Cholecystitis - Kev, Roan, Ronn
Transcript of Cholecystitis - Kev, Roan, Ronn
ANGELES UNIVERSITY FOUNDATION
COLLEGE OF NURSING
ANGELES CITY
CASE STUDY – CHOLECYSTITIS
JBL – MS WARD
Submitted by:
Diyco, Kevin Cesar
Pelayo, Roan Rae
Santos, Alvin Ronn
BSN 4-2, Group 6
Submitted to:
Luciano O. Coral III, RN, MN
INTRODUCTION
Cholecystitis, which has long been considered an adult disease, is quickly
gaining recognition in medical practice because of the significant documented
increase in nonhemolytic cases over the last 20 years. Gallbladder disease is
common throughout the adult population, affecting as many as 25 million
Americans and resulting in 500,000-700,000 cholecystectomies per year.
Although gallbladder disease is much rarer in children, with 1.3 pediatric
cases occurring per every 1000 adult cases, pediatric patients undergo 4% of all
cholecystectomies. In addition, acalculous cholecystitis, uncommon in adults, is
not that unusual in children with cholecystitis. Because of the increasing
incidence of gallstones and the disproportionate need for surgery in the pediatric
population, consider cholecystitis and other gallbladder diseases in the
differential diagnosis in any pediatric patient with jaundice or abdominal pain in
the right upper quadrant, particularly if the child has a history of hemolysis.
Cholecystitis is defined as inflammation of the gallbladder and is
traditionally divided into acute and chronic subtypes. These subtypes are
considered to be 2 separate disease states; however, evidence suggests that the
2 conditions are closely related, especially in the pediatric population. Most
gallbladders that are removed for acute cholecystitis show evidence of chronic
inflammation, supporting the concept that acute cholecystitis may actually be an
exacerbation of chronic distension and tissue damage. Cholecystitis may also be
considered calculous or acalculous, but the inflammatory process remains the
same.
Most information related to morbidity and mortality in gallstone disease is
related to the adult population, although some trends can be extracted and
applied to the pediatric population. In general, the mortality rate of
cholecystectomy in acute cholecystitis has dropped from 6.6% in 1930 to 1.8% in
1950 to nearly 0% in recent studies. In one study, the overall mortality rate in
42,000 patients receiving open cholecystectomy (OC) was 0.17%; the mortality
rate in patients younger than 65 years was 0.03%. Children can be expected to
do well, although comorbid conditions are common and may cause
complications. Risk factors for morbidity and mortality in the pediatric population
include associated conditions, such as cystic fibrosis (CF), obesity, hepatic
disease, diabetes mellitus, sickle cell disease, and immunocompromise.
General complications, such as pulmonary, cardiac, thromboembolic,
hepatic, and renal insufficiency, account for most deaths. Procedure-related
complications mainly contribute to morbidity and occur with higher frequency in
acute cholecystitis in which symptoms of gallstone disease have been present
longer than 1 year. The most common procedure-related complications are
wound infections, abscess, cholangitis or pancreatitis, ileus, hemorrhage, and
bile duct complications.
Laparoscopic cholecystectomy (LC) is associated with risks as well. Major
complications include bleeding, pancreatitis, leakage from the duct stump, and
major bile duct injury. The risk of ductal injury increases from 0.1-0.2% in OC to
0.5-1% in LC; however, Holcomb et al reported no iatrogenic injuries with LC in
their first 100 patients. They believe that with conscientious surgical care,
morbidity related to the laparoscopic approach can be minimized.
Racial and genetic influences in the adolescent age group are similar to
those of adults. African Americans without hemolytic disease and the African
Masai are less prone to cholelithiasis, whereas Chilean women, Pimas, and
whites are more predisposed to this disease. Two contributing diseases in
particular have a genetic component and racial distribution. Hemolytic diseases,
including sickle cell disease and hemoglobin C disease, occur almost exclusively
in the black population, although thalassemia also has a Mediterranean
distribution. CF, which occurs mainly in whites, may also contribute to the
formation of biliary sludge and, possibly, acalculous cholecystitis.
The physical examination in acute cholecystitis usually reveals right upper
quadrant tenderness. The classic triad is right upper quadrant pain, fever, and
leukocytosis. The patient may have abdominal guarding and a positive Murphy
sign (ie, arrest of inspiration on deep palpation of the gallbladder in the right
upper quadrant of the abdomen). Omental adherence to the inflamed gallbladder
combined with distension may create a palpable mass between the 9th and 10th
costal cartilages.
In rural Asia, infections with Opisthorchis sinensis or Ascaris
lumbricoides are predisposing conditions. In the United States, these gallstones
are more rare, although they have been found after cholecystectomy in which the
bile was infected (most often by E coli) and in infants and children infected
with Staphylococcus, Enterobacter, Citrobacter, and Salmonella species. In
addition, chronic urinary tract infections may predispose individuals to the
formation of these gallstones, and isolated gallstones associated
with Ascaris have been recorded in the United States.
Many disease processes can precipitate or foster these events. Infection
induces the deconjugation of bilirubin glucuronide, thereby increasing the
concentration of unconjugated bilirubin in the bile. Hemolysis overwhelms the
conjugation abilities of the liver, increasing the amount of unconjugated bilirubin
in the bile. Hemolytic diseases include hereditary spherocytosis, sickle cell
disease, thalassemia major, hemoglobin C disease, and possible uncontrolled
glucose-6-phosphate dehydrogenase (G-6-PD) deficiency. Multiple blood
transfusions also increase the pigment load, which predisposes the bile to the
formation of biliary sludge.
A. . Objectives
a. Nurse Centered
Short Term:
After the initial student nurse-patient interaction, the student nurses
will:
o Establish rapport with the patient.
o Introduce themselves and state their purpose to the patient.
o Use therapeutic communication during nurse-patient interactions.
o Obtain necessary data such as personal information, family history,
and history of past and present illness.
o Perform physical assessment in a cephalocaudal and IPPA
approach.
o Review and monitor diagnostic and laboratory results.
o Provide due care to the patient which includes medical,
pharmacological, and nursing interventions.
Long Term:
After the completion of this case study, the student nurse will:
o Review the medical condition of the patient.
o Identify precipitating and predisposing factors to the occurrence of
the disease condition.
o Review the book-based and patient-based manifestations of the
disease.
o Correlate other factors such as relevant data, laboratory results,
and abnormal findings in the physical assessment.
o Formulate nursing diagnoses and subsequent planning to aid the
patient’s prognosis.
o Implement what has been planned and provide health teachings as
appropriate.
o Evaluate patient’s response to over-all interventions through the
patient’s daily progress chart.
o Provide health teachings upon discharge of the patient such as the
maintenance of medical managements and measures to prevent
reoccurrences or to alleviate aggravating conditions.
b. Patient Centered
Short-Term:
After the initial student nurse-patient interaction, the student nurse
will:
o Acknowledge the presence of student nurse as part of the heal care
team responsible in taking care of her conditions.
o Build up a therapeutic relationship with the student nurse.
o Cooperate in different activities and management done.
o Provide pertinent data and cooperate in physical assessment
procedures.
o Understand the disease process and its complications.
o Comply with the treatment and management at hand.
Long-Term:
After the completion of this case study, the patient will be able to:
o Have a more stable health condition.
o Gain strong compliance and attain optimum level of functioning.
o Gain empowerment and responsibility of maintaining health.
o Apply the health teachings given regarding health promotion,
preventive measures, curative and rehabilitative means in her
everyday life.
A. Personal History
1. Demographic Data
Mrs. Chole is a twenty-seven years old female, and was born on October
17, 1983. Mrs. Chole parents are both Filipino, thus making her a Filipino citizen.
She was baptized under the Roman Catholic Church. She speaks Tagalog and
Pampango but her primary language is Pampango. She is married to Mr.Systitis
they have one child who is 3 years of age. She is living with her mother in law in
Fatima Calutlut City of San Fernando, Pampanga. She was admitted at a tertiary
hospital located at San Fernando City on December 05, 2010 at 3:25 PM.
2. Socio – economic and Cultural Factors
Mrs. Chole belongs to an extended type of family where she lives with her
mother in law. Mrs. Chole is a housewife and sometimes sells viand in their
neighborhood and earns around Php 500 – 800 depending on what kind of viand
she cooked, her husband works as a janitor at PCSO in pampanga and earns
around Php 7,000 – 8,000 per month. Mrs.Chole is a Roman Catholic and
usually go to church every Sunday. She do believe with herbolarios, and she
usually go to the Health Center for checkups. Mrs. Chole does utilize herbal
medicines such as pandan as diuretic and guava leaves as disinfectant. Mrs.
Chole practices self-medication when it comes to OTCs like paracetamol and
mefenamic acid.
B. Family Health-Illness History
Legend:
- Male - Female
- Deceased - Mrs. Chole
Family History:
Mrs. Chole told the researcher that her grandparents have Hypertension
and are still alive. She said that she does not know any persisting disease in her
parents except for hypertension. She is the 4th child among the six children, with
two males and four females. She said that no one in her siblings is already dead
and all are in normal conditions except for 2nd sister and 3rd brother who have
hypertension. She shares that there is no history diabetes mellitus, asthma, CRF
in their family.
C. History of Past Illnesses
+ +
+
Unknown Hypertension HypertensionStroke
HypertensioHypertensio
HypertensioHypertensio
Mrs.Chole had history of fever and coryza, but still, these disappeared
early and have been managed properly. She had German Measles at three years
old, and did not take medications at all. At seven Mrs.Chole, had mumps, and is
not given any medications. She declared that her mother had put “tina” or the
blue powder on Mrs.Chole’ s face, however, did not know what it is for.
Mrs.Chole had her menarche on her twelfth year of life. Aside from the
abovementioned diseases, Mrs.Chole had no other diseases.
D. History of Present Illness
One week Prior to admission Mrs. Chole have an right upper quadrant
pain it is characterized as continous, non-radiating pain, no consultation done
she has a positive edema and facial swelling. Three days prior to admission she
still have that right upper quadrant pain, Mrs. Chole vomited and still no
consultation was done, one day prior to admission they consulted local district
hospital and ultrasound was requested and done results revealed cholecystitis,
they referred Mrs. Chole to the tertiary hospital in San fernado.
A. Physical Examination (Cephalocaudal Approach)
December 05, 2010, Sunday (Chart PA)
HEENT: Anicteric sclera, pale palpebral conjunctiva
CHEST AND LUNGS: SCE, (-) murmurs
ABDOMEN: with right upper quadrant painflat, soft, an positive murphy’s sign
EXTREMITIES: with positve edema, full and equal pulses, pallor
December 06 2010, Monday
General Appearance:
The patient shows signs of weakness. The patient is quiet and is non-responsive.
Vital signs taken and recorded as follows: T= 36.8°C (axilla); PR= 82 bpm;
RR=27 bpm; BP= 100/70 mmHg
SKULL and FACE: Mrs. Chole has round normo-cephalic shaped skull with
absence of nodules or masses. She has symmetric facial features and facial
movements as she was able to smile, frown raise eyebrows and puff cheeks.
She does experience headache at a minimum.
HAIR and SCALP: Mrs. Chole has short, scarcely distributed hair, without
presence of lice or other infestations.
SKIN and NAILS: Mrs. Chole has pale complexion, with good skin turgor. She
has warm and moist skin with absence of nodules. She has smooth, convexly
curved, newly trimmed fingernails and toenails, but of pale color and with
capillary refill of more than 3 seconds upon Blanch test.
EYES and VISION: Eyebrows are evenly distributed and symmetrically aligned
with equal movements. Eyelashes are equally distributed and curled slightly
outward and upward. Eyelids close symmetrically with skin intact and no
discharges or discoloration noted. Bulbar conjunctiva is transparent and sclera
appears white. Palpebral conjunctiva is shiny, smooth but is pale. Lacrimal
ducts have no edema or tearing upon palpation. Pupils are equally rounded,
reactive to light and accommodation. She can see objects in the periphery when
looking straight ahead and is able to read a letter at a given distance.
EARS AND HEARING: Auricles are same as color of facial skin, symmetric and
aligned with canthus of eye. Ears are not tender and recoil after being folded.
She has slight amount of cerumen that is yellowish in color. She can hear
normal voice tone.
NOSE AND SINUSES: Nose is symmetric and straight. It has uniform color and
not tender. Nasal septum is intact and in midline. Air moves freely on both nares
as client breathes. Facial sinuses are not tender.
MOUTH AND OROPHARYNX: Lips are pale, soft and symmetrical. She was
able to purse her lips when she was asked to. She has an incomplete set of
teeth. Gums are pale, though there are no signs of bleeding. Tongue is at
the center and pinkish in color with no lesions, no tenderness and moves freely.
NECK: Neck muscles are equal in size and head is centered. She can move her
head freely with no discomfort. Lymph nodes are not palpable and trachea is in
the midline of neck. Thyroid gland is not palpable. Carotid and jugular veins are
not distended and visible, with no bruit sounds.
THORAX AND LUNGS: Chests are symmetrical in size and expansion. Spine is
vertically aligned. Skin is intact, with no palpable masses or nodules. She has no
rales and crackles heard on the both lung field.
ABDOMEN: Patient has no striae, scars, or visible veins, upon inspection. She
has a positive murphy’s sign, right upper quadrant pain. Normal bowel
sounds.
HEART: Heart rate is regular in rhythm upon auscultation without any murmurs.
Peripheral pulses are symmetrical with that of the apical pulse.
UPPER EXTREMITIES: Skin is uniformly fair in color, with good skin turgor.
Temperature of the skin is uniform in both extremities. Muscles are generally
equal in size on both sides with no tremors or contractures. There are no bone
deformities but there is presence of edema. She was able to adduct and abduct
her arm, supine and prone her hands, shrug her shoulders against resistance,
and flex and extend her arms. She also has good handgrip and was able to
perform the finger-nose test. Muscle strength is graded as five.
LOWER EXTREMITIES: Negative result of Romberg’s test She has bipedal
edema, with shiny, flaky skin. She can extend her legs and flex it.
December 07 2010, Tuesday
General Appearance:
The patient shows signs of weakness. The patient is quiet and is responsive.
Vital signs taken and recorded as follows: T= 37.1°C (axilla); PR= 86 bpm;
RR=20 bpm; BP= 110/80 mmHg
SKULL and FACE: Mrs. Chole has round normo-cephalic shaped skull with
absence of nodules or masses. She has symmetric facial features and facial
movements as she was able to smile, frown raise eyebrows and puff cheeks.
HAIR and SCALP: Mrs. Chole has short, scarcely distributed hair, without
presence of lice or other infestations.
SKIN and NAILS: Mrs. Chole has pale complexion, with good skin turgor. She
has warm and moist skin with absence of nodules. She has smooth, convexly
curved, newly trimmed fingernails and toenails, but of pale color and with
capillary refill of more than 3 seconds upon Blanch test.
EYES and VISION: Eyebrows are evenly distributed and symmetrically aligned
with equal movements. Eyelashes are equally distributed and curled slightly
outward and upward. Eyelids close symmetrically with skin intact and no
discharges or discoloration noted. Bulbar conjunctiva is transparent and sclera
appears white. Palpebral conjunctiva is shiny, smooth but is pale. Lacrimal
ducts have no edema or tearing upon palpation. Pupils are equally rounded,
reactive to light and accommodation. She can see objects in the periphery when
looking straight ahead and is able to read a letter at a given distance.
EARS AND HEARING: Auricles are same as color of facial skin, symmetric and
aligned with canthus of eye. Ears are not tender and recoil after being folded.
She has slight amount of cerumen that is yellowish in color. She can hear
normal voice tone.
NOSE AND SINUSES: Nose is symmetric and straight. It has uniform color and
not tender. Nasal septum is intact and in midline. Air moves freely on both nares
as client breathes. Facial sinuses are not tender.
MOUTH AND OROPHARYNX: Lips are pale, soft and symmetrical. She was
able to purse her lips when she was asked to. She has an incomplete set of
teeth. Gums are pale, though there are no signs of bleeding. Tongue is at
the center and pinkish in color with no lesions, no tenderness and moves freely.
NECK: Neck muscles are equal in size and head is centered. She can move her
head freely with no discomfort. Lymph nodes are not palpable and trachea is in
the midline of neck. Thyroid gland is not palpable. Carotid and jugular veins are
not distended and visible, with no bruit sounds.
THORAX AND LUNGS: Chests are symmetrical in size and expansion. Spine is
vertically aligned. Skin is intact, with no palpable masses or nodules. She has no
rales and crackles heard on the both lung field.
ABDOMEN: Patient has no striae, scars, or visible veins, upon inspection. She
has a positive murphy’s sign, right upper quadrant pain. Normal bowel
sounds.
HEART: Heart rate is regular in rhythm upon auscultation without any murmurs.
Peripheral pulses are symmetrical with that of the apical pulse.
UPPER EXTREMITIES: Skin is uniformly fair in color, with good skin turgor.
Temperature of the skin is uniform in both extremities. Muscles are generally
equal in size on both sides with no tremors or contractures. There are no bone
deformities but there is presence of edema. She was able to adduct and abduct
her arm, supine and prone her hands, shrug her shoulders against resistance,
and flex and extend her arms. She also has good handgrip and was able to
perform the finger-nose test. Muscle strength is graded as five.
LOWER EXTREMITIES: Negative result of Romberg’s test She has bipedal
edema, with shiny, flaky skin. She can extend her legs and flex it.
F. Diagnostic and Lab Procedures
Diagnostic or Laboratory Procedures
Date orderedDate
result(s) in
Indication(s) orPurposes
Results Normal ValuesAnalysis
and Interpretation of Results
CBC> Hemoglobin 12-05-10
12-05-10It evaluates the hemoglobin contents of erythrocytes. It measures the oxygen carrying capacity of the blood since hemoglobin is the primary component of the blood which carries oxygen.
125 g/L 120-160 g/L The client’s result of Hemoglobin is within normal range.
> Hematocrit 12-05-1012-05-10
It is used to measure the volume of RBC in whole blood expressed as percentage. The hematocrit value is roughly three times the hemoglobin concentration.
0.37 0.38-0.40 The client’s result of hematocrit is slightly below range which indicates that the patient’s RBC is low in proportion to whole blood.
> Platelet count
12-05-1012-05-10
It is done to examine the capability of the blood to clot
275 150-400x10^9/L The result is within normal range.
> WBC
> Neutrophils
12-05-1012-05-10
12-05-1012-05-10
A white blood cell count is a determination of number of WBC or leukocytes/unit volume in a sample of venous blood. The test is used to detect infection or inflammation and leukemia, also used to help monitor the body’s response to various treatments and to monitor bone marrow function, and to determine the need for further tests, such as differential count.
12.2
0.78
5.0-10.0
0.18-0.70
The result is above normal which indicates infection.
The result is above normal limits. Neutrophils is greater in amount as compared to other WBC component because in a normal inflammatory response, the neutrophils are the first ones to be release and act on the
> Lymphocytes 12-05-1012-05-10
0.22 0.10-0.48
injured site. Hence, they are greater in number.
The result is within normal range.
> Creatinine
12-05-1012-05-10
More specific to assess renal function because it is not affected by dietary consumption & hydration status.
77.6 umol/L 60-120 umol/L The result is within normal range.
> Potassium 12-05-1012-05-10
To monitor serum K+ level, a determinant of water balance and essential for myocardial contraction.
4.32 mmol/L 3.5-5 mmol/L The result is within normal range.
> Sodium 12-05-1012-05-10
To monitor serum Na level, a determinant of water balance.
132.4 mmol/L 136-145 mmol/L The result is below normal range which may indicate that the patient is dehydrated or has lost fluids due to the disease condition.
Nursing Responsibilities:
Before:
Explain the procedure to the patient.
Tell the patient that no fasting is required.
Inform the patient that this test requires a blood sample and he/she may experience transient discomfort from the
needle puncture and the pressure of the tourniquet.
During:
Collect approximately 5 to 7 ml of venous blood in a lavender-top tube.
Avoid hemolysis.
List on the laboratory slip any drugs that may affect test results.
After:
Apply pressure to the puncture site.
If hematoma develops at the venipuncture site, apply warm soaks. If the hematoma is large, monitor pulses distal
to the venipuncture site.
Ensure that subdermal bleeding has stopped before removing pressure.
Diagnostic or Laboratory Procedures
Date orderedDate
result(s) in
Indication(s) orPurposes
Results Normal Values Analysisand Interpretation of Results
> Urinalysis 12-06-1012-06-10
To monitor fluid imbalances or factor for fluid imbalances.
Color: yellow
Transparency:Slightly turbid
Specific Gravity: 1.015
Sugar: (-)
Reaction: acidic
RBC: 8-12 / HPF
Pus cells:8-10 / HPF
Yellow or Amber
Clear
1.010-1.035
Negative
Acidic
0-3
0-3
Urine color is normal
Turbid urine may contain RBC, WBC, bacteria or fat and may reflect renal infection
Urine specific gravity is normal
There is no sugar present in the urine
The result is normal
RBC in urine is slightly elevated which means there is an infection
This further proves that there is infection.
Nursing Responsibilities:
Before:
Check doctor’s order
Inform the patient about the procedure and explain the importance of the procedure to be done.
Inform the patient that there are no restrictions in food and fluid before the test.
Explain to the patient that this procedure is non invasive; no pain will be felt.
During:
Assist patient by giving him a bed pan.
Advise patient to clean the genitalia first.
Describe the procedure for collecting a clean- catch or midstream specimen.
After:
Chart time of collection of urine specimen.
Attach results to the chart as soon as they are available.
ANATOMY AND PHYSIOLOGY
HEPATOBILLARY TREE
LIVER
A. Location and size of the liver- largest gland in the body, weighs
approximately 1.5 kg; lies under the diaphragm; occupies most of the right
hypochondrium and part of the epigastrium.
B. Liver lobes and lobules- two lobes separated by the falciform ligament
1. Left lobe- forms about one sixth of the liver
2. Right lobe- forms about five sixths of the liver; divides into right lobe
proper, caudate lobe, and quadrate lobe
3. Hepatic lobules- anatomical units of the liver; small branch of
hepatic vein extends through the center of each lobule
C. Bile ducts
1. Small bile ducts form right and left hepatic ducts
2. Right and left hepatic ducts immediately join to form one hepatic
duct
3. Hepatic duct merges with cystic duct to form the common bile duct,
which opens into the duodenum
D. Functions of the liver
1. Glucose Metabolism
-after a meal, glucose is taken up from the portal venous blood by
the liver and converted into glycogen (glycogenesis), which is
stored in the hepatocytes. Glycogen is converted back to glucose
(glycogenolysis) and release as needed into the blood stream to
maintain normal level of the blood glucose.
-glucose can be synthesized by the liver through the process
gluconeogenesis
2. Ammonia Conversion
-use of amino acids from protein for gluconeogenesis result in the
formation of ammonia as a by product. Liver converts ammonia to
urea
3. Protein Metabolism
-Liver synthesizes almost all of the plasma protein including
albumin, alpha and beta globulins, blood clotting factors plasma
lipoproteins
4. Fat Metabolism
-Fatty acid can be broken down for the production of energy and
production of ketone bodies
5. Vitamin and Iron Storage
-stores vitamin A, D, E, K
6. Drug Metabolism
7. Bile Formation
-bile is formed by the hepatocytes
-composed of water, electrolytes such as sodium, potassium,
calcium, chloride, bicarbonate, lecithin, fatty acids, cholesterol, bile
salts
-collected and stored in the gallbladder and emptied in the intestine
when needed for digestion
a. Lecithin and bile salts emulsify fats by encasing them in shells to
form tiny spheres called micelles
b. Sodium bicarbonate increases pH for optimum enzyme function
c. Cholesterol, products of detoxification, and bile pigments (e.g.
bilirubin) are wastes products excreted by the liver and
eventually eliminated in the feces
GALLBLADDER
The gallbladder (or cholecyst, sometimes gall bladder) is a small organ whose
function in the body is to harbor bile and aid in the digestive process.
Anatomy
The cystic duct connects the gall bladder to the common hepatic duct to
form the common bile duct.
The common bile romero duct then joins the pancreatic duct, and enters
through the hepatopancreatic ampulla at the major duodenal papilla.
The fundus of the gallbladder is the part farthest from the duct, located by
the lower border of the liver. It is at the same level as the transpyloric
plane.
Microscopic anatomy
The different layers of the gallbladder are as follows:
The gallbladder has a simple columnar epithelial lining characterized by
recesses called Aschoff's recesses, which are pouches inside the lining.
Under the epithelium there is a layer of connective tissue (lamina propria).
Beneath the connective tissue is a wall of smooth muscle (muscularis
externa) that contracts in response to cholecystokinin, a peptide hormone
secreted by the duodenum.
There is essentially no submucosa separating the connective tissue from
serosa and adventitia.
Size and Location of the Gallbladder
The gallbladder is a hollow, pear-shaped sac from 7 to 10 cm (3-4 inches)
long and 3 cm broad at its widest point. It consists of a fundus, body and neck. It
can hold 30 to 50 ml of bile. It lies on the undersurface of the liver’s right lobe and
is attached there by areolar connective tissue.
Structure of the Gallbladder
Serous, muscular, and mucous layers compose the wall of the gallbladder.
The mucosal lining is arranged in folds called rugae, similar in structure to those
of the stomach.
Function of the Gallbladder
The gallbladder stores bile that enters it by way of the hepatic and cystic
ducts. During this time the gallbladder concentrates bile fivefold to tenfold. Then
later, when digestion occurs in the stomach and intestines, the gallbladder
contracts, ejecting the concentrated bile into the duodenum. Jaundice a yellow
discoloration of the skin and mucosa, results when obstruction of bile flow into
the duodenum occurs. Bile is thereby denied its normal exit from the body in the
feces. Instead, it is absorbed into the blood, and an excess of bile pigments with
a yellow hue enters the blood and is deposited in the tissues.
The gallbladder stores about 50 mL (1.7 US fluid ounces / 1.8 Imperial
fluid ounces) of bile, which is released when food containing fat enters the
digestive tract, stimulating the secretion of cholecystokinin (CCK). The bile,
produced in the liver, emulsifies fats and neutralizes acids in partly digested food.
After being stored in the gallbladder the bile becomes more concentrated
than when it left the liver, increasing its potency and intensifying its effect on fats.
Most digestion occurs in the duodenum.
BILIRUBIN PRODUCTION AND ELIMINATION
Bilirubin is the substance that gives bile its color. It is formed from
senescent red blood cells. In the process of degradation, the hemoglobin from
the red blood cell is broken down from biliverdin, which is rapidly converted to
free bilirubin thru biliverdin reductase. Free bilirubin, which is not soluble in
plasma, is transported in the blood attached to plasma albumin. Even when it is
bound to albumin, this bilirubin is still called free bilirubin. As it passes through
the liver, free bilirubin is released from its albumin carrier molecule and moved
into the hepatocytes. Inside the hepatocytes, free bilirubin is converted to
conjugated bilrubin thru glucoronyl transferase, making it soluble to bile.
Conjugated bilirubin is secreted as a constituents of bile, and in this form, it
passes through the bile ducts into the small intestine. In the intestine,
approximately one half of the bilirubin is converted into a higly soluble substance
called urobilinogen by the intestinal flora. Urobilinogen is either absorbed into the
portal circulation or excreted in the feces. Most of the urobilinogen that is
absorbed is returned to the liver to be re-excreted into the bile. A small amount of
urobilinogen, approximately 5% is absorbed into the general circulation and then
excreted by the kidneys.
Usually, only a small amount of bilirubin is found in the blood; the normal
level of total serum bilirubin is 0.1 to 1.2 mg/dL. Laboratory measurements of
bilirubin usually measure the free and the conjugated bilirubin as well as the total
bilirubin. These are reported as the direct (conjugated) bilirubin and the indirect
(unconjugated or free) bilirubin.
IV. The Patient’s Illness
Precipitating Factors:
Factors Rationale
Diet (high cholesterol,
high calorie, high
sodium)
Increased intake of calories, refined carbohydrate,
cholesterol, and saturated fats has all been
postulated to cause cholesterol gallstones. Patients
with cholesterol gallstones secrete a greater fraction
of dietary cholesterol into bile than do normal
subjects.
Medications and Oral
Contraceptives
Hypolipidemic agents (clofibrate, gemfibrozil) that
lower serum cholesterol by increasing biliary
cholesterol secretion increase the risk of cholesterol
gallstones by twofold to threefold.
Competitive inhibitors of 3-hydroxy-3-methylglutaryl
coenzyme A (HMGCoA) reductase (lovastatin,
simvastatin, pravastatin) decrease biliary
cholesterol saturation.
Estrogen therapy is associated with an increased
risk of developing cholesterol gallstones.
Oral contraceptive steroids increase biliary
cholesterol secretion and saturation but do not
affect gallbladder motility.
Total Parenteral
Nutrition
TPN is a powerful risk factor for gallstone formation.
Gallstones from during TPN because of decreased
gallbladder motility from lack of meal-stimulated
cholesystokinin (CKK) release, resulting in
increased fasting and residual volumes.
Spinal Cord Injury Patients with spinal cord injury have 10% incidence
of forming gallstones within the first year after injury.
This high risk, which is 20 times normal, is believed
to be secondary to abnormal gallbladder motility
and probably biliary hypersecretion of cholesterol
from the progressive reduction in body mass.
Primary Biliary
Cirrhosis
Patients with primary biliary cirrhosis have an
increased prevalence of gallstones. Stone analysis
has not been performed, but the elevated
cholesterol saturation of bile in these patients
suggest that they form cholesterol stones.
Diabetes Mellitus Despite obesity and increased total body
cholesterol synthesis and decreased gallbladder
motility seen in patients with diabetes, diabetes
mellitus itself does not appear to be an independent
risk factor for cholesterol gallstone disease.
Hemolytic Syndromes Inherited hemolytic anemia, sickle cell disease,
sphericytosis, thalassemia, chronic hemolysis
associated with artificial heart vavles, and malaria
dramatically increase the risk of pigment stone
formation because of increased biliary secretion of
total bilirubin conjugates, especially bilirubin
monoglucoronide, at the expense of the bilirubin
diglucuronide, the predominant conjugate in healthy
individuals.
Ileal Disease,
Resection, and Bypass
Patients with ileal dysfunction have a strikingly
increased risk for developing gallstones. Gallstones
develop in 30-50% of patients with ileal Chron’s
disease; the risk correlates positively with the extent
and duration of ileal dysfunction, Although ilieal
disease or resection leads to cholesterol
supersaturation and cholesterol stone formation in
some patients , careful studies now show that most
patients with ilieal dysfuncyion form black pigment,
not cholesterol stones.
Biliary Infection Brown pigment stones are frequently found in the
intrahepatic bile ducts and are always associated
with infection by colonic organisms usually E.coli, or
parasitic infestation (Ascaris lumbricoides, or other
helminthes). Intraductal stones developing after
cholecystectomy are invariable associated with bile
stasis, biliary tree infection, and/or retained suture
material.
Obesity Obesity is strongly associated with increased
gallstone prevalence. The risk is proportional to the
increase in total body fat. Obese people synthesize
more cholesterol in both hepatic and nonhepatic
tissues, transport it to the liver, and secrete more of
it into the bile, leading to bile that is often greatly
supersaturated with cholesterol.
Rapid Weight Loss/
Fasting diets
Obese patients undergoing rapid weight loss (1-2%
of body weight or approximately 1-2 kg/week),
either by very low caloric dieting or gastric stapling,
have a 25-40% chance of developing gallstones
within 4 months. During rapid weight loss, biliary
cholesterol saturation increases acutely as
cholesterol is mobilized from adipose tissue and
skin and secreted into bile.
Predisposing Factors:
Factors Rationale
Gender Women have twice the risk as men of developing
cholesterol gallstones because estrogen
increases biliary cholesterol secretion. Before
puberty this risk is negligible, and beyond
menopause the increased risk disappears.
Advancing Age The incidence increases with age. Less than 5-6%
of the population under age 40 have stones, in
contrast to 25-30% of those over 80.
Race Prevalence highest in North American Indians,
Chilean Indians, and Chilean Hispanics, greater in
Northern Europe and North America than in Asia,
lowest in Japan; familial disposition; hereditary
aspects
Heredity Family history alone imparts increased risk, as do
a variety of inborn errors of metabolism that lead
to impaired bile salt synthesis and secretion or
generate increased serum and biliary levels of
cholesterol, such as defects in lipoprotein
receptors (hyperlipidemia syndromes), which
engender marked increases in cholesterol
biosynthesis.
Parity/ Pregnancy Pregnancy is an independent risk factor for
cholesterol gallstones. The risk increases with
increasing parity, especially with more than two
children. During pregnancy, elevated estrogen
and progesterone levels increase biliary
cholesterol secretion. Elevated progesterone also
inhibits gallbladder contractility. 40% of women
develop biliary sludge in their gallbladder and 12%
of women form their first stones during pregnancy.
Symptomatology:
Symptoms Rationale
Biliary Colic/ Moderate to
Severe Pain
The most common symptom is in pain the right
upper part of the abdomen or epigastrium. This
can cause an attack of abdominal pain, called
biliary colic, which: develops quickly, is severe,
lasts about one to three hours before fading
gradually, isn't helped by over-the-counter and
isn't helped by passing wind. The pain may
radiate to the back, right scapula or shoulder.
The pain often begins suddenly following a
meal. The pain of biliary colic is caused by the
functional spasm of the cystic duct when
obstructed by stones, whereas pain in acute
cholecystitis is caused by inflammation of the
gallbladder wall.
Tenderness Palpation of the abdomen frequently elicits
localized tenderness in the right upper
quadrant which is associated with guarding
and rebound tenderness.
Murphy’s Sign The patient with acute inflammation of the
gallbladder might have a positive Murphy’s
sign, which is inspiratory arrest during deep
palpation in the right upper quadrant.
Nausea and Vomiting These signs and symptoms may accompany a
gallbladder attack. Pain is usually
accompanied by nausea and vomiting.
Fever and chills Gallstones sometimes get trapped in the neck
of the gallbladder and can cause persistent
pain that lasts more than several hours and is
accompanied by fever, also due to the irritation
and inflammation of the gallbladder wall.
Fever occurs in about one third of people with
acute cholecystitis. The fever tends to rise
gradually to above 100.4° F (38° C) and may
be accompanied by chills
Loss of appetite and
Anorexia
The pain often begins suddenly following a
large or rich meal. People tend not to eat,
especially fatty or oily foods, in order not to
experience that pain. Fat absorption is also
impaired for the lack of bile salts, As a result,
rapid loss of weight and anorexia can occur.
Pathophysiology
Risk factor Heredity Obesity Rapid Weight Loss, through diet or surgery Age Over 60 Female Gender Diet-Very low calorie diets, prolonged fasting,
and low-fiber/high-cholesterol/high-starch diets.
Bile must become supersaturated with
cholesterol and calcium
Bile must become supersaturated with
cholesterol and calcium
The solute precipitate from solution as solid
crystals
The solute precipitate from solution as solid
crystals
Crystals must come together
and fuse to form stones
Crystals must come together
and fuse to form stones
Gallstones
Gallstones
Obstruction of the cystic duct and common bile duct
Jaundice Jaundice Sharp pain in the right part of
abdomen
Sharp pain in the right part of
abdomen
Distention of the gall bladder
Venous and lymphatic drainage
is impaired
Venous and lymphatic drainage
is impaired
Proliferation of bacteria
Proliferation of bacteria
Localized cellular irritation or infiltration or both take place
Localized cellular irritation or infiltration or both take place
Areas of ischemia
may occur
Areas of ischemia
may occur
Cause of fever Cause of fever
Inflammation of gall bladder
Cholecystitis
Cholecystotomy
The operation of making an opening in the gall bladder, as for the removal of a gallstone.
Surgical Incision
Disruption of skin, tissue and muscle integrity
Stimulation of sensory nerve endings
PainPain
Destruction of skin layers
Impaired Skin integrity
Impaired Skin integrity
Broken skin and traumatized tissue
Destruction of Skin Layers
Increased risk for environmental exposure
to pathogens
Risk for InfectionRisk for Infection
Broken Skin and traumatized tissue
V. The Patient’s Care
IVF:
INTRAVENOUSFLUID
DATE ORDERED/DISCONTINUED
GENERALDESCRIPTION
INDICATION CLIENT’S RESPONSE TO TREATMENT
D5W x KVO via microset
Date ordered:12-05-10
Date discontinued:12-06-10
D5W is an isotonic solution which neither causes cells to swell nor shrink. However, the dextrose component is easily metabolized by the body making the solution hypotonic later on causing cells to swell.
It is used in repairing electrolyte and acid/base imbalances, and also includes total and partial, parenteral nutrition solutions.
The patient tolerated the IVF well.
Nursing Responsibilities:
Before starting IV therapy, consider duration of therapy, type of infusion, condition of veins and medical condition
of the patient to assist in choosing IV site.
Explain the procedure and its purpose to the patient.
After initiation of IV therapy, monitor patient frequently for signs of infiltration, phlebitis, sins of fluid overload or
dehydration.
OXYGEN THERAPY
DATE ORDERED/DISCONTINUED
GENERALDESCRIPTION
INDICATION CLIENT’S RESPONSE TO TREATMENT
O2 inhalation at 2-3LPM via nasal cannula
Date ordered:12-05-10
Date discontinued:12-05-10
Oxygen is an odorless, tasteless, colorless, transparent gas that is slightly heavier than air. It can be dispensed from a cylinder, piped-in system, liquid O2 reservoir or O2 concentration. It is generally prescribed when the amount of O2 in the blood and tissues are not sufficient to meet the body’s need.The most common intervention to improve gas exchange between the alveoli and the blood by increasing the concentration of oxygen in the inspired air and to assist the patient to meet cellular oxygen demand.
To treat the harmful and possible lethal effects of hypoxemia, and to decrease myocardial workload.
Relief in discomfort brought by difficulty of breathing.
Nursing Responsibilities:
Inform the patient that the oxygen therapy may be done to reduce risk of complications.
Be sure that you are giving the right amount and regulation to the right patient.
Instruct the client and the visitors about the hazard of smoking with oxygen use.
Make sure that the electrical devices are in good working condition to prevent the occurrence of short-circuit
sparks.
Drugs:
GENERIC/BRAND NAME
DATE ORDERED/ DISCONTINUED
DOSAGE, ROUTE AND
FREQUENCY
GENERALACTION
MECHANISM OFACTION
INDICATION/PURPOSE
CLIENT’S RESPONSE
Meperidine HCl / Demerol
Dates given:12-05-1012-06-10
25 mg IV PRN for pain
Opioid agonist analgesic
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 as those mediating the effects of endogenous opioids.
Relief of moderate to severe acute pain.
The patient was relieved of pain.
Ampicillin + Sulbactam
Dates given:12-05-1012-06-10
750mg + 50cc D5W to run in soluset BID
Antibiotic, Penicillin
Bactericidal action against sensitive organisms; inhibits synthesis of bacterial cell wall, causing cell death.
Treatment of infections cause by susceptible strains of Shigella, Salmonella, E. coli, H. influenzae, P. mirabilis, N. gonorrhoeae, enterococci, gram-positive organisms
Signs of infection such as fever were prevented.
Nursing Responsibilities:
Prepare the medication with correct dosage.
Administer the medication on the right route.
Clean the IV line where the drug is being administered.
Observe the patient for any reaction to the drug.
Advise patient to report fever, diarrhea and allergy.
To enhance absorption, give drug with meals.
Protect drug from light.
Monitor electrolyte levels, fluid intake and output, weight and blood pressure.
Inform the patient that eggs and milk, coffee and tea consumed with a meal or 1 hour after may significantly inhibit
absorption.
Do not crush or chew sustained release products.
Inform that it may cause change in stool color, abdominal cramps, diarrhea, or constipation.
Inform patient that citrus fruits enhance iron absorption.
Diet:
DIET REGIMEN
*DATE ORDERED/ **DISCONTINUED
GENERAL DESCRIPTION
INDICATIONSSPECIFIC FOODS
TAKENCLIENT’S RESPONSE
NPO*12-05-10**12-06-10
The patient is not allowed to eat or drink anything, including oral meds.
NPO status is prescribed because the patient’s chief complaint was vomiting. NPO status would prevent complications with regards to the patient’s GI.
Patient followed the diet.
Activity and Exercise:
EXERCISE REGIMEN *DATE ORDERED/ **DISCONTINUED
GENERAL DESCRIPTION
INDICATIONS CLIENT’S RESPONSE
Complete Bed Rest with Bathroom Privileges
*12-05-10**12-06-10
CBR with BRP is wherein the patient is instructed to stay in bed without any kind of strenuous activity except for going to the bathroom.
This is to reduce the metabolic demand of the body, especially the organs when a patient is experiencing a disease condition that requires rest.
Patient was cooperative with the activity.
A. Nursing Management
a) NCP (Nursing Care Plan)
a. Acute Pain
b. Risk for Hyperthermia
c. Risk for Impaired skin integrity r/t mechanical process (surgery)
d. Self-care deficit related to pain or discomfort
e. Risk for Infection r/t inadequate primary defenses
1. Acute Pain
ASSESSMENTNURSING
DIAGNOSIS
SCIENTIFIC
EXPLANATIONPLANNING
NURSING
INTERVENTIONSRATIONALE
EXPECTED
OUTCOME
S> Patient may
report:
-pain in the
surgical
incision site
- pain is felt
post
operatively
- dyspnea
O>Patient may
manifest:
-pain scale
greater than
5/10
-altered v/s
-restlessness
-fatigue
-elevated PR
-guarding
Acute pain Fracture itself
causes pain, but
in addition to this,
surgical
intervention also
leads to
stimulation of
pain receptors.
Pain is one of the
common
symptoms of post
operative
patients. Noxious
stimuli (bleeding)
causes release of
biochemical
mediators
(prostaglandin,
bradykinin,
Short-term:
After 4 hrs.
of NI, the
patient’s
pain scale
will
decrease
Long-term:
After 2 days
of NI, the
patient will
demonstrate
techniques
on how to
manage the
pain, if pain
occurs such
>Monitor and
record vital signs
>Assess pt’s
condition, perform
a comprehensive
assessment of
pain to include
location,
characteristics,
onset/duration,
frequency, quality
or severity and
precipitating or
aggravating
factors
>position in
comfortable
position
>Perform pain
>To obtain
baseline data
>To determine
extent of
condition, have a
basis for future
comparison, and
determine
appropriate
nursing
interventions to be
carried out to
alleviate the pain
>to provide non-
pharmacological
Short-term:
the patient’s
pain scale
shall have
decreased
Long-term:
The patient
shall have
demonstrated
techniques on
how to
manage the
pain, if pain
occurs such
behavior
-facial mask
-sleep
disturbance
-autonomic
alteration in
muscle tone
serotomin,
histamine,
substance P)
which then lead
to sensitization of
nociceptors
(receptors
responsible for
pain).
Transmission of
this pain
impulses will
occur in the
peripheral nerve
fibers to spinal
cord through the
spinothalamic
tract to brainstem
and thalamus
then to somatic
sensory cortex
where pain
as
relaxation
techniques
(deep
breathing
exercises).
assessment each
time pain occurs.
>Encourage pt. to
take a nap.
>plan care with
rest periods
>encourage
verbalization of
pain
>Encourage use
of relaxation
techniques like
deep breathing
>Instruct pt. to
increase intake of
foods, rich in vit.
C, CHON and
iron
>Instruct the
patient to
increase oral fluid
intake as ordered
pain
management.
>to know if the
pain is
progressing or
not.
>to divert feeling
of pain
> To
lessen/prevent
fatigue
>to assess pain
and involve
patient in plan of
care
>To provide
nonpharmacologic
management
>To provide
adequate nutrition
as relaxation
techniques
(deep
breathing
exercises).
perception
occurs. The client
becomes
conscious to pain
when it reaches
the cortical
structure. Then
for the client to
elicit a reaction it
will travel down
from neurons of
brainstem to the
spinal cord which
releases
biochemical
mediators
(opioids,
serotonin, and
norepinephrine).
>administer
analgesics as
ordered >To prevent
dehydration
>to decrease
painful sensation
2. Risk for Hyperthermia
Assessme
nt
Nursing
Diagnosis
Scientific
Explanation
Objectives Nursing
Intervention
Rationale Evaluation
S>Ø
O>The
patient
may
manifest:
increased
body
temp.
above
normal
range
(38)
flushed
skin
increased
RR
(tachypn
ea)
Risk for
Hyperthermia
It is caused by the
fever producing
substance known as
“pyrogens.” These
pyrogens are
secreted by toxic
bacteria or released
by degenerating
tissue of the body. It
is believed that this
substance stimulate
the release of the
second substance
known as leukocyte
which have been
drawn. This
leukocyre pyrogens
goes to the
bloodstream and
Short term:
After 4 hours of
Nursing
Interventions,
the patient’s
temperature
will decrease
from 38 to the
normal range
(36.5 C- 37.5
C)
Long term:
Patient will
maintain a
normal
temperature
>Establish rapport
>Assess patient’s
condition
>Monitor vital signs
> Perform TSB
>Loosen the
constrictive clothing
>Place cold
compress in the
forehead.
>Keep patient’s
>To gain
patient’s trust
>To monitor
physiologic
condition
>To have a
baseline data
>To facilitate
loss of heat
through the
process of
conduction and
evaporation
> To improve
ventilation
>Heat is lost
through
conduction
Short term:
Patient’s
body
temperature
shall have
decreased
from 38 to
37.5
Long term:
Patient shall
have
maintained
a normal
temperature
seizures stimulates the heat
regulating center, the
thermostat which is
the hypothalamus
and set it to a febrile
state, Febrile level of
the hypothalamus in
which there will be an
increase in
epinephrine
vasoconstriction.
back dry
>Provide adequate
ventilation
>Encourage
adequate fluid
intake
>Encourage
adequate rest.
>Provide
comfortable
beddings/ linens
> Administer drugs
such as anti-
pyretics as ordered
>Provide
supplementary
>To prevent
further
complication
>To promote
heat loss by
means of
convection
>To prevent
dehydration
>To reduce
oxygen demand
and
consumption.
>To promote
comfort and
prevent skin
irritations
>To aid in re-
setting core
temperature.
>To offset
.
oxygen as needed
and ordered
increased
oxygen demands
and consumption
3. Risk for Impaired skin integrity r/t mechanical process (surgery)
ASSESSMEN
T
NURSING
DIAGNOSIS
SCIENTIFIC
EXPLANATIO
N
PLANNINGNURSING
INTERVENTIONSRATIONALE
EXPECTED
OUTCOME
S> Patient
may report:
-itching
-numbness of
surrounding
area
O>pt may
manifest:
-edema or
inflammation
of the
surrounding
Impaired skin
integrity r/t
mechanical
process
(surgery).
Because of the
surgery, the
patient is
expected to
have an
incision site.
Thus impairing
the integrity of
the skin,
making it more
prone to
invasion of
microorganism
Short term:
After 4hrs, of
NI, the
patient will
be able to
participate in
preventive
measures to
improve skin
integrity
Long term:
After 2 days
> Assess pt’s
condition. Monitor
and record VS
>Assess for dry
scaling skin
>Assess for pruritus
>Note changes in
skin color, texture
> to gather
baseline data
> Uremic skin
does not have the
usual amount of oil
because of
decreased sweat
and oil glands
>Pruritus can be
caused by dry skin
or accumulation of
nitrogenous waste
Short term:
The patient
shall have
participated in
preventive
measures to
improved skin
integrity
Long term:
A The patient
shall have
area
-poor skin
turgor
-dry, scaly
skin
-erythema
-disruption of
skin surface
(epidermis)
-destruction
of skin layers
(dermis)
-invasion of
body
structures
s. of NI, the
patient will
display
timely
healing of
skin lesions/
wounds
without
complication
s
and turgor.
>Periodically
measure affected
area.
>Keep area clean,
dry and stimulate
circulation.
>Use appropriate
padding devices.
>Encourage early
ambulation or
mobilization.
>Instruct the patient
to wear loose fitting
clothing when
in the blood
>restrictive
clothing can
increase risk of
skin breakdown
>To determine
severity of the
condition.
>To monitor
progress of
healing.
>To decrease
potential skin
breakdown.
>To reduce
pressure and
enhance
circulation to
compromised
area.
>To promote
circulation and
displayed
timely healing
of skin
lesions/woun
ds without
complications
edema is present
>Stress the
importance of not
scratching skin and
keeping fingernails
short
>Instruct patient to
perform proper hand
washing
>Suggest use of
TSB for bathing
reduce risk
associated with
immobility.
>Scratching can
cause lesions and
open sores
> To prevent
transmission of
micro organism
>Increased
warmth can
increase the
itching
4. Self-care deficit related to pain or discomfort
Assessmen
t
Diagnosis Scientific
Explanation
Objectives Interventions Rationale Desired
Outcomes
S = Ø
O = Patient
Self care
deficit
related to
Due to the
different factors
namely pain,
SHORT
TERM:
After 5 hours
> establish
rapport
> to gain the trust
and compliance of
the client
SHORT
TERM:
The patient
may
manifest:
> inability to
prepare
food for
ingestion
>inability to
wash body
or body
parts
>impaired
ability to
obtain or
replace
articles of
clothing
>inability to
carry out
proper toilet
function and
hygiene
pain or
discomfort
discomfort and
musculoskeletal
impairment that
the surgical
procedures can
produce, the
ability of the
patient to move
and perform
activities will be
impaired. Such
impairment to
mobility and
activities may
prevent the client
from performing
his self care
activities hence
deficit on self
care can occur.
of nursing
interventions,
the patient will
be able to
identify
individual
areas of
weakness.
LONG TERM:
After a week
of nursing
interventions,
the patient will
be able to
demonstrate
technique/lifes
tyle changes
to meet self-
care needs.
> monitor vital
signs
>identify degree
of individual
impairment
>assess skills and
strengths of the
client
>Promote
client/SO
participation in
problem
identification and
decision making
>assist with
rehabilitation
program
>provide privacy
during personal
>to establish
baseline data
>to help in the
determination of
the measures to be
implemented
>to capitalize on
this strenght when
formulating plan of
care
> enhances
commitment to
plan optimizing
outcomes
>to enhance
capabilities
>to decrease the
anxiety of the
patient
will have
been able
to identify
individual
areas of
weakness
LONG
TERM:
The patient
will have
been able
to
demonstrat
e
technique/li
festyle
changes to
meet self-
care
needs.
care activities
>assist with
necessary
adaptations to
accomplish
ADL’s; begin with
easily
accomplished
tasks
>identify energy
saving behaviors
>review safety
concerns and
modify activities
or environment
>to encourage
client and build on
success
>to prevent fatigue
>to prevent injuries
5. Risk for Infection r/t inadequate primary defenses
ASSESSMEN
T
NURSING
DIAGNOSIS
SCIENTIFIC
EXPLANATIO
N
PLANNINGNURSING
INTERVENTIONSRATIONALE
EXPECTE
D
OUTCOM
E
S>Ø
O>The
patient may
manifest:
>increase in
body
temperature
>fatigue
>weakness of
muscles
>restlessness
>erythema
and
inflammation
Risk for
infection
related to
inadequate
primary
defenses
The skin is the
largest organ
in the body, it
is our physical
barrier against
friction and
shearing
forces and
protection
against
infection,
chemicals,
ultraviolet
irradiation,
particles. Due
Short term:
After 4 hours
of nursing
intervention
the patient
will verbalize
understandin
g of
individual
causative/risk
factors
>Monitor vital
signs.
>Assess patient for
causative factors.
>Wash hands
thoroughly with
warm water, soap,
and friction before
and after providing
client care. Teach
client to wash her
>To have a baseline
data
>To determine which
areas will be given
more attention to in
preventing
aggravation of the
condition.
>Effective hand
washing removes
pathogenic
organisms from the
hands thus
preventing the
transmission of micro
Short
term:
After 4
hours of
nursing
interventio
n the
patient
shall
verbalize
understand
ing of
individual
causative/ri
sk factors
of incision site to the surgical
incision,
pathogens or
microorganism
s that
contaminates
in the skin can
freely enter the
body cavity
and can cause
harmful effects
of infection.
Long term:
After 3 days
of nursing
intervention
the patient
will
demonstrate
techniques.
Lifestyle
changes to
promote safe
environment
hands before and
after using the
bathroom,etc.
>Monitor lab values
as obtained. Notify
caregiver of any
abnormal values.
>Instruct patient to
maintain dry and
clean environment.
>Teach client of
infection to report:
fever, abdominal
tenderness, foul
vaginal discharge.
>Administer
medications as
ordered.
organisms.
>Allows early
identification of
infectious and allows
prompt treatment.
>Decreases dark
moist environment,
which enhances
growth of micro-
organisms.
>Provides
information the client
needs to identify
infections early.
>To prevent
infection.
Long
term:
After 3
days of
nursing
interventio
n the
patient
shall
demonstrat
e
techniques
. Lifestyle
changes to
promote
safe
environme
nt
b) Actual SOAPIERs
FIRST STUDENT-NURSE INTERACTION, 2nd Hospital day (December 6,
2010)
S > O
O > Received patient on bed on supine position, conscious and coherent, with an
ongoing IVF of D5W x KVO via microset @ 100 cc level regulated infusing well
on the left hand, with good skin turgor; with an initial VS of the following: T=
36.8°C (axilla); PR= 82 bpm; RR=27 bpm; BP= 100/70 mmHg
A >Acute Pain
P > After 2 hours of nursing interventions, the patient will decrease pain
sensation from 7/10 to 5/10
I > established rapport.
> Assessed general condition/appearance.
> Ascertained knowledge of safety needs and injury prevention.
> Assessed pain sensory
> Monitored and recorded vital signs
> PM care rendered
> Provided regular skin and oral care
> Repositioned client every 2 hours
>Provided safety and comfort measures
> Instructed patient to request assistance as needed.
> identified energy-conserving techniques.
E > Goal Met; the patient decreased pain sensation
SECOND STUDENT-NURSE INTERACTION, 3rd Hospital day (December
7, 2010)
S > O
O > Received patient on bed on supine position, conscious and coherent, with no
IV fluid attached, with good skin turgor; with an initial VS of the following: T=
37.1°C (axilla); PR= 86 bpm; RR=20 bpm; BP= 110/80 mmHg
A > Acute Pain
P > After 2 hours of nursing intervention, the patient’s pain scale will decrease
from 10/10 to 7/10.
I > Established rapport.
> Assessed general condition/appearance.
> Assessed for referred pain
> Encouraged use of relaxation techniques
> Encouraged diversional activities
> repositioned every 2 hours
> Encouraged adequate rest periods
> encouraged early ambulation
> Maintained adequate hydration
E > Goal Met AEB patient’s pain scale of 7/10.
VI. CLIENT’S DAILY PROGRESS IN THE HOSPITAL
1. Client’s daily progress chart (From admission to discharge)
DAYS
(Specific date)
Admission
(12/05/10)
2
(12/06/10)
3
(12/07/10)
Nursing problems
a. Acute Pain
b. Risk for Hyperthermia
c. Risk for Impaired skin integrity r/t mechanical
process (surgery)
d. Self-care deficit related to pain or discomfort
e. Risk for Infection r/t inadequate primary defenses
*
*
*
*
*
*
Vital Signs
1. Temperature
2. Pulse Rate
3. Respiratory rate
4. Blood pressure
No records found T= 36.8°C
(axilla)
; PR= 82 bpm;
RR=27 bpm;
BP= 100/70
mmHg
T= 37.1°C (axilla);
PR= 86 bpm;
RR=20 bpm;
BP= 110/80
mmHg
DIAGNOSTICS/ LAB procedures
1. CBC
2. Urinalysis
*
*
Medical Mgmt.
1 D5W x KVO via microset
2. O2 inhalation
*
*
*
Drugs
1. Meperidine HCl / Demerol
2. Ampicillin + Sulbactam
*
*
*
*
Diet
1. NPO* *
Activity/ exercise
1. CBR with BRP * *
VII. CONCLUSION
After doing such case, the group have conclude and learned that
Cholecystitis, which has long been considered an adult disease, is quickly
gaining recognition in medical practice because of the significant documented
increase in nonhemolytic cases over the last 20 years. Gallbladder disease is
common throughout the adult population. Most information related to morbidity
and mortality in gallstone disease is related to the adult population, although
some trends can be extracted and applied to the pediatric population.
The physical examination in acute cholecystitis usually reveals right upper
quadrant tenderness. The classic triad is right upper quadrant pain, fever, and
leukocytosis. The patient may have abdominal guarding and a positive Murphy
sign (ie, arrest of inspiration on deep palpation of the gallbladder in the right
upper quadrant of the abdomen). Omental adherence to the inflamed gallbladder
combined with distension may create a palpable mass between the 9th and 10th
costal cartilages.
Surgery is one of the most medical/surgical interventions needed to be
done so as to remove the inflammation. Preventing of it such as low salt low
fat diet or balanced diet is the top priority to prevent the occurrence of the
disease process.