge base from which patient can make informed choices. Effective communication and support at this time can diminish anxiety and promote healing.

- Gallstones often recur, necessitating long-term therapy.DESIRED OUTCOMESNURSING INTERVENTIONSRATIONALE4. Instruct patient o avoid food/fluids high in fats (e.g., whole milk, ice cream, butter, fried foods, nuts, gravies, pork), gas producers (e.g., cabbage, beans, onions, carbonated beverages), or gastric irritants(e.g., spicy foods, caffeine, citrus).

5. Suggest patient limit gum chewing, sucking on straw/hard candy, or smoking- Prevents/limits recurrence of gallbladder attacks.

- Promotes gas formation, which can increase gastric distension/discomfort.DESIRED OUTCOMESNURSING INTERVENTIONSRATIONALEAfter 3 hours of appropriate nursing interventions the patient (upon order of the physician/the end of NPO) will maintain adequate fluid volume as evidenced by moist mucous membranesMaintain accurate record of I&O, noting output less than Intake, increased urine specific gravity. Assess skin/mucous membranes,peripheralpulses, and capillary refill.

2. Perform frequent oral hygiene

3.Provideskin and mouth care- Provides information about fluid status/circulating volume and replacement needs.

Decreases dryness of oral mucous membranes; reduces risk of oral bleeding.

- Skin and mucous membranes are dry, with decreased elasticity, because of vasoconstriction and reduced intracellular waterDESIRED OUTCOMESNURSING INTERVENTIONSRATIONALE4. Increase fluid intake

5. Ascertain patients beverage preferences, ands et up a 24-hr schedule for fluid intake. Encourage foods with high fluid contentPromotes hydration.

- Relieves thirst and discomfort of dry mucous membranes and augments parenteral replacement.DESIRED OUTCOMESNURSING INTERVENTIONSRATIONALEAfter 4 hours of nursing intervention the patient will report alleviation of pain.Observe and document location, severity (010scale),and character of pain (e.g., steady, intermittent, colicky).

2. Promote bedrest, allowing patient to assume position of comfort.Assists in differentiating cause of pain, and provides information about disease progression/resolution, development of complications, and effectiveness of interventions.

- Bedrest in low-Fowlers position reduces intra-abdominal pressure; however, patient will naturally assume least painful position.DESIRED OUTCOMESNURSING INTERVENTIONSRATIONALE3. Control environmental temperature

4. Encourage use of relaxation techniques, (e.g., guided imagery, visualization, deep-breathing exercises. Provide diversional activities.)

6. Administer analgesics as indicatedCool surroundings aid in minimizing dermal discomfort.

- Promotes rest, redirects attention, may enhance coping.

- Relief of pain facilitates cooperation with other therapeutic interventions.DRUG STUDYDrug nameMechanism of ActionIndicationsContraindicationSide effectsNursing InterventionsOmeprazoleGastric acid-pump inhibitor: Suppresses gastric acid secretion by specific inhibition of the hydrogen-potassium ATPase enzyme system at the secretory surface of the gastric parietal cells; blocks the final step of acid production.Short-term treatment of active duodenal ulcerFirst-line therapy in treatment of heartburn or symptoms of GERDShort-term treatment of active benign gastric ulcerGERD, severe erosive esophagitis, poorly responsive symptomatic GERDLong-term therapy: Treatment of pathologic hyper secretory conditions (Zollinger-Ellison syndrome, multiple adenomas, systemic mastocytosis)Contraindicated with hypersensitivity to omeprazole or its components.Use cautiously with pregnancy, lactation.CNS: Headache, dizziness, asthenia, vertigo, insomnia, apathy, anxiety, paresthesias, dream abnormalitiesDermatologic: Rash, inflammation, urticaria, pruritus, alopecia, dry skinGI: Diarrhea, abdominal pain, nausea, vomiting, constipation, dry mouth, tongue atrophyRespiratory: URI symptoms, cough, epistaxisOther: Cancer in preclinical studies, back pain, feverAdminister before meals. Caution patient to swallow capsules wholenot to open, chew, or crush them. If using oral suspension, empty packet into a small cup containing 2 tbsp of water. Stir and have patient drink immediately; fill cup with water and have patient drink this water. Do not use any other diluent.WARNING: Arrange for further evaluation of patient after 8 wk of therapy for gastro reflux disorders; not intended for maintenance therapy. Symptomatic improvement does not rule out gastric cancer, which did occur in preclinical studies.Administer antacids with omeprazole, if needed.