Sagun Pls Dont Dilit Huhuhhuhhu 123

8/3/2019 Sagun Pls Dont Dilit Huhuhhuhhu 123

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PERPETUAL HELP COLLEGE OF MANILA

1240 V. Concepcion St., Sampaloc, Manila

College of Nursing

In partial fulfillment of the requirements for

NCM 204 RLE

Grand Case Presentation on

CHRONIC CALCULOUS CHOLECYSTITIS

Submitted by:

Nacis, Michiko Grace D.

Pascual, Garnet DSagun, Star M.

Sanuco, Janine Vittoria M.

l b h


2/85

Si Eli b h C

I.CLIENTS DATA

PATIENT: PS

AGE: 40 years old

GENDER: MaleBIRTHDATE: August/7/1971

ADDRESS: 118 Barangay Sta. Cruz A.D Sapang Palay, Bulacan

CIVIL STATUS: Married

SPOUSE: AS (Housewife)

Children: PS (18 y/o) Third Year College

ES (17 y/o) Second Year College

DS (14 y/o) Second Year High School

OS (12 y/o) Grade VIRS (8 y/o) Grade III

EDUCATIONAL ATTAINMENT: High School Graduate

RELIGION: Catholic

NATIONALITY: Filipino

OCCUPATION: Jeepney Driver

ADMISSION DATA

DATE OF ADMISSION: July 5, 2011

INITIAL DIAGNOSIS Cholelithiasis

DIAGNOSIS: Chronic Calculous Cholecystitis

CHIEF COMPLAINT: Abdominal Pain, Right Upper Quadrant

DATE OF ASSESSMENT: July 8, 2011


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A2. PRESENT HEALTH HISTORY

Seven months prior to his admission, patient drinks 2-3 bottles of San Miguel a week and smokes 4-5 sticks of cigarette/day.( Dec, 28

2010) patient had his check up in Roquero General Hospital, Sapang Palay, San Jose Del Monte, Bulacan for having experienced of

jaundice and sudden onset of pain in the right upper quadrant of the abdomen with nausea and vomiting. Jaundice may also be seen as

yellowing of the skin, sclera (Icterus). He had an increased level of pain so he took Mefenamic acid as a pain reliever prescribed by the

doctor. He experienced the pain until 1-2 hours especially during after meal. He encouraged his self to socialize to others like

neighborhood because it helps to reduce or control pain.

Six months prior to his admission, he was still suffering from pain with the level of 6 out of 10. He also had insidious symptoms of

clay colored stool and dark yellow urine result from obstetric process without fever. He experienced mild to moderate pain with loss of

appetite. Low fat diet to prevent further pain of biliary colic. He experienced pruritus or burning sensation especially during bed time.

July 2, 2011 he was confined in Roquero General Hospital. The patient was still suffering with the level of 8 out of 10 severe pain

and he cant tolerate the pain. Duration of pain is 30 minutes -1 hour.

3 days PTA patient experienced severe pain on right upper quadrant so he consulted in Roquero General Hospital. He was

suffering a severe pain with a level of 8/10. On July 5, 2011, he was then transferred to East Avenue Memorial Medical Center for

further examination.

A1. PAST MEDICAL HISTORY

SP is fond of eating meats, salt cured foods, likes condiments (especially fish sauce), chicharon, oily foods. He drinks 2-3 bottles

of San Miguel beer per week and smokes 4-5 cigerettes per day.SP experienced common illness such as colds, cough, chicken pox, and fever during his childhood and had completed his

immunization. However he could not recall at what age he got the disease. He has an allergy on sea foods but no allergy on drugs. The

patient does not participate in any sports, exercises and routine.

SP goes to Roquero General Hospital for his check-ups.


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A3. FAMILY HEALTH HISTORY

The patients father is hypertensive which he inherited together with his youngest brother. He has 5 children (3 boys, 2 girls). His

first and fourth child has asthma which they inherited from their grandmother (mothers side). The patient is the only one in the family

who had a chronic calculous cholecystitis.

A4. SOCIAL HISTORY

Patient P.S is a High school graduate from Marcelo H. Del Pilar National High school. His occupation is a jeepney driver. Hes the

bread winner of his family. He drinks 2-3 bottles of San Miguel a week and smokes 4-5 sticks of cigarette per day. The patient does not

participate in any sports, exercises or routine. Patient is a Roman Catholic who usually goes to church every Sunday or whenever

possible to attend the mass or even just to offer a prayer. He have 5 children and they are all close to each other. They all live in Bulacan. Patient

is a very active and friendly person. He loves to socialize with his friends in their neighborhood during his free time. He considered his self as a holistichuman being as long as hes complete, healthy and his family is always there for him. Patient puts his self to sleep by watching primetime television

programs. He does not have usual time of sleep. He sleeps for a long period of time.


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GENOGRAM

Father Mother Father Mother

Asthma hypertension

v

Brother Sister Wife Sister Patient Sister Sister Brother Sister

Brother

Asthma Asthma hypertension

hypertension

Chronic Calculos Cholecystitis

39 yrs old

Asthma Asthma

Wifes side

Patients side


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The patient, his father and his youngest brother is hypertensive

The patient is married to Ms. AN on June 8 1995. He is a high school graduate from Marcelo H. Del Pilar Natinal High

Shool, Bulacan. They live in the same household together with his parents. They have five children. He is the only one in

his family who got Chronic Calculous Cholecystitis.

Two of his children got asthma from their mother side.


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B.Risk Factors Associated with Disease

B1. Non- modifiable

Age

B2. Modifiable Risk Factors

lifestyle

high- fat diet (chicharon, meat specially pork)

Drinking liquor

Smoking

Fond of eating salty foods


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III. PHYSICAL ASSESSMENT

GENERAL SURVEY:

The patient was admitted at East Avenue Memorial Medical Center Male Surgical Ward Room4019D.The patientt appeared

weak with yellowish skin color. His hair is well groomed and no body odor being noted during assessment. He is cooperative and

responds to questions appropriately with weak voice and low tone.

Initial Assessment: Taking of Vital Signs

DATE OF ADMISSION: July 5, 2011 (Tuesday)DATE OF ASSESSMENT: July 8, 2011 (Friday)

DIET: NPO


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PRE OPERATIVE

Vital Sign TechniqueNormal

FindingsActual findings Analysis Interpretation

Temp Digital

Thermometer

via Axilla

35.8-37.0C 37.2C Normal The normal axillary

temperature is

between 35.8 to

37.0C

(Udan, 2009, p.249).

In other literature,

the usual range of

normal is 36.0 to

37.8 [without routes

indicated].

(Kozier, 2008, p.528)

Pulse Rate Taken in radial

artery (thumb

side of the

inner aspect of

the wrist)

60-100bpm 80bpm, regular

rhythm, normal

strength,

bilaterally equal

on radial pulses

Normal The normal pulse

rate for adults is

between 60 to 100

beats per minute.


10/85

(Udan, 2009, p.251)

Respiratory

Rate

Inspection of

the rise and fall

of chest cavity

over 1 minute

12-20 cpm 32cpm Elevated RR Tachypnea is rapid

respiration above 20

breaths per minute

in an adult.

(Udan, 2009, p. 253)

Due to abdominal

pain

B/P

Rate

Auscultation

and BP

apparatus, left

arm

Systolic:

90-120 mmHg

Diastolic

60-80mm Hg

150/90mm Hg Hypertensiv

e

Factors associated

with hypertension

include thickening

of the arterial walls,

which reduces the

size of the arterial

lumen, and

inelasticity of the

arteries as well as

such lifestyle factors

cigarette smoking,

heavy alcohol

consumption, lack of

physical


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Appearance and mental status

Assessment Techniques Normal findings Actual findings Analysis

Body built, height and

weight

Inspection Proportionate

BMI= 18.5-24.9

Proportionate

BMI= 24.5

Within Normal Range

Posture Gait, standing,

seating and walking

Inspection Relaxed, erect posture;

coordinated movement

Patient is lying on bed in

a fetal position

Due to RUQ pain

Over all hygiene and

grooming body and

breath odor

Inspection No body order or minor

body odor relative to

work or exercise; no

breath odor

No presence of body or

breath odor noted;

patient is well groomed

and neat appearance

Normal

Signs of distress in

posture or facial

Inspection No distress noted With facial grimace Due to RUQ pain

exercise,high blood

cholesterol level and

continued exposure

to stress

Ref. Fundamental by

Kozier 8th

edition, p.

552


12/85

expression

Quantity of speech;

quality and organization

Inspection Understandable,

moderate phase, clear

tone and inflection;exhibits thoughts

association

With weak voice and

low tone.

Patient cant speak

clearly because he was

disturbed by the pain hefelt

Obvious signs of health

or illnesses

Healthy appearance Patient is jaundice and

exhibited signs of

weakness; there are no

visible lessions noted

Jaundice or icterus, is

the yellow pigmentation

of the sclerae, skin, and

deeper tissues caused

by excessive

accumulation of bile

pigments in the blood. It

is a common

manifestation of a

variety of liver and

biliary diseases and

serves as a starting

point for evaluating

many of these disorders


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Integumentary (skin)

Body part Technique used Normal findings Actual findings Analysis

Color

Uniformity of color

Inspection

Inspection

Varies from light to deep

brown, from ruddy pink to

light pink, from yellow

overtones to olive

Generally uniform except

for those areas exposed

to sun, pigmentation.

Yellowish

Yellowish

Jaundice appears when

there is an obstruction in

the common bile duct. It

results from the impaired

bilirubin transport and

excretion in the biliary

system. In this case, the

problem arises from

obstruction of an extra

hepatic bile duct by

gallstones.

Ref. Medical- Surgical

Nursing 6th

Edition Vol.2, by

Joyce M. Black

Skin moisture Inspection

Palpation

Moisture in the skin folds

and axillae.

Moisture skin Normal


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Skin

temperature

Skin turgor

Skin Itching

Inspection

Palpation

Inspection

Palpation

Inspection

Uniform within the normal

range.

When the skin is pinched,

brings back to previous

state.

Skin temperature is

uniform throughout the

body.

Poor skin turgor

(+) Pruritus

Normal

This indicate that the person

is dehydrated

(+) vomiting

Ref. Fundamental by Kozier

p. 580

Pruritus is the most

common skin symptoms;

occurs with dry skin, aging,

drug reactions, allergy,

obstructive jaundice,

uremia. Presence or absence

of pruritus may be

significant for diagnosis.Scratching may cause

excoriation of primary

lesion.

Ref. Physical Examination

and Health Assessment 3rd

Edition by Carolyn Jarvis,


15/85

p.218)

Integumentary (nails)

Body part Technique used Normal findings Actual findings AnalysisFingernail plate

shape and

curvature

Fingernail and toenail

texture and color

Inspection

Inspection

Palpation

Convex

structure and

160

Smooth

Texture and color

Convex

structure and

160

Smooth in texture, and

slowly returns to pink or

usual color upon

performing blanch test

Normal

Due to low hematocrit value

usually indicates the person

has anemia

(fundamental by Kozier,


16/85

of capillary refill. p.800)

Arterial insufficiency

(fundamental by Kozier,

p.800)


17/85

Head


Skull Inspection

Palpation

Smooth, no lumps,

Absence of nodules or

masses, No area of

tenderness,Symmetrical

with protrusions on the

lateral part of parietal

forehead and occipital

bone.Rounded, andnormocephalic and

symmetrical.

Smooth, no lumps,

absence of nodules or

masses, no area of

tenderness, symmetrical,

rounded, and

normocephalic

Normal

Scalp Inspection

Palpation

Lighter in color than

complexion, no scars, no

lesions, no masses, no

depression upon

palpation.

Lighter in color than

complexion, no scars is

noted, no lesions, no

masses, no depression

upon palpation. No nits,

no lice and no dandruff

Normal


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Hair Inspection Evenly

distributed

hair Black or Brown in

color, hair is evenly

distributed, No area of

baldness, thick,

fine.Curly/kinky/straight,

Dry/oily/shiny hair

Black in color, straight

hair and evenly

distributed

Normal

Face Inspection Appearance, symmetrical

facial expressions and well

coordinated facial

movements.

Facial Grimace.

aundice.

Facial grimace due to his

pain at right upper

abdominal quadrant.

Jaundice appearance is

cause by excessive

accumulation of bile

pigment in the blood. It is

common manifestation of a

variety of liver and biliary

diseases and serve as a

starting point for evaluatingmany of this disorder (Med-

surg black, p.1135)

Eyes


19/85


Eyebrows

Eyelashes

Inspection

Inspection

Hair evenly

distributed; skin intact

Equally

distributed,

curled slightly

outward

Hair evenly

distributed,

aligned, color black andwell-coordinated

movement

Evenly

distributed

and slightly curved

outward.

Normal

Normal

Eyelids Inspection Skin intact, no discharge,

no discoloration.

Lids close symmetrically.

Approximately 15 to 20

involuntary blinks per

minute; bilateral blinking

-Skin is intact and lids

close symmetrically. The

eyelids blink within the

normal range

Normal

Conjunctiva Inspection Shiny, smooth, moist,

pinky, shiny, with visible

blood vessels and no

discharge

Yellowish Resulting from the

increased levels of bilirubin

in the blood

(hyperbilirubinemia)

Reference (Virginia L.

Cassmeyer p.1496)


20/85


Sclera Inspection Appears white,clear

and vascular

yellowish Deviationfrom normal due

to effect of bilirubin in the

blood stream.

Reference (Virginia L.

Cassmeyer p.1496)

With yellowing of the sclera

of the eyes resulting from

the accumulation of the bile

pigments in those tissues.

(essentials of anatomy and

physiology by seely page

474)

Sclera of the eye, which

contains considerable elastic


21/85

fiber in which jaundice can

be affected because

bilirubin has a special

affinity for elastic tissue.

(Pathophysiology by

Lipincott, Page 850, Fourth

Edition)

Cornea Inspection Transparent, shiny and

smooth; details of the iris

are visible

Transparent, shiny and

smooth.

Normal

Iris Inspection No shadows of light, brown

and no cloudiness.

Symmetrical, round,

transparent/ shiny

No shadows of light,

brown and no

cloudiness. Symmetrical

round, transparent and

shiny

Normal

Pupil Inspection 3mm-7mm in diameter.

Black in color, equal in size,

round, smooth border.

illuminated pupil constricts

while non

The technique used is

Direct and Consensual

reaction to light. 3mm-

7mm in diameter. Black

in color, equal in size,

round, smooth border.

Illuminated pupil

constricts while

Normal

normal


22/85

illuminated dilates

Pupil constricts

when looking near object

while when looking distant

objects, it dilates.

non illuminated

dilates

Pupil constricts

when looking near

object while when

looking distant

objects, it dilates

Extra ocular

Muscles

Visual Fields

Inspection

Inspection

Both eyes are

coordinated,

move in unison

with parallel

alignment

When looking straight

ahead, client can see

objects periphery.

Both eyes are

coordinated,

move in unison

with parallel

alignment

When looking straight

ahead, client can

partially see objects

periphery. 20/20 both

eyes

Normal


23/85

Ears


Auricles Inspection

Palpation

Color same as

in facial skin

Auricle is aligned in with

the outer canthus of eye

Mobile, firm, and not

tender;

pinna recoils

back after it is

folded

Ear lobes are bean

shaped, parallel and

symmetrical.

The upper connection is

parallel with the outer

canthus of the eye same

in color as complexion,

no lesions.

Has a firm cartilage.

Pinna

recoils when

folded. No pain or

tenderness.

normal

External ear

canal and

Tympanic

membrane

Inspection Contains hair

follicles, moist waxy

cerumen and no foreign

body

Presence of wet

cerumen in both ear, no

skin

lesions, no pus

and no blood and have

presence of hair follicles

Normal


24/85

Nose


Nose

Nasal

Cavities

Nasal

Septum

InspectionPalpation

Symmetric,straight, uniform in color,

No discharge or flaring, no

tenderness, no lesions,

presence of cilia

Not tender, no

lesions, mucosa is pink,

clear and no lesions

Intact and in

midline

Uniform in colorin facial skin,

straight, presence of cilia

and no

discharge

No swelling, no presence

of discharges. No

lesions and pink

mucosal layer

Intact between the nasal

chambers

normal

Normal

Normal

Normal


25/85

Patency

Sinuses

Air moves freely when

breathing

No tenderness on maxillary

and frontal sinuses

Patency shallow

breathing

No tenderness on

maxillary and

frontal sinuses

Due to abdominal pain

Normal

Mouth


Lips Inspection Uniform pink in

color, soft,

moist, smooth texture,

symmetry of contour,

ability to purse lips and no

tenderness

symmetrical, dark in

color

Abnormal findings due to

poor

oral hygiene, smoking

caused by nicotine.

- Fundamentals of Nursing

by

Taylor,Lillis,LeMone,

Copyright

2005, (p.583)


26/85

Buccal

Mucosa

Inspection

Palpation

Pinkish in

color, Moist,

smooth, and

elastic

structure, no

lesions

Pinkish in

color, Moist,

smooth, and

elastic

structure, no

lesions

Normal

Teeth Inspection 32 adult teeth,

smooth and

white

Has incomplete adult

teeth 18 (10 teeth at the

upper area of the mouth

and 8 teeth at the lower

part)

with yellow

discoloration

of teeth. Presence of

tartar

Dark in discoloration of

teeth due to cigarette

smoking. Nicotine plays a

part in discoloration of

teeth.


by


Copyright

2005, (p.583)

Gums

Tongue /

Floor of the mouth

Inspection

Inspection

Palpation

No retraction of gums and

bleeding, pinkish in color.

Central position, pinkish in

color, no lesions and raised

papillae. It has prominent

No retraction of gum,

bleeding and moist. Dark

discoloration

Central position, whitish

in color, no lesions and

Dark discoloration due to

smoking, nicotine plays a

part in discoloration of the

gums.

A white coating on the

tongue from poor oral


27/85

veins

Moves freely and no

tenderness,

smooth with no

palpable nodules

raised papillae. It has

prominent veins.

Moves freely and

no tenderness,

smooth with no

palpable nodules

hygiene, irritation and

smoking.


by Taylor, Lillis, LeMone,

Copyright 2005, (p.583)

Palates

Uvula

Inspection Light pink, smooth palate.

Lighter pink

in hard palate than soft

palate

Positioned in the midline of

soft palate.

Palate: Yellowish soft

and hard palate

Uvula: moist, moist,

smooth texture

Jaundice is first noted in the

unction in the hard and soft

palate in the mouth and

sclera. It is due to rising

amounts of bilirubin in the

blood.


and health Assessment 3rd

Edition by Carolyn Jarvis

p.225

Pharynx and Tonsils Inspection

Palpation

Tonsils, no discharge, pink,

smooth.

Tonsils, no discharge,

pink, smooth.

Normal


28/85

Neck and Lymph nodes


Neck Muscles

Move the chin to the

chest

Move the head back so

that the chin points

upward.

Move the head so that

the ear is moved toward

the shoulder on each

side.

Turn the head to the

right and to the left

Inspection

Inspection

Inspection

Inspection

Inspection

Muscles equal in size; headcentered.

Head flexes 45

Head laterally 60

Head laterally

flexes 40

Head laterally

flexes 70

Muscles equal in size;head

centered.

Head flexes 45

Head laterally 60

Head laterally

flexes 40

Head laterally

This determines thefunction of the

sternocleidomastoid

muscle.

This determines thefunction of the trapezius

muscle.

This determines the

function of the

sternocleidomastoid

muscle.

This determines the

function of the

sternocleidomastoid

muscle.



29/85

flexes 70 8th edition vol. I by Kozier

& Erbs, Copyright 2008

(p.607)


Muscle Activity

Range of Motion

Inspection

Inspection

Equal strength

In both sides

Can perform freely

Decrease of strength

and tone

Cant perform freely

Due to lack of activities

Due to his presence

condition and pain felt by

the client


30/85

Lymph Nodes Inspection

Palpation

All lymph

nodes are not

palpable

No palpable lymph nodes. Lymph nodes are small oval

clumps of lymphatic tissue

located at intervals along

the vessels. Most nodes are

arranged in groups, both

deep and superficial in the

body.


and Health Assessment 2nd

Edition by Carolyn Jarvis, p.

574

Trachea Palpation Central

placement in

midline of the

neck

Central

placement in

midline of the

neck

A tube-like portion of the

breathing or "respiratory"

tract that connects the

"voice box" (larynx) with

the bronchial parts of the

lungs.


8th edition vol. I by Kozier& Erbs, Copyright 2008

(p.608)


31/85

Thyroid Gland Inspection

Palpation

Not visible in

inspection. Gland ascends

during swallowing.

lobes may not be palpated.

Not visible in

inspection.

No nodules noted upon

palpation

No indication of

hyperthyroidism,

hypothyroidism or endemic

goiter.

Ref. Fundamental of

Nursing 7th

Edition by

Kozier

Upper Extremities


Skin Inspection No presence of edema, skin

lesions.

No presence of edema

and skin lesions.

Yellowish in color

Jaundice is due to an

abnormally high

accumulation of bilirubin in

the blood, as a result of

which there is a yellowish

discoloration of the skin.

Jaundice develop when theplasma contains about

twice the normal amount

of bilirubin.

(Pathophysiology, Lipincott,

Page 850, Fourth Edition)


32/85

Muscle Strength and

tone

Inspection

Palpation

Equal strength on each

body side

Decrease of strength and

tone

Due to lack of activity


33/85

Joint range of motion Inspection Flexion:

Decreasing the angle of the

oint

Extension:

Increasing the angle of the

oint

Normal full movement of

oint.

Normal full movement of

oint.

The range of motion (ROM)

of a joint is the maximum

movement that is possible

for that joint. Joint range of

motion varies from

individual to individual and

is determined by genetic

makeup, developmental

patterns, the presence or

absence of disease, and the

amount of physical activity

in which the person

normally engages.


8th edition vol.2 by Kozier

& Erbs,

Copyright 2008 (p.1107)


34/85

Thorax


Posterior

Thorax

Inspection Chest

symmetric,

transverse

diameter of 3:5 skin intact;

uniform temperature, chest

wall intact

Anteroposterior

to transverse

diameter on ratio of 3:5;

chest symmetric

Normal

Respiratory

Excursion

Inspection

Palpation

Full/symmetric

chest expansion

Symmetric chest

expansion.Chest expand for about 3-

4 cm.

Normal

Percuss

Posterior

Thorax

Percussion Percussion notes resonate,

except over scapula

Resonance

/flatness over the lung

during percussion was

heard.

Normal

Auscultate

Posterior

Thorax

Auscultation Vesicular and

bronchovesicular breath

sounds

Vesicular and

bronchovesicular breath

sound

Vesicular breath sounds are

soft, low pitch sound, heard

best over base of the lungs

during inspiration, which is

longer than expiration.

Bronchovesicular are heard

over the main stem


35/85

bronchus and are Moderate

blowing sounds, with

inspiration equal to

expiration.


by


Copyright

2005, (p.587)


Breathing

patterns and sound

Inspection Quiet, rhythmic

and effortless

respiration

Shallow breathing Because of abdominal pain

Repiratory

Excursion

Inspection

Palpation

Full/ symmetric

Chest expansion

Symmetric chest, expand

for about 3-4cm

Full symmetric excursion;

thumbs normally separate 3-

5 cm.


8th

edition vol.1 by Kozier &

Erbs,



36/85

Percuss

Anterior

Thorax

Percussion Percussion notes

resonate down to sixth rib

at the level of diaphragm

but flat over areas of heavy

muscles and bone, dull on

areas over the

heart and liver,

tympanic over

the underlying

stomach

Resonance sounds which

is moderate and low, flat

sounds on the areas of

muscles and

bone, dull on the heart

and

liver and loud

tympanic on

the stomach

Normal- symmetry

percussion sounds on the

anterior thorax.

When a normal air filled

lung is percussed, the sound

is hollow, loud, low in pitch

and long of duration. This

percussion tone is known as

resonance. A flat tone is

heard over a bony or well

developed muscle tissue.

- Fundamentals of Nursingby


Copyright

2005, (p.586)


37/85


Auscultate the aortic,

pulmonic,

tricuspid, and apicalvalve

Auscultation Usually heard at all sites

dystole:

silent interval;slightly shorter

duration than

diastole at normal heart

rate

Diastole:

silent interval;

slightly longer

duration than

systole at normal heart

rates

Usually heard at all sites

systole: silent interval;

slightlyshorter duration than

diastole at

normal heart

rate

Diastole:

silent interval;

slightly longer

duration than

systole at normal heart

rates

The normal first two heart

sounds are produced by

closure of the valves of theheart.

S is louder at the tricuspid

and apical areas and its a

dull, low pitched sound

described as lub. S

occurs at the termination

of systole and corresponds

to the onset of ventricular

diastole. Its louder at the

aortic and pulmonic areas

and has a higher pitch

than S and is shorter in

duration and sound as

dub.


by


Copyright

2005, (p.591)


38/85


8th

edition vol.1 by Kozier &

Erbs,


Axillary Inspection

Palpation

no tenderness,

no masses, no

nodules

no tenderness,

no masses, no

nodules

The nodes are generally

not palpable; if palpable,

they should be small,mobile, smooth, and

nontender.


by


Copyright

2005, (p.591)

Abdomen

for skin

integrity

Inspection

palpation

Unblemished

skin, uniform

color

Jaundice

(+) edema

Increased level of bilirubin

Due to water retention,

the liver and kidney are

compensated


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Abdominal

Contour

Inspection )No evidence of

enlargement

of the liver andspleen

Symmetric

Contour

Symmetric contour Normal

Movements Inspection Symmetric

movement

Slowed movements Limited movements be

due to pain

Vascular

Pattern

Inspection No vascular

pattern

No visible

vascular

pattern

Normal

Auscultation

of theabdomen

Auscultation Audible bowel

sounds, absence of arterialbruits,

absence of friction rub

Audible bowel

sounds, absence of arterialbruits, absence of friction

rub

They are heard as clicks

and gurgles & usuallyoccur every 5-20 seconds.

Bruits are low-pitched,

murmur-like sounds that

occur when blood flow of

an artery is obstructed.


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by

Taylor,Lillis,LeMone

(p.596)

Muscoloskeletal System


Muscle size Inspection Equal size in both sides of

the body

Equal size in

both sides of

the body

Muscles groups are

observed forbilateral

symmetry. Normally, they

are symmetric in size.


by


Copyright

2005, (p.597)

Muscle tremors Inspection No tremors No tremors Normal



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Muscle activity

Range of motion

Inspection

Inspection

Equal strength

In both sides

Can perform freely

Weak muscle

Limited movements

Due to his condition and

pain felt by the patient

Due to his present

condition and pain felt by

the patient

Bone

Structures

Bone

Tenderness

Inspection

Palpation

No deformities

No swelling,

no tenderness

No deformities

No swelling,

no tenderness

Bones is assessed for

normal form. Bones is

dense, hard and

somewhat flexible

connective

tissue constituting the

bones of the human

skeletal & it has normal

findings.

- Mosbys Pocket

Dictionary of

medicine, nursing & health

professionals (p.189)


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Neurologic System


NeurologicSystem

Inspection Good sensation, reflexes,speech and oriented with

time place and persons.

Good sensation, reflexesand oriented with time,

place and persons

Normal

Lower Extremities


Skin Inspection No presence of edema, skin

lesions.

No presence of edema, no

visible bleeding and no

discharge seen.Yellowish in color.

Jaundice is due to an

abnormally high

accumulation of bilirubin Ithe blood, as a result of

wich there is a yellowish

discoloration of the skin.

Jaundice develop when

the plasma contains about

twice the normal amount


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of bilirubin.

(Pathophysiology,

Lipincott, Page 850, Fourth

Edition)

GENITALIA: the patient refuses to be assessed


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Post-operative

Vital Sign TechniqueNormal

FindingsActual findings Analysis Interpretation

Temp Digital

Thermometer

via Axilla

35.8-37.0C 37.2C Normal The normal axillary

temperature is

between 35.8 to

37.0C

(Udan, 2009, p.249).

In other literature,the usual range of

normal is 36.0 to

37.8 [without routes

indicated].

(Kozier, 2008, p.528)

Pulse Rate Taken in radial

artery (thumbside of the

inner aspect of

the wrist)

60-100bpm 80bpm, regular

rhythm, normalstrength,

bilaterally equal

on radial pulses

Normal The normal pulse

rate for adults isbetween 60 to 100

beats per minute.

(Udan, 2009, p.251)


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Respiratory

Rate

Inspection of

the rise and fall

of chest cavity

over 1 minute

12-20 cpm 20cpm Normal Normal respiration

is between 12-20

Cpm in adults.

(Udan, 2009, p. 253)

B/P

Rate

Auscultation

and BP

apparatus, left

arm

Systolic:

90-120 mmHg

Diastolic

60-80mm Hg

130/80mm Hg Normal The normal blood

pressure is a systolic

pressure of 90-120

mmHg. and it is

diastolic between

60- 80mmHg.

(Udan, 2009, p. 253)


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POST OPERATIVE

General appearance

Method Normal finding Actual finding Analysis

Psture and gait InspectionObservation

Relaxed, erect posture,coordinated movement

Slouched,uncoordinated

movement

Deviation from normaldue to the pain @ the

incision on the right

upper quadrant of the

abdomen

Signs of Distress Inspection and

Observation

No signs of illness or

disease

Appears weak with

facial grimace

and guarding behavior

Deviation from normal

due to present

condition; Post

cholecystectomy

Emotional Status Inspection No facial grimace (+) facial grimace Deviation from normaldue to pain at the site of

incision at right upper

quadrant of the

abdomen

Affect/mood,

appropriateness of

Responses

Inspection Appropriate to the

situation

Responses are

appropriate to the

situation; irritated


due to pain at the site of

incision at right upper

quadrant of the

abdomen.


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Physical Assessment

Color Inspection Uniform in color Yellowish discoloration Deviation from normal

due to the effect ofbilirubin that is still

present at the blood

streams.

Presence of Edema Inspection and

Palpation

Absence of Edema (+) peripheral edema Deviation from normal

due to water retention

caused by fluid shifting

from intracellular to

intravascular.

Presence of Lesions Inspection No Lesions With incision at the rightupper

quadrant of abdomen

Deviation from normaldue to status post

cholecystectomy

Color Inspection Sclera appears white Yellowish Deviation from normal

due to effect of bilirubin

in the blood streams

Breathing Pattern Inspection Rhythmic; effortless Use of accessory

muscles upon

breathing; shallow

breathing


due to pain

(compensatory

mechanism)

Skin integrity Inspection Unblemished skin;

uniform color

Impaired skin integrity

with

incision on the right

upper

quadrant


due to Cholecystectomy

on the right upper

quadrant of the

abdomen.

Bowel sounds Auscultation Audible bowel sounds Hypoactive bowel

sounds


due to status post

cholecystectomy


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Areas of tenderness Palpation No tenderness; relaxed

abdomen

Presence of tenderness Deviation from normal

due to status post

cholecystectomy

CONTRAPTIONS

Body part Tecnique used Normall findings Actual findings Analysis

Genitalia Folley catheter is noted This tubing is then

advance until it reaches

the bladder.performed

to drain urine from the

bladder or to instill

solution into the bladder.

To drain the urine of thepatient who in

trautamized tp prevent

infection or bacteria into

the organ.

(Fundamental by Kozier)


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IV.DEFINITION OF THE DISEASE

Calculous cholecystitis is caused by obstruction of stone in the bile duct leading to inflammation of the gallbladder. The

gallbladder is an organ which aids in the digestive process. Its function is to store and concentrate bile. The bile in turn emulsifiesfats and neutralizes acids in partly digested food. Despite its importance in the digestion of fat, many people are unaware of their

gallbladder. Fortunately enough, the gallbladder is an organ that people can live without. Perhaps, this fact contributes to the laxity

of the majority. The gallbladder tends to be taken for granted or ignored of the proper care and conditioning. Lifestyle together with

heredity, sex, race and age are just some factors that leave a room for gallbladder complications to occur. Gallstone disease is a

disease of hepato-biliary system, caused by cholesterol and/or bilirubin metabolic disorder, and characterized by formation of

stones in the gallbladder and/or the biliary tract.

Gallstones are categorized as cholesterol, mixed, black pigment, or brown pigment stones. Cholesterol gallstones are the

main type of gallstones and contain cholesterol as the major chemical constituent. Mixed cholesterol gallstones are composed of

more than 50% cholesterol. Cholesterol and mixed gallstones are formed from biliary sludge, which stays for a long time in the

gallbladder lumen. Biliary sludge consists of calcium bilirubinate granules, cholesterol monohydrate crystals, and biliary polymerized

glycoprotein mucin. The dynamics of the transformation of biliary sludge into cholesterol stones has been shown as follows: diffused

biliary sludge surface biliary sludge precipitating biliary sludge a cholesterol gallstone without acoustic shadow. The time of

formation of cholesterol stones depends on the intensity of the precipitation processes of cholesterol monohydrate crystals in biliary

sludge, and equals 3 to 36 months. Transformation proportion varies from 5 to 50% depending on the cause. Black pigment stones

are composed of either pure calcium bilirubinate or polymer-like complexes consisting of calcium, cooper, and large amounts of

mucin glycoproteins. Brown pigment stones are composed of calcium salts of unconjugated bilirubin, with varying amounts ofcholesterol and protein. These stones are usually associated with infection.

The natural history of gallstones is typically defined in two separate groups of patients: those with symptomatic gallstones

and those who are asymptomatic. The vast majorities of gallstones are asymptomatic and remain asymptomatic. As a rule, gallstone

disease is asymptomatic, which is called silent stones. The rate of development of biliary pain is approximately 2% per year for 5

years and then decreases over time. The incidence of complications in patients with asymptomatic stones is low, and prophylactic


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removal of the gallbladder for this condition is not necessary. Patients who had an episode of uncomplicated biliary pain in the year,

38% per year had recurrent biliary pain. An incidence of recurrent biliary pain as high as 50% per year in those with symptomatic

gallstones. 30% of patients with one episode of biliary pain will not have a recurrent episode. The estimated risk of developing biliary

complications is estimated to be 1% to 2% per year and is thought to remain relatively constant over time .


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V.Anatomy and Pathophysiology

LIVER

Largest organ in the body Lies under the diaphragm; occupies most of the right hypochondrium and part of the epigastrium. Weighing 1.5 kgs.

LIVER LOBES AND LOBULES

The liver has two lobes, separated by the falciform ligament Left lobe- about one sixth of the liver Right lobe- about five sixth of the liver.

BILE DUCTS

Right hepatic duct- drains bile from the right functional lobe of the liver


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Left hepatic duct- drains bile from the left functional lobe of the liver Common hepatic duct-is the duct formed by the convergence of the right hepatic duct and the left hepatic duct ; Length:

Usually 6 8 cm. Approximate width:

6 mm in adults; merges with cystic duct to form common bile duct, which opens into the duodenum.

Cystic duct- is the short duct that joins the gall bladder to the common bile duct. Common bile duct- formed by the union of the common hepatic duct and the cystic duct (from the gall bladder).

FUNCTIONS OF THE LIVER

The liver stores a multitude of substances, including glucose (in the form of glycogen), vitamin A (1 2 years' supply), vitaminD (1 4 months' supply),

vitamin B12, iron, and copper.Glucose metabolism- after meal, glucose is taken up from the portal venous blood by the liver and converted into glycogen

(glycogenesis), which is stored in

the hepatocytes. Glycogen is converted back to glucose (glycogenolysis) and release as needed into the blood stream tomaintain normal level of the blood

glucose Ammonia conversion- use of amino acid from protein for glycogenesis results in the formation of ammonia as a byproduct.

Liver converts ammonia to urea.

Protein metabolism- liver synthesizes almost all of the plasmas protein including albumin, alpha and betaglobulins, bloodclotting factor plasma lipoproteins.

Fat metabolism- fatty acid can be broken down for production of energy and production of ketone bodies. Bile formation- bile is formed by the hepatocytes

Composed of water, electrolytes such as sodium, potassium, calcium, bicarbonate, lecithin, fatty acids, cholesterol,bile salts

Collected and stored in the gallbladder and emptied in the intestine when needed for digestion.BILE

Bile is the greenish-yellow fluid (consisting of waste products, cholesterol, and bile salts) that is secreted by the liver cells toperform two primary functions,


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including the following: to carry away waste to break down fats during digestion Bile salt is the actual component which helps break down and absorb fats. Bile, which is excreted from the body in the form

of feces, bile gives feces its dark brown color.TRANSPORT BILE

1. When the liver cells secrete bile, it is collected by a system of ducts that flow from the liver through the right and left hepatic

ducts.

2. These ducts ultimately drain into the common hepatic duct.

3. The common hepatic duct then joins with the cystic duct from the gallbladder to form the common bile duct, which runs from the

liver to the duodenum (the

first section of the small intestine).

4. However, not all bile runs directly into the duodenum. About 50 percent of the bile produced by the liver is first stored in thegallbladder, a pear-shaped

organ located directly below the liver.

5. Then, when food is eaten, the gallbladder contracts and releases stored bile into the duodenum to help break down the fats.

GALLBLADDER

The gallbladder is a small organ whose function in the body is to store bile and aid in the digestive process. A hallow pear- shaped sac from 7- 10 cm (3-4 inches) long and 3 cm broad. It consists of a fundus, body and a neck. Fundus - the lower free and the expanded end of the Gall bladder. Body - the body of the gall bladder is the portion that is lying between that of the fundus and also the neck. The direction of

the body is upwards, backwards,

and to the left. Neck- takes a turn and becomes downwards and backwards. It can hold 30 to 50 ml of bile. right lobe and attached there by areolar connective tissue.


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The cystic duct connects the gallbladder to the common hepatic duct to form common bile duct.FUNCTION OF THE GALLBLADDER

Stores bile enters to the gallbladder by way of the hepatic and cystic duct. During this time the gallbladder concentrates bile five

folds to ten folds. Then later whendigestion occurs in the stomach and in the intestines, the gallbladder contracts, ejecting the concentrated bile into the duodenum.

Jaundice, a yellow discoloration of

the skin and the mucosa, results when obstruction of bile flow into the duodenum occurs. Bile is thereby denied its normal exit from

the body in the feces. Instead, it

absorbed in the blood, and an excess of bile pigments with a yellow hue enters the blood and is deposited in the tissues.

The gallbladder stores bile, which is released when food containing fat enters the digestive tract, stimulating the secretion of

cholecystokinin (CCK). The bile,

which is produced in the liver, emulsifies fats and neutralizes acids in partly digested foods.


55/85

Pathophisiology

Book base

Concentration and storage of bile

Stasis of bile

Stone formation

Obstruction of bile flow

Smooth muscle contractions

Impairment of fat absorption

Acute or chronic inflammation or infection of gallbladder

perforation


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Reference (Virginia L. Cassmeyer p.P1500)

VI. Diagnostic Procedure

COMPLETE BLOOD COUNT

COMPONENT NORMAL FINDINGS ACTUAL FINDINGS INTERPRETATION

WBC Count 5- 10 X 10q/L 10.9 WBC is slightly elevated based

on the normal value which

confirms the presence of

infection

HEMATOCRIT 0.40-0.50 0.38 A low hematocrit value usually

indicates the person has

anemia, overhydration,

hyperthyroidism, and dietary

deficiency.

(Fundamentals of Nursing by

Kozier, page 759)

. Hematocrit is the one that

control the level of space

(volume) red blood cells takes

up in the blood.


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NEUTROPHILS 55-70 50 A low neutrophils indicate that

the person has Aplastic

Anemia, dietary deficiency,

radiation therapy.

(Fundamentals of Nursing byKozier, page 759)

Neutrophils are one of the

first-responders of

inflammatory cells to migrate

towards the site of

inflammation

LYMPHOCYTES 20-40 40 The lymphocytes helps

provide a specific response to

attack the invading organisms.

MONOCYTES 2-8 0.6 Monocytes helps the WBC to

remove damage tissues,

destroy cells and regulate

immunity against foreign

substances.

EOSINOPHIL 1-4 0.4 Eosinophils become active

when you have certain allergic

diseases, infections, and other

medical conditions. The result

showed normal level of


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eosinophils.

BASOPHIL 0.5-1 0.5-1 Normal

PLATELETS 150-400x 10/ml 283 Platelets play a fundamental

role in hemostatis and are

natural source of growthfactors. They are involved in

hemostatis leading to the

information og blood clots.

Mean Corpuscular

Volume

80-95 87.9 The result shows MCV is in

normal range,it is measure of

the average red blood cell

volume that is reported as

part of a standard completeblood count.

Mean Corpuscular

Hemoglobin

27-31pg 27.9 The average amount of

hemoglobin (MCH) is

calculated value derived from

the measurement of

hemoglobin and the red cell

count.

Mean Corpuscular

Hemoglobin

Concentration

320-360 g/dl 317 Decrease level may indicate

iron deficiency anemia or

hemoglobinopathy.

(Medical-surgical,Workman,

page 882)

It is a measure of the


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concentration ofhemoglobin

in a given volume of packed

red blood cells. It is reported

as part of a standard complete

blood count.

URINALYSIS

Urinalysis is a physical, microscopic, or chemical examination of urine . The specimen is physically examined for color, turbidity,

specific gravity, and pH. The it is spun in a centrifuge to allow collection of a small amount of sediment that is examined

microscopically for blood cell, casts, crystals, pus and bacteria. Chemical analysis may be done to identify and quantify any of a large

number of substances, most often for ketones, sugar, protein, and blood.

MACROSCOPIC

Result Normal values Interpretation

Color Dark yellow color Straw; amber The excretion of the bile

pigments by the kidney

gives the urine a very

dark color

There is a presence ofpus cells in the urine

which means that there

is also the presence of

infection.

Transparency Clear Clear Normal

Specific gravity 1.013 1.010- 1.025 The result indicated
http://en.wikipedia.org/wiki/Hemoglobinhttp://en.wikipedia.org/wiki/Red_blood_cellshttp://en.wikipedia.org/wiki/Complete_blood_counthttp://en.wikipedia.org/wiki/Complete_blood_counthttp://en.wikipedia.org/wiki/Complete_blood_counthttp://en.wikipedia.org/wiki/Complete_blood_counthttp://en.wikipedia.org/wiki/Red_blood_cellshttp://en.wikipedia.org/wiki/Hemoglobin


60/85

normal value. Specific

gravity is an indication

of urine concentration,

or the amount of solutes

( metabolic waste andelectrolytes) present in

the urine (Kozier, p.770)

Ph 3.5 4.6- 8 Acidic( decrease pH) is

due to inability of the

kidney to excrete

hydrogen ions.

Associated with the

dehydration, and with adiet high in protein

fruits

(Kozier, p.770)

MICROSCOPIC

RESULT NORMAL VALUES INTERPRETATION

RBC 0.3/ hpf 0-3hpf RBC is only present inglomerulonephritis,

lupusnephritis, urinary tract

disease, and heart failure.

WBC 1.5/hpf 0-4 hpf WBC is only present in acute

UTI, fever and strenuous

exercise.


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Epithelial Cells Many None Epithelial cells in urine indicate

presence of infections,

inflammation and

malignancies.

Bacteria Few None Bacteria are common in urinespecimen because of presence

of infection and their ability to

rapidly multiply in urine.

CHEMICAL TEST

RESULT NORMAL FINDINGS INTERPRATAION

SUGAR Negative Negative The result indicated that thereis no presence of sugar in the

urine. Normally, the amount of

glucose in the urine is

negligible, although individuals

who have ingested large

amount of sugar may show

small amounts of glucose in

their urine.(Kozier,p771)

ALBUMIN Negative Negative Albumin is only presence in

glomerular damage in renal

disease, including

glomerulonephritis, kidney

stones.


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Is a protein produced by the

liver.

(Fundamental by Kozier,8th

edition,p. 803)

CRYSTALS

RESULT NORMAL VALUES INTERPRETATION

Amorphous urates Few None Urates in the urine are

sign that your urine had

gotten solidified

through the process of

dehydration and have

lodge themselves in

your urinary tract.


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SERUM EXAM

TEST NAME RESULTS NORMAL VALUES INTERPRETATION

Alkaline phosphate 187.6-high 50.00-136.00U/L High alkaline phosphate isvaluable in differentiating

obstructive from hepato

cellular jaundice. Alkaline

phosphate level rise with post

hepatic obstruction (obstructive

jaundice) or in intra hepatic

cholestatis hepatocanalicular

jaundice.Cholesterol 6.5-high 0-5.2mmol/L when there is bilary obstruction

the total cholesterol level is

elevated. It is because of the

diet of the patient.

Triglycerides 3.2-high 0.4-1.7mmol/L A high triglycerides level

combined with low HDL

cholesterol or high LDL

cholesterol seems maybegenetics (hereditary) induced

Total protein 76.4 64-82g/L A total serum protein test

measures the total amount of

protein in the blood. It also

measures the amounts of two

major groups of proteins in the


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blood, albumin and globulin.

Albumin 36.6 34-50g/L Albumin helps move many

small molecules through the

blood, including bilirubin,

calcium, progesterone, and

medications. It plays an

important role in keeping the

fluid from the blood from

leaking out into the tissues.

Globulin 39.9-high 30-32g/L Globulin high. Its have a

disturbances in beta lipoprotein

metabolism are seen in patients

with obstructive jaundice.

A/G ratio 0.92-low 1.1-1.6 The usefulness of A/G ratio is

limited, since it gives only the

proportion of the two types of

protein measure.

A/G ratio low. There maybe a

low ratio that might have

occurred because of either anunchanged albumin with an

increased globulin.

Total bilirubin 144.8-high 0.00-17.1Umol/L Increase in conjugated

hyperbilirubinemia may result

from impaired excretion of


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bilirubin from the liver due to

hepato cellular disease, or extra

hepatic biliary obstruction.

Reference: medical-surgicalnursing volume 2, 6

thedition by

joyce black

Indirect bilirubin 25.77-high 12.1-15.1Umol/L Increase level because jaundice

is caused by hepato cellular

dysfunction (hepatitis) results

in elevated the levels of indirect

bilirubin. When the formation

of unconjugated bilirubin

exceeds the liners capacity to

conjugate and excrete it.

Jaundice results the term

hemolytic jaundice is often

used to describe this condition.

AST

Aspartate aminotransferase

236-high 15.00-37.00U/L AST exist in large amounts in

liver and myocardial cells and in

smaller but significant amounts

in kidneys, pancreas and the

brain. Serum AST are usually

associated with hepatocellular

diseases in an acute phase.

ALT 501-high 30-65U/L High ALT because jaundice

patients an abnormal ALT will


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Alanine transaminase incriminate the liver rather than

RBC, hemolysis as a source of

the jaundice. Diseases affecting

the liver parenchyma will cause

a release of this hepatocellularenzymes into the blood stream,

thus elevating serum ALT levels.

COAGULATION REPORT

COMPONENTS RESULT NORMAL VALUES INTERPRETATION

PT

Prothrombine time

12.9 12.9-15.7seconds The test of prothrombine time

determines defects in extrinsicclotting mechanism by

reflecting the activity of

fibrinogen and prothrombine.

INR 0.89 PT evaluation can now be

based on an INR using

standardized thromboplastin

reagent to assist in making

decisions regarding oral anti-

coagulation therapy.

APTT

Activated partial

thromboplastin time

34.0 26-31 seconds Increase in hepato cellular

damage (increase risk for

bleeding)

Control 28.0 Seconds


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TEST NAME RESULT NORMAL VALUES INTERPRETATION

Cholesterol 7.5-high 0-5.2mmol/L When there is biliary

obstruction the total

cholesterol level is elevated. It

is because of the diet of the

patient.

Triglycerides 3.8-high 0.4-1.7mmol/L A high triglycerides level

combine with low HDL

cholesterol or high ADL

cholesterol since may be

genetics (hereditary) induced.

HDL cholesterol 0.45-low 0.91-1.56mmol/L Low HDL cholesterol is a

caused of his obesity and

cholestasis.

LDL 5.3-high 1.89-3.09mmol/L High LDL cholesterol is a

caused of his acute stress and

illness.

COMPONENT INDICATION NORMAL FINDINGS ACTUAL FINDINGS Possible Causes of AbnormalFindings

Creatinine This is the indicator of the renal

function

0.60-1.7mg/dl 1.0 Normal


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Fecalysis Result

MACROSCOPIC

COMPONENTS RESULTS Normal value INTERPRETATION

RBC NONE/ HDF None Normally there is no

red cell in the urine.

WBC 1-2/ HDF Negative It caused by

inflammation of the

intestines, such as a

bacterial infection.

COMPONENTS RESULTS Normal

Value

INTERPRETATION

COLOR Clay colored Brown Absence of bile

pigment (bile

obstruction)

Reference: Kozier

1227

CONSISTENCY Soft Soft

CROSS PLUS Negative Negative

CROSS BLOOD Negative Negative


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REPORT OF ULTRASOUND EXAMINATION

Name: Mr. SP Date: July 06, 2011

Age: 39 years old OPD WARD

Upper Abdominal Sonography

contains two strong shadowing echoes of less than 0.9 cm and two intra abdominal nodules of less than 0.6 cm. Biliary duct

are not diluted. Great vessel are normal in caliber. Para aortic and primary retopenial areas are clear. Gastro intestinal pattern is

unremarkable. Anterior abdominal wall is intact.

Urinary Tract and Prostatic Sonography

Both kidneys are normal in size and echo texture. Right and left kidneys measure 9.8 x3.6 cm and 8.9 x 4.1 cm respectively.

Pelvis and ureters are not dilated. Urinary bladder is physiologically distended with normal anechoeic lumen. Prostate is normal in

size measuring 3.2 x 3.1 x 3.1 cm and weight 17 grams. remainder is unremarkable.

IMPRESSION:

Gallstone, multiple

Gallbladder polyps, multiple

Negative, KUB and prostatic sonography


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VII. Medical Management

ReducePain. Pain may arise from contraction of the gallbladder during transient obstruction of the cystic duct by gallstones.

Analgesic may be administered intramuscularly or intravenously with a patient-controlled analgesia or as needed for pain.

During an acute attack of biliary colic, the client remains on NPO status, with IV fluids administered to maintain hydration(D5LR 1L x

8 @31gtts). The client is advised to avoid foods that precipitate biliary colic.

Antibiotics are administered to reduce the likelihood of infection.

Other medications ordered such as:

Pre- operative Medication:

Omeprazole 4g OD

Ceftriaxone 750mg OD

Tramadol 10 mg !V

Fentanyl 50 mg IV

Mefenamin Acid 500mg (PRN)

Surgical Management

Laparoscopic Cholecystectomy has become the treatment of choice of asymptomatic gallbladder disease. The procedure is suitable

tor most clients, because there is minimal trauma to the abdominal wall.(Med-surgical, Black page 1124)

Cholecystectomy consist of excising the gallbladder from the posterior liver wall and ligating the cystic duct.When stone are

susoected in the common duct, operative cholangioraphy my be performed.(Med-surgical, Black page 1125)


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A conventional open cholecystectomy is indicated when a laparoscopic cholecystectomy does not allow for retrieval of astone in the common bile duct and and when the clients physique does not allow access to the gallbladder.(Med-surgical,

Black page 1125)

VIII. Statement of the Problem

-ineffective breathing patter related to abdominal pain

- Risk For Infection r/t inadequate Primary defenses

-Acute pain r/t inflammation of the gallbladder as evidenced by guarding behavior, facial mask, sleep disturbance, and expressive

behavior such as fetal position.

-risk for bleeding

-fluid and electrolyte imbalance

-risk for aspiration

-hyperthermia

-hypertension


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IX. Nursing Care Plan

Assessment Nursing

Diagnosis

Inference Goal Nursing Intervention Rationale Evaluation

Subject:

Sumasakit

ang tyan ko

kapag

humihinga

ako

Objective:

-Shallow

Breathing

-Respiratory

Rate IS 32

Ineffective

Breathing

Pattern

R/T

Abdominal

Pain

Super

saturation of

bile

Bile stasis

Cholelithias

Obstruction

of cystic duct

Inflammation

of gallbladder

Wall

Irritation of

gallbladderwall

Inflammatory

response

Cholecystitis

After 4 hours of

nursing

interventions,

the client will

be able to

establish

normal/effective

respiratory

pattern

INDEPENDENT:

- Assess respiratory

rate and depth by

listening to lung

sounds.

- Encourage

sustained deep

breaths by

emphasizing slow

inhalation, holding

end inspiration)

-Elevelate head of

bed; maintain low-

fowlers position.

Support

Abdomen when

coughing,

ambulating.

- Respiratory rate and

rhythm changes are

early warning signs of

impending respiratory

difficulties

- these promote deep

inspiration & ventilation

of all lung segments

-Facilitates lung

expansion. Splinting

provides incisionalsupport/decreases

muscle tension to

promote cooperation

with therapeutic

regimen

After 4 hours of

nursing

Interventions,

the client was

able to establish

normal/effective

respiratory

pattern


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Abdominal

pain

Ineffective

breathing

pattern

- pace and schedule

activities providing

adequate rest

periods

-Stress importance of

good posture and

effective use of

accessory muscles

COLLABORATIVE:

>Tramadol

10 mg IV

-Assess for

Hypersensitivity

to tramadol; acute

intoxication with

alcohol, opioids,

psychotropic drugs

or other centrally

acting analgesics;

past or presenthistory

of opioid addiction

-Tell patient that he

may experience

these side effects:

Dizziness, sedation,

- This prevents dyspnea

resulting from fatigue

-To maximize respiratory

effort

-Relief of moderate tomoderately to severe

pain.

-Binds to mu-opioid

receptors and inhibits

the reuptake of

norepinephrine and

serotonin; causes many

effects similar to the

opioids- dizziness,

somnolence, nausea,constipation- but does

not have the respiratory

depressant effects.


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drowsiness, impaired

visual acuity (avoid

driving or performing

tasks that require

alertness); nausea,

loss of appetite(lie quietly, eat

frequent small

meals).

>Mefenamin Acid

500mg (PRN)

-tell patient to take

drug with food.-Assess patient for

allergies and history

of liver disease,

diabetes, or stomach

or bowel

Problems.

-Discontinue drugand consult your

health care provider

if rash, diarrhea, or

digestive problems

occur.

- Anti-inflammatory,

analgesic and antipyretic

activities related to

inhibition of

prostaglandinsynthesis;

exact mechanisms ofaction are not known.


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-Tell patient that

Dizziness or

drowsiness can

occur.


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Assessment Nursing

diagnosis

Inference Goal Nursing

Intervention

Rationale Evaluation

Objectives:

>With a

temperature

of 38.2 C

>(+)

Drainage on

the incision

>IncreasedWBC of 10.9

g/l. normal

value 5-

10x10g/l

>Wet

dressing

Risk For

Infection r/tinadequate

Primary

defenses

Super saturation

of bile

Bile stasis

Cholelithiasis

Obstruction of

cystic duct

Inflammation ofGallbladder

Irritation of

gallbladder wall

Inflammatory

response

Cholecystitis

Cholecystectomy

Risk for infection

After 30 mins.

of nursingintervention

the patient will

be able to

identify

interventions

to

prevent/reduce

risk of infection

> establish rapport

> assess Patients

general condition

> Teach patient to

wash hands often,

especially before

toileting , before

meals and before

and

after administering

self-care.> Discuss

to patients the

following signs of

infection -

redness, swelling,

increased pain ,or

purulent drainage

on the site and

fever

> Gain Patients trust and

cooperation ofthe patient

>To provide proper

Nursing intervention.

>Hand washing reduces

the risks for infection

and also in transmitting

pathogens from one area

of the body to another as

well as from one patient

to another.

>To provide early

detection of infection

and to provide earlynursing management.

After 30 mins

of nursingintervention,

the patient was

able to identify

interventions

to

prevent/reduce

risk of infection


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>Monitor wound

for Redness,

swelling, increased

pain, or purulent

drainage .

> Monitor

temperature and

the presence of

sweating and

chills.

> Maintain strict

aseptic technique

with all dressingchanges

> Encourage intake

of protein and

calorie rich foods.

Provide enteral

> Redness, swelling,

increased pain, or

purulent drainage is

suspicious of infection

and should be cultured.

> In the first 24-48 hours

fever up to 38 degrees C

(100.4F) is related to the

stress of surgery. After

48 hours fever above

37.7C (99.8F) suggests

infection. High fever with

sweating and chills

suggests septicemia.

> Strict asepsis is

necessary to prevent

cross-contamination and

nosocomial infections.

> Optimal nutritional

status promotes wound

healing.


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feeding in patients

who are NPO.

COLLABORATIVE:

> Administer Anti

microbial drug asprescribed or

ordered by the

physician

>to fight further

infection


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ASSESSMENT DIAGNOSIS INFERENCE GOAL INTERVENTION RATIONALE EVALUATION

S: Masakit po

yung tiyan ko sa

may bandang

kanan na

tumatagal ng15-30 minuto.

7/10 po yung

sakit niya as

verbalized by

the pt.

O:

>guarding

behavior>(+) facial mask

>(+) sleep

disturbance

>(+) expressive

behavior; fetal

position

Acute pain r/t

inflammation of

the gallbladder

as evidenced by

guardingbehavior, facial

mask, sleep

disturbance,

and expressive

behavior such

as fetal

position.

Super

saturation of

bile

Bile stasis

Cholelithiasis

Obstruction of

cystic duct

Inflammation of

gallbladder

Irritation of

gallbladder wall

Inflammatory

response

Cholecystitis

Acute Pain

After 30

minutes of

nursing

intervention,

the pt. will beable to

verbalize that

pain is relieved/

controlled.

Independent:

>Assess the pts

level of pain.

observe and

document location,severity (0- 10

scale), and

character of pain

>promote bed rest,

allowing patient to

assume position of

comfort

> encourage use of

relaxation

technique (deep

breathing exercise)

provide diversional

>assist in

differentiating

cause of pain,

and providesinformation

about diseases

progression or

resolution,

development of

complications

and

effectiveness of

interventions

>promote bed

rest in low-

fowlers position

reduces intra-

abdominal

pressure ;

however,

patient will

naturallyassume least

painful position.

>promotes rest,

redirects

attention may

After 30

minutes of

nursing

intervention,

the pt. was ableto verbalize that

pain is relieved/

controlled.

Goal partially

met, with a pain

scale of 3/10.


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activities

> make time to

listen to and

maintain frequent

contact with patient

Collaborative:

>Administered the

following meds as

ordered by the

physician:

Tramadol 10mg IV

Nursing

considerations:

Assess onset, type,

location, and

duration of pain.

Effect of medication

is reduced if full

pain recurs before

next dose.

Assess drug history

enhance coping

>Helpful in

alleviating

anxiety &

refocusing

attention, which

can relieve pain

> Analgesic

Centrally acting


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especially

carbamazepine, CNS

depressant

medication, MAOIs.

Review past medical

history, especially

epilepsy or seizures.

Assess renal or

hepatic function

laboratory values.

Give without

regards to meals

Monitor pulse and

blood pressure.

Assist with

ambulation if

dizziness or vertigo

occurs.

Dry crackers or cola

may relieve nausea.


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Palpate bladder for

urinary retention.

Monitor pattern of

daily bowel activityand stool

consistency.

Sips of tepid water

may relieve dry

mouth.

Assess for clinical

improvement and

record onset of

relief from pain.


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X. Discharge Planning

A. MedicationTramadol 10 mg !V

Fentanyl 50 mg IV

Omeprazole 4g OD

Ceftriaxone 750 mg OD

Mefenamin Acid 500mg (PRN)

B. Exercise Maintaining mobility to improve the overall function status, an appropriate program of exercise will help to decrease pain

and improve function.

.

C. Treatment The major goal for the treatment of patient include

Increase knowledge about the disease and treatment regimen, adherence to the medication and activity and observed for

complication. Practicing proper hygiene. Consuming nutritious and adequate rest Participating in appropriate level of activity Taking medication as prescribed Teach patient and family about infection control behaviour Emphasize importance of completing antibiotic regimen


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D. Health Teaching Maintain body hygiene Advice the client to avoid extraneous activity like running, jumping and high impact exercise

Advice the patient to increase high fiber diet and high protein diet Remind the patient to take medication as exactly doctors prescribeE. Out Patient Instruct the client for follow up check-up referral Doctor Ceverero at EAMMCF. Diet Emphasize the strict low calorie diet Emphasize high fiber diet especially vegetable

Advise patient on the importance of an individualized meal plan in maintaining the appropriate weight. Assist patient to identify problems that may have an impact on dietary adherence and possible solutions to these problems. Emphasize that lifestyle changes should be maintainable for life. Each meal should consist of a balance of carbohydrates, proteins, and fats. Consistency in timing of meals and amounts of food eaten on a day-to-day basis help regulate blood glucose levels. Increase the intake of soluble and insoluble fiber. Avoid salt whenever possible. Prepare foods to retain vitamins and minerals and reduce fats.

Distribute snacks in the meal plan Prohibit use of alcohol.G. Spiritual Provide emotional support coming from the family. Encourage the patient to participate in family affairs.


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Sagun Pls Dont Dilit Huhuhhuhhu 123

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