Operating Room - Case Pres

8/3/2019 Operating Room - Case Pres

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FAR EASTERN UNIVERSITY

INSTITUTE OF NURSING

CASE PRESENTATIONof

CHOLECYSTECTOMY

Submitted to:

Miss Glenda Santos RN, MAN

Miss Victoria Arceli RN, MAN

Submitted by:

BSN 207 - GROUP 25 A

Alamani, Jollybenson A.Alberto, Jamela Mer D.

Alcantara, Jaycel M.

Alfonso, Lester E.

Amihan, Ma. Luvimae N.

Bernardo, Naomi F.

December 3, 2011


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OPERATING ROOM

CASE PRESENTATION

I. Patients Data

Patients Name: JLP

Age: 25 years old

Gender: Female

Date of Birth: May 24, 1986

Address: Sabang, Baliuag Bulacan

Religion: Roman Catholic

Civil Status: Married

Attending Physician: Dr. Bugay

Operation Performed: Cholecystectomy

Type of Surgery: Open cholecystectomy

Surgeon: Dr. Rolando Valones

Date of Operation/Case No. : December 1, 2011 / 11-11-5113

Type of Anesthesia: Spinal anesthesiaAnesthesiologist: Dr. Dennis S. Lazaro

II. Anatomy/ Structure/ Function

a) Definition of operation performed:

Open cholecystectomy- surgery in which the abdomen is opened to

permit cholecystectomy -- removal of the gallbladder.

This operation has been employed for over 100 years and is a safe and effective method

for treating symptomatic gallstones, ones that are causing significant symptoms. At

surgery, direct visualization and palpation of the gallbladder, bile duct, cystic duct, and


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blood vessels allow safe and accurate dissection and removal of the gallbladder. Intra-

operative cholangiography has been variably used as an adjunct to this operation. The

rate of common bile duct exploration for choledocholithiasis (gallstones in the bile duct)

varies from 3% in series of patients having elective operations to 21% in series that

include all patients. Major complications of open cholecystectomy are infrequent and

include common duct injury, bleeding, biloma, and infections.

Open cholecystectomy is the standard against which other treatments must be

compared and remains a safe surgical alternative.

b) Discussion of anatomy involved:

The digestive system prepares food for use by hundreds of millions of body cells.

Food when eaten cannot reach cells (because it cannot pass through the intestinal walls

to the bloodstream and, if it could not be in a useful chemical state. The gut modifies

foo physically and chemically and disposes of unusable waste. Physical and chemical

modification (digestion) depends on exocrine and endocrine secretions and controlled

movement of food through the digestive tract. Stomach contractions send signals to the

brain making us aware of our hunger. Glucose level in the blood is maintained. Insulin

decreases glucose in blood making us feel hungry. Levels of glucose in the blood are

monitored by receptors (neurons) in the stomach, liver, intestines, they send signals tothe hypothalamus in the brain.

Mouth

Food enters the digestive system via the mouth or oral cavity, mucous membrane lined.

The lips (labia) protect its outer opening; cheeks form lateral walls, hard palate and soft

palate form anterior/posterior roof. Communication with nasal cavity behind soft

palate. Floor is muscular tongue. Tongue has bony attachments (styloid process, hyoid


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bone) attached to floor of mouth by frenulum. Posterior exit from mouth guarded by a

ring of palatine/lingual tonsils.Enlargement sore throat, tonsillitis. Food is first processed

(bitten off) by teeth, especially the anterior incisors. Suitably sized portions then

retained in closed mouth and chewed or masticated (especially by cheek teeth,

premolars, molars) aided by saliva Ducted salivary glands open at various points into

mouth. This process involves teeth (muscles of mastication move jaws) and tongue(extrinsic and intrinsic muscles). Mechanical breakdown, plus some chemical (ptyalin,

enzyme in saliva). Taste buds allow appreciation, also sample potential hazards

(chemicals, toxins).

Swallowing

In leaving the mouth a bolus of food must cross the respiratory tract (trachea is anterior

to esophagus) by a complicated mechanism known as swallowing or deglutination which

empties the mouth andensures that food does not enter the windpipe. Swallowing

involves coordinatedactivity of tongue, soft palate pharynx and esophagus. The first

(buccal) phase is voluntary, food being forced into the pharynx by the tongue. After this

the process is reflex. The tongue blocks the mouth, soft palate closes off the nose and

the larynx rises so that the epiglottis closes off the trachea. Food thus moves into the

pharynx and onwards by peristalsis aided by gravity. If we try to talk whilst swallowing

food may enter the respiratory passages and a cough reflex expels the bolus.

Esophagus

The esophagus (about 10") is the first part of the digestive tract proper and shares its

distinctive structure. Basic tissue layers of the gut are:

1. Mucosa- Innermost, moist lining membrane. Epithelium (friction

resistant stratified squamous in esophagus, simple beyond) plus a little

connective tissue and smooth muscle.2. Sub mucosa- Soft connective tissue layer, blood vessels, nerves,

lymphatic

3. Muscularisexterna- Typically circular inner layer, longitudinal outer layer of smooth

muscle

4. serosal fluid- producing single layer.

Stomach

C shaped, left side abdominal cavity (because liver is on right). Cardio esophageal

sphincter guarding entrance from esophagus is of doubtful anatomical integrity (though

functionally the diaphragmatic pinch cock serves). Pyloric sphincter guarding the outletis much better defined. Fundus, body and pylorus recognized as distinct regions.

Stomach secretes both acid and mucus (for self-protection). Surface area increased by

rugae. Serves as a temporary store for food which is also churned by muscular layers

(three here) to form chyme, creamy substance voided via pyloric sphincter to

duodenum


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Duodenum

First part of small intestine. C shaped 10" long and curves around head ofpancreas and

entry of common bile duct (accessory organs of digestion, pancreas, liver see below).

Chemical degradation of small controlled amounts of food controlled by pyloric

sphincter begins here, enzymes secreted by pancreas and duodenum itself aided by

emulsifying bile (which also lowers pH). Duodenal ulcers caused by squirting of acidstomach contents into duodenal wall opposite sphincter.

Small Intestine

Jejunum (8 feet) and ileum (12 feet) continue degenerative process. Surface area

increased by plicacirculares (circular folds) carrying villi: cells of villi carry microvilli. Each

villus has a capillary and

a lacteal (lymphatic capillary) Absorption of digested foodstuffs is via

these to the rich venous and capillary drainage of the gut. Towards the

end of the small intestine accumulations of lymphoid tissue (Peyer's

patches) more common. Undigested residue of food is rich in bacteria.

Large Intestine

Jejunum terminates at caecum. Caecum is small saclike evagination, important in some

animals as a repository for bacteria/other organisms able to digest cellulose. A blind

ending appendix may give trouble (appendicitis) if infected. The large intestinehas three

longitudinal muscle bands (taenia coli) with bulges in the wall (haustra) between them.

These may evaginate in the elderly to become diverticuli and infected in diverticulitis.

The large intestine resorbs water then eliminates drier residues as feces. Regions

recognized are the ascending colon, from appendix in right groin up to a flexure at the

liver, transverse colon, liver to spleen, descending colon, spleen to left groin, then

sigmoid (S-shaped) colon back to midline and anus. Anus has voluntary and involuntarysphincter and ability to distinguish whether contents are gas or solid. No villi in large

intestine, but many goblet cells secreting lubricative mucus.

Accessory digestive organs: Salivary glands

Three pairs, parotid, submandibular, sublingual. Mumps begins as infective parotitis in

the parotid glands in the cheek. The others open into the floor of the mouth. Saliva is a

mixture of mucus and serous fluids, each produced to various extents in various glands.

Also contains salivary amylase, (starts to break down starch) lysozyme (antibacterial)

and IgA antibodies.

Pancreas

Endocrine and exocrine gland. Exocrine part produces many enzymeswhich enter the

duodenum via the pancreatic duct. Endocrine part produces insulin, blood sugar

regulator.


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Liver

Multifunctional: important in this context since the capillaries of the small intestine

drain fat and other nutrient rich lymph into it via theHepatic portal system.

Liver and gallbladder

A cleftlike lumen, the bile canaliculus is between the cells of each hepatic cord. Bileproduced by the hepatocytes, flow through the bile canaliculi to the hepatic duct in the

portal of triads. The hepatic duct converge and empty into the right and left hepatic

ducts, which transport bile out of the liver. The right and left hepatic ducts units form a

single common hepatic duct. The common hepatic duct is joined by the cystic duct from

the gallbladder to form the common bile duct. The gallbladder is a small sac on the

inferior surface of the liver that stress and concentrates bile. Bile is responsible in

making the color of the stool dark brown.Bile, a watery greenish fluid is produced by the

liver and secreted via the hepatic duct and cystic duct to the gall bladder for storage,

and thence on demand via the common bile duct to an opening near the pancreatic duct

in the duodenum. It contains bile salts, bile pigments (mainly bilerubin, essentially the

non-iron part of hemoglobin) cholesterol and phospholipids. Bile salts and phospholipids

emulsify

c) Functions of organs/body parts involved:

The gallbladder is a saclike structure on the inferior surface of the liver that is about 8cm

long and cm wide. Three tunics form then gallbladder wall:

1. the inner mucosa folded into rugae that allow the gallbladder to expand.

2. amuscularis, which is a layer of the smooth muscle that allows the gallbladder to

contract


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3. an outer covering serosa. The cystic duct connects the gallbladder into common bile

duct.

Bile is continually secreted by liver and flows through the cystic duct to the gallbladder,

where 40-70ml of bile can be stored. While the bile is in the gallbladder, water and

electrolytes are absorbed, and bile salt and pigmented becomes as much as 5-10 timesmore concentrated than they were when secreted by the liver. Contraction of the

gallbladder moves the stored bile into duodenum. Secreting released from the

duodenum stimulate bile secretion, primarily by increasing the water and bicarbonate

ion content of bile. Cholecystokinin released from the duodenum stimulates the

gallbladder to contract and sphincter of bile duct and hepatopancreatic ampulla relax.

To a lesser degree, parasympathetic stimulation through the vagusnercescause the

gallbladder to contract. Thus large amount of concentrated bile move rapidly into

duodenum. Bile salt also increases bile secretion through a positive feedback system.

Over 90% of bile salt are reabsorbed in the elium and carrired in the blood back to liver,

where they contribute further bile secretion. The loss of bile salt in the feces is reduced

by this recycling process.

d) Etiology of the disease:

A gallstone, is a lump of hard material usually range in size from a grain of sand

to 3-4 cms. They are formed inside the gall bladder formed as a result of precipitation of

cholesterol and bile salts from the bile.

Types of gallstones and causes

Cholesterol stones Pigment stones

Mixed stones - the most common type. They are comprised of cholesterol and salts

Cholesterol stones are usually yellow-green and are made primarily of hardened

cholesterol. They account for about 80 percent of gallstones. Scientists believe

cholesterol stones form when bile contains too much cholesterol, too much bilirubin, or

not enough bile salts, or when the gallbladder does not empty as it should for some

other reason. Low grade infection in the gall bladder is another factor in the

development of gall stones.

Pigment stones are small, dark stones made of bilirubin. Bilirubin is the pigment

secreted by the liver The exact cause is not known. They tend to develop in people who

have cirrhosis, biliary tract infections, and hereditary blood disorders such as sickle cell

anaemia in which too much bilirubin is formed.

Other causes are related to excess excretion of cholesterol by the liver in the bile.

They include the following:


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Gender. Women between 20 and 60 years of age are twice as likely to develop

gallstones as men.

Obesity. Obesity is a major risk factor for gallstones, especially in women.

Oestrogen. Excess oestrogen from pregnancy, hormone replacement therapy, or birth

control pills

Cholesterol-lowering drugs. Diabetes. People with diabetes generally have high levels of fatty acids called

triglycerides.

Rapid weight loss. As the body metabolizes fat during rapid weight loss, it causes theliver to secrete extra cholesterol into bile, which can cause gallstones.

e) Signs and symptoms:

Many people with gallstones have no symptoms. These patients are said to be

asymptomatic, and these stones are called "silent stones." Gallstone symptoms can be

similar to those of many other conditions such as heart attack, appendicitis, ulcers,

irritable bowel syndrome, hiatal hernia, pancreatitis, and hepatitis. Accurate diagnosisis, therefore important.

Symptoms may vary and often follow fatty meals, and they may occur during the

night:

Abdominal bloating

Recurring intolerance of fatty foods

Severe pain in the upper abdomen that increases rapidly and lasts from 30

minutes to several hours

It may be associated with:

Pain in the back between the shoulder blades

Pain under the right shoulder

Nausea or vomiting

Indigestion & belching

f) Intra and post-operative risk factors:

Possible Complications

Complications are rare, but no procedure is completely free of risk. If you are planning

to have a cholecystectomy, your doctor will review a list of possible complications,

which may include:

Gallstones that have accidentally spilled into the abdominal cavity

Bleeding

Infection

Injury to other nearby structures or organs


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Reactions to general anesthesia

Blood clots

Some factors that may increase the risk of complications include:

Age: 60 or older

Pregnancy Obesity

Smoking

Malnutrition

Recent or chronic illness

Diabetes

Heart or lung problems

Bleeding disorders

Alcoholism and use of street drugs

Use of certain medicines

III. Procedure

a) Skin Preparation:

Clean the skin:

1. From the nipples to the pubis.

2. From the posterior axillary fold on the right side to the anterior axillary fold on the left.

3. Use two swabs on sticks with aqueous povidone iodine, followed by one to dry off.

4. Dry the skin completely or adhesive drape edges will not stick down.


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b) Draping:

First, they placed a folded drape sheet from the foot to the knees. Then, the scrub nurse

selected the sheet and handed one end to the surgeon across the operating site. The second

drape sheet was handled in the same manner. This sheet was placed above the incision site withthe edge of the sheet just above the incision site. Next, they placed a sterile sheet with an

appropriate size of a hole in the middle and put it around the selected incision site. Then, four

towel clips were clamped on all edges and connecting them to the two drape sheets.

c) Position:

Lateral shrimp position (during anesthesia injection)

Supine position (during the procedure)


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d) Anesthesia (technique used):

Spinal anesthesia, also called spinal analgesia or sub-arachnoid block (SAB), is a form of regional

anesthesia involving injection of a local anesthetic into the Subarachnoid space, generally

through a fine needle, usually 3.5inches (9 cm) long. For extremely obese patients, some

anesthesiologists prefer spinal needles which are seven inches (18 cm) long. T he tip of the

spinal needle has a point or small bevel. Recently pencil point needles have been made

available.

Indications:

This technique is very useful in patients having an irritable airway (bronchial asthma or allergic

bronchitis), anatomical abnormalities which make endotracheal intubation very difficult

(micrognathia), borderline hypertensives where administration of general anesthesia or

endotracheal intubation can further elevate the blood pressure, procedures in geriatric patients.

It is the technique of choice for diabetic patients.

Contraindications:

Non-availability of patient's consent, local infection or sepsis at the site of lumbar puncture,

bleeding disorders, space occupying lesions of the brain, disorders of the spine and maternal

hypotension.


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e) Incision Site:

Right side of the upper abdomen

f) Discuss the procedure:

Step I: Incision

Types of Incision:

Upper Right SubCostal IncisionKocher's Incision

Modified Kocher's Incision

Transverse Incision

The incision for open cholecystectomy is typically made 2 fingerbreadths below the right

costal margin, although an upper midline incision can also be used

Retractors are placed to retract the skin, as well as to retract the liver superiorly

Step II: Exposure of the Gallbladder

Retraction of the liver

Inferior surface of the right lobe of the liver is retracted upwards by retracter.


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The dome of the gallbladder is initially scored with electrocautery, and a tonsil clamp is

used to establish a plane in the thickened gallbladder in proximity to the gallbladder wall

itself. The cautery is then used to incise the peritoneal surface of the entire dome.

Step III: Removal of the Gallbladder

The fundus of the gallbladder is removed from the liver bed with blunt and sharp

dissection. Care should be taken in mobilizing the infundibulum of the gallbladder to be

certain that it is not adherent to the common bile duct. The cystic artery and its extension

are usually encountered on the medial surface of the gallbladder. The cystic artery can be

temporarily controlled with a clip on the surface of the gallbladder prior to its formal

ligation. The gallbladder is then completely mobilized from the liver bed until it is attached

only by the cystic duct.


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A clamp is placed on the gallbladder fundus and used to retract the gallbladder

superiorly. A second clamp can be used to retract the infundibulum of the gallbladder

laterally, exposing the triangle of Calot.

Ideally, the cystic artery is identified, circumferentially dissected, and ligated before

dissection of the gallbladder out of the gallbladder fossa. As in the laparoscopic case,

care should be taken not to injure the right hepatic artery. The gallbladder is then removed from the gallbladder fossa from the top down using

electrocautery.

Clamps are placed proximally and distally on the cystic duct. The cystic duct is divided

between the clamps, and the gallbladder is removed from the field.

The cystic duct stump is suture ligated using a 3-0 silk suture

The cystic duct and cystic artery stumps are examined for any signs of bile leakage or

bleeding

Step IV: Closing The placement of closed suction drains is not always required. They are placed only if

bile leakage from the cystic duct stump is expected or observed. If bile leakage is

observed, the surgeon must rule out common bile duct injury.

The fascia is closed in two layers using running or interrupted sutures.

The skin is then closed with absorbable subcuticular sutures or skin staples.


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CASE PRESENTATION

CHOLECYSTITIS

I. Patients Data

Patients Name: JLP

Age: 25 years old

Gender: Female

Date of Birth: May 24, 1986

Address: Sabang, Baliuag Bulacan

Religion: Roman Catholic

Civil Status: Married

Attending Physician: Dr. Bugay

Operation Performed: Cholecystectomy

Type of Surgery: Open cholecystectomy

Surgeon: Dr. Rolando Valones

Date of Operation/Case No. : December 1, 2011 / 11-11-5113

Type of Anesthesia: Spinal anesthesiaAnesthesiologist: Dr. Dennis S. Lazaro

II. NURSING HISTORY

a. PAST HEALTH HISTORY

The patient had childhood illness like mumps when she was 6 years old and measles

when she was 3 or 4 years old. According to her, she does not have chicken pox up to now.

She had complete immunization status. She has no allergies to food and medications. She

was admitted for caesarean section last 2008 in Sto. Nio Hospital in Bustos, Bulacan. She

was hospitalized for 3 days.

b. HISTORY OF PRESENT ILLNESS

Eight days prior to admission, she experienced on and off epigastric pain and radiating

to her back. She also felt pain in her head, nape and around her eyes. She also felt

abdominal bloating. She took Mefenamic acid 500 mg for the pain. Pain lessened but still

recurrent for 8 days. She experienced loss of appetite and difficulty in falling asleep. She had

her check-up last November 25, 2011. She went through ultrasound, pap smear and

urinalysis. Her ultrasound impression was cholelithiasis. She was admitted last November

30, 2011 in Castro Maternity and General Hospital.

c. FAMILY HISTORY

There are cases of hypertension, asthma, and skin cancer on the maternal side of the

patient. On her paternal side, heart diseases and breast cancer are present.


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III. ACTIVITIES OF DAILY LIVING

Activities of

Daily of Daily

Living

Before Hospitalization During Hospitalization Analysis and Interpretation

Nutrition According to the client

before hospitalization,

she eats rice at least

two times a day. At

breakfast the client

drinks a glass (7 oz) of

water every day and

she drinks at least

three to four times for

the whole day, eats

Lugaw, and eats

Yohgurt. During lunch

and dinner time, the

client eats a serving of

viands likeKalderetang Baka and

a cup of rice.

According to the

client, she loves to eat

spaghetti and palabok.

During hospitalization,

the client states that

there are no changes in

the appetite of the client.

The client also eats and

consumes foods that she

eats before

hospitalization. And also

there is no change in the

amount and quality of

food the client eats. The

client is advised to have

nothing per orem.

Interpretation:

ABNORMAL

The clients diet before

hospitalization and the diet

during her stay in the medical

center are not sustaining the

appropriate and adequate

nutrition required for her. She

seldom eats dinner because of

the pain she feels during that

time. She lacks carbohydrates

which are required to give

energy to her body. She seldom

eats fruits and vegetables too.

Her fluid intake is not in rightamount required to consume in

a day. She admitted that she

frequently drinks water.

ANALYSIS:

An adequate food intake

consists of a balance of


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essential nutrients: water,

carbohydrates, proteins, fats,

vitamins and minerals.

(Health Promotion in Nursing

process)

Normal fluid intake should be

up to 8 to 10 glasses a day.

(Kozier et.al. 2008.

Fundamentals of Nursing, 8th

edition). Singapore: Pearson

Education Asia Pte Ltd).

Proper nutrition encompasses

the study of nutrients and how

they are handled by the body

as well as the impact of human

behaviour and environment onthe process of nourishments.

Foods that provides nutrition

for both body and mind.

(Fundamentals of Nursing by

Taylor)

Elimination At home the client

urinates for at least

three times a day. The

color of the urine is

light yellow and

aromatic in odor. Theclient usually

defecates twice a day

and the usual color is

yellow brown,

pungent in odor and

semisolid. The client

does not feel any pain

during urination and

defecation. The client

said that she perspires

a lot.

The client urinates for

three times a day. The

color of the urine is still

the same as before the

hospitalization. And the

client usually defecatestwice a day and the usual

color is yellow brown,

pungent in odor and

semisolid. The client does

not feel any pain during

urination and defecation.

The client perspires less

in the hospital.

Interpretation:

ABNORMAL

The urinary output of the client

before and during the

hospitalization is little in

amount.

ANALYSIS:

Normal Feces

Color: brown

Consistency: soft, formed and

moist

Shape: cylindrical

Amount varies with diet

Aromatic in smell

(Kozier, et al. 2008.

Fundamentals of Nursing)

Urine

About 1200-1500 ml

Straw, amber or transparent in

color

Odor: faint aromatic

Sterility: No microorganisms

present


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Ph:4.5-8



Voiding that is either painful or

difficult (Dysuria) is an altered

urinary elimination.

Frequency of defecation is

highly individual, varying from

several times per day or 2-3

times a week.

Irregular defecation habits

occur when normal defecation

reflexes are inhibited or

ignored, which later on

progressively weakens. Whenhabitually ignored, the urge to

defecate is ultimately lost.

Children at play may ignore

these reflexes; adults ignore

them because of pressure of

time or work

Normal feces are made of

about 75% water and 25% solid

waste materials.

Normal feces require a normal

fluid intake; feces that contain

less water may be hard and

difficult to expel.



Activities At home, the client

usually helps her

mother in taking care

of their Sari-Sari store.

The client usually

watch television

shows. He also plays

games on cell phones

and laptops. She do

household chores and

takes good care of her

child.

In the hospital the client

has limited activities and

usually stays in the

hospital bed. Client

usually watches

television show and plays

games on cell phones

and laptops.

Interpretation:

NORMAL

The client can still continue her

need for physical activity in the

hospital because shes only

ambulatory not immobile,

capable of walking. Shes not

immobile which means she can

still perform a number of ROM

(range-of-motion exercises)

maintaining her muscle tone.

She just needs assistance when


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ambulating, for example going

to the comfort room, changing

into a sitting position, etc.

ANALYSIS:

The amount of exercise you

need depends on the type of

lifestyle you want to maintain.

For beginners, most experts

recommend at least 20 minutes

of exercise three times a week.

These 20 minutes can be a

combination of four 5-minute

sessions of exercise, two 10-

minute sessions or 20

continuous minutes. Just doing

something is better than no

exercise at all. Remember, 20minutes is considered the

minimum prescribed amount of

exercise for one day. As your

body adjusts to this level of

exercise, you should increase

the amount of exercise that

you are doing to continue

receiving the maximum

benefits.

(Kozier et.al. 2008.

Fundamentals of Nursing, 8

th

edition). Singapore: Pearson

Education Asia Pte Ltd)

Hygiene The client takes a bath

everyday. She usually

takes a bath in the

morning and takes a

half-bath during the

evening. And brush

her teeth two times a

day with the use of a

normal toothbrush.

The client usually

wears comfortable

clothes when shes at

home.

The child does sponge

bath in the hospital. And

brush her teeth with the

use of a normal

toothbrush. The client

usually wears tshirt and

leggings.

Interpretation:

NORMAL

The clients hygienic pattern

falls within a normal scale.

After the operation, the client

should recuperate a good

personal hygiene as similar

from her hygiene before she

was hospitalized.

ANALYSIS:

Hygiene is the self-care by

which people attend to such

functions as bathing, toileting,

general body hygiene and

grooming. It involves care of

the skin, hair, nails, teeth, oral


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and nasal cavities, eyes, ears

and perineal-genital areas.

(Kozier & Erb. Fundamentals of

Nursing. 8th

Edition. Volume 1)

Sleep and Rest The client doesnt

take any nap. She

usually sleeps at 10

oclock in the evening

and wakes up at 8

oclock in the morning

the following day.

The client has a difficulty

in sleeping. She usually

sleeps around 1 or 2

oclock in the morning

and wakes up around 6

or 7 oclock in the

morning. She

experiences pain when

closing her eyes.

Interpretation:

NORMAL

The clients sleeping pattern

before and during

hospitalization has big

difference. She lacks sleep

during her hospitalization

because she experiences pain

every time shell be sleeping.

One factor also is stress about

her operation and the sleeping

environment. With the aim of

promoting a good sleepingenvironment, nurses should

keep the lights low and using as

soft voice and as much as

possible overcome the sound

interference in the

surrounding.

ANALYSIS:

Children require 11-12 hours of

sleep each night with no

disturbance to prevent unduefatigue.

(Fundamentals of Nursing By

Kozier Et. Al 8th

Ed)

Sleep is a basic human need; it

is a universal biological process

common to all people. Human

requires sleep for many

reasons: to cope with daily

stresses, to prevent fatigue, to

conserve energy, to restore

mind and body, and to enjoy

life more fully.

(Fundamentals of Nursing By

Kozier Et. Al 8th

Ed)

Environment can promote or


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hinder sleep. Any change-for

example, noise in the

environment can inhibit sleep.

Discomfort from environmental

temperature (e.g. too hot or

too cold) and lack of ventilation

can affect sleep.

Substance Use The client doesnt

take any medications.

After the operation the

attending physician

ordered Mefenamic acid

500mg/tab if there is a

positive epigastric pain

happens.

Interpretation:

NORMAL

The patient is not going

through any kind of substance

abuse. She is currently taking

her prescribed medicine.

ANALYSIS:

Smoking is a risk factor for

hypertension, heart disease,peripheral vascular disease,

chronic obstructive pulmonary

disease (COPD), and cancer of

the lung, colon, larynx, oral

cavity, esophagus, bladder,

pancreas, and kidney. It also

worsens such conditions as

respiratory infections, peptic

ulcers, hiatal hernia, and

gastroesophageal reflux.

Not smoking promotes health

by increasing exercise

tolerance; enhancing taste bud

function; and avoiding facial

wrinkles and bad breath.

(Lipincott Manual of Nursing

Practice, 8th Edition)


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IV. PHYSICAL ASSESSMENT

CLIENTS BODY BUILT Height: 164 cmWeight: 57 kg

POSTURE AND GAIT Slouched

HYGIENE AND GROOMING Clean and neat

SIGNS OF DISTRESS(POSTURE/FACIAL)

In distress

SIGNS OF ILLNESS Unhealthy Appearance

ATTITUDE Cooperative

AFFECT AND MOOD Appropriate to situation

SPEECH(QUANTITY/QUALITY/ORGANIZATION)

Understandable if repeatedModerate paceClear Tone

RELEVANCE/ORGANIZATION OFTHOUGHTS

Mental status

Logical SequenceMakes SenseHas Sense Of Reality

Alert

Measurement Normal Findings Actual Findings Interpretation

Weight According to the Body

Mass Index (BMI) Chart,BMI of 18.6-22.9 is

normal, or = to 23

is overweight

57 kg (125 lbs) Normal

Height According to the Body

Mass Index (BMI) Chart,

BMI of 18.6-22.9 is

normal, or = to 23

is overweight

164 cm(54 feet) Normal

Vital signs

Temperature 36.5.7-37.5 36C Abnormal

Pulse rate 60-100 72bpm- regular Normal

Respiratory rate 12-20 cpm 18cycles Normal


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NORMAL FINDINGS ACTUAL FINDINGS INTERPRETATION

SKIN

Inspect skin color. Varies from light to

deep brown; from

ruddy pink to light pink;

from yellow overtones

to olive.

Pallor Deviated from normal

Inspect uniformity of skin

color.

Generally uniform

except in areas

exposed to the sun.

Generally uniform

except in areas

exposed to the sun.

Normal

Inspect presence of

edema

No edema No edema Normal

Observe and palpate skin

moisture.

Moisture in skin folds

and the axillae (varies

with environmental

temperature and

humidity, body

temperature, and

activity.)

Moist in skin folds Normal

Palpate skin temperature. Uniform; within normal

range.

Uniform; Cold Deviated from normal

Note skin turgor (fullness

or elasticity) by lifting and

pinching the skin on an

extremity.

When pinched, skin

springs back to

previous state.

Skin spring back to

previous state when

pinched

Normal

NAILS

Inspect fingernail plate

shape to determine its

curvature and angle.

Convex curvature;

angle of nail about 160

o.

Convex curvature,

angle approximately

160

Normal

Inspect fingernail texture. Smooth texture. Smooth Normal

Inspect fingernail bed

color.

Highly vascular and

pink in light-skinned

clients; dark-skinned

clients may have brown

or black pigmentation

Pallor Deviated from normal

Blood Pressure 120/80 mmHg 100/70 mmHg Deviated from normal


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in longitudinal streaks.

Inspect tissues

surrounding nails.

Intact epidermis. Intact epidermis Normal

Perform blanch test of

capillary refill.

Prompt return of pink

or usual color(generally less than 4

seconds.)

Return to usual color Normal

HEAD

Inspect the skull for size,

shape and symmetry.

Rounded

(normocephalic and

symmetric, with frontal,parietal, and occipital

prominences); smooth

skull contour.

Normocephalic,

smooth skull contour

Normal

Palpate the skull for

nodules, masses and

depressions.

Smooth, uniform

consistency; absence

of nodules or masses.

Smooth, uniform

consistency, no

nodules or masses

Normal

Color and appearance of

scalp

Scalp lighter than the

color of the facial skin

Scalp lighter than the

color of the facial skin

Normal

Areas of tenderness No tenderness No tenderness Normal

Hair evenness of growth Evenly distributed Evenly distributed Normal

Hair thickness or thinness

Texture and oiliness

Thick hair

Silky, resilient hair

Thick hair

Silky, resilient hair

Normal

Inspect the facial features. Symmetric or slightly

asymmetric facial

features; palpebral

fissures equal in size;

symmetric nasolabial

folds.

Symmetric facial

features

Normal

Note symmetry of facial

movements.

Symmetric facial

movements

Symmetric facial

movements

Normal

EYES

Inspect the eyebrows for Hair evenly distributed; Hair evenly distributed; Normal


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hair distribution and

alignment and skin quality

and movement.

skin intact; eyebrows

symmetrically aligned;

equal movement.

skin intact; eyebrows

symmetrically aligned;

equal movement.

Inspect the eyelashes for

evenness of distribution

and direction of curl.

Equally distributed;

curled slightly outward.

Equally distributed;

curled slightly outward.

Normal

Inspect the eyelids for

surface characteristics,

ability to blink, and

frequency of blinking.

Skin intact, no

discharge, no

discoloration; lids close

symmetrically;

approximately 15 to 20

involuntary blinks per

minute, bilateral

blinking.

Skin intact, no

discharge, no

discoloration; lids close

symmetrically; 17

involuntary blinks per

minute, bilateral

blinking.

Normal

Color, texture, and

presence of lesion in

bulbar conjunctiva

Transparent Transparent Normal

Color, texture, and

presence of lesion in

palpebral conjunctiva

Shiny, smooth, pink or

red

Shiny, smooth, pink Normal

Color and clarity of sclera White White Normal

Inspect the cornea for

clarity and texture.

Transparent, shiny and

smooth; details of the

iris are visible.

Transparent, shiny and

smooth; details of the

iris are visible.

Normal

Inspect the pupils for

color, shape and

symmetry of size.

Black in color; equal in

size normally 3 to 7

mm in diameter; round,

smooth border.

Black in color; equal in

size normally 4mm in

diameter; round,

smooth border.

Normal

Light reaction and

accommodation

Illuminated pupil

constricts and non-

illuminated pupil

constricts, pupil

constricts when looking

at near object and

dilate when looking at

far object; pupil

converge when near

object is moved toward

the nose

Illuminated pupil

constricts and non-

illuminated pupil

constricts, pupil

constricts when looking

at near object and

dilate when looking at

far object; pupil

converge when near

object is moved toward

the nose

Normal

Eye alignment and Both eyes move in

coordination and

Both eyes move in

coordination and

Normal


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coordination unison, with parallel

alignment

unison, with parallel

alignment

Assess near vision. Able to read newsprint. Able to read Normal

Assess distance vision. 20/20 vision on

Snellen-type chart.

20/150 Normal

EARS

Inspect the auricles for

color, symmetry of size

and position.

Color same as facial

skin; symmetrical;

auricle aligned with

outer canthus of eye

about 10o

from vertical.

Color same as facial

skin; symmetrical;

auricle aligned with

outer canthus of eye

about 10o

from vertical.

Normal

Palpate the auricles for

texture, elasticity, and

areas of tenderness.

Mobile, firm, and not

tender; pinna recoils

after it is folded.

Mobile, firm, and not

tender; pinna recoils

after it is folded.

Normal

Inspect ear canal for

cerumen, skin lesions,

pus, and blood.

Dry cerumen, grayish-

tan color, or sticky.

Dry cerumen, grayish-

tan color, or sticky.

Normal

Assess clients response

to normal voice tones.

Normal voice tones

audible.

Normal voice tones

audible.

Normal

Perform watch tick test. Able to hear ticking in

both ears.

Able to hear ticking in

both ears.

Normal

Perform Webers test. Sound is heard on bothears or is localized at

the center of the head

(Weber negative.)

Sound is heard on bothears weber negative

Normal

Conduct Rinne test AC > BC (positive

Rinne.)

Right-AC=9>BC=8;

Left-AC=10>BC=8

Positive rhine

Normal

NOSE

Inspect the external nose

for any deviations in

shape, size, or color and

flaring or discharge from

the nares.

Symmetric and

straight; no discharge

or flaring; uniform

color.

Symmetric and

straight; no discharge

or flaring; uniform

color.

Normal


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Presence of redness,

swelling, growth and

discharge in nasal cavity

Mucosa is pink; clear

watery discharge; no

lesion

Mucosa is pink and no

lesion

Normal

Lightly palpate the

external nose to

determine any areas of

tenderness, masses, and

displacements of bone

and cartilage.

Not tender; no lesions. Not tender; no lesions. Normal

Test patency of both

nasal cavities.

Air moves freely as the

client breathes through

nares.

Air moves freely as the

client breathes through

nares.

Normal

Inspect nasal septum

between the nasal

chambers.

Nasal septum intact

and in midline.

Nasal septum intact

and in midline.

Normal

Palpate for tenderness of

sinuses.

Not tender. No tenderness Normal

MOUTH

Inspect the outer lips for

symmetry of contour,

color and texture.

Uniform pink color;

soft, moist and smooth

texture; symmetry of

contour.

Uniform pink color;

soft, moist and smooth

texture; symmetry of

contour

Normal

Inspect and palpate the

inner lips and buccalmucosa for color,

moisture, texture and the

presence of lesions.

Uniform pink color;

moist, smooth, soft,glistening, and elastic

texture.

Uniform pink color;

moist, smooth, soft,glistening, and elastic

texture.

Normal

Inspect gums for the color

and condition.

Pink gums, firm texture

to gums.

Red gums, firm texture

to gums.

Normal

Inspect the tongue for

position, color, and

texture.

Central position; pink

color; dry, slightly

rough; thin whitish

coating.

Central position; pink

color; dry, slightly

rough; thin whitish

coating.

Normal

NECK AND LYMPH NODES

Palpate lymph nodes and

note for tenderness.

Not palpable. Not palpable Normal

Inspect and palpate

trachea for placement.

Central placement in

midline of the neck;

Central placement in

midline of the neck;

Normal


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spaces are equal on

both sides.

spaces are equal on

both sides.

ABDOMEN

Inspect the abdomen for

skin integrity.

Unblemished skin

Uniform color

Silver-white striae

(stretch marks) or

surgical scars

Unblemished skin

Uniform color

Silver-white striae

(stretch marks) or

surgical scars

Normal

Inspect the abdomen for

contour and symmetry:

Observe theabdominalcontour 9profileline from the ribmargin to thepubic bone) whilestanding at theclients side whenthe client issupine.

Ask the client totake a deepbreath and to holdit.

Assess thesymmetry of

contour whilestanding at thefoot of the bed.

If distention ispresent, measurethe abdominalgirth by placing atape around theabdomen at thelevel of theumbilicus.

Flat, rounded (convex),

or scaphoid (concave)

No evidence of

enlargement of liver or

spleen

Symmetric contour

Flat, rounded (convex),

or scaphoid (concave)

There is a slight

enlargement between

epigastric and

hypochondriac region.

Symmetric contour

Normal

Normal

Deviated from

normal

Normal

Observe abdominal

movements associated

with respiration,

peristalsis, or aortic

pulsations.

Symmetric movements

caused by respirations

Visible peristalsis in

very lean people

Aortic pulsations in thin

persons at epigastric

area

Symmetric movements



very lean people



area

Normal


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Observe the vascular

pattern

Symmetric movements



very lean people



area

Symmetric movements



very lean people



area

Normal

Normal

Auscultate the abdomen

foe bowel sounds,

vascular sounds, and

peritoneal friction rubs.

Audible bowel sounds

Absence of arterial

bruits

Absence of friction rub

Audible bowel sounds

Absence of arterial

bruits

Absence of friction rub

Normal

Perform light palpation

first to detect areas of

tenderness and/or muscle

guarding. Systematically

explore all four quadrants.

Ensure that the clients

position is appropriate for

relaxation of the

abdominal muscles, and

warm the hands.

No tenderness; relaxed

abdomen with smooth,

consistent tension



consistent tension

normal

Perform deep palpation

over all four quadrants



consistent tension



consistent tension

Normal

Palpate the liver to detect

enlargement and

tenderness

May not be palpable

Border feels smooth

May not be palpable

Border feels smooth

Normal

Palpate the area above

the pubic symphysis if the

clients history indicatespossible urinary distention

Not palpable Not palpable Normal

MUSCULOSKELETAL SYSTEM

Inspect muscles for size. Equal size on both

sides of the body.

Equal size on both

sides of the body.

Normal


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Inspect the muscles and

tendons for contractures

(shortening) and tremors.

No contractures; no

tremors.

No contractures; no

tremors.

Normal

Palpate muscles at rest to

determine muscle tonicity.

Normally firm. firm Normal

Test for strength (neck,

upper and lower

extremities.)

Equal strength on each

body side.

Equal strength on each

body side.

Normal

Inspect the skeleton for

structure.

No deformities. No deformities. Normal

Palpate the bones to

locate any areas of

edema or tenderness.

No tenderness or

swelling.

No tenderness or

swelling.

Normal

Inspect the joint for

swelling, tenderness,

smoothness, and

presence of nodules.

No swelling,

tenderness or nodules;

joints move smoothly.

No swelling,

tenderness or nodules;

joints move smoothly.

Normal

REFLEXES

Assess upper extremity

reflexes (biceps/ triceps/

supinator.)

+2 normal response. +2 normal response Normal

Assess lower exterimityreflexes (patellar, ankle,

plantar.)

+2 normal response. +2 normal response. Normal


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V. COURSE OF THE WARD

Admitting Diagnosis: Calulous Cholecystitis

Chief Complaint: Epigastric pain

History of Present Illness: One week prior to admission, on and off epigastric pain.

Ultrasound revealed cholelithiasis

Diet: Diet as Tolerated

IVF: D5LR x 30 gtts/min

Vital Signs:

Date Temperature Respiratory Rate Pulse Rate Blood Pressure

December 2, 2011 36 C 22 cpm 76 bpm 100/70 mm Hg

a. Diagnostics & Laboratories

CHEST X-RAY

Lungs clear

Heart not enlarged

Hemidiaphragms and costophrenic sulci are intact

IMPRESSION: Normal Chest Study

HEMATOLOGY

TEST S.I. S.I. Normal Range Interpretation

Hematocrit 0.39 M: 0.42-0.54

F: 0.36-0.46

Normal

Hemoglobin 129 M: 140-180 g/LF: 115-160 g/L

Normal

WBC 5.6 5.10 x 10 g/L Normal

Differential Normal

Segmenters 0.64 0.36-0.70 Normal

Lymphocytes 0.30 0.22-0.40 Normal

Eosonophils 0.03 0.01-0.04 Normal

Monocytes 0.03 0.00-0.06 Normal


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ABDOMINAL ULTRASOUND

(November 25, 2011)

The liver is within normal in size with homogeneous echopattern. The intrahepatic ducts are not dilated.

The common bile duct measures 3 mm. No focal cystic or solid nodule seen.

The gallbladder measures 66 x 23 mm. the wall is thin. There is an echogenic focus in the posterior wall

measuring 5 mm.

The pancreas is within normal in size and echopattern. The duct is not dilated. No focal cystic or solid

nodule seen.

The spleen is normal in size and echopattern. No focal cystic or solid nodule seen.

The right kidney measures 101 x 35 mm while the left kidney measures 105 x 47 mm. The echopattern is

homogeneous. No lithiasis or hydronephrosis seen. Both ureters are not dilated.

The urinary bladder is fairly distensible and echo free. The wall is thin.

The uterus is anteverted measuring 60 x 41 x 26 mm. the endometrium is thickened measuring 9 mm.

the echopattern is homogeneous. No focal cystic or solid nodule seen. Both adnexae are unremarkable.

IMPRESSION:

CHOLELITHIASIS

NORMAL LIVER, BILIARY TREE PANCREAS, SPLEEN, RENAL AND URINARY BLADDER.

NORMAL SIZE UTERUS WITH THICKENED ENDOMETRIUM.

NEGATIVE ADNEXAE


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VII. PROBLEMS IDENTIFIED

Significant Cues Nursing Diagnosis

Subjective:

Masakit angtagiliran ko as verbalized by patient.

Objective:

Facial mask of pain

Irritation

Self focusing

V/S taken as follows:

T: 36C

P: 76 bpm

R: 22 cpm

BP: 100/70 mmHg

Acute pain related to inflammation and

distortion of tissues.

Subjective:

Masakit ang inoperahan sa akin. Nahihirapan ako

kumilos, as verbalized by the patient.

Objective:

Facial mask of pain

Limited range

of motion

Disruption of skin


T: 36C

P: 76 bpm

R: 22 cpm

BP: 100/70 mmHg

Impaired tissue integrity related to

presence of secretions

Subjective:

Nilalamig nga ako simula pa kanina pagkagising

ko eh.

Objectives:

Cool skin

Pallor

Slow capillary refill

T: 36.0 C

RR: 22 cpm

PR: 76 bpmBP: 110/70

Hypothermia related to exposure to cool

or cold environment as manifested by

cool skin, paloor, and slow capillary refill.

Subjective:

Nahihirapan ako kumilos sa kalagayan ko ngayon

as verbalized by the patient.

Objective:

The patient may manifest:

Activity intolerance related to limited

range of activity


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Fatigue

Weakness

Inability in performing ADLs without assistance

with clean and dry wound dressing over right

upper quadrant

abnormal HR or BP

Pallor

Dyspnea

Exertional Discomfort

Dysrhytmias or ischemia


T: 36C

P: 76 bpm

R: 22 cpm

BP: 100/70 mmHg

Subjective:

Hindi ko alam gagawin sa sugat ko makati kasi at

medyo masakit, as verbalized by the patient.

Objective:

request for information


T: 36C

P: 76 bpm

R: 22 cpm

BP: 100/70 mmHg

Knowledge deficit regarding condition

and self care related to misinterpretation

of information

Subjective:

Nakakalungkot lang kasi hindi na ko mkakapag-

bathing suit kasi may peklat na naman eh

alam mo na yung feeling ng may natanggal sa

katawan mo as verbalized by the patient.

Objectives:

Facial expression of agitation while telling her

concern about her body image

Patient is conscious about her situation because

she asked many questions regarding the treatment

of the scar.

Body Image Disturbance related to

surgical incision secondary to

cholecystitis

Operating Room - Case Pres

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