CP on Calculous Cholelithiasis
151
Ateneo de Davao University College of Nursing Bachelor of Science in Nursing In Partial Fulfilment for the Requirements in Nursing Care Management [Related Learning Experience] - - - Calculous Cholelithiasis Submitted to: Theresa Kintanar, R.N. Ella Mae Navarro, R.N. Clinical Instructors Submitted by: Lim, Stephanie Marie Madrazo, Benedict Edmund Mangitngit, Jeferson Margaja, Dominique Dawn Maulion, John Charls Mendoza, Kathreen Glaiza
description
A Case Study on Calculous Cholelithiasis
Transcript of CP on Calculous Cholelithiasis
Ateneo de Davao UniversityCollege of NursingBachelor of Science in Nursing
In Partial Fulfilment for the Requirements inNursing Care Management [Related Learning Experience]
- - -
Calculous Cholelithiasis
Submitted to:Theresa Kintanar, R.N.Ella Mae Navarro, R.N.
Clinical Instructors
Submitted by:Lim, Stephanie Marie
Madrazo, Benedict EdmundMangitngit, Jeferson
Margaja, Dominique DawnMaulion, John Charls
Mendoza, Kathreen GlaizaNalzaro, Sheena Ann
Olalo, AngeliOmandac, Alyssa
BSN 3E; Group 3; College of NursingFebruary 26, 2009
TABLE OF CONTENTS
I. INTRODUCTION...............................................................................................
II. OBJECTIVES......................................................................................................
III. PATIENT’S DATA ............................................................................................
IV. FAMILY BACKGROUND/ HEALTH HISTORY ............................................
V. DEVELOPMENTAL DATA ..............................................................................
VI. DEFINITION OF COMPLETE DIAGNOSIS ...................................................
VII. PHYSICAL ASSESSMENT ..............................................................................
VIII. ANATOMY AND PHYSIOLOGY ....................................................................
IX. ETIOLOGY AND SYMPTOMATOLOGY .......................................................
X. PATHOPHYSIOLOGY ......................................................................................
XI. DOCTOR’S ORDER ..........................................................................................
XII. DIAGNOSTIC EXAM .......................................................................................
XIII. DRUG STUDY ...................................................................................................
XIV. NURSING THEORIES ......................................................................................
XV. NURSING CARE PLAN ....................................................................................
XVI. PROGNOSIS.......................................................................................................
XVII. DISCHARGE PLAN ..........................................................................................
XVIII. RECOMMENDATION ......................................................................................
I NTRODUCTION
Cholelithiasis refers to the presence of gallstones in the gallbladder which occurs
more often in women than men. Gallstones are formed within the gallbladder and can
range in size from as small as a particle to golf-ball size, depending on how long they
have been building.
A common digestive disorder worldwide, the annual overall cost of cholelithiasis
is approximately $5 billion in the United States, where 75-80% of gallstones are of the
cholesterol type, and approximately 10-25% of gallstones are bilirubinate of either black
or brown pigment. In Asia, pigmented stones predominate, although recent studies have
shown an increase in cholesterol stones in the Far East.
Gallstones are rock-like accumulations of material that take shape inside the
gallbladder. There are different types of gallstones, but cholesterol stones are the most
common. The gallbladder stores bile in the liver. The bile is composed of bile salts, bile
pigments, cholesterol, phospholipids and electrolytes. When bile contains excess
cholesterol, gallstones begin to form.
Cholesterol stones can be green, white or yellow in color and are made primarily
of cholesterol while pigment stones are somewhat dark and made of bilirubin and
calcium salts in bile. Much has been learned about how gallstones are formed and experts
believe that gallstones may be caused by a number of factors such as inherited genetic
chemistry, gallbladder movement and diet.
When bile builds up too much cholesterol, gallstones form. Furthermore, not
emptying the gallbladder enough may allow the bile to become compacted and form
stones. Increased levels of estrogen could raise cholesterol levels in bile, promoting the
formation of gallstones.
Persons with high cholesterol levels are more prone to develop Cholelithiasis.
Diets high in fats contribute to the formation of gall stones and over time the stones can
grow to considerable size, causing serious pain and discomfort.
Our patient, given the code name: Mr. R, is a hardworking supervisor for a certain
mining industry. He was admitted in DMSFH to undergo a surgery that will remove his
gall bladder. The operation he underwent was a Laparoscopic Cholecystectomy. We were
able to choose Mr. R as our case, with the help of our clinical instructor. Mr. R’s disease
is in line with our concept which is Nephrology and he was able to give us his approval
when we asked for his cooperation.
Throughout this Case Presentation, numerous data about Mr. R’s disease will be
presented for the deepened understanding of his disease, Calculous Cholelithiasis.
A CKNOWLEDGEMENT
Many people have been kind and helpful to us in finishing this case study. We
would like to extend our gratitude to the following:
First, we would like to thank the Almighty God for giving us guidance, strength
and enlightenment upon doing this case study.
Second, we would like to thank each and everyone’s parents for their support
financially, physically and emotionally.
Third, we would like to thank our dearest clinical instructor, Ms. Theresa
Kintanar, for guiding us in choosing the appropriate family for our case study and for
giving us some guidelines that could help us in acquiring necessary information.
Fourth, we would like to thank our group mates for their cooperation and
determination to finish and learn something from this case presentation.
Fifth, we would like to thank all the personnel and staff members of St. Joseph
ward, Davao Medical School Foundation Hospital for their accommodation and
assistance during our duty.
Lastly, we would like to extend our heartfelt gratitude to Mr. R. and his family for
their willingness to involve themselves openly in this case study.
O BJECTIVESGeneral Objectives:
To conduct a thorough and comprehensive study about Mr. R’s disease according
to the data that was gathered by conducting a series of interviews and extensive research.
Specific Objectives:
To organize our patient’s data for the establishment of good background
information
To analyze the family health history as well as the history of past and present
illness for the knowledge of what could be the predisposing factors that might
contribute to the patient’s illness
To create a Genogram containing different informations that will help out in
tracing hereditary risk factors
To evaluate our patient’s development through the use of different developmental
theories
To differentiate the definitions of our patient’s complete diagnosis for better
understanding
To describe the current condition of our patient through the Physical assessment
To explain the anatomy and physiology of different organs involved and affected
during cholelithiasis
To list several factors, signs and symptoms of cholelithiasis that are present or
absent in our patient
To compose a flow chart showing the pathophysiology of cholelithiasis for a clear
visualization of how cholelithiasis affects a person
To list the different orders of the physicians assigned to our patient together with
their rationale for a general knowledge of what consists of the medical
management for cholelithiasis
To interpret the different results of our patient’s diagnostic exams together with
comparisons of normal values for the understanding of what changes during the
disease
To classify the different drugs used by our patient so that we can identify its
functions and purposes
To analyze the different nursing theories that can be applied to our patient
To create Nursing Care Plans applicable to our patient
To construct a discharge plan following the METHOD format
To validate a prognosis according to a specific criteria.
To compose an over-all Conclusion and recommendations about the case study
To gather all the references used upon making this case study
P ATIENT’S D ATA
Patient's code name: Mr. R
Age: 53 yrs. Old
Address: San Mateo Laverna Buhangin, Davao City
Date of Birth: March 3, 1955
Nationality: Filipino
Civil Status: Married (living separately)
Occupation: Mining Engineer (DENR)
Sex: Male
Religion: Roman Catholic
Ward: St. Joseph 3-C
Bed no.: 325/4
Date of Admission: February 18, 2009
Time: 2:00 pm
Vital signs upon admission:
BP: 120/70 mmHg RR: 19 cpm
Temp.: 37.1 °C PR: 66 bpm
Admitting Diagnosis: Calculous Cholelithiasis
Attending Physician: Dr. Enojo
Type of Admission: Ambulatory
F AMILY B ACKGROUND
H EALTH H ISTORY
Mr. R, a 53 year-old male, was born in Bohol on March 3, 1955. He is currently
residing at B-12 L12 P1 San Mateo Laverna Buhangin, Davao City. They are 7 in the
family including his parents. He is the third child among the five children. Our patient
has completely received immunization since he was a child.
Upon interview, Mr. R said that they had a family history of the same type of
disease, which is the Diabetes Mellitus. He mentioned that within the family, they had 2
cases from his mother’s side and on his father side of the family. His aunt from his
father’s side was also diagnosed with cholelithiasis.
LIFESTYLE: ACTIVITIES
Mr. R described how his workplace is similar to his home in terms of stress. He
verbalized that there are times when he is stressed and there are others when he the
situations can let him relax.
When asked about how he usually spends his days, Mr. R was able to formulate a
schedule that would describe his activities of daily living. He would wake up at 6:00am.
The first thing he would do is take a bath. Right after taking a bath, he takes his breakfast.
After brushing his teeth, he rides his transportation service to his office. By 8:00am, he
arrives in his office. Here, he usually does paper work, participates in interviews and
meetings, records data in his office computer and, on some occasions, perform field work
as a supervisor. After work, he has the option to either go home directly (7:00pm arrival)
or have a night out with his friends from work. There are times that he chooses to go out
and drink; the most would be two times in a week. For every time that he goes out to
drink, he would consume an average of 2 bottles. If he chooses to go out and spend the
night outside the house, he’d get home by around 12:00 midnight and onwards.
LIFESTYLE: DIET
Since his grade school years, Mr. R was fond of eating all kinds of “lechon.” He
is also fond of drinking carbonated beverages and he drinks alcoholic beverages
occasionally. After he was diagnosed with Diabetes, he started eating less lechon and
more vegetables, whole grains and fish. During the interview, Mr. R was asked if he
knows any more changes in his diet. He only shrugged and said he was still unsure of
how his diet will change now that he is missing a gall bladder.
HISTORY OF PATIENT’S PAST ILLNESS
Mr. R was diagnosed of having Diabetes Mellitus type II last 1997. He was
advised by his doctor to be more particular on his diet (to eat more vegetables and fruits
and not to eat too much fatty foods) and do some exercise so that his diabetes will not get
complications. He was also diagnosed of having gallstone last 2003 at a community
hospital, which is located at Magallanes, through ultrasound on the hepato-biliary tree.
He recalls being instructed to take buscopan and co-amoxiclav after being diagnosed.
Mr. R had also mentioned that he has a history of hypertension. This wasn’t
evident during the group’s assessment on Mr. R. However, Mr. R remembers that he had
gone to several hospitals and doesn’t remember where he was diagnosed with
hypertension. Mr. R does remember this happened in the year 1995. Since then, he had
been taking anti-hypertensives like Pritor and Lipitor.
HISTORY OF PATIENT’S PRESENT ILLNESS
Mr. R started experiencing a sharp RUQ pain in the year 1994. He suspected a
disturbance in the stomach, so he took Kremil-S and Buscopan. As an additional self-
treatment for the pain, he frequently ate “lugaw” and he took a lot of rest. Eventually, the
pain went away but it came back three years later. In 1997, the year he was diagnosed
with Type 2 Diabetes Mellitus, he experienced the same sharp RUQ pain just like the one
in 1994. Knowing that his previous self-treatment was effective, he used it again, with an
additional advice from his doctor: drinking plenty of apple juice. Again, the pain went
away as expected. However, Mr. R did not know that his condition was actually getting
worse. Two years after the second incidence, the pain returned. Still not alarmed as he
was in the previous years, Mr. R still used his self-treatment for the pain in 1999. Mr. R
shared that after 1999, he experienced the pain every year already. He also shared that
every time, he used the same self-treatment.
By January 26, 2009, he experienced the worst pain of them all. He shared that his
self-treatment methods was able to ease the pain, but it surprisingly took longer than it
did before. By this time, he decided to have himself checked by a doctor. He was
admitted and undergone a surgical procedure which is Laparoscopic Cholecystectomy at
Davao Medical School Foundation Hospital after being diagnosed with Calculous
Cholelithiasis.
GENOGRAM
D EVELOPMENTAL D ATADEVELOPMENTAL DATA
Theorist Theory Stage Result and Justification
Erik Erikson’s
Psychosocial
Theory of
Development
Source:
Fundamentals of Nursing, 3rd EditionBy:Sue C. DelaunePatricia K. Ladner
Erik Erikson
theorized that
development is a
lifelong process and
does not end with
the cessation of
adolescence. Just as
physical growth
patterns can be
predicted, certain
psychosocial tasks
must be mastered in
each developmental
stage. The greater
the task
achievement, the
healthier the
personality of the
person. However,
failure to achieve a
Integrity Vs. Despair
(45 years old and above)
A person who can look
back on good times with
gladness, on hard times
with self – respect, and on
mistakes and regrets with
forgiveness, will find a
new sense of integrity and
a readiness for whatever
life or death may bring.
A person caught up in old
sadness, unable to forgive
themselves or others for
perceived wrongs, and
dissatisfied with the life,
they’ve led, will easily
drift into depression and
despair.
The patient has
positively achieved
this stage of
development. He
views his life as
meaningful and
fulfilling. He said
that he had coped
well with the
struggles and
problems that came
his way. He is
thankful because
the struggles made
him a better person.
Without doubt, Mr.
R did not have any
regrets in all things
he made whether it
task influences the
person’s ability to
achieve the next
task. The resolution
of the conflicts at
each stage enables
the person to
function effectively
in society.
A positive outcome in this
stage is achieved if the
person gains a self
fulfillment of about life
and a sense of unity
within himself and others.
That way, he can accept
death with a sense of
integrity.
be bad or good.
Mr. R said that
even though he is
separated with his
wife he still has a
very supportive and
caring family.
According to him,
he is very thankful
to have children
and family
members who are
always there to
care for him and to
support him no
matter what life
may give them.
He is also ready to
accept whatever
life or death may
bring him.
Lawrence
Kohlberg’s
Stages of
Moral
Development
Source:
Fundamentals of Nursing, 3rd EditionBy:Sue C. DelaunePatricia K. Ladner
Lawrence
Kohlberg’s theory
specifically
addresses moral
development in
children and adults.
The morality of an
individual’s
decision was not
Kohlberg’s concern;
rather, he focused
on the reasons the
individual makes a
decision. His model
states that a
person’s ability to
make moral
judgments and
behave in a morally
correct manner
develops over a
period of time.
Level III:
Postconventional
In this level, the person
lives autonomously and
defines moral values and
principles that are distinct
from personal
identification with group
values.
Stages:
Social Contract
Legalistic Orientation:
The social rules are not
the sole basis for
decisions and behavior
because the person
believes a higher moral
principle applies such as
equality, justice , or due
process
Universal Ethical
Principle Orientation:
He knows and
understands the
basic social rules
and laws that
should be followed
and he seriously
abides with it.
According to Mr.
R, when coming up
with a decision he
considers the
feelings and rights
of other people. He
makes sure that no
one will be hurt
whenever he makes
certain decisions.
Mr. R also
verbalized that in
making decisions,
it is important to
consider not just
the rules in our
Decisions and behaviors
are based on internalized
rules, on conscience rather
than social laws, and on
self chosen ethical and
abstract principles that are
universal,
comprehensive , and
consistent
society but one’s
feelings and
perceptions as well.
Our patient was
able to achieve the
last stage of this
level because when
he and his wife
made the decision
to separate, they
chose to follow
their feelings rather
than the social
norms. Even
though it is against
the norms in our
society to separate,
they still
considered to
separate from each
other because they
believe that doing
so would be the
right thing to do.
Robert
Havighurst’s
Developmental
Milestones
Theory
Source:
Fundamentals of Nursing, 3rd EditionBy:Sue C. DelaunePatricia K. Ladner
Havighurst
theorized that there
are six
developmental
stages of life, each
with essential tasks
to be achieved.
Mastery of a task in
one developmental
stage is essential for
mastery of tasks in
subsequent stages.
A successful
achievement of a
task leads to
happiness and to
success with later
tasks. However,
failure leads to
unhappiness in the
individual and
difficulty with later
tasks.
Middle Adulthood (30-60 years)
This stage in a person’s
life is concerned with the
achievement of the
following tasks:
Fulfill civic and
social
responsibilities
Maintain an
economic
standard of
living
Assist
adolescent
children to
become
responsible,
happy adults
X Relate to one’s
partner
Adjust to
physiological
Mr. R is currently
working as a
government
employee. He
works in DENR as
the chief mining
supervisor for
environmental and
safety division. He
also votes, pays his
taxes and abides
the laws.
Through his work
as an Engineer, he
was able to earn
enough money to
send his children to
school. In addition,
his salary is also
enough to sustain
their daily needs.
changes
Adjusting to
aging parents
Mr. R is a hands on
father. He guides
and supports his
children up to now.
According to him,
the way he raised
and disciplined his
children made them
good people.
The patient was not
able to achieve the
fourth task because
he is separated with
his wife for 12
years and they do
not communicate
with each other
anymore. However,
he does not restrict
his children to
communicate with
their mother.
Our patient accepts
the changes
accompanied by
aging, especially
with the changes in
health. He accepts
and complies with
his medications
religiously.
Mr. R’s father died
of stroke in the age
of 62 years old. His
mother is still alive
and is residing at
his sister’s house in
Bohol. According
to him, even
though his mother
is in Bohol he still
continues to check
on his mother’s
condition.
D EFINITION OF C OMPLETE D IAGNOSIS
Diagnosis: Calculous Cholelithiasis
Definition
1. Calculi, or gallstones, usually form in the gallbladder from the solid
constituents of bile; they vary greatly in size, shape, and composition.
(reference: Page 1347, Textbook of Medical-Surgical Nursing, Eleventh Edition, Brunner
and Suddarth's)
2. a stonelike mass that forms in the gallbladder
(reference: Saunders Comprehensive Dictionary, 3 ed. © 2007 Elsevier)
3. a calculus formed in the gallbladder or bile duct.
(reference: Dorland's Medical Dictionary for Health Consumers. © 2007 by Saunders, an
imprint of Elsevier, Inc.)
Calculous
- describing a substance that has the hardness of stone.
- pertaining to calculus
(reference: Page 201, Mosby's Pocket Dictionary of Medicine, Nursing and Allied
Health, Fourth Edition. )
Calculus
an abnormal stone formed in the body tissues by an accumulation of mineral salts.
Calculi are usually found in biliary and urinary tract.
(reference: Page 201, Mosby's Pocket Dictionary of Medicine, Nursing and Allied
Health, Fourth Edition.)
Calculus
A calculus (plural calculi) is a stone (a concretion of material, usually mineral
salts) that forms in an organ or duct of the body. Formation of calculi is known as
lithiasis. Stones cause a number of medical conditions.
(reference: http://en.wikipedia.org/wiki/Calculus_(medicine)
Cholelithiasis
the presence of gallstones in the gallbladder.
(reference: Page 256, Mosby's Pocket Dictionary of Medicine, Nursing and Allied
Health, Fourth Edition. )
the presence of gallstones in the gallbladder
(http://wordnetweb.princeton.edu/perl/webwn?s=cholelithiasis)
P HYSICAL A SSESSMENT
Patient’s Name: Mr. R
Age: 53 years old
Sex: Male
Ward: 3C - Surgical Ward (St. Joseph Ward)
GENERAL SURVEY
Our patient, Mr. R was assessed on February 21, 2009 @ 6:00 am. He was
received lying on bed awake, conscious and coherent. He has an ongoing IVF of D5NSS
1 liter regulated at 140cc/° infusing well at R metacarpal vein at 300cc level. He weighs
72 kilograms with a height of 5’6”. He has an endomorphic body structure. Calculation of
his BMI reveals that he is overweight (25.62kg/m2) He was responsive and cooperative
when asked. The patient was 1 day post-op.
VITAL SIGNS
6:00 am
BP – 120/80 mmHg
PR – 62 beats per minute
RR – 22 breathes per minute
Temp. – 36.9°C
SKIN
Our patient has a tan complexion. He has a good skin turgor as skin goes back to
its previous state after being pinched and with a capillary refill of 2 seconds. He has dry
skin with a rough texture. Nails were properly trimmed and no traces of dirt were noted.
HEAD
Our patient’s head is normocephalic. Presence of hair was noted in the head and
in the upper and lower extremities. Lesions, bleeding and bruises were not seen upon
inspection. His hair is evenly distributed and majority of hair color is grey with several
strands of black and white hair. No signs of dandruff and lice noted.
EYES
Eyes are symmetrical with each other. The cornea is moist and white in color. The
iris appears to be black on both eyes. Pupils are equally round and reactive to light and
accommodation with a pupillary size of 2 mm. He needs reading glasses when reads
small texts. His eyebrows are thick and eyelashes are evenly distributed along the margin
of the eyelids; both eyes move in unison; no signs of scratches on both eyes and no
discharges noted.
EARS
The shape of the pinnaes is oval and with no discharges noted. Upper margin of
the pinnaes is in line with the outer canthus of the eyes. Ears are firm and non-tender.
Signs of lesions, lacerations, swelling and bruises were not seen upon inspection. He was
able to repeat a sentence when it was softly said behind his ears, which reveals that he
does not have any hearing problems.
NOSE
External surface of the nose is smooth and oily. Nasolabial folds are symmetrical.
Nostrils are also symmetrical with no flaring and discharges noted. Nasal hairs are
present upon inspection. Nasal septum is not deviated. Both nostrils are patent. No signs
of tenderness were noted. Patient was able to distinguish the smell of rubbing alcohol
while eyes were closed.
MOUTH
Lips are dry with minimal cracks. Teeth are not complete with dentures noted
upon inspection. A total of 3 cavities were also seen upon inspection of the teeth. Gums
and buccal mucosa are pinkish in color. Tongue is in the midline of the mouth. Tonsils
are not inflamed. No signs of inflammation and laceration on the uvula. Bleeding,
ulceration and swelling were not seen upon inspection. Patient was on soft diet and was
able to drink coffee and medications with no dysphagia.
NECK
The neck of our patient can move easily without any difficulty, which includes
right and left lateral, right and left rotation, flexion and hyperextension. Neck can
properly support the head. No signs of enlargement and masses on the thyroid. Carotid
pulse is palpable. No signs of swelling or enlargement of the lymph nodes. No
deformities noted.
CHEST AND LUNGS
Chest muscle expansion during inspiration and relaxation during expiration are
symmetrical and painless. There were no presence of scars and lesions. He was not in
respiratory distress. Respiratory rate is 18 cycles per minute and rhythm was regular.
Breath sounds were clear on both lungs indicating that he is free of cough or colds.
ABDOMEN
Patient’s abdomen is globular in shape, soft, and flabby. Bowel sounds are
hyperactive with 17 sounds counted within one full minute. Four intact and dry
commercially prepared dressings were seen upon inspection. One dressing was seen on
the umbilical area, another dressing was seen just below the xiphoid process, and two
other patches were seen in the upper and lower regions of the iliac. A dull pain was felt
by the patient in the umbilical area and worsens upon palpation.
GENITO-URINARY
Patient refused to be assessed on his genital area. However, patient verbalized no
pain or difficulty upon urination and defecation. Average urine output of patient was 31
cc/hr. His total output for 8 hours was approximately 250cc.
UPPER EXTREMITIES
Patient’s upper limbs, shoulders and arms were symmetrical. No tenderness noted
on the bones of the wrist and fingers. No deformities and swelling noted. He could freely
move his shoulders. No structural deviations noted.
LOWER EXTREMITIES
Both legs of the patient are symmetrical and can stretch, flex, rotate, extend and
bend without any difficulty. No signs of deformities, lesions, lacerations, bruises and
bleeding were seen upon inspection. Patient does not have any difficulty ambulating.
A NATOMY AND P HYSIOLOGY
The liver is the largest internal organ in the body, and weighs about 3
pounds in an adult. The liver is located in the right upper quadrant of the
abdomen, just below the diaphragm. A thick capsule of connective tissue
called Glisson's capsule covers the entire surface of the liver. The liver is
divided into a large right lobe and a smaller left lobe. The falciform ligament
divides the two lobes of the liver.
Each lobe is further divided into lobules that are approximately 2 mm high and
1 mm in circumference.
These hepatic lobules are the functioning units of the liver. Each of the
approximately 1 million lobules consists of a hexagonal row of hepatic cells
called hepatocytes. The hepatocytes secrete bile into the bile channels and
also perform a variety of metabolic functions. Between each row of
hepatocytes are small cavities called sinusoids. Each sinusoid is lined with
Kupffer cells, phagocytic cells that remove amino acids, nutrients, sugar, old
red blood cells, bacteria and debris from the blood that flows through the
sinusoids. The main functions of the sinusoids are to destroy old or defective
red blood cells, to remove bacteria and foreign particles from the blood, and to
detoxify toxins and other harmful substances. Approximately 1500 ml of blood
enters the liver each minute, making it one of the most vascular organs in the
body. Seventy-five percent of the blood flowing to the liver comes through the
portal vein; the remaining 25% is oxygenated blood that is carried by the
hepatic artery.
The liver is responsible for important functions, including:
Bile production and excretion
Excretion of bilirubin, cholesterol, hormones, and drugs
Metabolism of fats, proteins, and carbohydrates
Enzyme activation
Storage of glycogen, vitamins, and minerals
Synthesis of plasma proteins, such as albumin and globulin, and clotting factors
Blood detoxification and purification
Gallbladder: muscular organ that serves as a reservoir for bile, present
in most vertebrates. In humans, it is a pear-shaped membranous sac on the
undersurface of the right lobe of the liver just below the lower ribs. It is
generally about 7.5 cm (about 3 in) long and 2.5 cm (1 in) in diameter at its
thickest part; it has a capacity varying from 1 to 1.5 fluid ounces. The body
(corpus) and neck (collum) of the gallbladder extend backward, upward, and to
the left. The wide end (fundus) points downward and forward, sometimes
extending slightly beyond the edge of the liver.
The gallbladder (or cholecyst, sometimes gall bladder) is a small non-
vital organ which aids in the digestive process and concentrates bile produced
in the liver. The cystic duct connects the gall bladder to the common hepatic
duct to form the common bile duct. This common bile duct then joins the
pancreatic duct, and enters through the hepatopancreatic ampulla at the major
duodenal papilla.
The different layers of the gallbladder are as follows:
• The gallbladder has a simple columnar epithelial 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, but there is a thin lining of muscular tissue to prevent
infection.
Function
The function of the gallbladder is to store bile, secreted by the liver and
transmitted from that organ via the cystic and hepatic ducts, until it is needed
in the digestive process. The gallbladder, when functioning normally, empties
through the biliary ducts into the duodenum to aid digestion by promoting
peristalsis and absorption, preventing putrefaction, and emulsifying fat.
Digestion of fat occurs mainly in the small intestine, by pancreatic enzymes
called lipases. The purpose of bile is to; help the Lipases to Work, by
emulsifying fat into smaller droplets to increase access for the enzymes,
Enable intake of fat, including fat-soluble vitamins: Vitamin A, D, E, and K, rid
the body of surpluses and metabolic wastes Cholesterol and Bilirubin.
The gallbladder stores about 50mL (1.7US 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.
Cholesterol Metabolism
Cholesterol is an extremely important biological molecule that has roles
in membrane structure as well as being a precursor for the synthesis of the
steroid hormones and bile acids. Both dietary cholesterol and that synthesized
de novo are transported through the circulation in lipoprotein particles. The
same is true of cholesteryl esters, the form in which cholesterol is stored in
cells.
The synthesis and utilization of cholesterol must be tightly regulated in
order to prevent over-accumulation and abnormal deposition within the body.
Of particular importance clinically is the abnormal deposition of cholesterol and
cholesterol-rich lipoproteins in the coronary arteries. Such deposition,
eventually leading to atherosclerosis, is the leading contributory factor in
diseases of the coronary arteries.
E TIOLOGY AND S YMPTOMATOLOGY
PREDISPOSING
FACTORSPRESENT ABSENT JUSTIFICATION
AGE / Mr. R is 53 years old; At his age,
the ability of his body to heal
itself is diminished, making him
more prone to developing
diseases like gall stones.
GENDER / Although the disease is not
exclusive to one gender only,
statistics show that women are
more prone to develop gall
stones.
HEREDITY / Gallstones are very common and
thus suspected to be hereditary.
However, Mr. R’s past illnesses
(DM and Hypertension) are found
to have hereditary causes. These
illnesses predispose him to
developing gall stones.
RACE / Statistics show that Caucasians
are more prone to develop
gallstones because their race is
exposed to resources that
provides a high fat diet for them.
PRECIPITATING
FACTORSPRESENT ABSENT JUSTIFICATION
HIGH CHOLESTEROL
DIET/
Mr. R verbalized that since his
grade school years, he is fond of
eating all kinds of lechon.
OVERWEIGHT / Mr. R’s BMI was 25.62kg/m2.
HYPERTENSION / Mr. R was diagnosed with
Hypertension in 1995.
DIABETES MELLITUS
II
/ Mr. R was diagnosed with type 2
DM in the year 1997.
NEGLIGENCE AND
LACK OF
KNOWLEDGE
/ Mr. R verbalized that he only took
Kremil-S and rest to treat his
sharp, intermittent RUQ pain – a
primary symptom of
cholelithiasis.
TREATMENT WITH
ESTROGEN
/ Mr. R never had the need of
estrogen therapy.
ILEAL RESECTION OR
ILEAL DISEASE
/ Mr. R’s ileus does not have a
disease had never been in need
of surgical manipulation.
Symptomatology
SYMPTOMS PRESENT ABSENT JUSTIFICATION
Pain /Mr. R had intermittent RUQ pain
for a span of approximately 14 years.
Biliary Colic /Mr. R’s gall stone can only be found within his gallbladder.
Jaundice /Mr. R had never experienced
jaundice.
Vitamin Deficiency /Mr. R’s laboratory results only
revealed hypokalemia.
Changes in Urine and Stool Color
/Mr. R verbalized that he had
never experienced changes in the urine and stool color.
P ATHOPHYSIOLOGY
PREDISPOSING FACTORS
-Age-Gender-Hereditary-Race
PRECIPITATING FACTORS
-Previous Illnesses: DM and Hypertension-Overweight-Lifestyle: Diet-Negligence and lack of knowledge-Estrogen therapy-Ileal resection or ileal disease
↑ fatty substances into the hepato biliary system
DM II - ↓ glucose utilization
cell hunger
polyphagia(with high cholesterol food preference)
liver excretes more cholesterol in to the bile
↓ gall bladder contractility and emptying; spasm of the sphincter of Oddi
↓ bile synthesis in the liver
gall bladder stasis
bile stasis inflammation of the gallbladder
formation of a NIDUS for stone growth
tissue injury in gallbladder
increased reabsorption of bile salts and lecithin
alteration in composition of bile
bile becomes supersaturated with cholesterol
fusion of crystals to form stones
interruption of bile flow DIAGNOSTIC PROCEDUREultrasound of the hbt
Diagnosis:CALCULOUS CHOLELITHIASIS
Medical Management
-Anti-inflammatory-Antibiotics-Analgesics
Surgical Management
Laparoscopic Cholecystectomy
Nursing Management
- low salt, low fat Diet- Promote Exercise- Deep breathing
If treated:
- good compliance of medication- adequate financial support
If not treated:
- poor compliance of medication- poor financial support
GOOD PROGNOSIS
POOR PROGNOSIS
DEATH
D OCTOR’S O RDERS
DATE DOCTOR'S ORDER RATIONALE REMARKS
Feb. 18, 2009
Wt – 73 kgTemp - 36˚CBP- 120/80RR-21PR-26HGT-120
Pls. admit under my service The patient is in need of medical attention so he is admitted in Davao Medical School Foundation Hospital for preparations for the Pre-operation.
DONE
TPRq4˚ Vital signs are recorded to obtain patients baseline data and are useful for further management. A temperature higher than normal may indicate the development of infection. Pulse & respiration is taken to watch out for tachycardia - a sign of hemorrhage & dehydration.
DONE
NPO post midnight The patient is maintained on NPO in order to prevent aspiration from vomiting which is one of the side effects of anesthesia.
DONE
Labs:CBC, Blood typing, platelet count, Urinalysis, Creatine,FBS,B1 B2, Alk phosphate, Protime, APTT,Chest X-ray PA view. ECG
These entire lab tests are performed to screen for alteration and to serve as a baseline data for future comparison.
DONE
Schedule patient for laparoscopic cholecystectomy.
Laparoscopic cholecystectomy does not require the abdominal muscles to be cut, resulting in less pain, quicker healing,
DONE
improved cosmetic results, and fewer complications such as infection and adhesions. The surgery must be scheduled so that all the necessary things could be prepared and arranged.
Pls. secure consent. For legal purposes: to ensure that the patient knows the majority of the operation to be done.
DONE
Inform OR & Dr. Camarao To schedule the operation DONERefer to OR and Dr. Camarao Referral is done to correct
unusualities as soon as possible and to inform the attending physician of the patient's condition.
DONE
Refer to Dr. Pasia for CP clearance
Referral is done to correct unusualities as soon as possible and to inform the attending physician of the patient's condition.
DONE
Start IVF D5LR 1L to run at 120cc/o prior to transport
For replacement of fluid electrolytes balance maintenance.
DONE
Give cirprobay 200mg IVTT NOW 30 mins prior to OR (ANST)
Prevents infections by inhibting the growth or action of the microorganism.
DONE
Refer accordingly Referral is done to correct unusualities as soon as possible and to inform the attending physician of the patient's condition.
DONE
Feb. 18, 2009
2:20pm
For Na, K, Creatinine, Mg These entire lab tests are performed to screen for alteration and to serve as a baseline data for future comparison.
DONE
Inform IM-ROD ( re: cp clearance )
To aware the IM-ROD about the result for further management.
DONE
HGT now To test the amount of glucose in the blood. An abnormal may signify further management.
DONE
Dr. Joy Enojo
5:00pm NPO Post midnight The patient is maintained on NPO in order to prevent aspiration from vomiting which is one of the side effects of anesthesia.
Start venoclysis once NPO: D5LR 1L @ 120cc/o-hold
For replacement of fluid electrolytes balance maintenance.
DONE
For HGT monitoring q6˚ ( 5-11 11-5)
Blood glucose testing can be used to screen healthy, asymptomatic individuals for diabetes and pre-diabetes because diabetes is a common disease that begins with few symptoms. Screening for glucose may occur during public health fairs or as part of workplace health programs. It may also be ordered when a patient has a routine physical exam. Screening is especially important for people at high risk of developing diabetes, such as those with a family history of diabetes, those who are overweight, and those who are more than 40 to 45 years old.
DONE
Continue maintenance meds c/o Rx’s stocks.
All medications previously ordered by attending physician should be continued to hasten patient's recovery.
DONE
Pls. do Hgt q6˚ (5-11 5-11)& relay to Medical ROD
Blood glucose testing can be used to screen healthy, asymptomatic individuals for diabetes and pre-diabetes because diabetes is a common disease that begins with few symptoms. Screening for glucose may occur during public health
DONE
fairs or as part of workplace health programs. It may also be ordered when a patient has a routine physical exam. Screening is especially important for people at high risk of developing diabetes, such as those with a family history of diabetes, those who are overweight, and those who are more than 40 to 45 years old.
Feb. 18, 2009@
Start venoclysis now: PNSS 1L+40meqs KCL to run @ 120cc/o.
For replacement of fluid electrolytes balance maintainance.
DONE
5:30pm
Feb. 18, 09 11:30pm
Hold surgery temporarily. The patient had low potassium levels which poses as a risk in the patient’s cardiac functions under anesthesia
DONE
DONEPls incorporate additional 20 meqs to current IVF (950cc PNSS + 40 meqs KCL) and set rate @ 100 cc/hr.
IV potassium is irritating to blood vessels and myocardium.
Kalium durule 2 tabs now then 1 tab t.i.d. Replaces potassium and
maintains potassium level.
DONE
Repeat serum K+ 6pm tomorrow.
To determine if potassium levels are normal already
DONE
February. 18, 09 @ 11:40pm
Will inform Dr. Malubay Informing the physician of the latest news about the patient will mean better care given to the patient.
DONE
Carry out IM orders. Orders from internal medicine will help prepare the patient
DONEPlease inform OR. To schedule the operation
and for the surgical team to
make their initial assessment procedures on the patient
Refer Referral is done to correct unusualities as soon as possible and to inform the attending physician of the patient's condition.
DONE
February.19,2009 @ 12am
Schedule surgery on Friday 8am.
To inform the nurses that a surgical operation is being planned; also, to signal preparation for pre-operative care.
Inform OR To schedule the operation. DONE
Inform Dr. Laminose - awareInforming the physicians of the latest news about the patient will mean better care given to the patient.
DONE
May have low fat, diabetic diet To prevent the patient from eating foods that may aggravate his illness which may lead to complications during the upcoming operation
DONE
refer Referral is done to correct unusualities as soon as possible and to inform the attending physician of the patient's condition.
DONE
@11pm D/C Hgt monitoring.To signal the cessation of the monitoring of the patient’s blood glucose
DONE
February.19,2009 @ 6:30 am
May go ahead of surgery if K+ is > or = to 3.5
Patients with low potassium levels are prone to bradycardia and will worsen when administered with anesthetics during surgery. A normal level of potassium is vital for operations
DONE
DONE@ 7am Please carry out IM
suggestions.Suggestions from internal medicine will help prepare the patient for his upcoming operation
@ 2am IVF TF: PNSS 1L and 60 meqs Kcl @ 100 cc/hr.
Daily maintenance of body fluids when less Na+ and Cl- are required.
DONE
Pre-op orders:
February. 19, 2009 @ 7:35pm
NPO post midnight The patient is maintained on NPO in order to prevent aspiration from vomiting which is one of the side effects of anesthesia.
DONE
V/S on call to OR Vital signs are recorded to obtain patients baseline data and be useful for further management.
DONE
General / oral hygiene PTOR General and Oral Hygiene is performed frequently to promote comfort and prevent infections. [PTOR – Prior To Operation]
DONE
IVF: D5NSS 1L @ 120 cc/hr. D5NSS restores sodium chloride deficit and extra cellular fluid volume.
DONE
Meds:1. Diazepam 10mg at 6 am with sips of water.2. Ranitidine 150mg3. Nalbuphine 5mg IVTT prior to transport
Diazepam- to treat anxiety, nervous tension, muscle spasm, and as an anticonvulsant.Ranitidine- to treat gastroesophageal reflux disease and gastric hypersecretory condition; to decrease gastric acid secretion in which preventing the stomach from scarring of the lining.Nalbuphine- to treat moderate to severe pain
DONE
Hgt prior to OR Blood glucose levels can vary within a short period of time. HGT prior to OR determines the blood glucose levels right before the operation is made. This will ensure that other complications will be dealt with according to the test results
DONE
Refer Referral is done to correct unusualities as soon as possible and to inform the attending physician of the patient's condition.
DONE
May have soft diet 8 hours post-op
To indicate the specific diet appropriate for the patient at a specific time. Soft diet is ordered because the GI tract may still be under trace effects from the anesthesia
DONE
Post-op orders
February.20,2009 @ 9:35 am
To PACU; then to ward once stable
For close monitoring of the patient. To watch out for any signs of unusualities.
DONE
VS q 15 mins. until stable; then q hourly.
Vital signs is taken to provide baseline data and to watch for any unusualities.
DONE
IVF rate; D5NSS to run in 160 cc/hr.
To prevent hypoglycemia and dehydration.
DONE
IVF TF: D5NSS 1L @ 140 cc/hr.
To follow-up IVF and maintain replacement of fluid and electrolyte balance.
DONE
Meds:1. Ciprofloxacin 200g IVTT q 8 x/ more doses then shift to ciprofloxacin 400g p.o. B.I.D.2. Ketorolac 30g IVTT q 8 hours x 2 more doses.3. Etoricoxib 120g p.o. B.I.D. to start at 6am tomorrow x 4 doses then decrease to OD thereafter.4. Tramadol retard 100 g to start at 6pm tonight T.I.D.5. Ranitidine 50g IVTT q 8 hours x 3 doses.
Ciprofloxacin - to fight bacteria in the body; to prevent or slow anthrax after exposure.Ketorolac - to reduce pain, fever & inflammation.Etoricoxib - to provide analgesic effect.Tramadol – to alleviate moderate to severe pain.Ranitidine - promoting healing of stomach and duodenal ulcers, and in reducing ulcer pain.
DONE
O2 inhalation at 2 cpm Oxygen therapy is provided to prevent patient from hypoxia.
DONE
Keep patient warm and well thermoregulated.
Warmth makes the patient comfortable and alleviate anxiety that may be helpful for his recovery.
DONE
Deep breathing exercise for 15 minutes, 3x a day.
To expand the lung fully and prevent atelectasis.
DONE
Moderate high back rest. To promote breathing and chest expansion.
DONE
May turn to sides once able. To prevent pulmonary complications as well as other complications.
DONE
Please do Hgt monitoring q 6 hours; may give 4 “u” HR SQ for Hgt > 240.
To monitor the blood sugar levels of the patient
DONE
Watch out for any unusualities; refer accordingly.
To ensure that immediate nursing interventions can be administered to avoid complications; Referral is done to correct unusualities as soon as possible and to inform the attending physician of the patient's condition.
DONE
@ 11pm IVF TF: D5NSS 1L @ 140 cc/hr.
For replacement of fluid electrolytes balance maintenance.
DONE
D IAGNOSTIC E XAM
Urinalysis
Name: Mr. R Feb. 18, 2009
Age/gender: 53/M 325-4
PE CE
Color: yellow Glucose: (-)
Transparency: clear Albumin: (-)
Rxn: 6.0
Specific Gravity: 1.005
Microscopic Examination
Pus cells: 0.1/hpf Uric Acid -------
RBC: 1.3/hpf calcium Oxalate ------
Epithelial cells (+) Triple phosphate -------
Mucous threads (-) Amorphous Urates
Yeast cells ------- Phosphate -------
Hyaline Cast ------ Others ------
Fine granular cast -------
Coarse granular cast -------
Oscar P. Grageda MD, FPSP, APCP
Pathologist
Date: 2/18/09
X-Ray Report
The lung fields are clear
The heart is not enlarged
Great vessels are not unusual
Diaphragm and costophrenic sulci are intact.
No other remarkable findings.
Impression: Normal Chest findings
Ultrasound Report
The liver is normal in size with mild diffuse increase in tissue attenuation. No
focal solid or cystic lesions demonstrated. The intra-hepatic ducts are not dilated. The
widest antero-posterior diameter of the common duct is about 2.4mm.
The gall bladder is adequately distended with slightly thickened walls measuring
up to 5.0mm. There is a 1.7cm intra-luminal echo exhibiting posterior sonic shadowing
but no dependent mobility in the gall bladder fundus.
Impression:
Mild Fatty liver
Calculous Cholecystitis
Hematology
Result Unit Reference:
Hemoglobin 133 g/dl M: 140 - 170
F: 120 - 150
Erythrocytes 4.29 10^12/L 4.0 - 6.0
Leukocyte 6.9 10^9/L 5.0 - 10.0
Segmenters 0.53 % 0.45 - 0.65
Lymphocyte (P) 0.39 % 0.20 - 0.35
Monocyte (P) 0.06 % 0.02 - 0.06
Eosinophils 0.02 % 0.02 - 0.04
Hematocrit 0.41 -- F: 0.38 - 0.4
M: 0.40 - 0.60
thrombocyte 177 10^9/L 150.0 - 450.0
Blood typing “B” Rht
Coagulation Result Form
Result Reference Range:
Protime
Patient
INR
PTPA
Control
13.8 sec
0.99
96.4
13.9 sec
11.5 - 14.5 sec
Normal: 1.0 - 1.2
Therapeutic: 2.0 - 3.0
APTT
Patient
Control
35.6 sec
30.2 sec
24 - 36 sec
APTT MIXING 1
INCUBATION
Patient
Control
-- sec
-- sec
CORRECTED APTT
Patient
Control
-- sec
-- sec
Index: less than 12-
corrected
Index: less than 16-not
corrected
Date: 2/18/09
Blood Chemistry
Test Name Result Normal Value Unit
Creatinine 99.6 H 53.0 - 97.6 Mmol/l
Bilirubin T 7.6 0.0 - 18.8 Mmol/l
Bilirubin O 1.2 0.0 - 4.3 Mmol/l
Alkaline Phosphate 142 64 - 306 U/l
Magnesium 0.94 0.80 - 1.00 Mmol/l
Others:
Calcium -- 1.13 - 1.32 Mmol/l
Chloride -- 95 - 108 Mmol/l
Potassium 2.73 3.5 - 5.3 Mmol/l
Sodium 140.1 135 - 148 Mmol/l
Magnesium -- 0.8 - 1.0 Mmol/l
Normal Value LDL: 0 - 4.73 mmol/l
Normal Value Globulin 28 -31 g/l
Normal Value A/G Ratio 1.5 - 2.4 ratio
Date: 2/19/09
Blood Chemistry
Test Name Result Normal Value Unit
Glucose 5.17 4.10 - 6.40 Mmol/l
Others:
Calcium -- 1.13 - 1.32 Mmol/l
Chloride -- 95 - 108 Mmol/l
Potassium 3.91 3.5 - 5.3 Mmol/l
Sodium -- 135 - 148 Mmol/l
Magnesium -- 0.8 - 1.0 Mmol/l
Normal Value LDL: 0 - 4.73 mmol/l
Normal Value Globulin 28 -31 g/l
Normal Value A/G Ratio 1.5 - 2.4 ratio
Clinical History
Present Complaint: RVQ pain
FyHy: (+) DM- maternal (+) HPN – maternal
Past Hy: (+) DM – 10yrs.
(+) HPN – unrecalled # of years.
(-) BA
(-)FDA
Maintenance Meds:
1. Lipitor
2. Plitor
Present Illness:
18 years PTA, Patient noted abdominal pain located @ RUQ area. No consultation done.
Took antacids which offered temporary relief.
6 years PTA, (+) recurrence of RUQ pain x 5 days UTZ done revealed gallstones. Took
Herbal meds. Patient did not consent for surgery. Patient tolerated the condition, until
PTA, (+) RUQ pain, sought consultation to admission.
PE
General Appearance: awake, afebrile, NIRD, not in jaundice
EENT: pinkish conjunctivae, anicteric sclera, PERLA
C/L: regular rate and rhythm, (-) murmur
Abdomen: soft, NABs, nontender, (-) murphy’s sign.
Extremities: No limitation of movement.
Neurologic exam: no neurologic deficit.
Impression: Calculus Cholecystitis Examiner: Dr. Enigo
D RUG S TUD
Generic Name: Ranitidine hydrochloride
Brand Name: Zantac
ClassificationsSuggested
Dose
Mode of Action
Indications ContraindicationsDrug
Interactions
Side Effects/Adverse
Reactions
Nursing Responsibilities
Antiulcer -50 mg q 8 hours IVTT x 3 doses
Competitively inhibits action of histamine on the h2 at receptor sites of parietal cells, decreasing gastric acid secretion.
- Duodenal and gastric ulcer (short-term treatment); pathologic hypersecretory conditions, such as Zollinger-Ellison syndrome
- Maintenance therpy for duodenal or gastric ulcer.
-Gastroesophageal reflux diseaseErosive Heartburnesopaghitis
- Contraindicated in patients hypersensitive to drug and those with acute porphyria.
Drug-drug. Antacids: May interfere with ranitidine absorption. Stagger doses, if possible.
Diazepam: May decrease absorption of diazepam. Monitor patient closely.
Glipizide: May increase hypoglycaemic effect. Adjust glipizide dosage, as
CNS: vertigo, malaise, headache
EENT: blurred vision
Hepatic: jaundice
Other: burning and itching at injection site, anaphylaxis, angioedema
1. Assess patient for abdominal pain. Note presence of blood in emesis, stool, or gastric aspirate.
2. Instruct patient on proper use of the drug
3. Instruct patient to take the drug without regard to meals because absorption isn’t affected by food.
4. Urge patient to avoid cigarette smoking because this may increase gastric acid secretion and worsen disease
5. Inform patient to
directed.
Procainamide: May decrease renal clearance of procainamide. Monitor patient closely for toxicity.
Warfarin: May interfere with warfarin clearance. Monitor patient closely.
take drug once daily prescription at bedtime for best results.
Alert: Don’t confuse ranitidine with rimantadine: don’t confuse Zantac with Xanac or Zyrtec.
Generic Name: KETOROLAC
Brand Name: Acular, Toradol
ClassificationsSuggested
Dose
Mode of Action
Indications ContraindicationsDrug
Interactions
Side Effects/Adverse
Reactions
Nursing Responsibilities
- Non-steroidal anti-inflammatory agents
- Non-opioid
Analgesics
- Analgesic, anti-inflammatory, antipyretic effects
30 mg q 8 hours IVTT x 2 more doses
- Inhibits prostaglandin synthesis by decreasing an enzyme needed for biosynthesis
Short-term management of pain (not to exceed 5 days total for all routes combined)
Hypersensitivity; cross-sensitivity with other NSAIDs may exist; labor, delivery or lactation; pre- or perioperative use; known alcohol intolerance
DRUG-DRUG
- concurrent use with aspirin may decrease effectiveness
- additive adverse GI effects with aspirin, other NSAIDs, potassium supplements, corticosteroids or alcohol
- chronic use with acetaminophen may increase the risk of
- CV: hypertension, flushing, syncope, pallor, edema, vasodilation
- CNS: dizziness, drowsiness, tremors
- EENT: tinnitus, blurred vision. Hearing loss
- GI: nausea, anorexia, vomiting, diarrhea, constipation, flatulence,
1. Obtain patient’s vital signs to note for signs of hypertension.
2. Assess for patient’s hypersensitivity reactions especially those who have asthma, aspirin-induced allergy, and nasal polyps.
3. For patient’s experiencing pain, note the type, location and intensity of pain prior to 1-2 hr following administration.
4. Instruct patient to make medication exactly as directed. If dose is missed, it should be taken as soon
adverse renal reactions
- may decrease the effectiveness of diuretics or hypertensive
- may increase serum lithium levels and increase the risk of toxicity.
- increased risk if bleeding with cefamandole, cefoten cefoperazone, valproic acid, plicamycin, thrombolytic agents or anticoagulants
- may increase the risk of nephrotoxicity from cyclosporine.
cramps
- GU: Nephrotoxicity: dysuria, hematuria, oliguria, azotemia
- HEMA: blood dyscrasias, prolonged bleeding
- INTEG: pupura, rash, pruritus, sweating
as remembered if not almost time for next dose.
5. Advice patient to call for assistance when ambulating and to avoid driving or any activities requiring alertness until response to the medication is known.
DRUG-NATURAL PRODUCTS
- increased bleeding risk with anise, arnica, chamomile, garlic, ginger, ginko, Panax ginseng
Generic Name: Etoricoxib
Brand Name: Arcoxia
ClassificationsSuggested
Dose
Mode of
ActionIndications Contraindications
Drug
Interactions
Side Effects/
Adverse
Reactions
Nursing
Responsibilities
Non Steroidal
Anti-
inflammatory
Drugs
(NSAIDs)
- 120 mg
P.O. BID x
4 doses
synthesis of
prostanoid
mediators of
pain,
inflammation
and fever.
Selective
clinical dose
range. COX-2
has been
shown to be
primarily
- For the
treatment of
rheumatoid
arthritis,
osteoarthritis
, ankylosing
spondylitis,
chronic low
back pain,
acute pain
and gout.
- Etoricoxib is
contraindicated to
patients with known
hypersensitivity to
Etoricoxib,
patients with active
peptic ulceration or
gastro-intestinal (GI)
bleeding, patients
who have developed
signs of asthma,
acute rhinitis, nasal
Oral
anticoagulants,
diuretics and
ACE inhibitors,
Acetylsalicylic
acid,
Cyclosporin and
Tacrolimus,
Lithium,
Methotrexate,
oral
myalgia
weight changes,
chest pain,
fatigue,
paraesthesia,
influenza-like
syndrome &
- Dry mouth, taste
disturbance,
mouth ulcers,
flatulence,
constipation,
1. Check renal
and hepatic
function
periodically in
patients on long
term therapy.
Stop drug if
abnormalities
occur and notify
prescriber.
2. because of
their antipyretic
responsible for
the
active, highly
selective
cyclooxygenas
e-2 (COX-2)
inhibitor
within and
above the
- exhibits anti-
inflammatory,
analgesic and
antipyretic
activities. It is
a potent, orally
With
decreased GI
toxicity and
without effects
on platelet
function.
polyps,
angioneurotic
oedema or urticaria
following the
administration of
acetylsalicylic acid
or other
contraceptives,
Prednisone/
Prednisolone,
Digoxin, drugs
metabolized by
sulfotransferases
(Ethinyl
Estradiol), drugs
metabolized by
CYP
isoenzymes,
Ketoconazole,
Rifampicin, and
Antacids have
interaction with
Etoricoxib.
appetite and and anti-
inflammatory
actions, NSAIDs
may mask signs
and symptoms of
infection
3. Blurred or
diminished vision
and changes in
color vision may
occur
4. serious G.I.
toxicity,
including peptic
ulcer and
bleeding, can
occur in patient
taking NSAIDs,
despite lack of
symptoms
5. tell patient to
inhibition of
COX-2 by
Etoricoxib
decreases
these clinical
signs and
symptoms
take drug with
meals or milk to
minimize adverse
G.I. reactions
6. caution patient
that use of
alcohol, aspirin or
corticosteroids
may increase risk
of G.I. adverse
reactions
7. teach patient to
watch for and
report to
prescriber
immediately
signs and
symptoms of GI
bleeding,
including blood
in the vomit,
urine or stool.
8. Warn patient to
avoid hazardous
activities that
require mental
alertness until
effects on CNS
are known.
Generic Name: Ciprofloxacin
Brand Name: Ciloxan, Cipro, Cipro HC Otic, Cipro I.V., Cipro XR, Proquin XR
Classifications
Suggested
Dose
Mode of Action
Indications ContraindicationsDrug
InteractionsSide Effects/
Adverse ReactionsNursing
Responsibilities
Fluroquinolone
Antibacterial
400mg P.O. B.I.D.
it's action depends upon blocking bacterial DNA replication by binding itself to an enzyme called DNA gyrase, thereby inhibiting the unwinding of bacterial chromosomal DNA during and after the replication.
complicated intra-abdominal infectionsevere or complicated bone or joint infection,
severe respiratory tract infection,
severe skin structure infectionsevere or complicated UTI,
infectious
avoid taking ciprofloxacin with antacids which contain aluminium, magnesium or calcium. Sucralfate, which has a high aluminium content, also reduces the bioavailability of ciprofloxacin to approximately 4%.
Ciprofloxacin should not be taken with dairy products or calcium-fortified
GI – nausea and vomiting, abdominal pain, constipation
CNS – headache, dizziness, fatigue, lethargy
GU – renal failure
Skin - rash
CNS; seizures, confusion, depression, dizziness, drowsiness, fatigue, hallucinations, headache, insomnia, light-headedness, paresthesia, restlessness, tremor
CV; chest pain, edema, thrombophlebitis
GI; pseudomembranous colitis, diarrhea, nausea, abdominal pain or discomfort, constipation and dyspepsia, flatulence, oral candidiasis, vomiting
GU; crystalluria,
• Arrange for culture and sensitivity tests before beginning therapy
• continue therapy for 2 days after signs and symptoms of infection are gone
• be aware that Proquin XR is not interchangeable with other forms
• ensure that patients swallow ER
diarrhea, typhoid feverpyelonephritisnosocomial pneumoniachronic bacterial prostatitisacute uncomplicated cystitis
mild to moderate cute sinusitis
juices alone, but may be taken with a meal that contains these products.
Heavy exercise is discouraged, as achilles tendon rupture has been reported in patients taking ciprofloxacin. Achilles tendon rupture due to ciprofloxacin use is typically associated with renal failure.
interstitiial nephritis,
hematologic; leukopenia, neutropenia,
musculoskeletal; aching, neck pain, tendon rupture
Skin; rash, pruritus
tablets whole; do not cut, crush, or chew
• ensure that patient is well hydrated
• give antacids at least 2 hrs after dosing
• monitor clinical response; if no improvement is seen or a relapse occurs, repeat culture & sensitivity
•
encourage patient to complete full course of therapy
• drink plenty of fluids while you are taking this drug
• report rah, visual changes, severe GI problems,
weakness, tremors
• tell patient to avoid activities that requires alertness
• Tell patient that this drug can be taken with or without food.
Generic Name: Diazepam
Brand Name: Valium
Classifications
Suggested
Dose
Mode of
Actions Indications
Contra
indications
Drug
Interactions
Side Effects/
Adverse Reactions
Nursing
Responsibilities
Anxiolytics 10 mg PO OD A benzodiazepine that probably potentiates the effect of GABA, depresses the CNS, and suppresses the spread of seizure activity.
preoperative sedation
before endoscopic procedures
muscle spasm
acute alcohol withdrawal
contraindicated in patients hypersensitive to drug or soy protein; in patients experiencing shock, coma, or acute alcohol intoxication
use cautiously in patients with liver or renal impairment.
Drug-drug
Cimetidine may decrease clearance of diazepam and increase risk of adverse effects
CNS depressants may increase CNS depression
Digoxin may increase risk of toxicity
Diltiazem may CNS depression and prolong
CNS; drowsiness, slurred speech, tremor, headache, fatigue
CV; bradycardia, hypotension
EENT; diplopia, blurred vision, nystagmus
GI;nausea, constipation,
Warn patient to avoid activities that require alertness and good coordination until effects of drug are unknown.
Warn patient not abruptly stop the drug because withdrawal symptoms may occur
tell patient to avoid alcohol while taking the drug
notify patient that smoking may decrease drug's effectiveness
Take this medication
effects of diazepam
Drug-Herb
Kava may increase sedation
Drug-lifestyle
Alcohol use may cause additive CNS effect
Smoking may decrease effectiveness of drug
diarrhea
GU; incontinence, urine retention
Hepatic; jaundice
Respiratory; apnea
Skin; rash
exactly as it was prescribed for you. Do not take the medication in larger amounts, or take it for longer than recommended by your doctor. Follow the directions on your prescription label.
diazepam interacts with the plastic; therefore, introducing diazepam into a container reduces drug availability.
Generic Name: Potassium chloride
Brand Name: Kalium Durules
ClassificationsSuggested
Dose
Mode of Action
Indications ContraindicationsDrug
InteractionsSide Effects/
Adverse ReactionsNursing
Responsibilities
potassium salt 1 tab t.i.d. replaces potassium and maintains potassium levels
indicated to prevent hypokalemia,
contraindicated in patients with severe renal impairment with oliguria.
Drug-drug;
ACE inhibitors, digoxin, potassium-sparing diuretics may cause hyperkalemia.
CNS; paresthesia of limbs, ;listlesness, confusion, weakness or heaviness of limbs, flaccids paralysis.
CV; postinfusion phlebitis, arrhytmias, heart block, cardiac arrest, hypotension, ECG changes
GI; nausea, vomiting, abdominal pain, diarrhea.
metabolic; hyperkalemia
Respiratory; respiratory paralysis
Teach patient signs and symptoms of hyperkalemia, and tell patient to notify prescriber if they occur
Tell patient that drug is commonly used orally with potassium-wasting diuretics to maintain potassium levels.
Monitor ECG and electrolytes levels during therapy
Swallow the tablets whole with a full (8-ounce) glass of water. Do not chew or suck on the tablet.
Do not take more of it, do not take it more often, and do not take it for a longer time than your doctor ordered.
Generic Name: Nalbuphine
Brand Name: Nubain
Classifications Suggested
Dose
Mode of
Actions
Indications Contra
indications
Drug
Interactions
Side Effects/
Adverse Reactions
Nursing
Responsibilities
analgesics 5mg IVTT Unknown. Binds with opiate receptors in the CNS, altering perception of and emotinal response to pain.
adjunct to balanced anesthesia
moderate to severe pain
contraindicated in patients hypersensitive to drug
Drug-drug. CNS depressants and sedatives may cause respiratory depression, hypertension, profound sedation or coma.
Opoid analgesics may decrease analgesic effect
Drug-lifestyle. Alcohol use may cause additive effects
CNS; dizziness, headache, sedation, vertigo, confusion, restlessness.
CV; bradycardia, hypotension, tachycardia, hypertension
EENT; blurred vision, dry mouth
GI; constipatio
Tell patient drug act as an antagonist and may cause withdrawal syndrome
Advise the patient to avoid any activities that requires alertness because this drug can cause dizziness
Explain to the patient that the drug can cause constipation.
Tell the patient to report to the prescriber immediately if there is severe itcheness.
n, nausea, vomiting, dyspepsia, cramps
GU; urinary urgency
Respiratory; asthma
Skin; burning, clamminess, diaphoresis, pruritus
Generic Name: Tramadol
Brand Name: ultram
Classifications
Suggested
Dose
Mode of Action
Indications
Contraindications
Drug Interactions
Side Effects/Adverse
Reactions
Nursing Responsibilities
Analgesics 100mg P.O. t.i.d.
The mode of action of tramadol has yet to be fully understood, but it is believed to work through modulation of the noradrenergic and serotonergic systems in addition to its mild agonism of the μ-opioid receptor.
indicated to treat moderate to moderately severe pain
Hypersensitivity to tramadol. In acute intoxication with alcohol, hypnotics, centrally acting analgesics,opiates, or psychotropic drug.
drug-drug
Carbamezepine may increase tramadol metabolism
CNS depressants may cause additive effects
Cyclobenzaprine may increase risk of seizures
Quinidine may increase the level of
CNS; dizziness, headache, somnolence, vertigo, seizures, anxiety, asthenia, CNS stimulation, confusion, coordination disturbance, euphoria, malaise, nervousness, sleep disorders
CV; vasodilation
EENT; visual disturbances
GI; constipation, nausea, vomiting, abdominal pain, anorexia, diarrhea, dry mouth, dyspepsia, flatulence
• Document indications for therapy, location, onset, and characteristics of symptoms. Use a pain rating scale.
• Assess for history of drug addiction, allergy to opiates or codeine, or seizures; drug may increase the risk of convulsions.
• Monitor VS, I & O, liver and renal function studies; reduce dose with dysfunction and if over 75 yrs. Old.
• Do not perform activities
tramadol GU; proteinuria, urinary frequency, urine retention
Musculoskeletal; hypertonia
Respiratory; respiratory depression
Skin; diaphoresis, pruritus, rash
that require mental alertness; drug may cause drowsiness and impair mental or physical performance. Alcohol may intensify drug effect.
• Report lack of response. Review list side effects (nausea, dizziness, constipation, somnolence, and pruritus) that one may experience and report if persistent or intolerable.
N URSING T HEORIES
BETTY NEUMAN’S Systems Model
Betty Neuman’s systems model focuses on the wellness of the client system in
relation to the environmental stressors and reactions to stressors. These stressors include
intrapersonal (occur within person, e.g. emotions and feelings), interpersonal (occur
between individuals, e.g. role expectations), and extrapersonal stressors (occur outside
the individual, e.g. job or finance pressures). The nursing interventions involved in this
theory focuses on retaining or maintaining system stability on three preventive levels: [1]
Primary prevention (includes health promotion and maintenance of wellness.), [2]
Secondary prevention (focuses on preventing damage to the central core by strengthening
the internal lines of resistance and/or removing the stressor.), and [3] Tertiary prevention
(offers support to the client and attempts to add energy to the system or reduce energy
needed in order to facilitate reconstitution).
Application to patient:
Last 2006, the patient was diagnosed of Cholelithiasis and was given medications
like pain reliever () and antibiotic (). The pain and discomfort were relieved because of
the medications given. After three years, he experienced recurrence of pain and
discomfort. This made him decide to consult his physician and agreed to the suggested
surgery, which is Laparoscopic Cholecystectomy
Our patient belongs to the tertiary prevention since he had already undergone
Laparoscopic Cholecystectomy. As a health care provider, we rendered health teachings
that would prevent him from developing the same condition. Additional information was
also given to the patient that would help hasten the healing process. Examples of health
teachings rendered to him are encouraging him to have a strict compliance of his
therapeutic regimen, to have a regular exercise and emphasizing the importance of
having a healthy and balance diet. Also, teach the patient and the family about the
importance of psychological well being in recovery.
IMOGENE KING’s Goal Attainment Theory
Imogene King’s model is a model of three interacting systems: Personal,
Interpersonal, and Social. The major elements of the theory are seen in the interpersonal
systems in which two people, who are usually strangers, come together in a health care
organization to help and be helped to maintain a state of health that permits functioning
in roles. She states that client goals are met through the transaction between nurse and
client.
Application to the patient:
As health care providers, we need to learn how to interact and establish rapport
to our patients. We must encourage them to verbalize their concerns and feelings in order
for us to provide the proper interventions necessary to their condition.
During our course of care, we were able to establish a good nurse-patient
relationship with Mr. R. Because of this, we were able to obtain information regarding
his plans after his discharge. In line with this, involved Mr. R in creating a plan of care
and exploring means of achieving this upon his discharge. We must also give him enough
information especially on prevention of illnesses so that his role as an individual will not
be affected.
LYDIA HALL’S Care, Core, and Cure Model
Lydia Hall presented her theory of nursing visually by drawing three interlocking
circles, each circle presenting a particular aspect of nursing. The circle represents care,
core, and cure. The care circle represents the nurturing component of nursing and is
exclusive to nursing. The professional nurse provides bodily care for the patient and helps
the patient to complete such basic daily biological functions as eating, bathing,
elimination and dressing. When providing this care, the nurse’s goal is the comfort of the
patient. The core circle of patient care is based in the social sciences, involves the
therapeutic use of self, and is shared with other members of the health team. The
professional nurse, by use of the reflective technique helps the patient look at and explore
feelings regarding his or her current health status and related potential changes in
lifestyle. The cure circle of patient care is based in the pathological and therapeutic
sciences and is shared with other members of the health team. The professional nurse
helps the patient and family through the medical, surgical, and rehabilitative prescriptions
made by the physician. During this aspect of nursing care, the nurse is an active advocate
of the patient.
Application to the patient:
In the care circle, we were able to ensure client safety through raising side rails
of bed to prevent patient from falling, assisting patient whenever he ambulates, and
imparting health teachings that would help him to have a speedy recovery.
In the core circle, we were able to allow the patient to explore his feelings about
his condition through letting him express his concerns and worries regarding his
condition. Through this, the patient will be motivated to make appropriate decisions in
promoting good health.
In the cure circle, we were able to perform a medical procedure that would help
the physician to determine the proper treatment that should carried-out to the patient.
N URSING C ARE P LANS
DATE/TIME CUES NEEDS NURSING DIAGNOSIS
OBJECTIVES OF CARE
NURSING INTERVENTIONS EVALUATION
Feb. 21, 2009@ 5am
S: ‘’medyo sakit2x ang gi operahan diri sa akong tiyan’’ as verbalized by the patient.O: - Presence
of patches on the operative sites.
- Grimaced face when patch on umbilicus was palpated
- Pain scale of 5- moderate
COGNITIVE-PERCEPTUAL
PATTERN
Acute pain r/t surgical tissue trauma secondary to laparoscopic cholelithiasis.
R: Unpleasant sensory and emotional experience arising from actual or potential tissue damage; sudden or slow onset of any intensity from mild to severe with an anticipated or predictable end and duration of less than 6 months.
Source: Nurse’s Pocket Guide, Marilynn E.
Within our span of care, our patient will be able to:
- Follow interventions to relieved pain.
- Verbalized minimal pain.
- - utilize comfort measures and techniques effectively to reduce or alleviate pain.
1.Observe and document location, severity (1-10 pain scale), and character of pain(steady, intermittent, colicky.)R: assists in differentiating cause of pain and provides information about disease progression/resolution, development of complications, and effectiveness of interventions.2.Promote bedrest , allowing patient to assume position of comfort.R: bedrest in low Fowler’s position reduces intraabdominal pressures; however, patient will naturally assume least painful position.3.Encourage use of relaxation techniques, e.g., deep breathing exercises.R: promotes rest, redirects attention, may enhance coping.4.Make time to listen to complaints and maintain frequent contact with the patient.R: helpful in alleviating anxiety and refocusing attention, which can relieve pain.5.Administer medications as indicated.R: to maintain ‘’acceptable’’ level of pain. Notify physician if regimen is inadequate to meet pain control goal. 6.Observe and document location, severity (1-10 pain scale), and character of pain(steady, intermittent, colicky.)R: assists in differentiating cause of pain and provides information about disease progression/resolution, development of
GOAL MET
Patient was able to:
- minimize manipulation of affected area and utilize relaxation techniques to minimize pain.- patient verbalized pain scale of 3
Doenges, Mary Frances, Moorhouse, Alice C. Murr
complications, and effectiveness of interventions.7.Promote bedrest , allowing patient to assume position of comfort.R: bedrest in low Fowler’s position reduces intraabdominal pressures; however, patient will naturally assume least painful position.8.Encourage use of relaxation techniques, e.g., deep breathing exercises.R: promotes rest, redirects attention, may enhance coping.9.Make time to listen to complaints and maintain frequent contact with the patient.R: helpful in alleviating anxiety and refocusing attention, which can relieve pain.10.Administer medications as indicated.R: to maintain ‘’acceptable’’ level of pain. Notify physician if regimen is inadequate to meet pain control goal.
DATE/TIME CUES NEEDS NURSING DIAGNOSIS
OBJECTIVES OF CARE
NURSING INTERVENTIONS EVALUATION
Feb. 21, 2009@ 5am
S:
–“Dili ko sure kung unsaon nako ang akoang diet karon na wala na ko’y gall bladder.”
O:
Patient is S/P laparoscopic cholecystectomy
C
O
G
N
I
T
I
V
E
-
P
E
R
C
E
P
Knowledge deficit [Medications] r/t unfamiliarity with information resources.
R: Absenc e or deficiency of cognitive information
related to specific topic.
Within our span of care, patient will be able to:
–participate in the learning process
–identify interferences to learning and specific actions to deal with them
–exhibit increased
learning of medicines
taken.
1. Assess client's level of understanding.
R: Facilitates planning of postoperative teaching program, identifies content needs.
2. Identify motivating factors for the individual.
R: Motivating factors will help in the teaching process
3. provide information relevant to the situation.
R: for the patient to be informed regarding her present condition.
4. Provide positive reinforcement.
R: to encourage continuation of efforts.
5. Identify information that needs to be remembered.
R: The client will know what specific information will help out in remembering what is learned
6. Determine client's method of accessing information and include in teaching plans.
GOAL MET
The patient was able to:
- perform necessary
interventions correctly
-
verbalize understandi
ng of condition/disease
process and treatment.
- Identify medications
use to treat his
condition.
T
U
A
L
P
A
T
T
E
R
N
R: to know teaching method to be used and to help facilitate learning.
7 Provide written information and guidelines for client to refer to as necessary.
R: Written information will be more reliable for the client whenever information will be forgotten
8. Begin with information that client already knows and move to what the client does not know.
R: This will ensure that the client will not have a hard time learning new things
9. Provide information about additional learning resources.
R: to assist client with further learnings and
promote learning at own pace.
DATE/TIME CUES NEEDS NURSING DIAGNOSIS
OBJECTIVES OF CARE
NURSING INTERVENTIONS EVALUATION
Feb. 21, 2009@ 5am
O: Disruption of skin layers (epidermis and dermis) due to laparoscopic procedure.
NUTRITIONAL
-
METABOLIC
PATTE
Impaired skin integrity r/t tissue damage secondary to laparoscopic cholecystectomy procedure.
R: Altered epidermis and/ or dermis.
Source: Nurse’s Pocket Guide, Marilynn E. Doenges, Mary Frances, Moorhouse, Alice C. Murr
Within our span of care, the client will be able to
- display timely healing of skin lesions/ wounds/ pressure sores without complication.
- Maintain optimal nutrition/ physical well-being.
1. Identify underlying condition/ pathology trauma. (e.g. surgical incision)R: Identifies impairments and allows for identification of appropriate interventions.2. Note changes in skin color, texture, and turgor.R: changes in the integument to determine skin integrity 3. Determine depth of damage to integument system (epidermis, dermis, and underlying tissues.)R: this will help client’s recovery. To note underlying complications for further management.4. Note odors emitted from the skin/ area of injury.R: this will determine occurrence of gangrene5. Note presence of compromised vision, hearing, or speech. R: Skin is a particularly important avenue of communication for these people and, when compromised, may affect responses.6. Keep the area clean/ dry, carefully dress wounds, support incision, prevent infection, and stimulate circulation to surrounding areas.
Goal Met:
Patient was able to:
- participate in prevention measures and treatment program.
- verbalize feelings of increased self-esteem and ability to manage situation.
RN
R: to assist body’s natural process of repair.
7. Use appropriate barrier dressings, wound coverings, drainage appliances, and skin-protective agents for open/ draining wounds.
R: to protect the wound and/ or surrounding tissues.
8. Provide skin care every 8 hours and prn. Change wet clothing and linens prn
R: Helps to promote circulation and reduces potential for skin breakdown.
9. Provide optimum nutrition and increased protein intake.
R: to provide a positive nitrogen balance to aid in healing and to maintain general good health.
10. Assist the patient in understanding and following medical regimen and developing program of preventive care and daily maintenance
R: Enhances commitment to plan, optimizing outcomes.
DATE/TIME CUES NEEDS NURSING DIAGNOSIS
OBJECTIVES OF CARE
NURSING INTERVENTIONS EVALUATION
Feb. 21, 2009
@ 5am
Objective:
>loss of appetite as evidenced by untouched meals and as verbalized by the patient and his significant others.
>the patient has undergone laparascopic cholecystectomy.
N
U
T
R
I
T
I
O
N
A
L
-
M
E
T
Altered nutrition less than body requirements related to impaired fat digestion due to obstruction of bile flow.
Within our 8 hours span of care, the patient will be able to achieve relief of nausea and vomiting.
1.Monitor vital signs
®serves as a baseline data
2.Monitor IVF
® To maintain the fluid and electrolytes balance in the patient’s body
3. Monitor Intake and output.
®To determine any unusualties for immediate medical management.
4. Assess for abdominal distention, frequent belching, guarding, and reluctance to move.
®Nonverbal signs of discomfort associated with impaired digestion, gas pain.
5. Consult with patient about likes/dislikes, foods that cause distress, and preferred meal schedule.
®Involving patient in planning enables patient to have a sense of control and encourages patient to eat.
eb. 21, 2009 @ 6:00am
Goal met:
The patient was able to demonstrate achievement in relief of nausea and vomiting.
A
B
O
L
I
C
P
A
T
T
E
R
N
6. Provide a pleasant atmosphere at mealtime; remove noxious stimuli
®useful in promoting appetite/reducing nausea.
7. Keep comments about appetite to a minimum
®Focusing on problem creates a negative atmosphere and may interfere with intake.
8. Provide oral hygiene before meals.
®A clean mouth enhances appetite.
9. Offer effervescent drinks with meals, if tolerated.
®May lessen nausea and relieve gas.
10. Ambulate and increases activity as tolerated.
®Helpful in expulsion of flatus, reduction of abdominal distention. Contributes to overall recovery and sense of well-being and decreases possibility of secondary problems related to immobility.
DATE/TIME CUES NEEDS NURSING DIAGNOSIS
OBJECTIVES OF CARE
NURSING INTERVENTIONS EVALUATION
Feb. 21, 2009@ 5am
O:
- surgical incision noted on abdomen as possible portal of entry for pathogenic organisms.
H
E
A
L
T
H
P
E
R
C
E
P
T
I
O
Risk for infection r/t abdominal incision done secondary to laparoscopic procedure.
R: At increased risk for being invaded by pathogenic organisms.
Source: Nurse’s Pocket Guide, Marilynn E. Doenges, Mary Frances, Moorhouse, Alice C.
Within our span of care, patient will be able to:
- identify interventions to prevent/ reduce risk of infection.
- achieve timely wound healing.
1. Monitor vital signs and patient for presence of fever and chills.
R: Fever, tachycardia, and tachypnea may indicate presence of infection.
2. Stress proper hand washing techniques between therapies/clients.
R: A first-line defense against nosocomial infections/ cross-contamination.
3. Cleanse incisions or change dressings as needed/indicated.
R: Dressings help protect the area to reduce further injury.
4. Administer/ monitor medication regimen and note client’s response.
R: to determine effectiveness of therapy/ presence of side effects.
5. Use sterile or strict aseptic technique for all dressing changes.
R: .Abdominal incision makes the patient susceptible to infection.
6. Instruct patient/ family regarding signs and
GOAL MET
The patient was able to:
-demonstrate technique
es, lifestyle changes to
promote safe environ
ment.
-stay afebrile.
-and achieve timely
wound healing.
N
-
H
E
A
L
T
H
M
A
N
A
G
E
M
E
N
T
Murr symptoms to observe for, such as demarcated area changes, redness, change or presence of drainage, and so forth
R: May indicate presence of infection or that tissue necrosis is extending.
7. Instruct patient/family regarding maintaining proper nutrition, with increased protein intake.
R: adequate nutrition is required for maximum wound healing.
8. Instruct patient on all medications and procedures.
R: Promotes knowledge and helps to facilitate compliance with medical regimen.
P ROGNOSIS
CategoryPoor
(1)
Fair
(2)
Good
(3)Justification
1. Duration
of Illness
It's been 14 years since the first
sign of pain
2. Onset of
Illness
As soon as the pain got really
worse, he immediately sought
medical treatment, but he could
have done this earlier
3.
Predisposing
Factors
2 out of 3 predisposing factors are
present; his susceptibility to the
disease is unavoidable.
4.
Precipitating
Factors
His lifestyle could have been
adjusted and hid disease could
have been avoided altogether
5.
Willingness
to take the
medications
or
compliance
to treatment
regimen
Patient verbalized that this
experience has taught him
valuable lesson in keeping healthy
and preventing illnesses by
taking his medication religiously
6.
environment
Patient verbalized that his home
environment and work place only
give him manageable stress.
7. family
support
During our interview Mr. R's
nephew was present; his son was
also expected to visit in the
morning; Mr. R was also observed
to answer two phone calls from
two of his siblings.
Calculation
s
3x1 =
3
1x2 =
23x3 = 9
3 + 2 + 9 = 14
14/7 = 2
Ranges:
1.0 – 1.5 = Poor
1.5 – 2.5 Fair
2.5 – 3.0 = Good
Mr. R has a FAIR prognosis.
His disease could have been totally avoided just by a change in lifestyle and diet.
Mr. R could have paid attention to his weight gain and the rising issues about obesity and
what diseases it could bring about. And most of all, Mr. R should have had his RUQ pain
checked by a doctor early on. If the gall stones were still during its early stages, they
could have been removed by Mr. R taking medications and an invasive procedure could
have been avoided. However, the usual prognosis of post laparoscopic cholecystectomy
patients is usually very good. Having smaller incisions brings about lower risks for
infections. Early ambulation is readily done which then will bring about early recovery.
Mr. R has also been educated on the changes in his lifestyle that he could do in order for
him to have a good life ahead of him even if he doesn’t have a gall bladder anymore.
D ISCHARGE P LAN
MEDICATION
Explain each purpose of the medication
® Knowledge about what medications will make the client become aware of
what he is taking and for the family to participate more in the client’s treatment.
Inculcate to the client to comply all the medications prescribed at the ordered
dosage, route and at the ordered time.
® Taking the drugs at the ordered dose, route and time limits the chance for
toxicity and ensure its effectiveness.
Instruct client not to take over-the-counter drugs without doctor’s knowledge.
Ò Non-prescribed drugs may have an antagonistic effect or synergistic effect in
any drug therapy.
Explain the side effects or adverse reactions of each medication. Instruct the client
and family to watch out for it and to report it immediately as soon as possible to
the physician.
® Explaining the side effects will let the client and family identify what harmful
effects to expect and for them to distinguish the adverse reaction to medication for
them to report it to their physician immediately.
Advice client to take medications with food if not contraindicated or to take
medicine one hour before meals or one hour after meals.
® Some medications are irritating to the gastric mucosa.
Let patient complete the whole course of the drug therapy.
Ò This can help the patient alleviate the problem and be able to experience the
full therapeutic effect of the medication.
EXERCISE
Instruct client to avoid strenuous activities for at least a week or a month until
fully recovered.
Ò Activities that require great muscle strength should be avoided to prevent
injury and muscle strain.
Encourage early ambulation.
Ò Walking is good exercise and could promote circulation, hence, proper healing.
Promote exercise to the client especially ROM.
® This will promote good physical health.
Advise patient to have adequate rest and sleep.
Ò To gain back the lost strength and be able to return to its normal state thus
allow ample time for healing.
Practice deep breathing exercise.
Ò This will help alleviate any pain or discomfort that patient will encounter
TREATMENT
Explain the need of treatment after discharge and must take it seriously so as to
prevent such complications to the patient
Ò To make the client and family aware that the treatment does not only end at
hospital but needs to be continued at home to make the client responsible towards
medication.
Explain to the family the condition of the patient and give them factual
information about the illness.
Ò To have better understanding of the patient’s condition and to be able to know
what intervention they should give that could not alter the effect of the therapy.
HYGIENE
Encourage having proper hygiene like taking a bath, meticulous hand washing,
and brushing of teeth every after meal.
Ò Hygiene promotes comfort and cleanliness to the patient. It also increases the
sense of wellness, which is very much needed in the therapeutic process.
Encourage patient to continue hygienic measures practiced at present such as
changing clothes everyday and changing of underwear as often as necessary,
keeping the nails neatly trimmed, maintaining own supplies/items for personal
necessities.
Ò Keeping all practiced measures is necessary in consistent maintenance of
proper hygiene. Owning personal accessories for hygiene purposes keep client
away from contamination and infectious diseases.
Provide a calm, clean, and accepting environment.
Ò Calm, clean and non threatening environment may lessen the occurrence of
possible infection and would be a good place for healing.
OUTPATIENT ORDER
Inform the patient that follow-up check-up is important to have continuous
monitoring and care even after attainment of the course medical therapy.
Ò Through constant visits as out patient, the physician would still monitor the
progress of the therapeutic intervention availed by the patient.
Advice the client and the family to carry out follow-up diagnostic examinations
® This is to evaluate the therapeutic response of the patient to the treatment.
Instruct the family to report any unusual signs and symptoms experienced by the
patient.
Ò This will help detect early signs and symptoms of recurrence of the disease.
DIET
Encourage client to eat a variety of nutritious foods like fruits and vegetables once
instructed by the physician.
Ò To maintain and promote a healthy body.
Instruct client to take vitamins as ordered.
Ò To boost the body’s defense mechanism.
Encourage patient to increase oral fluid intake.
Ò This hydrates the body for normal functioning and maintain acid-base balance.
Advise client not to skip meals and have a regular eating pattern/schedule.
Ò Regular interval of meals is the basic principle of a good dietary plan.
Tell patient not to eat foods contraindicated by the physician.
Ò To prevent the occurrence of complications.
Instruct patient to avoid drinking liquors and smoking
® To also avoid illness to be triggered.
R ECOMMENDATION
