CHRONIC CALCULOUS CholeCYSTITIS

Group III Case Presentation

Janfil Roy L. Gealon

Lisa Mar G. Elgario

Abegail F. Fiedacan

Joyce Ann B. Quicho

Valeen Eleanore C. Pacaldo

TABLE OF CONTENTS

I. NURSING HEALTH HISTORY

i. Introduction 3

ii. Biographic/Demographic Data 4iii. History of Present Illness 4iv. Past Health History 4

Childhood Illnesses Immunizations Hospitalizations Current Medications

v. Family History of Illness 5vi. Lifestyle/Activities of Daily Living 5

II. PHYSICAL ASSESSMENT 6

III. LABORATORY/DIAGNOSTIC EXAMINATION RESULTS 8

IV. MEDICATIONS AND TREATMENTS GIVEN 9

V. ANATOMY AND PHYSIOLOGY 11

VI. PATHOPHYSIOLOGY OF THE DISEASE 13

VII. PRIORITIZED LIST OF NURSING PROBLEMS 15

VIII. NURSING CARE PLAN 16

IX. DISCHARGE PLAN 22

i. Medicationsii. Exercise

iii. Treatmentiv. Health Teachingv. Out Patient (Follow-up Consultation)

vi. Dietvii. Spiritual

I. NURSING HEALTH HISTORY

i. INTRODUCTION

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Gallbladder plays a major role in the digestive process. Despite its importance in the digestion of fat, many people are unaware of their gallbladder. Fortunately enough, the gallbladder is an organ that people can live without. Perhaps, this fact contributes to the laxity of the majority. The gallbladder tends to be taken for granted – ignored of the proper care and conditioning, such in the case of our chosen patient for our case presentation.

Lifestyle together with heredity, sex, race and age are just some factors that leave a room for gallbladder complications to occur. In the case of our patient, his diet along with his sedentary lifestyle would be the precipitating factors that lead him to have Cholelithiasis, presence of stones to gallbladder. He was first diagnosed to have Cholelithiasis two years ago but due to his negligence it leads to another complication of Cholecystitis, inflammation of the gallbladder.

Last May 28, he underwent a procedure called Cholecystectomy. The patient was placed under General Anesthesia and then a surgical incision is made at the right upper quadrant of the abdomen to surgically remove the gallbladder.

General Objectives:This case study will help and serve us to enhance our knowledge and to understand more

information about Cholelithiasis and Cholecystitis, thus to give us an idea of how we could give proper nursing care for our clients with this condition, and so that we could apply them on our future exposures as nurses.

Specific Objectives:This case study aims to determine “How the patient acquired the illness and the process by which

the body responds to the situation”. This also specifically attempts to answer the following questions:

What are Cholelithiasis and Cholecystitis? What system, organs or parts of the body are affected by the disease process? Where and how the illness was obtained, how it progressed and affected the body? What were the predisposing factors that lead the patient to acquire the disease? What interventions are needed to manage such condition? Were the interventions effective in helping the patient recover?

PrevalenceAn estimated 10-20% of Americans have gallstones, and as many as one third of these people

develop acute cholecystitis. Cholecystectomy for either recurrent biliary colic or acute cholecystitis is the most common major surgical procedure performed by general surgeons, resulting in approximately 500,000 operations annually. Cholelithiasis, the major risk factor for cholecystitis, has an increased prevalence among people of Scandinavian descent, Pima Indians, and Hispanic populations, whereas cholelithiasis is less common among individuals from sub-Saharan Africa and Asia.

In Palawan Adventist Hospital alone, there are 11,300 case rates of patients who had “Calculous of gallbladder with other cholecystitis, chronic cholecystitis and cholecystitis with cholelithiasis.”

ii. BIOGRAPHIC/DEMOGRAPHIC DATA

Name: EEM

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Address: Honda Bay

Age: 37 years old

Birthdate: July 17, 1976

Gender: Male

Religious Affiliation: Roman Catholic

Marital Status: Single

Occupation: Event Host (Freelancer)

Room Number: 320 bed 1

Chief Complaint: Severe abdominal pain

Provisional Diagnosis: Cholelithiasis

Post-operative Diagnosis: Chronic Calculous Cholecystitis

Attending Physician: Dr. Sabando

iii. HISTORY OF PRESENT ILLNESS

Last December 2011, the patient was on a Christmas party drinking alcohol with friends when he felt severe abdominal pain. So his friends took him to a hospital in Pasig, he underwent ultrasound and was diagnosed to have gallstones. He was advised to have an operation but he refused. The patient only requested a medicine for his severe pain so he was given Tramadol. “Umiinom lang ako ng Tramadol pag sobrang sakit na ng abdomen ko, siguro I took that for 2 consecutive years then I stopped.” the patient claimed. After taking Tramadol for 2 years, the pain suddenly stopped so he did not take any pain medications.

One month prior to confinement, the patient again experienced right upper quadrant tenderness, intermittent, colicky pain. So he took Tramadol but felt only temporary relief. “Sobrang sakit na talaga ng tiyan ko noon, nawalan na din ako ng appetite. Kapag kakain ako sinusuka ko lang.” the patient said. Three days prior to confinement, the patient and his friends noticed the yellowing of his sclera and skin, so he decided to consult a doctor.

iv. PAST HEALTH HISTORY

1. Childhood illnessesThe patient usually experienced common colds and cough during his childhood and was

never been confined in a hospital.2. Immunizations

Mr. EEM verbalized that he was unsure if he had and completed his immunizations. He was unable to confirm that information due to family problems.

3. HospitalizationsAccording to Mr. EEM he was hospitalized on December 2011 when he felt severe

abdominal pain. He was diagnosed to have gallstones. He only stayed there for two days after he refused to undergo an operation to remove the stones.

4. Current MedicationsPrior to hospitalization the patient has been taking Tramadol to relieve the abdominal

pain that he was experiencing. No other medications other than that, according to the patient. Not even vitamins.

v. FAMILY HISTORY OF ILLNESS

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The patient said that both sides of his parents have a history of hypertension. They also have a

history of leukemia on his father’s side and tumor on his mother’s side. There is no family history

of Diabetes Mellitus on both sides of his parents.

vi. LIFESTYLE/ACTIVITIES OF DAILY LIVING

ADL Before Hospitalization During Hospitalization Interpretation & AnalysisNutrition The patient is fond of

eating fatty foods, he only take small amount of vegetables and fruits. He said that his favorite dish is liempo and sinigang na baboy. He drinks 8-10 glasses of water a day.

Two days after his operation, he was given a soft diet. Mostly soups and eggs are served to him.

Since he is a post-operative patient, soft diet will help him to have loose stools so he won’t need to strain himself when defecating.

Protein rich diet will also help for faster wound healing.

Elimination The client did not have any problems with his urination and bowel movement. He urinates approximately six times a day and defecates once a day.

The patient said that he’s having a problem when defecating because he is anxious about his post-operative site.

Anxiety is usually expected to patients who underwent operation. They are afraid to move and strain themselves. But since he is on a soft diet, his stool is probably loose.

Exercise The client did not engage in formal exercise. “Parang sedentary lifestyle kasi ako.”

After his operation, he was only confined to bed, having a hard time in moving because of his post-operative site.

Obviously, the patient cannot have enough activity because of his condition. However, he is recommended to ambulate early for fast recovery.

Hygiene The patient takes a bath a minimum of twice a day and does other hygienic activity.

The patient does his hygiene with the help of his friends.

Few days after the operation would be difficult for the patient to move so he needs the help of his friends to maintain a good hygiene.

Hygiene is very important for him because improper hygiene could bring infection to his surgical incision.

Sleep and rest The patient said that he finds difficult to sleep at night. He usually sleeps at 2am and wakes up at 11am.

The patient still have a hard time to fall asleep because of the environment.

One factor of good sleeping pattern is the environment. The patient doesn’t get enough sleep because he is not comfortable with his environment.

Substance use The patient claimed that he is a smoker. He smokes 1 pack per day and is an alcohol drinker.

During his hospitalization, the patient refrained himself from smoking cigarette.

It is advised to patients who are admitted to refrain from smoking inside the hospital facilities. It will also aid him for faster recovery.

II. PHYSICAL ASSESSMENT

Norms Actual Findings Interpretation and AnalysisGeneral Appearance1. Posture/Gait

2. Note obvious signs of health or illness (skin color)

3. Personal Hygiene/ Grooming

5. Age Appropriateness

Relaxed/ erect posture; coordinated movement

Healthy Appearance

Clean, neat

Appropriate to Age

Relaxed, lying on bed

Slightly yellowish

Clean, fresh-looking

Appropriate to Age

Normal for post-operative patients but is recommended to ambulate early.

Cholestatic jaundice develops as a consequence of bile flow obstruction.

Normal

Normal

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6. Verbal Behavior Exhibits thoughts ofAssociation

Answers questions properly

Normal

Measurements Pre-operative:1. Temperature2. Pulse Rate3. Respiratory Rate4. Blood Pressure

Post-operative:1. Temperature2. Pulse Rate

3. Respiratory Rate4. Blood Pressure

36.5 C-37.5 C80 (60-100) bpm16 (12-20) cpm120/80 mmHg

36.5 C-37.5 C80 (60-100) bpm

16 (12-20) cpm120/80 mmHg

36.6 C96 bpm20 cpm120/90 mmHg

37.3 C105 bpm

22 cpm130/90 mmHg

NormalNormalNormalNormal for age group

NormalIncreased; patients who are in pain usually have increased vital signs.IncreasedIncreased

Body Part Norms Actual FindingsInterpretation and

AnalysisSkin1. Inspect skin color.

2. Inspect uniformity of skin color.

3. Observe and palpate skin moisture.

Varies from light to deep brown; from ruddy pink to light pink; from yellow overtones to olive.

Generally uniform except in areas exposed to the sun; areas of lighter pigmentation (palms, lips, nail beds) in dark-skinned people.

Moisture in skin folds and axillae

Slightly yellowish

Uniform

Moisture in skin folds and axillae

Cholestatic jaundice develops as a consequence of bile flow obstruction.

Normal

Normal

External Eye Structure1. Inspect the bulbar conjunctiva for color, texture, and the presence of lesions.

2. Inspect the palpebral conjunctiva.

3. Inspect the pupils for color, shape and symmetry of size.

Transparent; capillaries sometimes evident; sclera appears white

Shiny, smooth, and pink or red

Black in color; equal in size; normally 3-7 mm in diameter; round smooth border, iris flat and round

Transparent; yellowish sclera

Pale

Black in color; equal in size; round smooth border, iris flat and round

Deviation from normal; Cholestatic jaundice develops as a consequence of bile flow obstruction.

Deviation from normal; possible cause is anemia

Normal

Anterior Thorax1. Auscultate the anterior chest.

Bronchovesicular and vesicular breath sounds

Normal breath sounds Normal

Heart and central Vessels1. Simultaneously inspect and palpate precordium for the presence of abnormal pulsations, lifts, or heaves.

2. Auscultate the heart in all four anatomic sites (aortic, pulmonic, tricuspid and apical.

No pulsations

S1: usually heard at all sites (louder at apical area)

S2: Usually heard at all sites (usually louder at the base of the heart)

S3: in children and young adults

No pulsations

No abnormalities

Normal

Normal

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3. Auscultate the carotid artery.

S4: in many older adults

No sound heard upon auscultation.

No sound heard upon auscultation.

Normal

Peripheral Vascular System1. Palpate the peripheral pulses on both side of the client's body individually, simultaneously and systematically to determine the symmetry of pulse volume.

2. Inspect the skin of the hands and feet for color, temperature, edema, and skin changes.

3. For capillary refill test, squeeze the client’s fingernail and toenail between your fingers sufficiently to cause blanching.

Symmetric pulse volumes.

Full pulsations.

Skin color pink.

Skin temperature not excessively warm or cold.

No edema.

Skin moisture resilient and moist.

Immediate return of color

Symmetric pulse volumes.

Full pulsations.

Skin color pink.

Skin temperature not excessively warm or cold.

No edema.

Skin moisture resilient and moist.

Immediate return of color

Normal

Normal

Normal

Upper Abdomen1. Inspect for symmetry, redness and swelling. Palpate upper abdomen for presence of tenderness.

Lower Abdomen1. Inspect for symmetry, redness and swelling. Palpate lower abdomen for presence of tenderness.

Symmetrical; No tenderness

Symmetrical; No tenderness

Pre-op: Pain upon palpation; (+) Murphy’s sign

Post-op: (+) redness in post-operative site

Symmetrical; No tenderness

Biliary colic occurs when the bile duct muscle contracts the mucosa presses on the stone’s surface.

Redness is usually normal in post-operative sites but may signify presence of infection on the site.

Normal

Musculoskeletal System1. Inspect the muscles for size. Compare the muscles on one side of the body to the same muscle on the other side.

2. Test muscle strength and compare the right side from the left side.

Equal size on both sides of body.

Equal strength on each body side.

Equal size on both sides of body.

Equal strength on each body side.

Normal

Normal

Neurologic System1. Compare the light-touch sensation of symmetric areas of the body.

Light tickling or touch sensation

Light tickling or touch sensation

Normal

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III. LABORATORY/DIAGNOSTIC EXAM RESULTS

Complete Blood CountDiagnostic Tests Patient’s Results Normal Values Significance

Hemoglobin 140-180 180 NormalHematocrit 0.54 0.400-0.54 Normal

Red Blood Cell 5.45 4.6-6 NormalMVC (Mean Corpus Volume) 85.9 80-100 Normal

MCH 28.5 27-34 NormalMCHC 332 320-360 Normal

RDWSD 42.4 35-56 NormalRDWCV 12 11-16 Normal

White Cells 9.32 4.3-10x10 NormalNeutrophils 72.5 50-70 Slightly ElevatedEosinophils 3.3 0.5% ElevatedBasophils 0.3 0-1% Normal

Lymphocytes 20.3 20-40% NormalMonocytes 3.6 0-7 Normal

Clinical ChemistryAlanine Transaminase (ALT)

Serum Glutamic Pyruvate Transaminase (SGPT)

825.1 U/L 0.0-41.0 U/L Elevated

Potassium 3.4 3.5-5.3 NormalTotal Bilibrubin 12.00 0.1-1.0 mg/dl ElevatedDirect Bilirubin 11.50 0.00-0.3 Elevated

Indirect Bilirubin 0.50 0.15-0.70 NormalPhosphatase 562 35-104 Elevated

UrinalysisColor Dark Straw

pH AcidicTransparency Hazy

Specific Gravity 1.025Protein TraceGlucose NegativePus Cells 8-12

Red Blood Cells 0.3

Ultrasound Whole Abdomen ResultThe liver is not enlarged but with slight non-homogenous hyperechogenisity of the parenchyma.

Impression: Non-specific liver parenchyma disease (Fatty infiltration or hepatitis)

Gallbladder Findings: Adenomyomatosis More than five stones (sizes 4.3-12.6mm) Minimal bile sludge Acute medical renal disease with microlithiasis: Right Kidney Microlithiasis: Left Kidney (Acute renal disease is not ruled out) Boarder line prostate size

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IV. MEDICATIONS AND TREATMENTS GIVEN

Ranitidine (Zantac) 50mg IV q 8hoursClassification: Gastro-intestinal agents, Anti-secretory (H2-receptor antagonist)Mechanism of Action: Ranitidine is a specific, rapidly acting histamine H2-antagonist. It inhibits

basal and stimulated secretion of gastric acid, reducing both the volume and the acid and pepsin content of the secretion. Ranitidine has a long duration of action and so a single 75- or 150-mg dose effectively suppresses gastric acid secretion for at least 12 hrs.

Clinical evidence has shown that ranitidine combined with amoxicillin and metronidazole eradicates Helicobacter pylori in approximately 90% of patients. This combination therapy has been shown to significantly reduce duodenal ulcer recurrence. Helicobacter pylori infects about 95% of patients with duodenal ulcer and 80% of patients with gastric ulcer.

Indication: Duodenal and Gastric Ulcers, GERD, Erosive Esophagitis, HeartburnSide Effects: (CNS) headache, malaise, dizziness, somnolence, insomnia, vertigo, mental

confusion, agitation, depression, hallucination; (Cardio) Bradycardia; (GI) constipation, nausea, abdominal pain, vomiting, diarrhea; (Skin) rashes; (Hematologic) reversible decrease in WBC count, thrombocytopenia

Contraindication: Pregnancy and lactationPrinciples of Care: Give with or without food. Administer adjunctive antacid treatment 2 hours

before or after taking the medication.Treatment: Monitor lab results. Monitor hepatic functioning. Monitor intake and output every

shift. Monitor vital signs every 4 hours.

Cefuroxime 750mg IV q 8hoursClassification: Anti-infective agents, CephalosporinMechanism of Action: Inhibits bacterial cell wall synthesis by binding to one or more of the

penicillin-binding proteins (PBP’s).Indication: Treatment of susceptible infections of lower respiratory tract, skin and soft tissue, bone

and joint, and sepsis.Side Effects: (GI) Diarrhea, abdominal cramps, nausea, vomiting, oral candidiasisContraindications: Hypersensitivity to Cefuroxime, any component, or other cephalosporinsPrinciples of Care: Inject direct IV over 3-5 minutes. Infuse intermittent infusion over 15-30

minutes. Absorption is increased when given with or shortly after food.

Omeprazole 20mg IV ODClassification: Proton Pump InhibitorMechanism of Action: Decreases the amount of acid produced in the stomach.Indication: To treat symptoms of Gastroesophageal Reflux Disease and other conditions caused by

excess stomach acid. It is not for immediate relief of heartburn symptoms. Use to promote healing of erosive esophagitis (damage to esophagus caused by stomach acid).

Side Effects: Fever, cold symptoms such as stuffy nose and sneezing, sore throat, stomach pain, gas, nausea, vomiting, mild diarrhea, and headache.

Contraindications: Allergy to Omeprazole and to its components.Principles of Care: Take Omeprazole before meals.

Buscopan 1 ampule IV q 8hoursClassification: Anti-spasmodicMechanism of Action: It blocks the muscarinic receptors found on the smooth muscle walls which

means it blocks the action of acethylcholine on the receptors found within the smooth muscle of the gastrointestinal and urinary tract and thus spasm and contractions. This relaxes the muscle and thus reduces pain from the cramps and spasms.

Indication: Spasm in the genitourinary tract, gastrointestinal tract, billiary tract and colicSide Effects: Constipation, decreased sweating, mouth, skin and eye dryness, blurred feeling,

bloating, dysuria, nausea and vomiting, headache, body weakness

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Contraindications: Myesthenia gravies, megacolon hypersensitivity to drug contents, narrow angle glaucoma, prostate hypertrophy with urinary retention.

Principles of Care: Take this drug 30 min. to 1 hour before meals. Buscopan will potentiate the effect of alcohol and other CNS depressants. Do not take antacids and anti-diarrheal 2-3 hours prior taking this drug. It is necessary to take the medication if you are not in pain. Avoid driving or operating machinery after parenteral dose.

Diclofenac 75mg IVClassification: Non-steroidal Anti-inflammatory DrugsMechanism of Action: Reduces inflammation and as an analgesic reducing pain in certain

conditions.Indication: Used to treat mild to moderate postoperative or post-traumatic pain, in particular when

inflammation is also present.Side Effects: Stomach upset, nausea, heartburn, diarrhea, constipation, gas, headache, drowsiness

and dizziness.Contraindications: Hypersensitivity against Diclofenac. Active stomach and/or duodenal ulceration

or gastrointestinal bleeding, inflammatory bowels such as Crohn’s disease or ulcerative colitis, cautions in patients with severe bleeding such as cerebral hemorrhage.

Principles of Care: Do not drive, use machinery, or do any activity, that requires alertness until you are sure you can perform such activities safely. This medication may make you more sensitive to the sun. Avoid prolonged sun exposure, tanning booths or sunlamps. Use a sunscreen and wear protective clothing when outdoors.

V. ANATOMY AND PHYSIOLOGY

The gallbladder is part of the digestive system. It is a small, pear-shaped hollow sack resting beneath the right lobe of the liver. Bile, which is being secreted continuously by the liver, enters the small bile ducts within the liver. The small bile ducts join to form two larger ducts which emerge from the undersurface of the liver as the right and left hepatic ducts but which immediately join to form the common hepatic duct.

The hepatic duct merges with the cystic duct from the gallbladder, forming the common bile duct. The common bile duct merges with

the pancreatic bile duct to form the ampulla of Vater (dilated portion in small channel) before opening into the small intestine. The terminal parts of both ducts and the ampulla are surrounded by circular muscle fibers, known as the sphincter of Oddi. Hepatic bile may not immediately enter the duodenum; instead, after passing down the hepatic duct, it may be diverted into the cystic duct and gallbladder.

In the gallbladder, the lymphatics and blood vessels absorb water and inorganic salts, so that gallbladder bile is about 10 times as concentrated as hepatic bile. At intervals the gallbladder contents are emptied into the duodenum by simultaneous contraction of the muscular coat and relaxation of the sphincter of Oddi. The normal stimulus of gallbladder contraction and emptying is the entry of acid chime into the duodenum. The presence of fatty foods is the strongest stimulus to contraction.  

The body can function without the gallbladder. If doctors need to remove it because of disease, there are no serious long-term effects and the body can still digest food. 

Structure

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The gallbladder and bile ducts are also called the biliary system or biliary tract. It is about 7.5–10 cm (3–4 inches) long and about a 2.5 cm (1 inch) wide. The gallbladder is made up of layers of tissue:

Mucosa: the inner layer of epithelial cells (epithelium) and lamina propria (loose connective tissue)

a muscular layer: a layer of smooth muscle perimuscular layer: connective tissue that covers the muscular layer serosa: the outer covering of the gallbladder

FunctionThe principal function of the gallbladder is the storage and concentration of bile, a yellowish-

green fluid made by the liver. It is capable of holding about 40-70ml of bile. The gallbladder absorbs water from the bile, making it more concentrated. When bile is needed for digestion after a meal, the gallbladder contracts and releases it into the cystic duct. The bile then flows into the common bile duct and is emptied into the small intestine, where it breaks down fats. Bile helps the body digest fats. It is mainly made up of:

bile salts bile pigments (such as bilirubin) cholesterol water

 

VI. PATHOPHYSIOLOGY OF THE DISEASE

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Gallstones are hard, pebble-like structures that obstruct the cystic duct. The formation of gallstones is often preceded by the presence of biliary sludge, a viscous mixture of glycoproteins, calcium deposits, and cholesterol crystals in the gallbladder or biliary ducts. Most gallstones consist largely of bile supersaturated with cholesterol. This hypersaturation, which results from the cholesterol concentration being greater than its solubility percentage, is caused primarily by hypersecretion of cholesterol due to altered hepatic cholesterol metabolism. A distorted balance between pronucleating (crystallization-promoting) and antinucleating (crystallization-inhibiting) proteins in the bile also can accelerate crystallization of cholesterol in the bile. Mucin, a glycoprotein mixture secreted by biliary epithelial cells, has been documented as a pronucleating protein. It is the decreased degradation of mucin by lysosomal enzymes that is believed to promote the formation of cholesterol crystals.

Loss of gallbladder muscular-wall motility and excessive sphincteric contraction also are involved in gallstone formation. This hypomotility leads to prolonged bile stasis (delayed gallbladder emptying), along with decreased reservoir function. The lack of bile flow causes an accumulation of bile and an increased predisposition for stone formation. Ineffective filling and a higher proportion of hepatic bile diverted from the gallbladder to the small bile duct can occur as a result of hypomotility.

Occasionally, gallstones are composed of bilirubin, a chemical that is produced as a result of the standard breakdown of RBCs. Infection of the biliary tract and increased enterohepatic cycling of bilirubin are the suggested causes of bilirubin stone formation. Bilirubin stones, often referred to as pigment stones, are seen primarily in patients with infections of the biliary tract or chronic hemolytic diseases (or damaged RBCs). Pigment stones are more frequent in Asia and Africa.

The pathogenesis of cholecystitis most commonly involves the impaction of gallstones in the bladder neck, Hartmann's pouch, or the cystic duct; gallstones are not always present in cholecystitis, however. Pressure on the gallbladder increases, the organ becomes enlarged, the walls thicken, the blood supply decreases, and an exudate may form. Cholecystitis can be either acute or chronic, with repeated episodes of acute inflammation potentially leading to chronic cholecystitis. The gallbladder can become infected by various microorganisms, including those that are gas forming. An inflamed gallbladder can undergo necrosis and gangrene and, if left untreated, may progress to symptomatic sepsis. Failure to properly treat cholecystitis may result in perforation of the gallbladder, a rare but life-threatening phenomenon. Cholecystitis also can lead to gallstone pancreatitis if stones dislodge down to the sphincter of Oddi and are not cleared, thus blocking the pancreatic duct.

Gallstones are generally asymptomatic. In the uncommon event that a patient develops symptomatic cholelithiasis, presentation can range from mild nausea or abdominal discomfort to biliary colic and jaundice. Biliary colic, usually sharp in nature, is postprandial epigastric or right-quadrant pain that lasts for several minutes to several hours. The pain often radiates to the back or the right shoulder, and in more intense cases it may be accompanied by nausea and vomiting. Upper-right-quadrant tenderness and palpable infiltrate in the region of the gallbladder are revealed upon physical examination. Cholecystitis presents in the same manner; however, the obstruction of the cystic duct is persistent (rather than transient), and fever is common.

A patient with cholecystitis also may exhibit Murphy's sign (discomfort so severe that the patient stops inspiring during palpation of the gallbladder) or jaundice. Jaundice, a yellow discoloration of the skin and the sclera of the eyes, occurs when the common bile duct is obstructed because of an impacted stone in Hartmann's pouch (Mirizzi's syndrome). Other nonspecific symptoms, such as indigestion, intolerance to fatty or fried foods, belching, and flatulence, may also be present.

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VII. PRIORITIZED LIST OF NURSING PROBLEMS

Nursing Diagnosis Cues JustificationAltered Comfort: Acute Pain related to tissue trauma secondary to cholecystectomy as manifested by facial grimace of pain, appears irritable, restless, guarded or protective behavior and diaphoresis.

Subjective Cues:“Makirot pa rin ung sugat ng inoperahan sa akin”, pain scale of 7, 10 as worst.

Objective Cues:Vital signs: BP= 130/90 mmHg PR=105 bpm RR= 22 cpm

(+) Facial Grimaces Appears irritable, restlessness noted Guarded or protective behavior in the surgical wound

(RUQ of the abdomen) Slightly diaphoretic

HIGHEST PRIORITY

2nd day Post-operative pain with a pain scale of 7 is considered as severe therefore it needs to be highly prioritized. Immediate interventions should be done to reduce the pain sensation.

The existing problem makes the patient in an uncomfortable state and reduces his ability to perform his activities of daily living.

Activity Intolerance related to generalized weakness secondary to cholecystectomy as manifested by difficulty turning from one side to side, limited ROM and muscle weakness.

Subjective Cues:“Nahihirapan pa ako kumilos pagkatapos ko maoperahan.”

Objective Cues: Difficulty from side to side Muscle weakness Limited range of motion Needs assistance when moving

2 ND PRIORITY

Post-op patients usually have limited strength due to the stress from the past operation. This problem disables them to perform ADLs at ease and needs the assistance of others.

This was secondly prioritized because in order to intervene with this problem, the pain sensation should be reduced first since it is an immediate problem. Presence of pain adds to the burden of the patient’s intolerance of his activities.

Deficient knowledge about the disease process related to unfamiliarity of information resources.

Subjective Cues:“Mahilig akong kumain ng karne at taba araw-araw at bihira akong kumain ng prutas at gulay”.

Objective Cues: SP cholecystectomy because chronic calculous

cholecystitis

3 RD PRIORITY

The patient’s lifestyle including the pattern of his usual diet, and activity was one of the greatest factors that lead to his condition and prompted his surgery.

Deficient knowledge about the importance of proper nutrition, regular exercise and reduction of stress made it possible for him to engage in unhealthy ways.

We had therefore concluded that this problem must also be given emphasis and proper health education should be rendered to the

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client to hasten his recovery and maintain optimum level of health as possible.

Risk for infection related to impaired primary defense secondary to cholecystectomy

Objective Cues: presence of surgical wound on RUQ abdominal region Insufficient knowledge on how to avoid exposure to

pathogens

LEAST PRIORITY

This was lastly prioritized since it is a risk problem. The patient did not manifest any signs of infection post-operatively but proper interventions must still be rendered to prevent the occurrence of this problem in the future.

VIII. NURSING CARE PLAN

Nursing Care Plan #1

Assessment Nursing DiagnosisScientific

Explanation (Rationale)

Planning Nursing Interventions Rationale Evaluation

Subjective Cues:“Makirot pa rin ung sugat ng inoperahan sa’kin”, pain scale of 7, 10 as worst.

Objective Cues:>vital signs:BP= 130/90 mmHgPR= 105 bpmRR= 22 bpm

> (+) facial grimaces>appears irritable, restlessness>guarded or protective behaviour on the surgical site (RUQ of the abdomen)

Altered comfort: Acute pain related to tissue trauma secondary to cholecystectomy

Surgical incision from

cholecystectomy

Tissue trauma

Release of chemical mediators such as

bradykinin

Direct irritation to the nerve endings

Signal will be sent to the cortex and

Short-term goal:

-After 1 hour of nursing interventions, the patient will report slight relief from pain.

-After 4 hours of nursing interventions, the patient will be able to verbalize non-pharmacologic measures for pain relief.

Independent:1. Establish rapport with the

patient and the significant others

2. Monitor and record vital signs

3. Assess the severity, frequency, and characteristic of pain

4. Encourage diversional activities and relaxation techniques to relieve pain such as focused breathing, listening to music, reading magazines or watching movies.

1. To enhance nurse-patient interaction.

2. Vital signs are usually altered in acute pain.

3. Pain is a subjective data; therefore it should be assessed to determine the patient’s level of pain.

4. To distract attention and reduce tension.

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Long-term goal:

-After 4 days of nursing interventions, the patient will verbalize that the pain is controlled.

Short term:

-After 1 hour of nursing interventions, the patient reported relief from pain, pain scale of 5 out of 10.

-After 4 hours of nursing interventions, the patient demonstrated non-pharmacological measures to relief pain such as focused breathing.

Long-term:-After 4 days of nursing interventions, the patient reported that the pain is controlled.

>slightly diaphoretic>difficulty in sleeping

thalamus of the brain

Pain perception is produced

5. Provide non-pharmacologial interventions such as touch and frequent changing of position.

6. Encourage adequate rest periods and early ambulation if tolerated.

Dependent:1. Administer pain medication as

ordered.-Diclofenac 75 mg IM single dose

-Remopain 30 mg IV q 6 for 6 doses

-Dolmal drip 6 amps in D5W 500 cc @ 20 gtts/min

5. To provide comfort.

6. To prevent fatigue. Early ambulation helps hasten recovery.

1. To reduce pain

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Nursing Care Plan #2

Assessment Nursing DiagnosisScientific Explanation

(Rationale)Planning Interventions Rationale Evaluation

Subjective Cues:“Nahihirapan pa rin akong kumilos pagtapos ko operahan.”

Objective Cues:

Activity Intolerance related to generalized

weakness secondary to cholecystectomy

Post-cholecystectomy

Presence of surgical incision

Stimulation of nerve endings during

movement increases pain sensation

Generalized weakness

Activity Intolerance

Short-term:-After 1 hour of nursing intervention, the patient will verbalize understanding on improvement of activity tolerance within his limitation.

Long-term:-After 4 hours of nursing intervention, the patient will participate in measures to enhance ability to perform activities.

Independent1. Establish rapport.

2. Monitor vital signs

3. Assess the patient’s general condition.

4. Provide adequate rest.

5. Assist patient to lean and demonstrate safety measures

6. Encourage patient to maintain a positive attitude; suggest use of relaxation techniques such as visualization/ guided imagery as appropriate.

1. To establish nurse patient relationship.

2. To have a baseline data

3. To gather baseline data and compare it to normal findings

4. To prevent fatigue and conserve energy.

5. To prevent injuries

6. To enhance sense of well-being.

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>difficulty turning from one side to side.> generalized weakness>limited ROM>needs assistance when moving>muscle weakness

Short term:-The patient verbalized understanding on improvement of activity tolerance within his limitation.

Long term:-The patient participated in measures to enhance ability to perform activities.

7. Teach ways on how to conserve energy such as sitting instead of standing when doing activities, (eg. combing hair)

Dependent:1. Administer medication

as ordered prior to activity as needed.-Diclofenac 75 mg IM single dose

-Remopain 30 mg IV q 6 for 6 doses

-Dolmal drip 6 amps in D5W 500 cc @ 20 gtts/min

7. To limit fatigue and maximize use of energy.

1. For pain relief, to permit maximal effort and involvement in activity.

Nursing Care Plan #3

Assessment Nursing Diagnosis Scientific Explanation (Rationale)

Planning Interventions Rationale Evaluation

Subjective Cues:“Mahilig akong kumain ng karne at taba araw-araw.”

Objective Cues:>S/P cholecystectomy because of chronic calculous cholecystitis

Deficient knowledge about the disease process related to unfamiliarity of

information resources

Lack of exposure to the disease process

Lack of knowledge about the impact of improper

nutrition to his condition

Unfamiliarity of the

Short-term:-Verbalize understanding of disease process, surgical procedure /prognosis, and potential complications

Long-term:-The patient will initiate necessary lifestyle

Independent:1.Establish rapport.

2.Monitor and record vital signs.

3.Review disease process, surgical procedure/prognosis.

1. To establish nurse-patient interaction.

2. To have a baseline data.

3. Provides knowledge base on which patient can make informed

Short-term:-After 1 hour of nursing interventions, the patient verbalized understanding of the disease process, surgical procedure/ prognosis, and potential complications.

Long-term:

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information resources

Deficient knowledge about the disease process

changes and participate in therapeutic regimen

4.Emphasize importance of maintaining low-fat diet, eating frequent small meals, gradual reintroduction of foods/fluids containing fats over a 4- to 6-mo period

5.Discuss avoiding /limiting use of alcoholic beverages.

6. Identify signs/symptoms requiring notification of healthcare provider, e.g., dark urine; jaundiced color of eyes/skin; clay-colored stools, excessive stools; or recurrent heartburn, bloating.

choices.

4. During initial 6 months after surgery, low-fat diet limits need for bile and reduces discomfort associated with inadequate digestion of fats.

5. Minimizes risk of pancreatic involvement.

6. Indicators of obstruction of bile flow/altered digestion, requiring further evaluation and intervention.

-After 4 hours of nursing interventions, the patient initiated necessary lifestyle changes and participated in therapeutic regimen.

Nursing Care Plan #4

Assessment Nursing DiagnosisScientific Explanation

(Rationale)Planning Interventions Rationale Evaluation

Objective Cues:>Presence of surgical wound on RUQ abdominal region

>Insufficient knowledge

Risk for infection related to impaired primary defenses secondary to cholecystectomy

Post- cholecystectomy,

incision and suture

Short-term:-After 1 hour of nursing intervention, the patient will demonstrate techniques in reducing risk of having infection.

Independent:1. Establish rapport.

2. Monitor vital signs

1. To establish nurse patient relationship.

2. To have a baseline data

Short term:-After 1 hour of nursing interventions, the patient demonstrated techniques in reducing risk of having infection.

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on how to avoid exposure to pathogen

made in the abdomen

break in the continuity of the first line

defense which is the skin

the pathogens will easily invade the body’s system

risk of acquiring infection

Long term:-After 8 hours of nursing intervention, the patient will achieve timely wound healing, be free of purulent drainage and be afebrile.

3. Stress proper hand washing techniques

4.Follow strict compliance to hospital control, sterilization, and aseptic policies.

5. Encourage to increase oral fluid intake if not contraindicated.

6. Encourage early ambulation, deep-breathing, coughing and positioning changes.

Dependent:1. Administer antibiotic

as ordered.-Cefuroxime 750 mg every 8 hours

2.Change wound dressing as indicated using proper technique for changing/disposing of contaminated materials.

3. It’s the first line of defence against nosocomial infection or cross-contamination.

4. To establish mechanism to prevent occurrence of infection.

5. To hasten wound healing

6. For mobilization of respiratory infections, and prevention of respiratory infections.

1. To prevent occurrence of infection

2. To achieve timely wound healing of the surgical wound

Long term:-After 8 hours of nursing interventions, the patient achieved timely wound healing, had been free of purulent drainage and remained afebrile.

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IX. DISCHARGE PLAN

i. MEDICATIONS Teach the client and the family members about the medications that will be taken after the

hospitalization.1. Roflexin 500 mg 1 tablet 2x a day for 1 week2. Celexib 200 mg 1 tablet 2x a day for 3 days-The more clients understand the medical regimen; the more adept they will be in monitoring for them.

Educate the patient and family members about the side effects or adverse reaction of the drug.- Knowledge of the potential side effects will adept in proper monitoring of the condition.

Warn patient never to stop drug abruptly or adjust the dosage without discussing it with the prescriber.- To avoid harm or injury to the patient

Instruct family members and patient to double check and compare it to the order of the physician before administration.-To know if the drug given is correct

Educate the patient and family to follow strictly the prescribed medication.- To prevent drug resistance

Encourage the patient to avoid alcohol and cigarette smoking.- To prevent further complications and so that the desired effects of the drugs will be achieved

Instruct the client and his family not to administer drugs that are not prescribed by the physician.- Non-prescription drugs may have an antagonistic or synergetic effect if taken with other drugs. Side effects and adverse effects from drug reactions can transpire and cause damage or complication to the client’s body.

ii. EXERCISE Encourage to do light exercises like walking and avoid intense exercises and strenuous activities.

- Light exercises like ambulation helps hasten recovery.

Drink plenty of water every day.- To help prevent constipation

Instruct the family to provide the client adequate rest and sleep.- Sufficient rest and sleep can help for faster healing and recovery. It can also help to prevent injury and harm.

iii. TREATMENT Explain to the S.O.s of the client the medical condition involved and provide them with

information regarding the illness.- This is to have a comprehensive understanding of the client’s condition so that they will be able to give appropriate intervention and optimum care.

Instruct the patient and family/ significant others to follow physician’s order until the end of the course treatment.- To obtain the desired therapeutic effect and may improve the status of the client.

Instruct the patient and family/ significant others to immediately report any unusualities noted.- This is important so that appropriate interventions can be done to prevent aggravation of the problem noted.

Teach patient and family/ significant others about proper wound dressing and drain care daily.-Prevent occurrence of infection.

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iv. HYGIENE Instruct the family/ significant others of the client to provide good, clean, and safe environment.

- This will prevent the occurrence of further complications.

Encourage the significant others to do hand washing before and after contact with patient and preparing food.- Hand washing reduces risk of infection and cross-contamination.

Advise the patient to do oral care and bath and groom daily and regularly and with the assistance of the significant others if necessary.- Proper hygiene and grooming promotes cleanliness, comfort and relaxation.

v. OUTPATIENT (FOLLOW-UP) Encourage the patient to comply with regular check-ups.

- This will enable the physician to evaluate client’s progress after the medical intervention.

Instruct the family of the client to immediately report any unusualities noted.- This is to render prompt interventions and treatment regarding patient’s condition.

vi. DIET Emphasize importance of maintaining low-fat diet, eating frequent small meals, gradual

reintroduction of foods/fluids containing fats over a 4 to 6 month period.-During initial 6 months after surgery, low-fat diet limits need for bile and reduces discomfort associated with inadequate digestion of fats.

Advise the client to eat foods rich in fiber and protein such as vegetables and fruits.-Protein and fiber rich foods can facilitate tissue healing and will delay the onset of uremic symptoms.

Encourage the family to give food rich in vitamin C such as oranges, citrus juices, and green leafy vegetables.- Food rich in vitamin C can aid in strengthening the body’s immune system to combat infection and other illnesses.

Encourage to have a regular and balance diet.-Aids in sustaining energy throughout daily activities

Discuss avoiding/limiting use of alcoholic beverages.-Minimizes risk of pancreatic involvement.

vii. SPIRITUAL: Discuss God’s plan for every individual’s life.

Advise the client to pray and trust to God.

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