Ateneo de Davao University College of Nursing

ATENEO DE DAVAO UNIVERSITY

College of Nursing

IN PARTIAL FULFILLMENT OF OUR REQUIREMENTS

IN NURSING CARE MANAGEMENT 103

RELATED LEARNING EXPERIENCE

A CASE STUDY ABOUT CHOLECYSTITIS

Presented to:

MRS. GISSELLE CHARADE A. ZAMORA, R.N.

Presented by:

MR. MICAH NOEL I. PERPETUA

MR. JONI S. PURAY

MS. MA. PRINCESS H. GCCAE SANTILLAN

MS. ARNIKKA B. RUBIA

MR. RIEL R. SEGURA

BSN – 3H

GROUP 4

TABLE OF CONTENTS

PART PAGE

Acknowledgement………………………………………………………………….…

Introduction……………………………………………………………………………

Objectives…………………….……………………………………………………….

Patient’s Data………………………………………………………………………….

Genogram……………………………………………………………………………..

Family History………………………………………………………………………..

Developmental Data…………………………………………………………………...

Physical Assessment……………………….…………………………………………..

Complete Diagnosis……………………………………………………………………

Anatomy and Physiology………………………………………………………………

Etiology…………………………………………………………………………………

Symptomatology…………………………………………………………….………….

Pathophysiology…………..……………………………………………………….……

Doctor’s Order……………………………………………………………………..……

Diagnostic Examiation.………………………………………………………………….

Drug Study………………………………………………………………………………

Procedural Report……………………………………………………………………….

Nursing Theories…………………………………………………………………………

Nursing Care Plans……………………………………………………………………….

Discharge Planning……………………………………………………………………….

Prognosis…………………………………………………………………………………..

Conclusion…………………………………………………………………………………

Recommendation………………………………………………………………………….

Bibliography……………………………………………………………………………….

Acknowledgement

The student nurses would like to express their gratitude and

appreciation primarily to Mr. Police for allowing them to have his case as

their study. He had been very accommodating and cooperative to them

during the entire exposure. Moreover, he was also very patient with them

while providing them sufficient information regarding him and his case.

Furthermore, they are grateful to Anna for being supportive and also

for giving them an opportunity to learn more regarding her husband’s case

so that they could provide effective and efficient nursing interventions.

The staff nurses are also acknowledged for their kind accommodation.

Their humility in sharing some of their knowledge was great help to the

student nurses’ learning. Consequently, their efforts and assistance have

made the student nurses efficient in rendering nursing care towards the

valued patients.

The student nurses would also like to thank Ma’am Gisselle Charade A.

Zamora, R.N. for giving them the appropriate orientation and facilitation on

their first exposure to St. Joseph. She had been very patient and

understanding to them, and gave them an enjoyable and unforgettable

experience that made them further appreciate the “journey of our being.”

In addition, they would also want to express their heartfelt thanks to

Sir Anselmo Lafuente, R.N., their substitute clinical instructor at St. Joseph

ward at DMSF Hospital, for guiding and inspiring them with his remarkable

holistic teachings that encouraged them not only to be better nurses, but as

well as better individuals. May they find the right path towards God, as he

wishes them to.

The student nurses would also like to thank their respective families

who have always supported and encouraged them to be confident in what

they are doing; for the financial and moral support and for understanding.

Thank you for the love. The group would also like to extend their gratitude to

the Perpetua family for welcoming them into their home and for securing

them enough provisions and moral support.

And above all, they are very thankful to the Almighty Father for gracing

them with His wonderful blessings. He is their ultimate strength and hope.

They pray for His loving guidance as they continue their journey in their

nursing careers.

INTRODUCTION

The gallbladder is a small pear-shaped organ which aids in the

digestive process. Its function is to store and concentrate bile - a digestive

liquid continually secreted by the liver. The bile in turn emulsifies fats 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 – 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.

This study is about cholecystitis. The most common cause of

cholecystitis is gallstones (90% of the cases). The bile becomes concentrated

in the gallbladder. This later causes irritation and is probably the leading

cause of inflammation. Cholecystitis affects women more often than men and

is more likely to occur after age 40. People who have a history of gallstones

are at increased risk for cholecystitis. In the international level, cholecystitis

has an increased prevalence among people of Scandinavian descent, Pima

Indians, and Hispanic populations, whereas cholelithiasis is less common

among individuals from sub-Saharan Africa and Asia. It affected 20.5 million

people (1988-1994) with a mortality record of 1,077 deaths in 2002.

Hospitalizations total up to 636,000 in the same year and over 500,000 have

undergone cholecystectomies. In the Philippines alone, an extrapolated

prevalence of 5,073,040 people are affected by the disease last 2007.

(http://digestive.niddk.nih.gov/statistics)

The student nurses have chosen this case as they see it fit for the peri-

operative concept as the patient has had undergone open cholecystectomy.

Moreover, despite the cholecystitis’ low incidence, they would like to give

credit and to know more of the nature and function of the gallbladder. Much

often this small organ is not given importance. Thus they are in a pursuit for

knowledge to be able to impart it to others. Furthermore, this case is quite

interesting since it does not always affect only females and elderly. It can

affect everyone. It can be alarming since many people are confused and

unaware of the symptoms presented.

As teen-agers living in a fast-phased world and governed by schedules,

they too are predisposed to lifestyle modification – especially diet and food

preferences which can contribute to the disease. With this study, the student

nurses hope to apply their learning in taking care not only of their patients

but also of themselves.

As nursing students and future nurses, they would want to understand

and appreciate more on what is happening to a patient with cholecystitis.

Consequently, they are interested on what will be the necessary

management that will be given. Through this, they are hoping that they will

be able to find the right plan of care and sound interventions, not forgetting

the patient’s rights as a person. All in all, these will help them to become

efficient nurses and better persons later on.

Objectives

After 5 days of data gathering, research and analysis, the student

nurses shall have devised objectives that will guide them for the proper

understanding and fair interpretation of the case of their chosen patient.

GENERAL OBJECTIVES

Cognitive

The student nurses’ first main goal is to gain knowledge through the

completion of the case study and to impart this learning to Mr. Police and to

those directly and indirectly involve with the completion of this case.

Specific Objectives under Cognitive aspect

Within the 5 days span of duty, the student nurses will be able to:

• Gather significant data from the patient’s chart which includes the

doctor’s order, laboratory exams and etc. to have complete

information about the patient’s current condition.

• Research on the anatomy and physiology of the clients affected

system.

• Research on the possible causes and also the symptoms the patient

experienced that may suggest the current condition of the patient.

• Research and understand the disease process of the patient’s illness.

• Determine and interpret the medical management employed including

laboratory and diagnostic procedures.

• Identify and study the drugs prescribed to the patient which affects the

patient’s current situation.

Psychomotor

In this aspect, the student nurse’s goal is to apply all what they have

learned during the process of completing this case study to improve nursing

care that will meet Mr. Police’s need for the improvement of his general

welfare.

Specific Objectives under Psychomotor aspect


• Conduct a thorough physical assessment and to interpret the

assessment in order to give the care the patient need.

• Formulate nursing care plans and apply them to satisfy the patient’s

needs and give appropriate nursing interventions.

• Make a discharge plan for the patient using M.E.T.H.O.D and validate

the patient’s prognosis according to categories.

Affective

With the knowledge gained and through the application of this

knowledge, another goal is that the student nurses will be able to empathize

with the current situation of the patient and to gain some values like the

value of patience and calmness which is important for a them to have in

order to become better nurses in the future.

Specific Objectives under Affective aspect


• Establish rapport and therapeutic communication in order to gain

information about the patient which includes the medical and family

health history, expectations of his condition to him gather significant

data from the patient’s chart and to his family and etc.; and for the

betterment of nursing care.

• Assume the role of being the patient’s advocate.

PATIENT’S DATA

Personal Data

Name: Mr. Police

Age: 46 years old

Sex: Male

Nationality: Filipino

Date of Birth: August 28, 1962

Place of Birth: General Santos City

Civil Status: Married

Address: Cabantian, Country Homes, Davao City

Religion: Christianity (Roman Catholic)

Educational attainment: College Graduate

Occupation: PNP

Clinical Data

Admitting Date and Time: April 27, 2009 at 10:40 am

Case Number: 01-36-90

Ward: St. Joseph (3C)

Room/ Bed: 325-5

Attending Physician: Dr. Batucan, Wolter

Chief Complaint: right upper quadrant pain

Diagnosis: Cholecystitis T/C Cholelithiasis

VS upon admission:

BP –120/90 mmHg R – 28 cpm P – 109 bpm Temp

– 36.5˚C

Sources of info: Chart, Mr. Police himself, and his wife

GENOGRAM

Legend:

ħ: Hypertensive

±: Unknown cause of death

Ø: Suicide

Δ: Died of childhood illness

†: Deceased

Lolo A±

Lola

ADad B 3Mo1 ħ

4 5 6

Mr. Police Sis Step-Step-

brod ØA

BB 1 BB 2

Lolo B †ħ

Lola

HEALTH HISTORY

A. Family Background

Mr. Police is the eldest among Mr. Dad‘s and Mrs. Mom‘s two children.

But his younger sister died of a childhood illness at the age of three

years old, he could not recall. He grew up at General Santos City where

the relatives of his mother live. When Mr. Police was a first year high

school, his parents got separated because of third party. He lived with

his mother and Mrs. Mom’s live-in partner at Davao City, while his

father returned to Leyte where his other relatives live. With his

mother’s second family, he had another two siblings, Step-brod and

Step-sis. Step-brod died at the age of 18 because of suicide. He had

suicide because of altered mental status due to shabu use. Today,

Step-sis has her own family at Leyte.

Because Mr. Police had been away from the relatives of his father, he

does not know any significant disease they have or had. He doesn’t

also know the causes of deaths of his grandmother and grandfather on

the paternal side. On the other hand, what he only knows is that the

eldest sister of her mother has hypertension, and that his grandfather

on the maternal side died of hypertension.

Currently, Mr. Police has been married to Anna for 15 years. They met

at Mandug, Davao City, where Mr. Police had been assigned at work

before. The couple had difficulty conceiving a child because Anna has

an obstetrical problem. She verbalized, “ingon sa doctor naa man gud

daw gas-gas akoang matres.” Fortunately, nine years after their

marriage, they were blessed with BB 1 who is now a kindergarten

student, aged six years old. Two years after, BB 2 followed.

B. Personal Background

Mr. Police graduated at MATS with a 4-year degree of BS-MT. But

because he couldn’t find a job with the course he had, he had six-

month training to become a policeman. Currently, he had been

assigned to San Pedro Police Station for a year already. He works 24

hours straight, then have a two-day rest.

On his rest day, he stays in their house and on the evening, goes with

his friends and has a drinking session. He enjoys watching TV, and

sometimes does the cooking as he likes to. He is not as close as the

children are to Anna. But he enjoys playing with them sometimes and

taking them out on weekends. He is a “barkadista” as his wife, Anna,

describes him. He has a set of close friends who are also policemen like

him. He is a Roman Catholic, who does not always goes to Church

every Sundays but is a Sto. Niño devotee. Every January, he goes back

to General Santos City, to attend certain activities in celebrating Sto.

Niño fiesta.

Mr. Police has been a smoker since he was 20 years old. His wife said

he smokes three boxes of cigarettes everyday. He has also been an

alcoholic drinker since he was 13 years old. He drinks three glasses of

alcoholic drink everyday. Furthermore, he doesn’t have a regular

exercise. But he enjoyed boxing with his friends, as an exercise, which

only lasted for six months (September 2008- February 2009). He

stopped because his friends also decided to stop. With regards to his

diet, he is a “meat-addict,” as Anna verbalized. Everyday, he eats

meat, and could not sleep without eating such. He also eats lots of

pulutan during their drinking sessions such as laman-loob, chicaron,

and other pica-pica. Moreover, he does not eat vegetables but eats all

kinds of fruits. Moreover, he has no known drug and food allergy.

C. Effects/ Expectations of Illness to Self/ Family

Because of his condition, he had to undergo an operation which means

he had to have a sick leave from his work. Moreover, Anna also has to

watch over him and she has to leave the children under the care of her

elder sister for a while. Moreover, Anna is worried of the effect of the

operation to the health of her husband. But she is hoping that because

of this hospitalization, he would realize that he should have a healthy

control over his health, that he would cease drinking and smoking.

Furthermore, Anna is also expecting that her husband would regain his

strength back soon.

D. History of Past Illness

Mr. Police experienced common illness such as colds, cough, and fever

during his childhood. He also had chicken pox during his childhood.

However, he could not recall at what age he got the disease and as

well as the management of his chicken pox.

Five years prior to admission (2004), he was diagnosed with diabetes

with an FBS result of 7.8 mmol/dL. They were having an annual check

up when he discovered that he has elevated blood sugar. He was then

advised to control his diet and have a regular exercise but he was not

given any maintenance drug. Moreover, he was not compliant with the

doctor’s advice.

Two years ago (2007), he was admitted to Davao Medical Center due to

loss of consciousness. Prior to that, he was experiencing palpitations,

and pain on the suboccipital area (nape) associated with headache. He

had elevated blood pressure of 180/100 as he could remember during

the VS taking at the emergency room. He was admitted for one day

and was diagnosed with hypertension. He was then given Lopicard

5mg tab OD, as a maintenance anti-hypertensive medication. The

doctor advised him to cease smoking and drinking alcohol, and as well

as to avoid over fatigue. He stopped smoking, but only for two months.

E. History of Present Illness

A month prior to admission, Mr. Police experienced right upper

quadrant pain associated with a sense of bloatedness, without nausea

and vomiting. The pain was tolerable so he did not seek medical

attention yet. He said he also had an increased level of pain tolerance

so he also didn’t mind to take any pain relievers. Until three days prior

to admission, patient had severe right upper quadrant pain, which was

said to be intolerable. Moreover, when pressure is applied on the RUQ

of the abdomen, pain is elicited. He had also lost his appetite because

of the pain. His scleras were also slightly icteric during admission and

he was positive with Murphy’s sign. So he sought consultation at Out-

Patient Department- Emergency Room at Davao Medical School

Foundation Hospital. Ultrasound revealed cholecystitis, so patient was

advised admission and operation.

DEVELOPMENTAL DATA

TheoriesAssessme

ntStages Justification

Freud’s

Psychosexual

Theory

Genital (13

years and

older)

A

C

H

I

E

V

E

D

Genital

Energy is directed

toward attaining a

mature sexual

relationship. This

stage involves a

reactivation of the

pregenital impulses.

These impulses are

usually displaced, and

the individual passes

to the genital stage of

maturity. An inability

to resolve conflicts

can result in sexual

problems, such as

frigidity, impotence,

and the inability to

have a satisfactory

sexual relationship.

Mr. Police and Anna have a

good sexual relationship.

Though Mr. Police has an

erection-related problem,

the couple are able to

maintain a healthy sexual

relation with each other.

Anna said that she

understands that this

might be due to Mr.

Police’s diabetes, though

they sometimes do not

achieve sexual

satisfaction. The erection-

related problem of Mr.

Police does not damage

the couple’s relationship. It

even made the couple

more mature and

understanding of each

other’s sexual needs.

Furthermore, Mr. Police

compensates by wooing

his wife through romantic

dinners and being sweet

with her, even in public.

Moreover, energy is

directed towards his work

as a policeman, being

committed to his work and

as well as to his

colleagues, who are also

the recipient of Mr. Police’s

energy towards his social

relationships to other

people.

Erikson’s

Psychosocial

Theory

Stage 7:

Generativity vs.

Stagnation

(Middle

Adulthood

40-65 yrs.)

A

C

H

I

E

V

E

D

Stage 7: Generativity

vs. Stagnation

The middle adult

years are a time of

concern for the next

generation as well as

involvement with

family, friends, and

community. Socially-

valued work and

disciplines are

expressions of

generativity. Simply

having or wanting

children does not in

and of itself achieve

generativity. There is

a desire to make a

contribution to the

world. If this task is

not met, stagnation

results, and the

person becomes self-

absorbed and

obsessed with his or

her own needs or

regresses to an

earlier level of

coping.

Mr. Police is able to send

his child to a private

school, to ensure a high

standard of his educational

needs. Moreover, he works

alone to provide the

family’s financial needs.

He doesn’t allow his wife

to work to make sure that

the children receive a

direct parental guidance in

their growing years.

Moreover, as he works as a

policeman, he is satisfied

with his service to the

public through their

protection and crime

control activities. He

yearns for the

community’s peace and

order and is achieved

through his public service

as a policeman.

Havighurst’s

Development

al Theory

Middle

Adulthood

(40-65 yrs. old)

A

C

H

I

E

V

E

D

Middle Adulthood

Developmental tasks

for middle adulthood

include:

• Accepting and

adjusting to

physical changes

• Attaining and

maintaining a

satisfactory

occupational

performance

• Assisting children

to become

responsible adults

• Relating to one’s

spouse as a person

• Adjusting to aging

parents

• Achieving adult

social and civic

responsibility

Mr. Police said that it is

normal that in his age,

people get disease

because they are aging.

Moreover, he is able to

obtain a satisfactory

occupational performance,

as he stayed on his job for

already more than 20

years already. Though his

children are still four and

six years old, he teaches

them values such as

honour, respect, and

honesty, for them to

become like him, a

responsible citizen of our

country. In addition, Mr.

Police said that he is

blessed with their

relationship because Anna

is not just a wife to her,

but also a friend, whom he

could confide his problems.

As his parents are also

getting old, he said that he

visits them at least once or

twice a year. He even said

that wants them to live

their remaining life happy

and satisfied with it.

Moreover, he has achieved

social and civic

responsibility through his

public service as a

policeman.

PHYSICAL ASSESSMENT

GENERAL SURVEY

At 4 pm on April 30, 2009, physical assessment was done. Mr. Police, a

46 year old Filipino male, was lying in bed, asleep; with an IVF # 3

D5NSS 1L at the level of 80 cc, regulated at 120 cc/hr, infusing well at

right metacarpal vein; with epidural catheter; with Jackson Pratt drain;

with slightly soaked, intact dressing at right upper quadrant of the

abdomen, status post open cholecystectomy. Patient is responsive and

coherent when awaken; with complain of pain at the incision site, with

a pain scale of 6 out of 10. Patient was on NPO. He appeared

endomorphic. Patient was in good grooming, wearing clean patients

gown. Respiratory distress was not noted. Aside from that, he weighs

85 kg and stands 5’5” and has a body mass index of 31.18 which

denotes that he belong to the obese type I which ranges from 30 –

34.9.

VITAL SIGNS

BP= 120/180 mm Hg PR= 85 bpm RR= 15 cpm

T= 36 °C

SKIN

Skin was warm to touch, slightly dry, rough, and with good skin turgot.

Neither jaundice nor cyanosis observed. Papules on the face observed,

with nevi noted on the right side of the nose. Patient was not cyanotic.

No bruises or discolorations observed. No edema noted.

HEAD

Skull size was normocephalic. Skull and face were symmetrical with an

equal distribution of hair. Hair was black in color with fair amount of

white and gray strands, short, dry, and fine. There was no dandruff or

infestation present. No lesions, lacerations, tenderness, masses and

depressions noted.

FACE

The forehead was furrowed with wrinkles. Face portrayed emotions

with symmetrical movements. No masses or involuntary movement.

The face was round, with no edema, lesions, discolorations present.

EYES

Mr. Police did not use any corrective aids such as glasses or contact

lenses. Eyebrows were evenly distributed and symmetrically aligned

with no of flakes, scars and lesions noted. Eyelashes were evenly

distributed and slightly curled outward. Lid margins were clear,

lacrimal duct openings were evident at the nasal side of the upper and

lower lids. Blinking reflex was present. Skin around the eyes was intact

with equal movement, with no discharges and no discolorations

observed. Eyelids close symmetrically. No edema seen in the

periorbital region. Shiny smooth and pink palpebral conjunctiva noted.

No edema or tenderness over lacrimal gland observed. Eye color was

dark brown. His pupils were equal within 1-2 mm diameter in size and

both have a brisk reaction to light and uniform reaction to

accommodation. Small anterior polar opacification was observed on

both eyes. Nystagmus, strabismus and lid lag were not evident.

EARS

Ears were symmetrical with same size bilaterally and color consistent

with face. Pinnas were free from lesions, masses, swelling, redness,

tenderness, and discharges and were in line with the eyes. External

canals were clear with no cerumen seen. No inflammation, masses,

discharges and foreign bodies noted. Gross hearing acuity was good.

No pain on the mastoid process was reported upon palpation.

NOSE

The nose was symmetrical with no deformities, skin lesions, masses

present. Nasal septum is intact and in midline. No nasal flaring was

observed. No discharges were present. No tenderness in his sinuses

upon palpation.

MOUTH

Mouth was proportional and symmetrical. Lips were rust colored and

were dry with no presence of ulcerations, sores or lesions. Teeth were

yellowish in color with some dental caries noted. Right upper first

premolar tooth was absent. Tongue was in central position and moves

freely with no swelling or ulcerations observed. Gag reflex was present

as evidenced by patient swallowing. Tonsils were not inflamed.

Halitosis was also noted.

NECK

Neck was symmetrical with no masses or swelling noted. No jugular

vein distention was noted. Range of motion was normal and moves

easily without discomfort upon rotation, flexion, extension and

hyperextension. Thyroid was not enlarged has no nodules, masses, and

irregularities upon palpation. Trachea is symmetrical and in midline

without deviation.

BREAST

Nipples were dark brown in color, inverted and in the midline. No

crusting and masses noted. Breasts were symmetrical with no edema

noted. Both axilla were free of lesions rashes, and infections. Lymph

nodes were not palpable.

CHEST and LUNGS

No thorax deformity observed. Respiratory rate was 15 cycles per

minute with regular breathing pattern. Symmetrical chest expansion

was observed during respiration. No use of accessory muscles during

breathing observed. Chest wall was intact; no tenderness and masses

noted. Uniform temperature also noted. No adventitious breath sounds

heard upon auscultation. No cough present. No dyspnea, hemoptysis,

hiccups noted.

HEART

Apical heart beat was present upon auscultation with a point of

maximal impulse at the 5th intercostal space left midclavicular line;

with cardiac rate of 85 beats per minute with a regular rhythm. No

abnormal beats, palpitations, thrills or murmurs present upon

auscultation.

ABDOMEN

Abdomen was slighty enlarged and globular when patient was in

supine position; with slightly soaked, intact dressing on the right upper

quadrant with Jackson Pratt drain. Pulsations were not visible. The

abdomen had hypoactive bowel sounds of two bowel sounds per

minute. Tenderness noted on the right upper quadrant near the incision

site.

GENITO –URINARY

Unable to perform inspection in the genitourinary region. However,

patient verbalized that he had not noted any discharges from his

genitalia nor presence of papules or ulcerations. Patient had not yet

voided since he had arrived from the OR.

BACK & EXTREMITIES

Symmetrical shoulder movement observed during respiration. Spine

was located at the midline with no discrepancies noted. Shoulders,

arms, elbows and forearms were free from nodules, deformities and

atrophy. Range of motion was not limited. Neither pallor nor bone

enlargements were noted upon inspection of the upper extremities. A

permanent tattoo was present on his right deltoid area, anchor-

designed. Upper extremities were not edematous. Radial and brachial

pulses were present. Hip joint and thighs were symmetrical with no

deformities present. No edema noted at both legs. No inflammation

noted in the lower extremities. Range of motion was active and not

limited.

DEFINITION OF COMPLETE DIAGNOSIS

CHOLECYSTITIS

- Cholecystitis is the inflammation of the galbladder

Source: Smeltzer, S.C., Bare, B.G. Brunner & suddarth’s Textbook of

Mecial-Surgical Nursing 11th Edition.

- Cholecystitis refers to inflammation of the gallbladder and cystic

duct.

Source: Barbara Gould, Pathophysiology for the Health Professions,

Third Edition, Saunders Elsivier

- Cholecystitis refers to inflammation of the gallbladder.

Source: Carol Mattson Porth, Pathophysiology, Concepts of Altered

Health Sciences

CHOLELITHIASIS

- The presence of calculi in the gallbladder

Source: Smeltzer, S.C., Bare, B.G. Brunner & suddarth’s Textbook of

Mecial-Surgical Nursing !0th Edition.

- Cholelithiasis refers to formation of gallstones, which are masses

of solid material or calculi that forms in the bile.

Source: Barbara Gould, Pathophysiology for the Health Professions,

Third Edition, Saunders Elsivier

- Cholelithiasis, or gallstones, is caused by precipitation of

substances contained in bile, mainly cholesterol and bilirubin.

Source: Carol Mattson Porth, Pathophysiology, Concepts of Altered

Health Sciences

ANATOMY AND PHYSIOLOGY

HEPATOBILLARY TREE

LIVER

A. Location and size of the liver- largest gland in the body, weighs

approximately 1.5 kg; lies under the diaphragm; occupies most

of the right hypochondrium and part of the epigastrium.

B. Liver lobes and lobules- two lobes separated by the falciform

ligament

1. Left lobe- forms about one sixth of the liver

2. Right lobe- forms about five sixths of the liver; divides into

right lobe proper, caudate lobe, and quadrate lobe

3. Hepatic lobules- anatomical units of the liver; small branch

of hepatic vein extends through the center of each lobule

C. Bile ducts

1. Small bile ducts form right and left hepatic ducts

2. Right and left hepatic ducts immediately join to form one

hepatic duct

3. Hepatic duct merges with cystic duct to form the common

bile duct, which opens into the duodenum

D. Functions of the liver

1. Glucose Metabolism

-after a meal, glucose is taken up from the portal venous

blood by the liver and converted into glycogen

(glycogenesis), which is stored in the hepatocytes.

Glycogen is converted back to glucose (glycogenolysis)

and release as needed into the blood stream to maintain

normal level of the blood glucose.

-glucose can be synthesized by the liver through the

process gluconeogenesis

2. Ammonia Conversion

-use of amino acids from protein for gluconeogenesis result

in the formation of ammonia as a by product. Liver

converts ammonia to urea

3. Protein Metabolism

-Liver synthesizes almost all of the plasma protein

including albumin, alpha and beta globulins, blood clotting

factors plasma lipoproteins

4. Fat Metabolism

-Fatty acid can be broken down for the production of

energy and production of ketone bodies

5. Vitamin and Iron Storage

-stores vitamin A, D, E, K

6. Drug Metabolism

7. Bile Formation

-bile is formed by the hepatocytes

-composed of water, electrolytes such as sodium,

potassium, calcium, chloride, bicarbonate, lecithin, fatty

acids, cholesterol, bile salts

-collected and stored in the gallbladder and emptied in the

intestine when needed for digestion

a. Lecithin and bile salts emulsify fats by encasing them in

shells to form tiny spheres called micelles

b. Sodium bicarbonate increases pH for optimum enzyme

function

c. Cholesterol, products of detoxification, and bile pigments

(e.g. bilirubin) are wastes products excreted by the liver

and eventually eliminated in the feces

GALLBLADDER

The gallbladder (or cholecyst, sometimes gall bladder) is a small organ whose function in the body is to harbor bile and aid in the digestive process.

Anatomy• The cystic duct connects the gall bladder to the common hepatic

duct to form the common bile duct.

• The common bile romero duct then joins the pancreatic duct, and

enters through the hepatopancreatic ampulla at the major

duodenal papilla.

• The fundus of the gallbladder is the part farthest from the duct,

located by the lower border of the liver. It is at the same level as

the transpyloric plane.

Microscopic anatomy

The different layers of the gallbladder are as follows:• The gallbladder has a simple columnar epithelial lining

characterized by recesses called Aschoff's recesses, which are

pouches inside the lining.

• Under the epithelium there is a layer of connective tissue

(lamina propria).

• Beneath the connective tissue is a wall of smooth muscle

(muscularis externa) that contracts in response to

cholecystokinin, a peptide hormone secreted by the duodenum.

• There is essentially no submucosa separating the connective

tissue from serosa and adventitia.

http://en.wikipedia.org/wiki/Adventitia

http://en.wikipedia.org/wiki/Serosa

http://en.wikipedia.org/wiki/Submucosa

http://en.wikipedia.org/wiki/Duodenum

http://en.wikipedia.org/wiki/Hormone

http://en.wikipedia.org/wiki/Peptide

http://en.wikipedia.org/wiki/Cholecystokinin

http://en.wikipedia.org/wiki/Smooth_muscle

http://en.wikipedia.org/wiki/Connective_tissue

http://en.wikipedia.org/wiki/Epithelium

http://en.wikipedia.org/wiki/Simple_columnar_epithelium

http://en.wikipedia.org/wiki/Transpyloric_plane

http://en.wikipedia.org/wiki/Liver

http://en.wikipedia.org/wiki/Fundus_of_the_gallbladder

http://en.wikipedia.org/wiki/Major_duodenal_papilla

http://en.wikipedia.org/wiki/Major_duodenal_papilla

http://en.wikipedia.org/wiki/Ampulla_of_Vater

http://en.wikipedia.org/wiki/Pancreatic_duct

http://en.wikipedia.org/wiki/Common_bile_duct

http://en.wikipedia.org/wiki/Common_hepatic_duct

http://en.wikipedia.org/wiki/Common_hepatic_duct

http://en.wikipedia.org/wiki/Cystic_duct

http://en.wikipedia.org/wiki/Bile

http://en.wikipedia.org/wiki/Organ_(anatomy)

Size and Location of the Gallbladder

The gallbladder is a hollow, pear-shaped sac from 7 to 10 cm (3-4

inches) long and 3 cm broad at its widest point. It consists of a fundus,

body and neck. It can hold 30 to 50 ml of bile. It lies on the

undersurface of the liver’s right lobe and is attached there by areolar

connective tissue.

Structure of the Gallbladder

Serous, muscular, and mucous layers compose the wall of the

gallbladder. The mucosal lining is arranged in folds called rugae,

similar in structure to those of the stomach.

Function of the Gallbladder

The gallbladder stores bile that enters it by way of the hepatic

and cystic ducts. During this time the gallbladder concentrates bile

fivefold to tenfold. Then later, when digestion occurs in the stomach

and intestines, the gallbladder contracts, ejecting the concentrated bile

into the duodenum. Jaundice a yellow discoloration of the skin and

mucosa, results when obstruction of bile flow into the duodenum

occurs. Bile is thereby denied its normal exit from the body in the

feces. Instead, it is absorbed into the blood, and an excess of bile

pigments with a yellow hue enters the blood and is deposited in the

tissues.

The gallbladder stores about 50 mL (1.7 US fluid ounces / 1.8

Imperial fluid ounces) of bile, which is released when food containing

http://en.wikipedia.org/wiki/Food


http://en.wikipedia.org/wiki/Fluid_ounce

fat enters the digestive tract, stimulating the secretion of

cholecystokinin (CCK). The bile, produced in the liver, emulsifies fats

and neutralizes acids in partly digested food.

After being stored in the gallbladder the bile becomes more

concentrated than when it left the liver, increasing its potency and

intensifying its effect on fats. Most digestion occurs in the duodenum.

http://en.wikipedia.org/wiki/Duodenum





http://en.wikipedia.org/wiki/Cholecystokinin

http://en.wikipedia.org/wiki/Secretion

http://en.wikipedia.org/wiki/Gastrointestinal_tract

BILIRUBIN PRODUCTION AND ELIMINATION

Bilirubin is the substance that gives bile its color. It is formed

from senescent red blood cells. In the process of degradation, the

hemoglobin from the red blood cell is broken down from biliverdin,

which is rapidly converted to free bilirubin thru biliverdin reductase.

Free bilirubin, which is not soluble in plasma, is transported in the

blood attached to plasma albumin. Even when it is bound to albumin,

this bilirubin is still called free bilirubin. As it passes through the liver,

free bilirubin is released from its albumin carrier molecule and moved

into the hepatocytes. Inside the hepatocytes, free bilirubin is converted

to conjugated bilrubin thru glucoronyl transferase, making it soluble to

bile. Conjugated bilirubin is secreted as a constituents of bile, and in

this form, it passes through the bile ducts into the small intestine. In

the intestine, approximately one half of the bilirubin is converted into a

higly soluble substance called urobilinogen by the intestinal flora.

Urobilinogen is either absorbed into the portal circulation or excreted in

the feces. Most of the urobilinogen that is absorbed is returned to the

liver to be re-excreted into the bile. A small amount of urobilinogen,

approximately 5% is absorbed into the general circulation and then

excreted by the kidneys.

Usually, only a small amount of bilirubin is found in the blood;

the normal level of total serum bilirubin is 0.1 to 1.2 mg/dL. Laboratory

measurements of bilirubin usually measure the free and the

conjugated bilirubin as well as the total bilirubin. These are reported as

the direct (conjugated) bilirubin and the indirect (unconjugated or free)

bilirubin.

ETIOLOGY AND SYMPTOMATOLOGY

Precipitating Factors:

Factors Present Rationale

Diet (high

cholesterol,

high calorie,

high sodium)

Present Increased intake of calories, refined

carbohydrate, cholesterol, and

saturated fats has all been postulated

to cause cholesterol gallstones.

Patients with cholesterol gallstones

secrete a greater fraction of dietary

cholesterol into bile than do normal

subjects.

SOURCE: Harrison’s Principle of

Internal Medicine, 16th EditionMedications and

Oral

Contraceptives

Absent Hypolipidemic agents (clofibrate,

gemfibrozil) that lower serum

cholesterol by increasing biliary

cholesterol secretion increase the risk

of cholesterol gallstones by twofold to

threefold.

Competitive inhibitors of 3-hydroxy-3-

methylglutaryl coenzyme A (HMGCoA)

reductase (lovastatin, simvastatin,

pravastatin) decrease biliary

cholesterol saturation.

Estrogen therapy is associated with an

increased risk of developing

cholesterol gallstones.

Oral contraceptive steroids increase

biliary cholesterol secretion and

saturation but do not affect

gallbladder motility.

Source: Barbara Gould,

Pathophysiology for the Health

Professions, Third Edition, Saunders

ElsivierTotal Parenteral

Nutrition

Absent TPN is a powerful risk factor for

gallstone formation. Gallstones from

during TPN because of decreased

gallbladder motility from lack of meal-

stimulated cholesystokinin (CKK)

release, resulting in increased fasting

and residual volumes.


Internal Medicine, 16th EditionSpinal Cord

Injury

Absent Patients with spinal cord injury have

10% incidence of forming gallstones

within the first year after injury. This

high risk, which is 20 times normal, is

believed to be secondary to abnormal

gallbladder motility and probably

biliary hypersecretion of cholesterol

from the progressive reduction in body

mass.


Internal Medicine, 16th EditionPrimary Biliary

Cirrhosis

Absent Patients with primary biliary cirrhosis

have an increased prevalence of

gallstones. Stone analysis has not

been performed, but the elevated

cholesterol saturation of bile in these

patients suggest that they form

cholesterol stones.


Internal Medicine, 16th EditionDiabetes

Mellitus

Present Despite obesity and increased total

body cholesterol synthesis and

decreased gallbladder motility seen in

patients with diabetes, diabetes

mellitus itself does not appear to be an

independent risk factor for cholesterol

gallstone disease.


Internal Medicine, 16th EditionHemolytic

Syndromes

Absent Inherited hemolytic anemia, sickle cell

disease, sphericytosis, thalassemia,

chronic hemolysis associated with

artificial heart vavles, and malaria

dramatically increase the risk of

pigment stone formation because of

increased biliary secretion of total

bilirubin conjugates, especially

bilirubin monoglucoronide, at the

expense of the bilirubin diglucuronide,

the predominant conjugate in healthy

individuals.


Internal Medicine, 16th Edition

Ileal Disease,

Resection, and

Bypass

Absent Patients with ileal dysfunction have a

strikingly increased risk for developing

gallstones. Gallstones develop in 30-

50% of patients with ileal Chron’s

disease; the risk correlates positively

with the extent and duration of ileal

dysfunction, Although ilieal disease or

resection leads to cholesterol

supersaturation and cholesterol stone

formation in some patients , careful

studies now show that most patients

with ilieal dysfuncyion form black

pigment, not cholesterol stones.


Internal Medicine, 16th EditionBiliary Infection Absent Brown pigment stones are frequently

found in the intrahepatic bile ducts

and are always associated with

infection by colonic organisms usually

E.coli, or parasitic infestation (Ascaris

lumbricoides, or other helminthes).

Intraductal stones developing after

cholecystectomy are invariable

associated with bile stasis, biliary tree

infection, and/or retained suture

material.



Obesity Present Obesity is strongly associated with

increased gallstone prevalence. The

risk is proportional to the increase in

total body fat. Obese people

synthesize more cholesterol in both

hepatic and nonhepatic tissues,

transport it to the liver, and secrete

more of it into the bile, leading to bile

that is often greatly supersaturated

with cholesterol.




ElsivierRapid Weight

Loss/ Fasting

diets

Absent Obese patients undergoing rapid

weight loss (1-2% of body weight or

approximately 1-2 kg/week), either by

very low caloric dieting or gastric

stapling, have a 25-40% chance of

developing gallstones within 4 months.

During rapid weight loss, biliary

cholesterol saturation increases

acutely as cholesterol is mobilized

from adipose tissue and skin and

secreted into bile.



Predisposing Factors:

Factors Present RationaleGender Absent Women have twice the risk as men of

developing cholesterol gallstones

because estrogen increases biliary

cholesterol secretion. Before puberty

this risk is negligible, and beyond

menopause the increased risk

disappears.




ElsivierAdvancing Age Present The incidence increases with age.

Less than 5-6% of the population

under age 40 have stones, in contrast

to 25-30% of those over 80.

Source: Carol Mattson Porth,

Pathophysiology, Concepts of Altered

Health SciencesRace Absent Prevalence highest in North American

Indians, Chilean Indians, and Chilean

Hispanics, greater in Northern Europe

and North America than in Asia,

lowest in Japan; familial disposition;

hereditary aspects



Heredity Absent Family history alone imparts increased

risk, as do a variety of inborn errors of

metabolism that lead to impaired bile

salt synthesis and secretion or

generate increased serum and biliary

levels of cholesterol, such as defects

in lipoprotein receptors

(hyperlipidemia syndromes), which

engender marked increases in

cholesterol biosynthesis.


Internal Medicine, 16th EditionParity/

Pregnancy

Absent Pregnancy is an independent risk

factor for cholesterol gallstones. The

risk increases with increasing parity,

especially with more than two

children. During pregnancy, elevated

estrogen and progesterone levels

increase biliary cholesterol secretion.

Elevated progesterone also inhibits

gallbladder contractility. 40% of

women develop biliary sludge in their

gallbladder and 12% of women form

their first stones during pregnancy.



Symptomatology

Symptoms Present RationaleBiliary Colic/

Moderate to

Severe Pain

Present The most common symptom is in

pain the right upper part of the

abdomen or epigastrium. This can

cause an attack of abdominal pain,

called biliary colic, which: develops

quickly, is severe, lasts about one to

three hours before fading gradually,

isn't helped by over-the-counter and

isn't helped by passing wind. The

pain may radiate to the back, right

scapula or shoulder. The pain often

begins suddenly following a meal.

The pain of biliary colic is caused by

the functional spasm of the cystic

duct when obstructed by stones,

whereas pain in acute cholecystitis

is caused by inflammation of the

gallbladder wall.

Source: Carol Mattson Porth, Pathophysiology, Concepts of Altered Health Sciences

Tenderness Present Palpation of the abdomen frequently

elicits localized tenderness in the

right upper quadrant which is

associated with guarding and

rebound tenderness.

Source: Carol Mattson Porth,

Pathophysiology, Concepts of

Altered Health Sciences Murphy’s Sign Present The patient with acute inflammation

of the gallbladder might have a

positive Murphy’s sign, which is

inspiratory arrest during deep

palpation in the right upper

quadrant.


Internal Medicine, 16th EditionNausea and

Vomiting

Absent These signs and symptoms may

accompany a gallbladder attack.

Pain is usually accompanied by

nausea and vomiting.

Source: Barbara Gould, Pathophysiology for the Health Professions, Third Edition, Saunders Elsivier

Fever and chills Absent Gallstones sometimes get trapped in

the neck of the gallbladder and can

cause persistent pain that lasts

more than several hours and is

accompanied by fever, also due to

the irritation and inflammation of

the gallbladder wall.

Fever occurs in about one third of

people with acute cholecystitis. The

fever tends to rise gradually to

above 100.4° F (38° C) and may be

accompanied by chills


Internal Medicine, 16th Edition fLoss of appetite

and Anorexia

Present The pain often begins suddenly

following a large or rich meal.

People tend not to eat, especially

fatty or oily foods, in order not to

experience that pain. Fat absorption

is also impaired for the lack of bile

salts, As a result, rapid loss of

weight and anorexia can occur.



PATHOPHYSIOLOGY

Liver cells secrete cholesterol into bile

along with phospholipid in the form of unilamellar

vesicles

Liver cells also secrete

bile salts

Residual vesicles Some of the unilamellar

vesicles dissolve

Formation of mixed micelles

Liver excrete relatively high proportion of

cholesterol in the bile

Liver excrete some

unconjugated bilirubin into

bile

Calcium enters bile passively

along with other electrolytes

Unconjugated Bilirubin tends to

form insoluble precipitates with

calcium

Formation of Calcium

Bilirubinate

Invasion of

bacteria

Liver excrete conjugated

bilirubin into bile

The bacteria hydrolyze conjugated bilirubin

Bacterial hydrolysis of lecithin

Release of fatty acids

Increase in unconjugated

bilirubin

A

Precipitating Factors:DietMedications and Oral ContraceptivesObesityRapid Weight LossSpinal Cord InjuryPrimary Biliary CirrhosisDiabetes MellitusHemolytic SyndromesIleal Disease, Resection and BypassBiliary InfectionTotal Parenteral Nutrition

Predisposing Factors:GenderAgeRaceHeredity Pregnancy

The cholesterol carrying capacity of

the micelles and residual vesicles is

exceeded

Bile is supersaturated with

cholesterol

Formation of Crystals

Cholesterol Gallstones

Black Pigment Gallstones

Formation of Calcium

Bilirubinate

fatty acids forms complex with calcium

Brown Pigment Gallstones

A

Bacteria release lytic

enzyme

Attraction of

Leukocytes

leukocytes hydrolyze bilirubin

conjugates and fatty

acids

Mixed Stones

Nucleation of cholesterol crystals

CHOLELITHIASIS

Gallstone tries to go out of the gallbladder

Obstruction of the cystic duct by

gallstones

Obstruction of the common bile duct by

gallstones (Choledocholelithiasis)

Cholestasis

Prolong Cholestasis Absence of Bile in the duodenum

↑ levels of bilirubin/bile

pigments in the circulation

S/S jaundice, ecteric sclera, pruritus, dark urine

S/S Indigestion, Vit ADEK deficiency, gray stools

Hepatomegaly

Fibrosis

Liver Cirrhosis

Release of phospholipase from the epithelium of the

gallbladder

Disruption of mucous coat of the gallbladder

epithelium

Hydrolization of lecithin into lysolecithin

Damages mucosal cells due to detergent action of

bile salts

Irritation of the gallbladder wall

Fibrous nodules distorts the architecture of the liver

Resistance to portal blood flow

Increase pressure in hepatic portal

vein

Portal Hypertension

Z

Release of prostaglandins within the gallbladder wall

ACUTE CHOLECYSTITIS

S/S Biliary Colic, Tenderness, Murphy’s sign, nausea and vomiting, fever, elevated wbc, anorexia

IF TREATED:Open Cholecystectomy

Laparoscopic Cholecystectomy

LitotripsyUrsodeoxycholicacid

GOOD PROGNOSIS

IF NOT TREATED

Bacteria invade the injured gallbladder through the blood,

lymphatic or bile ducts form adjacent organs

(Empyema of the gallbladder)

External surface of the

gallbladder is scarred and layered by fibrinous

exudates and distended

Edema, hemorrhage and suppuration of the gallbladder wall

MK

Compression of blood vessels

Increased Intraluminal pressure

Compromised blood flow to the mucosa and lymphatic stasis

Ischemia

Ulcerations of the mucosa

Necrosis

Gangrenous Cholecystitis

Free Perforation

Adhesion to an adjacent hollow

viscus (duodenum)

Cholecystoenteric fistula formation

Gall stone induced intestinal obstruction

(gallstone ileus); drainage of bile into

adjacent organs; entry of air and bacteria into

the biliary tree

Localized Perforation

Pericholecystic abcess

Cut off the blood supply to the

affected portion of your intestine

Ischemia

As the intestine becomes

congested, its ability to absorb food and fluids

decreases

Necrosis

Perforation in the intestinal wall

Generalized Peritonitis

Sepsis

Septic Shock

S/S fever, chills, tachycardia

DEATH

Dehydration

Hypovolemia

Hypovolemic shock

Liver failure

Liver is unable to convert the protein byproduct ammonia

into urea

Shunting of blood into the splenic vein

Spleen enlarges to compensate decreased liver function

Blockage or increase pressure in the portal vein causes blood to

backflow to the different vessels located near the esophagus and

GIT

Increase pressure in peritoneal capillaries

Fluid shifting from the portal vein to the peritoneal cavity

Z

Ammonia enters general circulation

Morphologic changes in astrocytes

Astrocytes may undergo Alzheimer type II astrocytosis

Astrocytes become swollen

Development of a large pale nucleus, a prominent nucleolus, and margination of chromatin

HEPATIC ENCEPHALOPATHY

S/S Anorexia, Nausea, Liver tenderness, Jaundice

Splenomegaly

Increase in size decreases the spleen’s ability to function properly or loss of function

Increases in blood waste product since spleen is not able to properly destroy RBC’s

Death

S/S Thrombocytopenia, anemia, leukopenia

Gastroesophageal Varices

Rupture

Hypovolemia

Death

Ascites

Invasion of bacteria from the blood, or lymph or through the bowel wall

Spontaneous Bacterial Peritonitis

Sepsis

Death

S/S Fever, diarrhea, abdominal pain

S/S Asterixis

Septic Shock

Hypovolemic shock

Cerebral edema

Increased intracranial pressure

Brain Hernation

Hepatic Coma

DEATH

M

Increased subepithelial and subserosal fibrosis and

proliferation of lymphocytes and other chemical mediators

Chronic Cholecystitis

Extensive dystrophic

calcification of the gallbladder wall

(Porcelain bladder)

Growth of gallbladder carcinoma

Metastasize to the liver

K

Secondary Liver Cancer

DOCTOR’S ORDER

Date & Time

Order Rationale Remarks

04-27-0910:40am

Pls. admit under Dr. Walter G. Batucan

For proper evaluation and management and care underDr. Batucan who is an expert on General Surgery, Liver, Gallbladder, Billiary and Pancreatic Surgery.

Done

Low fat diet Bile contains large amount of cholesterol that usually remains dissolved in the bile but when there is oversaturation with cholesterol, cholesterol becomes insoluble and crystallizes. Low fat diet serves as a prevention and treatment for gallstone formation.

Done

Labs:CompleteBloodCount, PlateletCount

Complete blood count is the determination of the quantity of each quantity of each type of each blood cell in a given specimen of blood, often including the amount of hemoglobin, hematocrit, and the proportion of various white cells.Platelet count and other blood components that will help determine the underlying diagnosis.

DoneHemoglobin –

172g/dLRBC – 5.46 X10^12/L

Hematocrit – 0.53

WBC – 15.2 X 10^9/L

Segmenters- 0.72

Lymphocyte-0.28

Platelet – 222 X10^9/L

Blood Typing Patient is to undergo an invasive surgery which could lead to

DoneBlood type –

O+

blood loss therefore blood typing is done before blood can be transfused on him to replace the loss blood.

Urinalysis An indicator of health and disease, it is helpful in the detection of renal or metabolic disorders. It is an aid in diagnosing and following the course of treatment in diseases of the kidney and urinary system and in detecting disorders in other parts of the body such as metabolic or endocrinic abnormalities in which the kidneys function normally.

DoneYellow; cloudyRxn:6

Spec. gravity-1.030

Glucose (-)Albumin (+++)

Pus cells 2-4/hpf

RBC 1-2/hpfMucus

threads (+)

Chest X-ray Chest X-ray provide a good outline of the heart nad major blood vessels and ussualy can reveal a serious disease in the lungs, the adjacent spaces, and the chest wall, including the ribs. Ordered so as to check patient’s cadio-pulmonary condition before undergoing an invasive surgery.

Done> Suggestive of an inflammatory lung disease compatible with bibasal pneumonia. Please correlate clinically.

ECG ECG is a recording of the electrical impulses of the heart. Such test is an important indicator of how well the heart is functioning. Prior to surgery, the heart must first be checked to determine whether or

DoneNormal Sinus

Rhythm

not it can handle the surgery.

Fasting Blood Sugar Prior to surgery, blood glucose is to be checked to determine if the patient has a disorder in glucose metabolism mainly diabetes for healing tends to be longer if one has diabetes.

Done6.84mmol/L

Creatinine Creatinine is a breakdown product of creatine phosphate in muscle, and is usually produced at a fairly constant rate by the body. It is mainly filtered by the kidney, though a small amount is actively secreted. Measuring serum creatinine is used to indicate renal function.

DONE148umol/L

Uric Acid Measurement of uric acid is most commonly in evaluation of renal failure, gout and leukemia.

Done0.497mmol/L

Total Bilirubin Evaluates impairment of the liver or hemolytic anemia.

Done33.3umol/L

Direct BilirubinIndirect Bilirubin

Direct and Indirect bilirubin are differentiation on why there is an increased bilirubin. Direct bilirubin is associated with liver dysfunction or blockage while Indirect bilirubin is related to destruction of red blood cells.

Done7.6umol/L

Done25.7umol/L

Alkaline Phosphatase This enzyme test is used chiefly as an index of liver and bone

Done228U/L

disease when correlated with other clinical findings.

Albumin The test helps in determining if a patient has liver disease or kidney disease, or if not enough protein is being absorbed by the body.

Done55.4

Attach ultrasound result

Prior to admission patient had undergone UTZ, attaching the result in the chart allows better diagnosis and analysis for the rest of the medical team involved in his upcoming surgery.

DoneCholecystitis

with bile sludge

formation and

suggestive hydrophoric

change. Cannot

entirely rule out calculus in the cystic

ductRefer accordingly Call doctor’s attention

immediately once any unusuality occurs.

Done

11:20am Meds:Lopicard 5mg tab OD – c/o patient’s stock

Patient is hypertensive, and was ordered to continue his maintenance medication.

Done

04-28-097am

Please refer to Dr. Torno for Cardio-Pulmonary clearance – co management

Prior to surgery Cadio-Pulmonary system must first be diagnosed whether or not the patient’s circulatory and respiratory system can handle the surgery.Dr. Torno is an Intenist whose specialty is cardio and pulmo.

Done

Pls. schedule for lap cholecystectomy

Surgical removal of the gallbladder using a

Done

http://adam.about.com/encyclopedia/encyclopedia/nutrition/Protein-in-diet.htm

http://adam.about.com/encyclopedia/encyclopedia/infectiousdiseases/Kidney-disease.htm

http://adam.about.com/encyclopedia/encyclopedia/infectiousdiseases/Liver-disease.htm

laparascope is indicated for acute cholecystitis.

Secure consent Securing consent ensures the safety of both the medical team and the patient. It is the permission obtained from the patient that he is to undergo a surgical procedure.

Done

Anesthesiologist: Dr. Eugene Barinaga

Dr. Barinaga may be the partner anesthesiologist of Dr. Batucan.

Start vitamin K 10g IV OD

Pre-operative standard operating procedure so as to prevent excessive bleeding during the actual surgical procedure.

Done

Follow up all lab results and attach to chart

Lab results are not yet available, thus a follow up must be made in order for the doctors to correlate the findings.

Done

10am Start PLR iL @ KVO rate PLR an isotonic solution that resembles blood serum used as passage for the Vit. K IVTT that was ordered beforehand and for future medications. It is also used for hydration and electrolyte replacement.

Done

04-28-0912:20pm

Anesthesiologist: Pre-op EvaluationThanks for this referral

The referral was made so as to ensure a safe and successful surgical procedure.

Patient seen and evaluated, chart review done

Anesthesiologist made rounds to the patient so as to establish a therapeutic

Done

relationship prior to the scheduled operation and to evaluate the patient.

Anesthesia plans explained consequences and benefits explained

Explaining the pros and cons of the anesthesia allows the patient to contemplate and to have a mutual understanding with the anesthesiologist by agreeing with what anesthesia to use.

DoneAccepted by

patient

Nothing per orem temporary at 5am after breakfast

To clear the digestive tract in preparation for the operation to avoid GI disturbances and reduce the possibility of vomiting and aspiration and the risk of possible bowel obstruction.

Done

Pre-meds:Midiazolan 15mg 1tab ½ tab @ 12nn tomorrow with 30cc of water.

An anti-anxiety drug, given so as to relieve patient’s anxiety regarding his upcoming surgery.

Done

Resume consent for anesthesia

Consent is a written understanding and a permission from the patient that allows the use of certain anesthesia in the surgical procedure that he’ll undergo.

Done

04 -28-093pm

Reschedule OR tomorrow at 7am

OR schedule was not indicated on prior orders. 7am was ordered for it was the most convenient time for patient, his medical team and the OR staffs.

Done

Inform OR, Dr. Barinaga Informing Dr. Barinaga Done

regarding the scheduled surgery allows him time to prepare and ready himself for the upcoming surgical procedure.

04-28-09 IM: thank you for referNo history of cough but with rales at L>RCXR – pneumonia

Patient showed signs and symptoms of pneumonia.

CAP low risk HPN T/C DM2

Patient was diagnosed with CAP low risk due to the findings above, HPN due to history of hypertension and T/C due to high serum glucose as shown in his FBS.

Start Sulperazone 1.5g IV q8

Given to treat respiratory infection and also serves as pre-operative prophylaxis.

Done

Continue Lopicard Patient may continue with his maintenance medication.

Done

04-28-095pm

Pls. reschedule surgery on Thursday

After being seen by his internist, his surgeon then rescheduled the operation maybe due to patient having pneumonia.

Done

Anesthesiologist: Dr Tozon

Change of anesthesiologist instead of Dr. Barinaga due to the rescheduling of the surgery.

10pm Schedule at 7am After rescheduling the day, OR finally gave the time for the patient’s surgery.

Done

Anesthesiologist aware The new anesthesiologist was made aware of the upcoming surgery for

Done

him to be prepared.04-29-0910:40am

For Surgery tomorrow at 7am once cleared

The scheduled procedure will be carried out once the Internist cleared the patient for surgery.

Done

Cefoxitin (Monowell) 1amp IVTT ANST now prior to OR

Serves as pre-operative prophylaxis.

Done

04-29-091:40pm

Kindly inform Dr. Batucan – Sulperazone will serve as pre-op antibiotic management discontinue Cefoxitin if ok with Dr. Batucan

Although Sulperazone and Cefoxitin can serve as pre-operative prophyaxis, the internist chose Sulperazone over Cefoxitin maybe because the former is more potent than the latter but still it’s the attending physician’s decision on what drug to give.

Done

No absolute contraindication to planned surgery CP ok

Surgery can now be done after CP clearance was done.

5pm Plan carry out above orders

For abrupt implementation.

Done

For open cholecystectomy instead of lap chole

Patient has gangrenous gallbladder and open cholecystectomy is indicated for such.

04-30-0912mn

IntraOpNPO now Patient was put on NPO

for he is to undergo surgery the following day.

Done

Metoclopramide 1amp IVTT at 6am

Promotes gastric emptying prior to surgery.

Done

Ranitidine 1amp IVTT at 6am

Patient was on NPO so ranitidine, an H2 antagonist, was ordered because it inhibits the action of histamine at the H2

Done

receptors of the parietal cells inhibiting gastric acid secretion.

04-30-09 PostOpTo PACU For intensive

monitoring after the surgery and for recovery.

Done

NPO Nothing per orem until patient passes out flatus for he still has no peristalsis and so as to avoid aspiration.

Done

VS q15 until stable, then q1° X 4hrs then q4°

Monitoring the vital signs determines patient’s body’s reaction after he had undergone the surgery and so as for prompt intervention for any deviations in vital signs.

Done

IVF D5NSS iL at 120cc/hr To replenish fluids, nutrients and electrolytes.

Done

Meds:1. Tramadol 50mg q6 IVTT

Relief of moderate to moderately severe pain, serves also as a post operative analgesia.

Done

2. Ketorolac 30mg q8 IVTT

Short-term management (up to 5 days) of moderately severe acute pain and reduces signs and symptoms of inflammation - redness, swelling, fever, and pain.

Done

3. Ranitidine 50mg q8 IVTT

Ranitidine serves as post surgery antacid and to prevent ulcer of which is ketorolac’s adverse effect.

Done

4. Sulperazone 1.5g q8 IVTT

Post operative prophylaxis

Done

Epidural anesthesia: Bupivacaine 0.25% 10cc + 0.25 MSO4 OD c/o Dr. Tozon

Bupivacaine serves as analgesia for surgery added with magnesium sulfate so as to prevent seizue, convulsion and to lower the blood pressure.

Done

Morphine precaution Ordered because morphine increases biliary spasm.

Done

I & O q shift Anesthetics and surgery affect the hormones regulating fluid and electrolyte balance (Aldosterone and ADH), placing the client at risk for decreased urine output and fluid and electrolyte imbalances. Monitoring I & O help assess fluid balance. Accurate measurement of a patient's fluid intake and output will identify those patients at risk of becoming dehydrated or overhydrated. Postoperative patients are at risk of these.

Done

Refer accordingly Call doctor’s attention immediately once any unusuality occur

Done

04-30-095pm

IVFTF: D5NSS iL at 120cc/hr

To continue IVTT medication administration and to replenish electrolyte and fluid loss due to the surgical procedure.

Done

DIAGNOSTIC EXAMINATIONS

Exam ResultReference

Range

Clinical

Indication

Interpretatio

n

Nursing

ResponsibilityHematology (April 27, 2009)

Hemoglobi

n

172 M: 140-

170

F: 120 –

150

g/dL

Hemoglobin is

an important

component of

red blood cells

that carries

oxygen and

carbon dioxide

to and from

tissues. The

hemoglobin

determination

test is used to

screen for

diseases

associated

with anemia

and in

determining

acid-base

balance. The

oxygen

carrying

capacity of the

blood is also

determined by

the

Hemoglobin

concentration.

Above

normal

range.

Erythrocyt

e

5.46 4.0-6.0

X10^9/L

This test is

used to

evaluate any

type of

Within

normal

range.

Blood Typing

O+ This blood test is performed

to match donor blood

with recipient who requires

blood transfusion. Blood typing identifies the

inherited antigens that compromise one of four

possible blood types: A, B,

AB, O.

Type O people have

red blood cells with neither

antigen, but produce

antibodies against both

types of antigens.

Because of this

arrangement, type O can be safely

given to any person with

any ABO blood type. Hence, a

person with type O blood is said to be a "universal donor" but

cannot receive blood except from

the correspondin

g O type people

Inform the patient about the purpose or significance of

the test.

Follow up results in the laboratory.

Inform the patient the result of the

test.

http://labtestsonline.org/understanding/analytes/hematocrit/glance.html

http://labtestsonline.org/understanding/analytes/hemoglobin/glance.html

Exam ResultReferenc

e Range

Clinical

Indication

Interpretatio

n

Nsg

ResponsibilityUrinalysis (April 27, 2009)

Physical Exam

Color Amber Yellow Urine specimens

may vary in

color from pale

yellow to dark

amber. The color

of urine changes

in many disease

states due to the

presence of

abnormal

pigment.

Amber

colored urine

is normal but

it indicates

high specific

gravity and a

small amount

of urine.

Specific

gravity is

above 1.020

and output

less than 1L

per dayAppearance Cloudy Clear Urine specimen

may appear

clear to cloudy.

This helps to

indicate

presence of

WBC, RBC,

bacteria, pus,

phosphates,

urates and uric

acid in the urine

composition.

However,

excretion of

cloudy urine

may not be

abnormal

since the

change on

urine pH may

cause

precipitation

within the

bladder of

normal

urinary

constituents.

Alkaline urine

may appear

Prepare client:

-Explain that

this test is to

X-ray Report

(April 27, 2009)

Chest PA

Clinical Indication: Chest X-ray is done to diagnose pulmonary disease

and diseases of the mediastinum and bony thorax. This test also gives

valuable information on the condition of the heart, lungs,

gastrointestinal tract and thyroid gland.

Findings: Heart is within normal limit in size. There are infiltrates on

both lung bases. Rest of the lung fields is clear. Lateral CP sinuses are

sharp.

Impression: Suggestive of an inflammatory lung disease compatible

with bibasal pneumonia. Please correlate clinically.

Interpretation: Chest X-ray was ordered so as to assess the patient’s

cadio and pulmonary system prior to surgery and it was found out that

aside from having cholecystitis, patient also has pneumonia which then

needs an Internist to determine whether he can proceed with the

scheduled surgery.

Nursing Responsibilities:

- Explain to the patient that the chest x-ray will be used for

screening, diagnosis and evaluation of change in his

respiratory system.

- Explain the nature of the procedure to the patient

- Instruct the patient to remove all metal objects between

his neck and chest and change to hospital gown.

- Instruct the patient to take a deep breath and exhale; then

he is required to take another deep breath but hold it while

the picture is taken.

- Tell patient that the procedure takes only a few minutes.

- Inform the patient regarding the result of the test.

ECG Result

(April 27, 2009)

Rate: 25 min

PR interval: 0.10second

Rhythm: Sinus

QRS: 0.08second

Axis: +15°

QTc: 0.44seconds Position Intermediate

Interpretation: Normal Sinus Rhythm

>The electrical impulse is formed in the SA node and conducted

normally.

>This is the normal rhythm of the heart.


Inform patient on why and how the test is done. Tell him that

this is not an invasive procedure, painless and a safe test.

Place patient in a supine position in the bed or table.

Prepare the skin (shave if there is excess hair) by applying

contact paste or prejelled discs.

Place the electrodes accurately.

Inform the patient regarding the result.

Exam ResultReference

Range

Clinical

IndicationInterpretation

Nsg

ResponsibilityBlood Chemistry (April 27, 2009)

FBS 6.84 4.20 –

6.40

mmol/L

Fasting blood

sugar test

measure the

amount of

glucose in the

blood and to

detect any

disorder of

glucose

metabolism.

Above normal

level, indicates

diabetes.

- Explain that

a blood

sample will

be taken from

the hand or

arm and that

the sample

will be

evaluating

the amount

of sugar

present in the

blood that

may indicate

diabetes and

evaluate if

metabolic

derangement

has resulted

by the

disease.

-Instruct the

client not to

eat or drink

anything, 12

hours prior to

taking the

test. He can

just drink

water.

-Administer

Omeprazole

400 mg tab,

1 tab OD to

suppress

gastric acid

secretion,

preventing

hyperacidity

since the

patient will

be on NPO for

12 hours.

Creatinine 148 53 – 97

umol/L

Creatinine is a

nitrogenous

waste product

produced

during protein

metabolism in

muscle tissue.

The test is

used to

determine

kidney

function

and/or

Above normal

range, which

indicates a

decreasing

kidney

function, or

muscle

disease.

1. Explain

that this test

is important

to help

understand

how well the

kidneys are

working.

2. Assess fluid

and

nutritional

status of

damage. client for

clues or renal

impairment

and other

disease

causing

changes in

creatinine

levels.

3.

Continuously

monitor fluid

balance

through daily

weights and

intake and

output

recordings.

4. Evaluate

for increased

fluid volume

manifested by

edema,

decreased

urine out put,

neck vein

distention,

dyspnea and

hepatomegaly

Total

Bilirubin

33.3 2.0 – 21.0

umol/L

Direct

Bilirubin

7.6 0.0 – 3.4

umol/L

Indirect

Bilirubin

25.7 2.0 – 17

umol/L

The

measurement

of bilirubin is

important in

evaluating

liver function,

and hemolytic

anemia. A

NORMAL level

of total

bilirubin reules

out any

significant

impairment in

the excretory

function of the

liver or

excessive

hemolysis of

red blood

cells.

Differentiation

of bilirubin is

done to

determine

which of the

problems

above is the

cause of the

elevation of

total bilirubin.

An in crease in

Above normal

range, may

indicate

obstructive

jaundice of

which is a

result of

obstruction of

the common

bile duct or

hepatic ducts

due to stones

or neoplasm.Above normal

range, may

indicate

choledocholithi

asis.Above normal

range, may

indicate

hemolytic

anemia.

Explain the

purpose and

the

procedure of

the test.

Tell patient

that 10ml

venous blood

is to be

collected

before he

eats his

breakfast.

Inform

patient

regarding the

test result.

Uric Acid 0.497 0.2 – 0.4

umol/L

Uric acid is

formed from

the breakdown

of nucleonic

acids and is an

end product of

purine

metabolism.

Measurement

of uric acid is

most

commonly in

evaluation of

renal failure,

gout and

leukemia.

Above normal

range, could be

associated with

nitrogen

retention and

with increase in

urea, creatinine

and other non-

protein

nitrogenous

substances in

the blood. May

indicate a

decreased

renal function.

Explain the

purpose and

the

procedure of

the test.

Inform the

patient

regarding the

result.

Monitor

patient’s

intake and

output so as

to determine

if he has a

decreased

renal

function.Alkaline

Phosphatas

e

228 64 – 306

U/L

This enzyme

test is used

chiefly as an

index of liver

and bone

disease when

correlated with

other clinical

findings. In

liver disease,

the blood level

Within normal

range

Explain the

purpose and

the

procedure of

the test.

Inform the

patient

regarding the

result.

rises when

excretion of

this enzyme is

impaired as a

result of

obstruction in

the biliary

tract.Albumin 55.4 38 – 51

g/L

This test can

help

determine if a

patient has

liver disease

or kidney

disease, or if

the body is not

absorbing

enough

protein.

Above normal

range, may

indicate renal

disease.

Explain the

purpose and

the

procedure of

the test.

Inform the

patient

regarding the

result.

http://www.nlm.nih.gov/medlineplus/ency/article/002467.htm




Ultrasound Report

(04/27/09)

Ultrasound Report

(This report is based on sonographic findings and must be correlated

clinically.)

The liver is normal in size and tissue attenuation with smooth

external outline. No cystic or solid parenchymal lesions demonstrated

here. The intrahepatic ducts are not dilated. The width AP diameter of

the common bile duct is 0.4cm. no focal lesions noted intraluminally.

The gallbladder is significantly distended to 11.6cm to 4.1cm

(length X AP dm) with diffusely thickened walls that measures up to

1.1cm low level echoes are seen in the dependent portion of the

gallbladder. Quetionable echoes are seen in the partly obscured cystic

duct.

The pancreas is obscured by overlying bowel gas preluding

adequate assessment.

Impression:

> Cholecystitis with bile sludge formation and suggestive

hydrophoric change. Cannot entirely rule out calculus in the

cystic duct

> Sonographically normal liver and biliar ducts

Interprertation: Based on the above findings (patient has gangrenous

gallbladder), he then needs to undergo open cholecystectomy instead

of lap cholecystectomy.


Explain the purpose and the procedure of the test.

Inform patient that ultrasound is a noninvasive procedure.

Instruct him not to eat solid food for the 12 hours prior to

exam to allow greatest dilation of the gallbladder.

Inform him that water is permitted.

Inform patient regarding the result.

DRUG STUDY

Generic Name: Amlodipine besylate

Brand Name: Lopicard

Classification: Calcium channel blocker;

Antianginal; Antihypertensive

Mode of Action: Blocks the transport of calcium into the smooth muscle

cells lining the coronary arteries and other arteries of the body. Since

calcium is important in muscle contraction, blocking calcium transport

relaxes artery muscles and dilates coronary arteries and other arteries

of the body. By relaxing coronary arteries, amlodipine is useful in

preventing chest pain (angina) resulting from coronary artery spasm.

Relaxing the muscles lining the arteries of the rest of the body lowers

the blood pressure, which reduces the burden on the heart as it pumps

blood to the body. Reducing heart burden lessens the heart muscle's

demand for oxygen, and further helps to prevent angina in patients

with coronary artery disease.

Dosage: Lopicard 5mg tab OD

http://www.medicinenet.com/script/main/art.asp?articlekey=262


Indication: Hypertension

Contraindication: Hypersensitivity to amlodipine, impaired hepatic or

renal function, sick sinus syndrome, heart block (second or third

degree), lactation

Side Effects: dizziness, light-headedness, headache, fatigue, edema of

the lower extremities, flushing, nausea, vomiting, palpitations,

stomach pain, drowsiness, muscle cramps, abdominal discomforts

Adverse Effects: asthenia, arrhythmias, chest pain, yellowing of the

eyes or skin, difficulty breathing

Drug - Drug Interaction: Risk of congestive heart failure with beta-

adrenergic blockers.

Increased antihypertensive effects with other

antihypertensives.

Possible increased serum levels and toxicity of

cyclosporine if taken

concurrently.


1. Assess patient for contraindication.

2. Assess for baseline data.

3. Administer drug without regard to meals.

4. Monitor patient’s vital signs carefully while adjusting drug to

therapeutic dose.

5. Instruct patient to take drug with meals if stomach upset

occurs.

6. Instruct him to take drug exactly as prescribed by his

physician.

7. Tell patient that he may experience some side effects brought

upon by the drug.

8. Instruct him to report intolerable side effects so management

can be done.

9. Instruct him to eat frequent small meals if vomiting occurs.

10.Oral care if patient vomits.

11.Instruct him to adjust lighting, noise and temperature if he

experiences headache and report if it is intolerable so that

medication may be given.

12.Instruct him to report any adverse effects that he may

experience.

Generic Name: Vitamin K

BRAND NAME: Aqua-Mephyton

CLASSIFICATION: Fat soluble vitamin

MECHANISM OF ACTION: Vitamin K is essential for the hepatic

synthesis of factors II, VII, IX, and X, all of which are essential for blood

clotting. Vitamin K deficiency causes an increase in bleeding tendency,

demonstrated by ecchymoses, epistaxis, hematuria, GI bleeding.

DOSAGE: Vitamin K 10g IV OD

INDICATION: Prevention of bleeding, Vitamin K malabsoption,

hypoprothrombinemia

CONTRAINDICATION: Hypersensitivity, severe hepatic disease, last few

wk of pregnancy

SIDE EFFECTS: Dizziness, flushing, transient hypotension after IV

administration, rapid and weak pulse, diaphoresis, erythema, pain

swelling and hematoma at injection site

ADVERSE REACTION: Anaphylaxis or anaphylactoid reactions, usually

after rapid IV administration

DRUG INTERACTION:

Cholestyramine, mineral oil: may inhibit Gi absorption of vitamin

K

Oral anticoagulants: decreased anticoagulant effect

Antibiotics: may inhibit vitamin K production leading to bleeding

NURSING RESPONSIBILITIES :

1. Assess for contraindication.


3. Monitor protime during treatment; monitor for bleeding,

pulse and BP.

4. Teach patient not to take other supplements, unless

directed by prescriber, to take this medication as directed.

5. Tell patient that he may experience side effects brought

about by the drug and to report intolerable ones so as

prompt interventions be done.

6. Instruct patient to report symptoms of bleeding: bruising,

nosebleeds, bleack tarry stools, hematuria.

7. Stress the need for periodic lab tests to monitor

coagulation level.

8. Instruct patient to report adverse effect that he may

experience.

Generic Name: Midazolam HCl

Brand Name: Dormicum

Classification: Benzodiazepine (short-acting);Anxiolytic; CNS

depressant; Anticonvulsant

Mode of Action: Acts mainly at the limbic system and reticular

formation; potentiates the effects of gamma amino butyric acid

(GABA), an inhibitory neurotransmitter; anxiolytic and amnesia effects

occur at doses below those needed to cause sedation, ataxia; has little

effect on cortical function.

Dosage: Midazolam 15mg 1tab ½tab at 12nn with 30cc of water

Indication: Sedation, anxiolysis, and amnesia prior to surgery

Contraindication: Hypersensitivity to benzodiazepines;psychoses,

acute marrow-angle glaucoma, shock, coma, acute alcoholic

intoxication, pregnancy (cleft lip or palate, inguinal hernia, cardiac

defects, microencephaly, pyloric stenosis have been reported when

used in the first trimester; neonatal withdrawal syndrome reported in

infants); neonates

Side Effects: Drowsiness, dizziness, GI upset, difficulty concentrating,

fatigue, nervousness, crying, dreams, hiccups, diaphoresis,

incontinence, nausea, vomiting, diarrhea, constipation, dry mouth,

salivation, headache, light-headedness

Adverse Effects: Lethargy, apathy, disorientation, delirium, stupor,

dysarthria, dystonia, tremor, rigidity, vertigo, euphoria, vivid dreams,

psychomotor retardartion, extrapyramidal symptoms, nystagmus,

bradycardia, tachycardia, urticaria, gastric disorder, jaundice, hepatic

dysfunction, paresthesias, gynecomastia, bronchospam, laryngospam,

drug dependence, respiratory depression, respiratory arrest

Drug – Drug Interaction:

Increased CNS depression with alcohol, opioids, barbiturates,

other sedatives and anaesthetics.

Increased respiratory depression with opiates, phenobarbital,

other benzodiazepines.

Plasma concentrations increased by CYP3A4 inhibitors such as

cimetidine, erythromycin, clarithromycin, diltiazem, verapamil,

ketoconazole and itraconazole, antiretroviral agents, quinupristin

with dalfopristin.

Midazolam concentration decreased by phenytoin,

carbamazepine, phenobarbital, rifampicin.

Halothane, thiopental requirements may be reduced during

concurrent use.




3. Monitor level of consciousness before, during and for at least

2 – 6hours after administration.

4. Carefully monitor VS during administration.

5. Keep patient on bed for 3hours, not to permit ambulation

upon administration.

6. Teach him that the drug helps him to relax and will make him

sleep, and the drug is a potent amnesiac and he will not

remember what has happened on him.

7. Instruct him to take the drug exactly as prescribed.

8. Instruct him to avoid alcohol, or sleep – inducing, or OTC

drugs before receiving the drug.

9. Tell patient that he may experience side effects brought upon

by the drug.

http://www.mims.com/Page.aspx?menuid=alertr&Druglist=midazolam+**halothane**

http://www.mims.com/Page.aspx?menuid=alertr&Druglist=midazolam+**rifampicin**

http://www.mims.com/Page.aspx?menuid=alertr&Druglist=midazolam+**carbamazepine**

http://www.mims.com/Page.aspx?menuid=alertr&Druglist=midazolam+**phenytoin**

http://www.mims.com/Page.aspx?menuid=alertr&Druglist=midazolam+**dalfopristin**

http://www.mims.com/Page.aspx?menuid=alertr&Druglist=midazolam+**quinupristin**

http://www.mims.com/Page.aspx?menuid=alertr&Druglist=midazolam+**itraconazole**

http://www.mims.com/Page.aspx?menuid=alertr&Druglist=midazolam+**ketoconazole**

http://www.mims.com/Page.aspx?menuid=alertr&Druglist=midazolam+**verapamil**

http://www.mims.com/Page.aspx?menuid=alertr&Druglist=midazolam+**diltiazem**

http://www.mims.com/Page.aspx?menuid=alertr&Druglist=midazolam+**clarithromycin**

http://www.mims.com/Page.aspx?menuid=alertr&Druglist=midazolam+**erythromycin**

http://www.mims.com/Page.aspx?menuid=alertr&Druglist=midazolam+**cimetidine**

http://www.mims.com/Page.aspx?menuid=alertr&Druglist=midazolam+**phenobarbital**

http://www.mims.com/Page.aspx?menuid=alertr&Druglist=midazolam+**alcohol**

10.Instruct patient to report adverse effects that he may

experience.

Generic Name: Cefoperazone Na 1 g, Sulbactam Na 0.5 g

Brand Name: Sulperazone® [vial]

Classification: Cephalosporin, antibiotic

Mode of Action: Inhibits bacterial cell wall synthesis causing cellular

death

Dosage: Sulperazone 1.5g q8 IVTT

Indication: Treatment of respiratory infection caused by S. pneumoniae,

H. parainfluenzae, S. aureus, E. coli, Klebsiella, H. influenzae, S.

pyrogenes; Perioperative prophylaxis; Post operative prophylaxis

Contraindication: Hypersensitivity to cephalosporin or penicillin, or

renal failure

Side Effects: diarrhea, nausea, vomiting, headache, dizziness,

hypotension, abdominal pain, pain at injectionsite, inflammation at IV

site, rash

Adverse Effects: paresthesia, seizure, liver toxicity, nephrotoxicity,

bone marrow depression, leukopenia, anaphylaxis, hematuria,

vasculitis, shock


Increased nephrotoxicity with aminoglycosides

Increased bleeding effects with anticoagulant

Disulfiram-like reaction may occur if alcohol is taken 72hrs

after drug administration




3. Inject slowly over 3-5 minutes.

4. Have vitamin K injection readily available in case of

hypoprothrombinemia.

5. Tell patient that he may experience side effects that are

brought about by the drug.


can be done.


8. Oral care if patient vomits.

9. Minimize stimuli (adjust temperature, lighting and avoid

noise) if headache occurs and if intolerable pain medication

may be given as ordered.

10.Instruct patient to avoid alcohol because severe reactions

could occur.

11.Tell patient to report any adverse effects that he may

experience.

Generic Name: Cefoxitin Sodium

Brand Name: Monowell

Classification: Antibiotic; Cephalosporin (second generation)

Mode of Action: Bactericidal: inhibits synthesis of bacterial cell wall,

causing cell death.

Dosage: Cefoxitin 1 amp IVTT ANST now prior to OR

Indication: Surgical prophylaxis

Contraindication: Hypersensitivity to cephalosporins or penicillins.

Side Effects: Nausea, vomiting, diarrhea, flatulence, anorexia,

headache, phlebitis, rash, fever, pain on injection site, dizziness,

stomach upset

Adverse Effects: Lethargy, pseudomembranous colitis, paresthesias,

liver toxicity, nephrotoxicity, convulsion, leukopenia, decreased

hematocrit, decreased platelet, anaphylaxis, superinfection,

Drug –Drug Interaction:

Enhanced nephrotoxicity with aminoglycosides and loop diuretics

e.g. furosemide.

Renal excretion inhibited by probenecid.

Increase bleeding with oral anticoagulants.

Disulfiram-like reaction may occur if alcohol is taken within

72hours after drug administration.




3. Have vitamin K readily available in case of

hypoprothrombinemia occurs.

4. Instruct patient to avoid alcohol for 3days after drug

administration because serious reactions often occur.


upon by the drug.


can be done.


8. Oral care if patient vomits.

9. Instruct him to report any adverse effects that he may

experience.

Generic Name: Metoclopramide

Brand Name: Octamide PFS, Reglan

Classification: GI stimulant, antiemetic, dopaminergic blocker

Mode of Action: Stimulates the muscles of the gastrointestinal tract

including the muscles of the lower esophageal sphincter, stomach, and

small intestine by interacting with receptors for acetylcholine and

dopamine on gastrointestinal muscles and nerves; decreases the reflux

of stomach acid by strengthening the muscle of the lower esophageal

sphincter; stimulates the muscles of the stomach and thereby hastens

emptying of solid and liquid meals from the stomach and into the

intestines; interacts with the dopamine receptors in the brain and can

be effective in treating nausea.

Dosage: Metoclopramide 1amp IVTT @ 6am

Indication: Stimulation of gastric emptying prior to surgery

Contraindication: Hypersensitivity to metoclopramide, GI hemorrhage,

mechanical obstruction or perforation; pheochromocytoma (may cause

hypertensive crisis); epilepsy

Side Effects: drowsiness, restlessness, fatigue, anxiety, insomnia,

depression, sedation, nausea, diarrhea, urinary frequency

Adverse Effects: parkinsonm-like reactions, involuntary muscle

movements, facial grimacing, dystonic reactions resembling tetanus,

transient hypertension, tardive dyskinesia, myoclonus





Drug – Drug Interaction

Decreased absorption of Cefprozil, cimetidine, digoxin from the

stomach

Increased oral bioavailability or absorption of acetaminophen,

cyclosporine, ethanol, levodopa, tetracycline

Decreased effect on gastric emptying with anticholinergic, opioid

analgesics, levodopa

Increased risk of serious adverse effects due to excess release of

neurotransmitters with MAOIs for example, isocarboxazid

(Marplan), phenelzine (Nardil), tranylcypromine (Parnate),

selegiline (Eldepryl), and procarbazine (Matulane)




3. Give direct IV dose slowly (over 1 to 2 minutes).

4. Monitor BP carefully during IV administration.

5. Monitor for extrapyramidal reactions, and consult physician if

they occur.

6. Keep diphenhydramine injection readily available incase of

extrapyramidal reactions.

7. Have phentolamine readily available in case of hypertensive

crisis (most likely to occur with undiagnosed

pheochromocytoma).


by the drug.

9. Instruct patient to report involuntary movement of the face,

eyes or limbs, severe depression, severe diarrhea.

10.Provide a safe environment if restlessness, involuntary muscle

movement occur.



Generic Name: Ranitidine

Brand Name: Zantac

Classification: Histamine 2 antagonist

Mode of Action: Competitively inhibits the action of histamine at the H2

receptors of the parietal cells f the stomach, inhibiting basal gastric

acid secretion and gastric acid secretion that is stimulated by food,

insulin, histamine, cholinergic agonist, gastrin, and pentagastrin.

Dosage: Ranitidine 50mg q8 IVTT

Indication: Post surgery antacid to prevent ulcer formation

Contraindication: Hypersensitivity to ranitidine, lactation.

Side Effects: headache, rash, dizziness, vertigo, constipation, diarrhea,

nausea, vomiting, abdominal discomforts, local burning or itching at IV

site

Adverse Effects: malaise, insomnia, somnolence, urticaria, tachycardia,

bradycardia, leukopenia, pancytopenia, thrombocytopenia,

gynecomastia, impotence, hepatitis

Drug – Drug Interaction: Increased effects of warfarin, tricyclic

antidepressants




3. Tell patient that he may experience side effects brought about

by the drug.

4. Instruct patient to take his meal if nausea or vomiting occurs.

5. Oral care if vomiting occurs.

6. Adjust lighting and temperature and avoid noise if he

experiences headache and instruct him to report if it is

intolerable so that medication may be given.

7. Instruct him to report intolerable side effects so as prompt

intervention could be done.

8. Instruct him to report adverse effects that he may experience.

Generic Name: Tramadol HCl

Brand Name: Ultram

Classification: Analgesic, centrally acting

Mode of Action: Binds to mu-opioid receptors and inhibits the reuptake

of norepinephrine and serotonin; causes many effects similar to opioids

– dizziness, somnolence, nausea, constipation – but does not have the

respiratory effects.

Dosage: Tramadol 50mg q 6° IVTT

Indication: Relief of moderate to moderately severe pain; post surgery

analgesia

Contraindication: Hypersensitivity to tramadol or opioids or acute

intoxication with alcohol, opioids, or psychoactive drugs

Side Effects: Nausea, constipation, dizziness, headache, drowsiness,

vomiting, somnolence, sedation, headache, dry mouth, sweating,

diarrhea, rash, visual disturbances, vertigo

Adverse Effects: Confusion, anxiety, seizure, tachycardia, bradycardia,

pallor, anaphylactoid reactions


Carbamazepine reduces the effect of tramadol by increasing its

inactivation in the body.









Quinidine (Quinaglute, Quinidex) reduces the inactivation of

tramadol, thereby increasing the concentration of tramadol by

50%-60%.

Combining tramadol with monoamine oxidase inhibitors (for

example, Parnate) or selective serotonin inhibitors [(SSRIs, for

example, fluoxetine (Prozac)] may result in severe side effects

such as seizures or a condition called serotonin syndrome.

Tramadol may increase central nervous system and respiratory

depression when combined with alcohol, anesthetics, narcotics,

tranquilizers or sedative hypnotics.


1. Assess for contraindications.



by the drug.

4. Instruct him to report side effects that are intolerable.

5. Control environment (temperature, lighting) if sweating or

CNS effects occur.

6. Encouraged small frequent meals if vomiting occurs.

7. Oral care for dry mouth and vomiting.

8. Encourage him to increase oral fluid intake.

9. Instruct patient to report adverse effects that he may

experience.





Generic Name: Ketorolac tromethamine

Brand Name: Toradol

Classification: NSAID, Nonopioid analgesic

Mode of Action: Reduces the production of prostaglandins, chemicals

that cells of the immune system make that cause the redness, fever,

and pain of inflammation and that also are believed to be important in

the production of non-inflammatory pain. It blocks the enzymes that

cells use to make prostaglandins (cyclooxygenase 1 and 2). As a result,

pain as well as inflammation and its signs and symptoms - redness,

swelling, fever, and pain - are reduced.

Dosage: Ketorolac 30mg q8 IVTT

Indication: For short-term management (up to 5 days) of moderately

severe acute pain that otherwise would require narcotics. It most often

is used after surgery.

Contraindication: Hypersensitivity to ketorolac, renal Impariment,

aspirin allergy

Side Effects: rash, ringing in the ears, headaches, dizziness,

drowsiness, abdominal pain, nausea, diarrhea, constipation, heartburn,

fluid retention, somnolence, insomnia, dyspepsia, dry mucous

membrane, sweating, peripheral edema, GI pain

Adverse Effects: gastric or duodenal ulcer, renal impairment, liver

failure, dysuria, bleeding, platelet inhibition, neutropenia, leukopenia,

pancytopenia, thrombocytopenia, bone marrow depression












Increased levels of ketorolac in the body and increased

side effects with Probenecid (Benemid).

Increase risk of lithium toxicity with lithium (Eskalith)

Reduced kidney function with concominatnt use with

angiotensin converting enzyme (ACE) inhibitors.

Increase risk of bleeding with anticoagulants (warfarin),

aspirin

Increased risk of nephrotoxicity with other nephrotoxins

(aminoglycosides, cyclosporine)




3. Infuse slowly as a bolus over no less than 15 seconds.

4. Administer with ranitidine to avoid ulceration.


by the drug.

6. Encouraged oral fluid intake to avoid dry mucous membrane.

7. Provide comfort measures if headache occurs.

8. Instruct to report intolerable side effects for prompt

intervention.

9. Instruct to report signs of bleeding such as black tarry stool,

weakness and dizziness upon standing.

10.Instruct to report if he experiences adverse effects.




Generic Name: Bupivacaine

Brand Name: Bupican

Classification: Anesthesia

Mode of Action: Block the generation and the conduction of nerve

impulses, presumably by increasing the threshold for electrical

excitation in the nerve, by slowing the propagation of the nerve

impulse, and by reducing the rate of rise of the action potential. The

analgesic effects of Bupivacaine are thought to be due to its binding to

the prostaglandin E2 receptors, subtype EP1 (PGE2EP1), which inhibits

the production of prostaglandins, thereby reducing fever,

inflammation, and hyperalgesia

Dosage: Bupivacaine 0.25% 10cc + 0.25MSO4 OD

Indication: Local or regional anesthesia; analgesia for surgery

Contraindication: Hypersensitivity to bupivacaine or other local

anesthesia e.g. lignocaine, blood clotting disorder, low blood pressure,

Side Effects: nervousness, tingling around the mouth, tinnitus, tremor,

dizziness, blurred vision, ringing of the ears, feeling of disorientation,

nausea, vomiting, drowsiness, numbness of tongue, lightheadedness

Adverse Effect: convulsion, seizures, unconsciousness, arrhythmias,

tachycardia, bradycardia, cardiac arrest, hypotensive shock,

respiratory arrest, myocardial depression,

http://www.answers.com/topic/seizure

http://www.answers.com/topic/tinnitus

Drug – Drug Interaction: Additive effects when used with

antiarrhythmic drugs




3. Monitor vital signs carefully, drug depresses the pulmonary

and cardiac system.

4. Monitor for side effects.

5. Tell patient that he may experience side effects brought about

by the drug and if such is/are intolerable he must report them

so as prompt interventions be done.

6. Oral care if vomiting occurs.

7. Monitor for occurrence of adverse effects, report to the

anesthesiologist any signs and symptoms of adverse effects.

8. Continue to monitor patient following discontinuation of

anesthesia.

Generic Name: Magnesium Sulfate

Brand Name:

Classification: Electrolyte, Antiepilecptic, Antihypertensive, Laxative

Mode of Action: An important cofactor for enzymatic reactions and

plays an important role in neurochemical transmission and muscular

excitability; prevents or controls convulsions by blocking

neuromuscular transmission and decreasing the amount of

acetylcholine liberated at the end plate by the motor nerve impulse;

attracts and retains water in the intestinal lumen and distends the

bowel to promote mass movement and relieve constipation; acts

peripherally to produce vasodilation; larger doses cause lowering of

blood pressure.

Dosage: Bupivacaine 0.25% 10cc + 0.25MSO4 OD

Indication: Parenteral anticonvulsant for the prevention and control of

seizures, lowers BP while in surgery

Contraindication: Hypersensitivity to magnesium sulfate, heart block,

myocardial damage; abdominal pain, appendicitis, fecal impactation,

hepatitis, intestinal and biliary tract obstruction

Side Effects: weakness, dizziness, excessive bowel movement,

sweating, flushing, headache, nausea, vomiting, palpitations

Adverse Effects: fainting, magnesium intoxication, hypotension,

depressed reflexes, flaccid, paralysis, hypothermia, circulatory

collapse, cardiac and CNS depression, hypocalcemia, tetany


Potentiation of neurotransmuscular blockade produced by

nondepolarizing neuromuscular relaxants (tubocurarine,

atracurium, pancuronium, vecuronium)

CNS depression and peripheral transmission defects produced by

magnesium is antagonized by calcium.

Reduces antibiotic activity of streptomycin, tetracycline and

tobramycin when given together.




3. Do not administer unless solution is clear and container is

undamaged. Discard unused portion.

4. Monitor knee-jer reflex before repeated parenteral

administration. If it is suppressed, do not administer the drug

for it may cause respiratory center failure.

5. Administer with caution if flushing and sweating occurs.

6. Have calcium gluconate readily available if signs and

symptoms of hypermagnesemia occur.


about by the drug and instruct him to report intolerable side

effects so as prompt intervention be done.

8. Oral care when vomiting occurs.

9. Volume for volume replacement when excessive bowel

movement and vomiting occurs to replace the loss fluid.

10.Instruct patient to report adverse effects immediately.

Procedural Reporton Open Cholecystectomy

Surgeon: Dr. Batucan, Wolter

Operation: Open Cholecystectomy

Anesthesiologists: Dr. Togon

Date of Surgery: 04/30/09 at 7:00 am

Definition

Cholecystectomy is the excision (removal) of the gallbladder.

Discussion

Cholecystectomy may be performed to treat chronic or acute

cholecystitis, with or without cholelithiasis, or to resect a malignancy.

Note:

Cholecystectomy, performed laparoscopically, is the preferred

treatment for symptomatic gallstones unless the patient is extremely

obese, there are excessive adhesions, or ductal or vascular anomalies

exist. If unexpected pathology is encountered, if acute inflammation

distorts normal tissue planes, or if there is excessive bleeding or

surgical injury, the laparoscopic procedure is promptly converted to

“open” cholecystectomy.

Type of Anesthesia

• General anesthesia

• Thoracic epidural anesthesia (as an alternative)

Preparation of the Patient

Antiembolitic hose may be put on the legs,

as requested. The patient is supine; both arms

may be extended on padded armboards. A pillow

may be placed under the sacrum and/ or under the

knees to avoid straining back muscles. Pad all

bony prominences and areas vulnerable to skin

and neurovascular pressure of trauma. A

nasogastric tube may be inserted by the anesthesia provider. A foley

catheter is not routinely placed. An electrosurgical dispersive pad is

applied.

Skin Preparation

Begin at the intended site of incision, either right subcostal (most

frequently used), right paramedian, or medline, extending from the

axilla to the pubic symphysis and down to the table on the sides.

Procedure

The incision is right subcostal, right paramedian, or midline. The

abdominal cavity is entered in the usual manner. The gallbladder is

grasped (generally with a Pean clamp). The cystic duct, cystic artery,

and common bile duct are exposed. The surgeon must be aware of

anomalies of these structures. The cystic artery is clamped (using two

right-angle clamps) and ligated with a suture passed on a long

instrument or by clips (e.g., Hemoclips), as is the cystic duct. The

gallbladder is mobilized by incising the overlying peritoneum and after

local dissection is removed. The underlying liver bed may be

reperitonealized. A drain (e.g., Jackson-Pratt ™) may be employed

exiting a stab wound and secured to the skin with a stitch. The wound

is closed in layers. The skin is closed with interrupted stitches, tapes,

or skin staples.

Instruments, Machines and Supplies

Draping

• 4 folded towels and a laparotomy sheet

Equipment

• Folded blanket or pad (for positioning)

• Sequential compression device with disposable leg wraps, if

ordered

• Suction

• Ultrasound generator, if requested

• Laser (e.g., Nd: YAG laser fiber or pulsed dye) when requested

Instrumentation

• Major procedures tray

• Long Metzenbaum scissors

• Hemoclip or other ligating clip appliers

• Biliary tract tray (for common duct exploration)

• Choledochoscope when requested; if unavailable, a uteroscope

or small cystoscope may be substituted

Supplies

• Antiembolitic hose

• Basin set

• Blades, (2) #10, (1) #15, or (1) #11

• Suction tubing

• Hemoclips or similar ligating clips

• Electrosurgical pencil and cord with holder and scrape pad

• Needle magnet or counter

• Dissectors (e.g, peanut or Kittner sponges)

• Drains, e.g., Penrose 1” or suction drain (e.g., Jackson-Pratt or

Hemovac™), optional

• Mushroom-tipped (retention) catheters, e.g., Pezzer or Malecot,

available

• Culture tubes, one aerobic and one anaerobic

• Hemostatic agent e.g., Surgicel™, Helistat™, Thrombostat™,

Avitene™, available

Nursing Responsibilities

Preoperative

• All care that is given and observations made regarding the

patient (e.g., condition of skin preoperatively) must be

documented in the operative record for continuity of care and for

medicolegal reasons.

• The nurse conveys to the patient that he will act as the patient’s

advocate by speaking for him while the patient is in surgery.

• Assess health factors that affects the patient preoperatively:

nutritional status, drug or alcohol use, cardiovascular status,

hepatic and renal function, endocrine function, immune function,

previous medication use, psychosocial factors, as well as the

spiritual and cultural beliefs.

• When the circulator reviews patient allergies with the patient, he

ascertains that the patient has no history of allergy to

radiopaque dye.

• Inform the patient of the scheduled date and time of the surgery

and where to report

• Instruct what to bring (insurance card, list of meds & allergies)

• Check the chart for patient’s sensitivities and allergies e.g.

allergy to iodine. Document allergies noted preprocedure and

document alternative used.

• Instruct what to leave at home such as jewelry, watch,

medications and contact lenses

• Instruct what to wear ( loose fitting, comfortable clothes and flat

shoes)

• Remind the patient not to eat or drink if directed

• The patient may have fear and anxiety regarding the surgical

procedure and the unfamiliar environment. Explain nursing

procedures before performing them and the sequence of

perioperative events.

• Assess and document patient’s anxiety level and level of

knowledge regarding the intended procedure. Clarify

misconceptions by answering the patient’s questions in a

knowledgeable manner and refer questions to the surgeon as

necessary.

• Decrease fear

• Teach deep-breathing, coughing or incentive spirometer

• Provide emotional support to the patient regarding feelings of

altered body image by providing the patient an opportunity to

express her feelings.

• Respect cultural, spiritual and religious beliefs

Intraoperative

• It is imperative that the patient be positioned over the correct

area on the table to ensure accurate visualization of the biliary

tract.

• A protective facial shield is suggested for those scrubbed to

avoid inadvertent splashing of contaminated fluids onto mucous

membranes and eyes.

• All medications, dyes, etc., on the opening field must be labeled.

Scrub person should use a marking pen on labels to identify all

solutions. All medication containers should be kept in the room

until the completion of the procedure.

• Instruments used on the gallbladder are isolated in a basin

(considered contaminated)

• Prevent musculoskeletal injuries to team members by employing

ergodynamic measures when positioning the patient.

• Take appropriate measures to maintain patient’s body

temperature e.g., offer warm blanket or raise room temperature

as necessary.

• Keep the patient adequately covered to maintain patient’s

privacy, expose only the immediate area involved for the

procedure.

• Strictly follow the principles of surgical asepsis

• Keep surgical conscience

• Count all instruments and sharps with circulating nurse before

and after the procedure

• Know the name and use of the instrument

• Never pile the instruments on top of each other

• Know the name and use of the instrument and handle the

instrument individually

• Hand the surgeon the correct instrument

• Pass the instrument firmly and decisively

• Be careful in handling of sharp instruments at all times

• The scrub person sets up the instruments on the back table for

the surgeon.

• Scrub person needs to have a right angle clamp (Mixter)

available throughout the dissection of the biliary tree.

• Usually a stab wound is made in the cystic duct using a #11

blade. The incision is extended with Pott’s scissors.

• Have T-tubes available following common duct exploration

• One syringe is filled with saline, and a second syringe is filled

with radiopaque dye diluted to half strength (labeled accordingly)

• Scrub person takes care to make certain that the saline or dye

catheters are devoid of air bubbles (which can be confused for

calculi)

• Use a small basin to accept the specimen

• Aerobic and anaerobic cultures may be taken of the bile or

gallbladder bed.

Postoperative

• The circulator accompanies the anesthesia provider and the

patient to the PACU; he/she gives the PACU perioperative

practioner a detailed intraoperative patient report regarding the

course of events as they apply to the individual.

• Assess the patient: appraise air exchanges status & note skin

color; verify & identify operative status & surgeon performed;

assess neurological status (LOC)

• PACU nurse observes the patient’s breathing, monitors blood

pressure and vital signs, and documents all pertinent

information.

• PACU nurse assumes the role as the patient’s advocate..

• Report for abnormalities especially for signs and symptoms of

shock

• Perform safety checks – good body alignment, side rails and

maintain patent airway and cardiovascular stability

• Relieve pain and anxiety

Reference

pp. 148-153, Maxine A. Goldman 2008, Pocket Guide to the Operating

Room. 3rd edition

F.A. Davis Company.Philadelphia

Nursing Theories

Ma. Estine Levine’s Conservation Model

Levine’s conservation model provides a thoughtful basis for making effective wound management choices in order to improve wound healing and consequently ameliorate individual well being and quality of life. The relationship between effective wound management and positive patient outcomes draws on Levine’s four conservation principles, about which she states:

The conservation principles address the integrity of the individual…from birth to death. Every activity requires an energy supply because nothing works without it. Every activity must respect the structural wholeness of the individual because well-being depends on it. Every activity is chosen out of the abilities, life experience, and desires of the “self”’ who makes the choices. Every activity is a product of the dynamic social systems to which the individual belongs.

The patient last April 30, 2009 was on status post cholecystectomy. Cholecystectomy was done to remove the gallbladder. Incision was made. To have an effective wound healing and prevent complications, vital signs was monitored. Patient was encouraged to take a rest. To regain structure and function, the body needs to restore structural integrity through repair and healing. It is very important to take note of the discharges, its quantity and characteristic. Aseptic technique in wound dressing was applied to prevent possibility of infection. In addition, to promote healing, antibiotics was also given.

Jean Watson

Dr Watson believes that a new paradigm is emerging in health care. She states that conventional medicine has become increasingly technological, typically centering on treatment to cure disease with medications and surgery. In contrast, the caring approach of nursing focuses on conscious compassionate skills that help patients achieve a healthy state of mind, body, and spirit. Dr Watson relates that caring is intrinsic to the therapeutic interpersonal relationship between the nurse and patient. Ten primary carative factors form the structure of Dr Watson's caring theory

Psychological caring-healing therapies strive to instill hope or faith. To meet the psychological or spiritual needs of patients, nurses traditionally incorporate humanistic, altruistic values by using the power of prayer, spiritual beliefs, or suggestions or through a trusting therapeutic nurse-patient relationship. The nurse's relationship and

interpersonal teaching enables the patient to provide self-care, determine personal needs, and provide opportunities for personal growth. Therapeutic communication is implemented through nonverbal behavior and listening, facilitating nonpossessive warmth, initiating self-understanding, and communicating with personalized responses to develop a helping, trusting relationship

After developing a therapeutic trusting relationship, the nurse can help the patient relax before surgery with the caring-healing therapies of holistic nursing. Being available to the patient, listening to his concerns, and providing silence was practiced to relieve patient’s anxiety. Medications were also given such as anxiolytic medicines to decrease anxiety.

Faye Abdellah

According to her, nursing is based on an art and science that

mould the attitudes, intellectual competencies, and technical skills of

the individual nurse into the desire and ability to help people , sick or

well, cope with their health needs.

To view Abdellah’s 21 nursing problems according to Maslow’s hierarchy of needs, in the physiologic needs, the nurse must facilitate the maintenance of a supply of oxygen to all body cells, nutrition of all body cells, fluid and electrolyte balance, elimination, maintain good body mechanics and prevent and correct deformities, good hygiene and physical comfort, promote optimal activity: exercise , rest and sleep and to facilitate the maintenance of regulatory mechanisms and functions.

Patient’s needs was attended such as proper positioning, cough and deep breathing exercises to prevent post operative complications. Patient was on NPO, but it is very important to increase fluid intake and eat high caloric foods to prevent dehydration and weakness due to increased metabolic demands of the body. It is very important to take into consideration the diet after NPO because the body is on the process of repairing.

Nursing Care Plan

Date/Time

Cues Need Nursing Diagnosis

Objectives of Care

Nursing Interventions Evaluation

April 27, 2009

3-11pm

S: “ Sakit jud akoa tiyan karun (pointing at the right upper quadrant of the abdomen), mura man ug gimakumot na dili nako masabtan.”, as verbalized by the patient.

O: Grimaced faceWith guarding behaviorRestlessnessRigidity of the abdomenRR= 32cpmSplinted respiration with short and

COGNITIVE

-

PERCEPTUAL

PATTE

Acute Pain related to inflammation and distortion of tissues

® If gallstone obstruct the cystic duct, the gallbladder becomes distended, inflamed and eventually infected. Inflammation and swelling depresses the free nerve endings and cause the pain. The patient may have biliary colic with excruciating upper right abdominal pain

Within my 8 hr care, the client will be able to:

1. Report pain is controlled if not relieved.

2. Demonstrate the use of relaxation skills and diversional activities as indicated for individual situation

1. Observe and document location, severity and character of pain.® Assists in differentiating cause of pain and provides information about disease progression/ resolution, development of complications and effectiveness of interventions.

2. Administer anticholinergics as indicated.® Anticholinergics relieves reflex spasm or smooth muscle contraction and assist in pain management.

3. Administer smooth muscle relaxants, nitroglycerin as ordered.®Relieves ductal spasm.

4. Administer Chenodeoxycholic acid.® Chenodeoxycholic acid is

Goal met.

Although pain was not totally relieved, the patient verbalized, “ Na ok ok raman ko karun, medyo sakit pero dili na pareha ganina.” The patient had identified relaxing techniques such as deep breathing exercises and freeing the mind from worry which is helpful in minimizing pain.

shallow breathing

RN

that radiates to the back or right shoulder.

Source:Porth CM. (2002). Pathophysiology: Concepts of Altered Health States. Philippines: Lippincott Williams & Wilkins.

a natural bile acid that decreases cholesterol synthesis reducing size of gallstones.

5. Antibiotics® To treat infectious process reducing inflammation.

6. Hyperlipidemic agents.® Reduces itching or pruritus from bile salts in skin

7. Note response to medication and report if pain is not being relieved.® Severe pain not relieved by routine measures may indicate developing complications/ need for further intervention

8. Promote bedrest, allowing patient to assume position of comfort.® Bedrest in Fowler’s position reduces intraabdominal pressures; however, patient will naturally assume least

painful position.

9. Use soft, cotton lines, calamine lotion, cool or moist compress as indicated,® Reduces irritation/ dryness of skin and itching sensation.

10. Control environmental temperature, maintain a cool room temperature.®Cool surroundings aid in minimizing dermal discomfort.

11. Encourage use of relaxation techniques such as deep breathing exercises. Provide diversional activities such as watching television.®Promotes rest, redirects attention, may enhance coping.

12. Make time to listen to complaints and maintain frequent contact with the patient.®Helpful in alleviating

anxiety and refocusing attention, which can relieve pain.

Date/Time


Objectives of Care


April 28, 2009

3-11pm

S: “Wala ko kasabot sa ako gibati, mura ko ug nahadlok karun sa ako operasyon ug unsa ang mahitabo sa akua panhuman ato.”

O: RestlessnessReports of uncertainty and being scared

SELF-PERCEPTION SELF-CONCEPT PATTERN

Anxiety related to gallbladder removal surgery

® Anticipated surgery can be a source of many threats. These threats can produce vague feelings ranging from mild uneasiness to panic. Identifying a threat as merely surgery is too simplistic, personal threats are also involved. Moreover, although some uneasiness may be attributed to fear, the remaining feelings relate to anxiety.

Source:Carpenito-Moyet. Nursing Diagnosis Application to Clinical Practice, 11th

Ed. Lippincott Williams and Wilkins, 2005

Within my 4 hour care, the client will be able to:

1.Verbalize awareness of feelings of anxiety and health ways to deal with them.

2. Report anxiety is reduced to a manageable level.

1. Be available to the patient. Maintain frequent contacts with the patient/SO. Be available for listening and talking as needed.® Establishes rapport, promotes expression of feelings.Demonstrates concern and willingness to help. Helpful in discussing sensitive subjects.

2. Identify patient’s perception of the threat represented by the situation.®Helps recognition of extent of anxiety and identification of measures that may be helpful for the individual.

3. Encourage patient to acknowledge reality of stress without denial or reassurance that everything will be alright. Provide information about measures being taken to correct or alleviate condition.®Helps patient to accept what is happening and reduce level of anxiety. False reassurance is not helpful, because neither nurse nor patient knows the final outcome. Information can provide reassurance/ help reduce

Goal met.

Patient was able to identify ways reducing anxiety such as use of deep breathing exercises, and anxiety was reduced to a manageable level, “ Kung sige ko ug istorya sa ako ginabati ug sa ako kaguol kay mabwasan ang ako kaguol. Magwapo ako ginhawa kung muhinga ko ug lalom.”

Date/Time


Objectives of Care


April 28,2009

3-11pm

S: Report of pain

O: Limited range of motionSlowed movementDecreased posturing change speed

ACTIVITY-EXERCISE

PATTERN

Impaired physical mobility related to pain at incision site.

® Pain impairs mobility and activity. Full function may be affected and be delayed.

Source:

Monks. Home health nursing: assessment and care planning. Elsevier Health Sciences, 2002

Within my 8 hour care, the client will be able to:

1.Verbalize willingness to and demonstrate participation in activities

2. Maintains optimal position of function as evidenced by the absence of contractures and decubitus ulcers.

1. Administer medication prior to activity as needed for pain relief.®To permit maximal effort or involvement in activity.

2. Change position frequently when on bedrest; support affected body parts or joints with pillows.®Decreases discomfort, maintains muscle strength/ joint mobility, enhances circulation and prevents skin breakdown.

3. Provide skin massage. Keep skin clean and dry well. Keep linens dry and wrinkle-free.®Stimulates circulation and prevents skin irritation.

4. Encourage deep breathing and coughing. Elevate head of bed Turn side to side.®Mobilizes secretions,

Goal partially met.

Patient refused to perform range of motion exercises for a fear of experiencing pain after the activity. On the other hand, there were no contractures and complications observed after an 8 hour care with the client.

improves lung expansion and reduces risk of respiratory complications.

5. Assist with active and passive range of motion exercises. ®Maintains joint flexibility, prevents contractures and aids in reducing muscle tension.

6. Provide safe environment such as giving assistance in sitting and transferring from bed to chair or chair to bed and use of wheelchair if possible.®Avoids accidental injuries and falls.

7. Encourage early ambulation. Support abdomen when ambulating.®Early ambulation prevents postop complications. Splinting provides incisional support/ decreases muscle tension to promote cooperation

with therapeutic regimen.Provide adequate rest periods in between activities.®To prevent fatigue.

8. Provide diversion such as talking with the patient or watch television.®Decreases boredom, promotes relaxation.

Date/Time


Objectives of Care


April 30, 2009

S/O:Incision at right upper quadrantwith Jackson Pratt drainwith slightly soaked, intact dressing at right upper quadrant of the abdomen,status post open cholecystectomy

NUTRITIONAL-METABOLIC PATTERN

Impaired tissue integrity related to surgical incision

® In gallbladder removal surgery, a surgeon makes a large incision (cut) in your belly to open it up and see the area. The surgeon then removes your gallbladder by reaching in through the incision and gently lifting it out.The surgeon will make a 5 to 7 inch incision in the upper right part of your

Within an 8 hour care, the client will be able to:

1. Be free of complications such as heavy bleeding at the incision site.

2. Demonstrate behaviors to prevent skin breakdown

1. Check the incisional drain, make sure that they are free flowing.® Incision site drains are used to remove any accumulated fluid and bile. Correct positioning prevents back up of the bile in the operative area.

2. Observe color and character of the drainage.®Initially, may contain blood and blood-stained fluid, normally changing to greenish brown (bile color) after the first several hours.

3. Place patient in low or semi-fowler’s position. ®Facilitates drainage of bile.

4. Change dressings as often as necessary. Clean the skin with soap and water. Use sterile Vaseline gauze, zinc oxide or karaya powder around the incision.

Goal met.

Within the span of care, hemorrhage was not observed and patient was able to demonstrate behaviors to prevent skin breakdown through participation in the change of dressing and change of positions.

belly, just below your ribs. The surgeon will cut the bile duct and blood vessels that lead to the gallbladder. Then your gallbladder will be removed.

Source:


®Keeps the skin around the incision clean and provides a barrier to protect skin from excoriation.

5. Observe skin, sclerae, urine for change in color.®Developing jaundice may indicate obstruction of the bile flow.

6. Note color and consistency of stools.®Clay colored stools result when bile is not present in the intestines.

7. Investigate increased or consistent RUQ pain; development of fever, tachycardia; leakage of bile drainage from wound.®Signs of suggestive of abscess or fistula formation requiring medical intervention.

8. Administer antibiotics.®Necessary for treatment or prohylaxis for abscess or infection.

9. Monitor laboratory studies such as WBC® Leukocytosis reflects inflammatory process such as abscess formation or development or peritonitis or pancreatitis.

Date/Time


Objectives of Care


April 30, 2009

3-11pm

S/O: Surgical incision at right upper quadrant

HEALTH PERCEPTION-HEALTH MANA

Risk for infection related to presence of surgical incision

®The skin is the first line of defense against infection. Any break in its continuity may allow microorganisms to enter the body which in turn can cause the infection, and since the patient had undergone cholecystectomy, there is a break of continuity of the skin, which may contribute to the development of

Within an 8 hr care, the client will be able to:

1. Be free of purulent drainage or erythema; be afebrile

1. Monitor vital signs. Note onset of fever, chills, diaphoresis, changes in mentation, and complaints of increasing abdominal pain.®Suggestive of presence of infection/ developing sepsis, abscess or peritonitis.

2. Practice good hand washing and aseptic wound care.®Reduce risk of spread of bacteria.

3. Inspect incision and dressings. Note characteristics of drainage from wound.®Provides early detection of developing infectious process and monitor resolution of pre-existing peritonitis.

4.Administer antibiotics®May be given

Goal met.

Within the span of care, temperature remained normal, patient was not afebrile. No purulent drainage noted.

GEMENT PATTERN

future infections.

Source:

Mattson Porth, Essentials of Pathophysiology Concepts of Altered Health Status, Lippincott Williams and Wilkins, 2007

prophylactically or to reduce number of multiplying microorganisms in the presence of infection to decrease spread and seeding of the abdominal cavity.

5. Use sterile gloves for wound care. Practice aseptic technique.®Prevents invasion of bacteria or microorganisms at site and eventually prevents possible infection.

6. Instructed to maintain clean dry clothes preferably cotton fabric®Skin friction caused by stiff or rough clothes leads to irritation of fragile skin and increases risk for infection.

7. Cleanse incision site with povidone iodine.®Disinfects site and prevents multiplication of microorganisms which may cause infection.

8. Instruct client not to wet incision site.® Microorganisms thrive at damp areas and makes it conducive for replication.

9. Provide a cool environment. Adjust air conditioner as preferred by the client.® Hot room temperature induces sweating which may inhibit the healing of wound and eventually cause moisture at the area delaying the healing process.

Discharge Planning

Medicines:

• Tramadol

• Ketorolac

• Ranitidine

• Sulperazone

Mr. Police should comply with the medications he has been prescribed

with in order to aid in the recovery state after surgery. With regards to his

medications, he must know and understand the general knowledge of the

drugs, their side effects and their adverse effects. If he experiences any

adverse effects, he needs to refer to his physician immediately.

Exercise:

Cholecystectomy actually requires time to recover. Laparoscopic

cholecystectomy usually requires only one night in the hospital. A major

advantage of the procedure is that it patients can return to work in 1 to 2

weeks. But compared to open cholecystectomy, it is advised to have 4 to 6

weeks duration time for recovery. Once home, it is possible to tire more

easily than usual to begin with, so it is important to take it easy. Strenuous

exercise and lifting should be avoided. Light exercise such as walking is

recommended. Normal activities, including returning to work, can usually be

resumed after about a week. Patient must follow his surgeon's advice about

driving. He shouldn't drive until he is confident that he could perform an

emergency stop without discomfort.

Treatment:

Gallbladder disease usually is treated by removing the gallbladder.

Now that the patient had his gallbladder removed, the rest is up to him. It is

important to rest and let the body recover after surgery. Consequently, to

prevent other complications, he must have his lifestyle and diet modified.

Health Teachings:

• Explain to patient what to expect afterwards. As the anaesthetic wears

off, there is likely to be some pain. The anaesthetist will prescribe

painkillers. Suffering from pain can slow down recovery, so it's

important to discuss any pain with the doctors or nurses.

• On discharge, the nurse must advise about caring for the stitches,

hygiene and bathing, and will arrange an outpatient appointment for

the stitches to be removed, if necessary. Some people will have

dissolvable stitches, which do not need to be removed.

• Instruct patient to comply with the home medications that would be

given by his physician. Remind him to complete the full course of the

antibiotic treatment.

• Encourage patient to do the recommended light exercises such as

walking. Avoid doing strenuous activities which could slow down his

recovery.

• Encourage him to comply with the dietary modifications; limit the

intake of saturated fat and avoid the consumption of alcoholic

beverages to prevent the occurrence of serious post-cholecystectomy

side-effects.

• Explain to patient to refer for unusualities immediately.

Out-patient Care:

Remind patients that regular check-ups are important to ensure that

the patient condition is constantly monitored by the doctor. If any of the

following symptoms are noted, he should contact his doctor:any of the

wounds start to bleed

• any of the wounds become more

• painful, red, inflamed or swollen

• the abdomen swells

• pain is not relieved by the prescribed painkillers

• a fever develops.

These could be signs of an infection that may need to be treated with

antibiotics

Diet:

In time, patients who have suffered cholecystectomy are exposed to a

high risk of developing heart disease, diabetes and disorders of the nervous

system. This is due to inappropriate synthesis and assimilation of vital

nutrients, vitamins and minerals. In order to prevent the occurrence of

serious post-cholecystectomy side-effects, operated patients need to make

drastic lifestyle and dietary changes. They should limit the intake of

saturated fat and avoid the consumption of alcoholic beverages. Also, they

should eat smaller amounts of food during a single meal. People who have

had gall bladder removal surgery are advised to eat around 5 or 6 smaller

meals a day instead of 2 or 3 usual meals. Considering the fact that the

organism is unable to completely absorb important nutrients without the

help of the gall bladder, operated patients also need to take vitamin and

mineral supplements and bile salts to aid the process of digestion.

PROGNOSIS

Category Poor Fair Good Rationale

Onset of

illness

/ A month prior to admission, Mr. Police

experienced right upper quadrant

pain associated with a sense of

bloatedness, without nausea and

vomiting. The pain was tolerable so

he did not seek medical attention yet.

He said he also had an increased level

of pain tolerance so he also didn’t

mind to take any pain relievers. Until

three days prior to admission, patient

had severe right upper quadrant pain,

which was said to be intolerable.

Moreover, when pressure is applied on

the RUQ of the abdomen, pain is

elicited. He had also lost his appetite

because of the pain. His scleras were

also slightly icteric during admission

and he was positive with Murphy’s

sign. So he sought consultation at

Out-Patient Department- Emergency

Room at Davao Medical School

Foundation Hospital. Ultrasound

revealed cholecystitis, so patient was

advised admission and operation.Duration of

illness

/ Though no complications aroused yet,

Mr. Police did not immediately seek

medical attention as he had persistent

RUQ pain a month ago. He waited for

the pain to become intolerable before

seeking medical advice. Moreover, the

obstruction brought about by the

cholecystitis caused his icteric sclera,

which could have been absent if he

sought medical attention earlier.Precipitating

factors

/ Only three out of eleven known

precipitating factors are present with

Mr. Police’s case which is the

following: diet (high cholesterol, high

calorie, and high sodium), diabetes

mellitus and obesity.Attitude and

willingness

to

medication

and

treatment

/ Mr. Police said he would undergo any

treatment regimen he has to as long

as his condition would get better.

Moreover, he let himself be admitted

to the hospital and to undergo surgery

as he is determined to get well as

soon as possible. Environment / DMSFH is a hospital with an

environment, very conducive for

healing. Moreover, the personnel in

the institution which includes the

medical team are very responsive to

the needs of the patients. Age / The client is almost 50 years old. The

wear and tear theory states that as

one grows older, most of our organs

are already used and abused. As one

ages, one also becomes more

susceptible to infections and organ

failure.Family

support

/ Anna is always watching over Mr.

Police during his admission. She said

she will always be with Mr. Police

through his ups and downs, as he

vowed him during their wedding day.

Moreover, relatives come to Davao to

visit Mr. Police, and together with

them are the encouragement and

support they give Mr. Police.Total 0/7 3/7 4/7

Computation:

No. of categories rated POOR (1) + No. of categories rated FAIR (2)

+

No. of categories rated GOOD (3) divided by TOTAL NO. OF

CATEGORIES= SCORE FOR GENERAL PROGNOSIS.

=0(1) + 3(2) + 4(3)

= 6 + 12

=18/7

=2.57

Scoring for General Prognosis:

1-1.6 =POOR

1.7-2.3 =FAIR

2.4-3.0 =GOOD

General Prognosis:

The general prognosis of the client is good. This means that the client

has a good chance of recovering from his illness.

Conclusion

Generally, the student nurse’s one week exposure and duty at the

Davao Medical School Foundation Hospital has been a memorable

experience to them. The exposure had been an avenue for further

development and enhancement of their skills and capabilities in rendering

care and promoting holistic wellness to their clients. It reminded them again

that nursing profession entails a deep sense of responsibility and challenging

tasks.

After five days of exposure at St. Joseph (3C) ward, the student nurses

has identified and understood the causative factors of cholecystitis, its signs

and symptoms, clinical manifestations, diagnostic studies, medical,

pharmacological and nursing interventions through obtaining cues and

health history in conjunction to the disease process. They underwent

extensive research in order to comprehensively understand his condition.

Upon learning his case, it challenged and motivated them to work hard to

provide the appropriate and effective nursing intervention and care.

Moreover, cholecystitis is the most common problem resulting from

gallbladder stones. It occurs when a stone blocks the cystic duct, which

carries bile from the gallbladder. Predisposing factors can include heredity,

age, sex and race. With the presented factors that cannot already be

modified, one has to take action towards preventing the disease to happen.

The only one who can help yourself is you alone. With the proper knowledge

about the nature of the disease as well as its preventive measures along with

responsibility and sense of will, one can surely direct himself away from the

complications.

Our gallbladder is not to be taken for granted. There have been reports

that mortality can be as high as 15% for immunocompromised patients.

Furthermore complicated cholecystitis has 25% mortality (eg, gangrene,

empyema of gallbladder).

“No matter how the disease has already reached an alarming incidence rate or not, it is

a duty of every human person to take care of his own body, not just for the sake of other people

that depend on him, but most especially for himself ~ a primary obligation that he must fulfil.”

Recommendation

Every exposure is a learning experience filled with lessons. After

thoroughly studying Mr. Police’s case, the group has come up with the

following recommendations:

To the client:

Recovering after open cholecystectomy surgery doesn’t depend solely

on the healthcare team. More than anything else, there must be willingness

to recover on the part of the patient. With this, he must carry out his

responsibilities in fighting his own condition. He is encouraged to verbalize

his thoughts and feelings to his medical attendants, such as his nurses,

because it would be better for him to express whatever is causing stress on

his part thus, hindering his recovery or yet understand that the things that

his nurses is doing for him is for his own good and betterment in life. He is

encouraged to willingly and actively participate in therapeutic activities that

will render improvement of his condition. Moreover, he should fight his as

much as he can through complying with the treatment being given to him

and through continuing his rehabilitation process so that the chances of his

recovery will be greater.

To the patient’s family

Undeniably, the patient’s family plays a significant part in his battle

against the disease. The family members should be involved with his

treatment as much as possible since their support motivates him to exert

more effort in the recovery process. They should not only be physically

present. More than that, they should give their emotional support to boost

the patient’s morale. In addition, they are encouraged to be oriented and

educated with the basic facts about the patient’s condition so that they will

understand his condition better. Not only that, they should always asked the

student nurses for assistance, advices, or clarifications because they are

always ready to lend a helping hand. Through this, they would be able to

know how to manage and meet his needs when he is discharged from the

institution where he is admitted.

To the group

Maintain practicing teamwork and unity within the group so that better

output will be formulated. Be sensitive and respond to the needs of other

group members. If one is done with the task, try to help the others and

contribute something that would make the work better. Being calm is always

a good move. Fix the problems in a peaceful manner. Be open-minded to

suggestions and prevent intensive discussions so that healthy relationship

within the group will be maintained.

To the fellow student nurses

It is not through a single effort that you learn the entirety of a certain

illness. Rather, it takes continued research and study in order to be more

updated with information that will render an insightful understanding of what

it is all about. As student nurses, you should do your best to be equipped

with the necessary knowledge that will help you in your endeavors especially

when you go on duty in units where intensive care is needed. It is through

this that you can provide the quality and holistic nursing care that patients

need. You should realize that your patients are also humans, though suffering

from a chronic illness. You should always be humane in treating and

approaching them so that you can be of help in the best way you can.

Nursing students of AdDU should be committed to the goal of being men and

women for others. They should not only appreciate the concepts during

lecture session but should also positively digest the experiences they get

from their duties and exposures.

To the Ateneo de Davao University- College of Nursing

The AdDU- College of Nursing has been exerting much effort in

providing the best exposures to its nursing students. The faculty and staff

are encouraged to continue elevating the standard of the Ateneo Nursing

Curriculum through quality training of Clinical Instructors in the advent of

seminar, forums or trainings, quality-level lectures and affiliations with

various medical institutions for the students’ exposures and duties.

To the Professional Medical World

Open cholecystectomy undeniably has its own disadvantages. The scar

alone after surgery is one of the major disadvantages. Furthermore,

Minilaparotomy cholecystectomy presents exposition difficulties, and

laparoscopy requires expensive equipment and additional training.

Laparotomy is more painful, causes trauma to the abdominal wall, and

requires a longer convalescence; it is also less aesthetic. Researches and

studies have been conducted to discover a new technique of minimal

invasive cholecystectomy. Such new technique presented for minilaparotomy

cholecystectomy is transcylindrical. As the medical field advances, the

people’s trend as well as preference also changes. As much as possible, a

cheaper, less invasive and more aesthetic procedure is preferred. The group

would like to comment on the success of the emergence of new studies and

invention. They are to look forward to further studies and improvement.

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Ateneo de Davao University College of Nursing

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