ANGELES UNIVERSITY FOUNDATION

COLLEGE OF NURSING

ANGELES CITY

CASE STUDY – CHOLECYSTITIS

JBL – MS WARD

Submitted by:

Diyco, Kevin Cesar

Pelayo, Roan Rae

Santos, Alvin Ronn

BSN 4-2, Group 6

Submitted to:

Luciano O. Coral III, RN, MN

INTRODUCTION

Cholecystitis, which has long been considered an adult disease, is quickly

gaining recognition in medical practice because of the significant documented

increase in nonhemolytic cases over the last 20 years. Gallbladder disease is

common throughout the adult population, affecting as many as 25 million

Americans and resulting in 500,000-700,000 cholecystectomies per year.

Although gallbladder disease is much rarer in children, with 1.3 pediatric

cases occurring per every 1000 adult cases, pediatric patients undergo 4% of all

cholecystectomies. In addition, acalculous cholecystitis, uncommon in adults, is

not that unusual in children with cholecystitis. Because of the increasing

incidence of gallstones and the disproportionate need for surgery in the pediatric

population, consider cholecystitis and other gallbladder diseases in the

differential diagnosis in any pediatric patient with jaundice or abdominal pain in

the right upper quadrant, particularly if the child has a history of hemolysis.

Cholecystitis is defined as inflammation of the gallbladder and is

traditionally divided into acute and chronic subtypes. These subtypes are

considered to be 2 separate disease states; however, evidence suggests that the

2 conditions are closely related, especially in the pediatric population. Most

gallbladders that are removed for acute cholecystitis show evidence of chronic

inflammation, supporting the concept that acute cholecystitis may actually be an

exacerbation of chronic distension and tissue damage. Cholecystitis may also be

considered calculous or acalculous, but the inflammatory process remains the

same.

Most information related to morbidity and mortality in gallstone disease is

related to the adult population, although some trends can be extracted and

applied to the pediatric population. In general, the mortality rate of

cholecystectomy in acute cholecystitis has dropped from 6.6% in 1930 to 1.8% in

1950 to nearly 0% in recent studies. In one study, the overall mortality rate in

42,000 patients receiving open cholecystectomy (OC) was 0.17%; the mortality

rate in patients younger than 65 years was 0.03%. Children can be expected to

do well, although comorbid conditions are common and may cause

complications. Risk factors for morbidity and mortality in the pediatric population

include associated conditions, such as cystic fibrosis (CF), obesity, hepatic

disease, diabetes mellitus, sickle cell disease, and immunocompromise.

General complications, such as pulmonary, cardiac, thromboembolic,

hepatic, and renal insufficiency, account for most deaths. Procedure-related

complications mainly contribute to morbidity and occur with higher frequency in

acute cholecystitis in which symptoms of gallstone disease have been present

longer than 1 year. The most common procedure-related complications are

wound infections, abscess, cholangitis or pancreatitis, ileus, hemorrhage, and

bile duct complications.

Laparoscopic cholecystectomy (LC) is associated with risks as well. Major

complications include bleeding, pancreatitis, leakage from the duct stump, and

major bile duct injury. The risk of ductal injury increases from 0.1-0.2% in OC to

0.5-1% in LC; however, Holcomb et al reported no iatrogenic injuries with LC in

their first 100 patients. They believe that with conscientious surgical care,

morbidity related to the laparoscopic approach can be minimized.

Racial and genetic influences in the adolescent age group are similar to

those of adults. African Americans without hemolytic disease and the African

Masai are less prone to cholelithiasis, whereas Chilean women, Pimas, and

whites are more predisposed to this disease. Two contributing diseases in

particular have a genetic component and racial distribution. Hemolytic diseases,

including sickle cell disease and hemoglobin C disease, occur almost exclusively

in the black population, although thalassemia also has a Mediterranean

distribution. CF, which occurs mainly in whites, may also contribute to the

formation of biliary sludge and, possibly, acalculous cholecystitis.

The physical examination in acute cholecystitis usually reveals right upper

quadrant tenderness. The classic triad is right upper quadrant pain, fever, and

leukocytosis. The patient may have abdominal guarding and a positive Murphy

sign (ie, arrest of inspiration on deep palpation of the gallbladder in the right

upper quadrant of the abdomen). Omental adherence to the inflamed gallbladder

combined with distension may create a palpable mass between the 9th and 10th

costal cartilages.

In rural Asia, infections with Opisthorchis sinensis or Ascaris

lumbricoides are predisposing conditions. In the United States, these gallstones

are more rare, although they have been found after cholecystectomy in which the

bile was infected (most often by E coli) and in infants and children infected

with Staphylococcus, Enterobacter, Citrobacter, and Salmonella species. In

addition, chronic urinary tract infections may predispose individuals to the

formation of these gallstones, and isolated gallstones associated

with Ascaris have been recorded in the United States.

Many disease processes can precipitate or foster these events. Infection

induces the deconjugation of bilirubin glucuronide, thereby increasing the

concentration of unconjugated bilirubin in the bile. Hemolysis overwhelms the

conjugation abilities of the liver, increasing the amount of unconjugated bilirubin

in the bile. Hemolytic diseases include hereditary spherocytosis, sickle cell

disease, thalassemia major, hemoglobin C disease, and possible uncontrolled

glucose-6-phosphate dehydrogenase (G-6-PD) deficiency. Multiple blood

transfusions also increase the pigment load, which predisposes the bile to the

formation of biliary sludge.

A. . Objectives

a. Nurse Centered

Short Term:

After the initial student nurse-patient interaction, the student nurses

will:

o Establish rapport with the patient.

o Introduce themselves and state their purpose to the patient.

o Use therapeutic communication during nurse-patient interactions.

o Obtain necessary data such as personal information, family history,

and history of past and present illness.

o Perform physical assessment in a cephalocaudal and IPPA

approach.

o Review and monitor diagnostic and laboratory results.

o Provide due care to the patient which includes medical,

pharmacological, and nursing interventions.

Long Term:

After the completion of this case study, the student nurse will:

o Review the medical condition of the patient.

o Identify precipitating and predisposing factors to the occurrence of

the disease condition.

o Review the book-based and patient-based manifestations of the

disease.

o Correlate other factors such as relevant data, laboratory results,

and abnormal findings in the physical assessment.

o Formulate nursing diagnoses and subsequent planning to aid the

patient’s prognosis.

o Implement what has been planned and provide health teachings as

appropriate.

o Evaluate patient’s response to over-all interventions through the

patient’s daily progress chart.

o Provide health teachings upon discharge of the patient such as the

maintenance of medical managements and measures to prevent

reoccurrences or to alleviate aggravating conditions.

b. Patient Centered

Short-Term:

After the initial student nurse-patient interaction, the student nurse

will:

o Acknowledge the presence of student nurse as part of the heal care

team responsible in taking care of her conditions.

o Build up a therapeutic relationship with the student nurse.

o Cooperate in different activities and management done.

o Provide pertinent data and cooperate in physical assessment

procedures.

o Understand the disease process and its complications.

o Comply with the treatment and management at hand.

Long-Term:

After the completion of this case study, the patient will be able to:

o Have a more stable health condition.

o Gain strong compliance and attain optimum level of functioning.

o Gain empowerment and responsibility of maintaining health.

o Apply the health teachings given regarding health promotion,

preventive measures, curative and rehabilitative means in her

everyday life.

A. Personal History

1. Demographic Data

Mrs. Chole is a twenty-seven years old female, and was born on October

17, 1983. Mrs. Chole parents are both Filipino, thus making her a Filipino citizen.

She was baptized under the Roman Catholic Church. She speaks Tagalog and

Pampango but her primary language is Pampango. She is married to Mr.Systitis

they have one child who is 3 years of age. She is living with her mother in law in

Fatima Calutlut City of San Fernando, Pampanga. She was admitted at a tertiary

hospital located at San Fernando City on December 05, 2010 at 3:25 PM.

2. Socio – economic and Cultural Factors

Mrs. Chole belongs to an extended type of family where she lives with her

mother in law. Mrs. Chole is a housewife and sometimes sells viand in their

neighborhood and earns around Php 500 – 800 depending on what kind of viand

she cooked, her husband works as a janitor at PCSO in pampanga and earns

around Php 7,000 – 8,000 per month. Mrs.Chole is a Roman Catholic and

usually go to church every Sunday. She do believe with herbolarios, and she

usually go to the Health Center for checkups. Mrs. Chole does utilize herbal

medicines such as pandan as diuretic and guava leaves as disinfectant. Mrs.

Chole practices self-medication when it comes to OTCs like paracetamol and

mefenamic acid.

B. Family Health-Illness History

Legend:

- Male - Female

- Deceased - Mrs. Chole

Family History:

Mrs. Chole told the researcher that her grandparents have Hypertension

and are still alive. She said that she does not know any persisting disease in her

parents except for hypertension. She is the 4th child among the six children, with

two males and four females. She said that no one in her siblings is already dead

and all are in normal conditions except for 2nd sister and 3rd brother who have

hypertension. She shares that there is no history diabetes mellitus, asthma, CRF

in their family.

C. History of Past Illnesses

+ +

+

Unknown Hypertension HypertensionStroke

HypertensioHypertensio

HypertensioHypertensio

Mrs.Chole had history of fever and coryza, but still, these disappeared

early and have been managed properly. She had German Measles at three years

old, and did not take medications at all. At seven Mrs.Chole, had mumps, and is

not given any medications. She declared that her mother had put “tina” or the

blue powder on Mrs.Chole’ s face, however, did not know what it is for.

Mrs.Chole had her menarche on her twelfth year of life. Aside from the

abovementioned diseases, Mrs.Chole had no other diseases.

D. History of Present Illness

One week Prior to admission Mrs. Chole have an right upper quadrant

pain it is characterized as continous, non-radiating pain, no consultation done

she has a positive edema and facial swelling. Three days prior to admission she

still have that right upper quadrant pain, Mrs. Chole vomited and still no

consultation was done, one day prior to admission they consulted local district

hospital and ultrasound was requested and done results revealed cholecystitis,

they referred Mrs. Chole to the tertiary hospital in San fernado.

A. Physical Examination (Cephalocaudal Approach)

December 05, 2010, Sunday (Chart PA)

HEENT: Anicteric sclera, pale palpebral conjunctiva

CHEST AND LUNGS: SCE, (-) murmurs

ABDOMEN: with right upper quadrant painflat, soft, an positive murphy’s sign

EXTREMITIES: with positve edema, full and equal pulses, pallor

December 06 2010, Monday

General Appearance:

The patient shows signs of weakness. The patient is quiet and is non-responsive.

Vital signs taken and recorded as follows: T= 36.8°C (axilla); PR= 82 bpm;

RR=27 bpm; BP= 100/70 mmHg

SKULL and FACE: Mrs. Chole has round normo-cephalic shaped skull with

absence of nodules or masses. She has symmetric facial features and facial

movements as she was able to smile, frown raise eyebrows and puff cheeks.

She does experience headache at a minimum.

HAIR and SCALP: Mrs. Chole has short, scarcely distributed hair, without

presence of lice or other infestations.

SKIN and NAILS: Mrs. Chole has pale complexion, with good skin turgor. She

has warm and moist skin with absence of nodules. She has smooth, convexly

curved, newly trimmed fingernails and toenails, but of pale color and with

capillary refill of more than 3 seconds upon Blanch test.

EYES and VISION: Eyebrows are evenly distributed and symmetrically aligned

with equal movements. Eyelashes are equally distributed and curled slightly

outward and upward. Eyelids close symmetrically with skin intact and no

discharges or discoloration noted. Bulbar conjunctiva is transparent and sclera

appears white. Palpebral conjunctiva is shiny, smooth but is pale. Lacrimal

ducts have no edema or tearing upon palpation. Pupils are equally rounded,

reactive to light and accommodation. She can see objects in the periphery when

looking straight ahead and is able to read a letter at a given distance.

EARS AND HEARING: Auricles are same as color of facial skin, symmetric and

aligned with canthus of eye. Ears are not tender and recoil after being folded.

She has slight amount of cerumen that is yellowish in color. She can hear

normal voice tone.

NOSE AND SINUSES: Nose is symmetric and straight. It has uniform color and

not tender. Nasal septum is intact and in midline. Air moves freely on both nares

as client breathes. Facial sinuses are not tender.

MOUTH AND OROPHARYNX: Lips are pale, soft and symmetrical. She was

able to purse her lips when she was asked to. She has an incomplete set of

teeth. Gums are pale, though there are no signs of bleeding. Tongue is at

the center and pinkish in color with no lesions, no tenderness and moves freely.

NECK: Neck muscles are equal in size and head is centered. She can move her

head freely with no discomfort. Lymph nodes are not palpable and trachea is in

the midline of neck. Thyroid gland is not palpable. Carotid and jugular veins are

not distended and visible, with no bruit sounds.

THORAX AND LUNGS: Chests are symmetrical in size and expansion. Spine is

vertically aligned. Skin is intact, with no palpable masses or nodules. She has no

rales and crackles heard on the both lung field.

ABDOMEN: Patient has no striae, scars, or visible veins, upon inspection. She

has a positive murphy’s sign, right upper quadrant pain. Normal bowel

sounds.

HEART: Heart rate is regular in rhythm upon auscultation without any murmurs.

Peripheral pulses are symmetrical with that of the apical pulse.

UPPER EXTREMITIES: Skin is uniformly fair in color, with good skin turgor.

Temperature of the skin is uniform in both extremities. Muscles are generally

equal in size on both sides with no tremors or contractures. There are no bone

deformities but there is presence of edema. She was able to adduct and abduct

her arm, supine and prone her hands, shrug her shoulders against resistance,

and flex and extend her arms. She also has good handgrip and was able to

perform the finger-nose test. Muscle strength is graded as five.

LOWER EXTREMITIES: Negative result of Romberg’s test She has bipedal

edema, with shiny, flaky skin. She can extend her legs and flex it.

December 07 2010, Tuesday

General Appearance:

The patient shows signs of weakness. The patient is quiet and is responsive.

Vital signs taken and recorded as follows: T= 37.1°C (axilla); PR= 86 bpm;

RR=20 bpm; BP= 110/80 mmHg

SKULL and FACE: Mrs. Chole has round normo-cephalic shaped skull with

absence of nodules or masses. She has symmetric facial features and facial

movements as she was able to smile, frown raise eyebrows and puff cheeks.

HAIR and SCALP: Mrs. Chole has short, scarcely distributed hair, without

presence of lice or other infestations.

SKIN and NAILS: Mrs. Chole has pale complexion, with good skin turgor. She

has warm and moist skin with absence of nodules. She has smooth, convexly

curved, newly trimmed fingernails and toenails, but of pale color and with

capillary refill of more than 3 seconds upon Blanch test.

EYES and VISION: Eyebrows are evenly distributed and symmetrically aligned

with equal movements. Eyelashes are equally distributed and curled slightly

outward and upward. Eyelids close symmetrically with skin intact and no

discharges or discoloration noted. Bulbar conjunctiva is transparent and sclera

appears white. Palpebral conjunctiva is shiny, smooth but is pale. Lacrimal

ducts have no edema or tearing upon palpation. Pupils are equally rounded,

reactive to light and accommodation. She can see objects in the periphery when

looking straight ahead and is able to read a letter at a given distance.

EARS AND HEARING: Auricles are same as color of facial skin, symmetric and

aligned with canthus of eye. Ears are not tender and recoil after being folded.

She has slight amount of cerumen that is yellowish in color. She can hear

normal voice tone.

NOSE AND SINUSES: Nose is symmetric and straight. It has uniform color and

not tender. Nasal septum is intact and in midline. Air moves freely on both nares

as client breathes. Facial sinuses are not tender.

MOUTH AND OROPHARYNX: Lips are pale, soft and symmetrical. She was

able to purse her lips when she was asked to. She has an incomplete set of

teeth. Gums are pale, though there are no signs of bleeding. Tongue is at

the center and pinkish in color with no lesions, no tenderness and moves freely.

NECK: Neck muscles are equal in size and head is centered. She can move her

head freely with no discomfort. Lymph nodes are not palpable and trachea is in

the midline of neck. Thyroid gland is not palpable. Carotid and jugular veins are

not distended and visible, with no bruit sounds.

THORAX AND LUNGS: Chests are symmetrical in size and expansion. Spine is

vertically aligned. Skin is intact, with no palpable masses or nodules. She has no

rales and crackles heard on the both lung field.

ABDOMEN: Patient has no striae, scars, or visible veins, upon inspection. She

has a positive murphy’s sign, right upper quadrant pain. Normal bowel

sounds.

HEART: Heart rate is regular in rhythm upon auscultation without any murmurs.

Peripheral pulses are symmetrical with that of the apical pulse.

UPPER EXTREMITIES: Skin is uniformly fair in color, with good skin turgor.

Temperature of the skin is uniform in both extremities. Muscles are generally

equal in size on both sides with no tremors or contractures. There are no bone

deformities but there is presence of edema. She was able to adduct and abduct

her arm, supine and prone her hands, shrug her shoulders against resistance,

and flex and extend her arms. She also has good handgrip and was able to

perform the finger-nose test. Muscle strength is graded as five.

LOWER EXTREMITIES: Negative result of Romberg’s test She has bipedal

edema, with shiny, flaky skin. She can extend her legs and flex it.

F. Diagnostic and Lab Procedures

Diagnostic or Laboratory Procedures

Date orderedDate

result(s) in

Indication(s) orPurposes

Results Normal ValuesAnalysis

and Interpretation of Results

CBC> Hemoglobin 12-05-10

12-05-10It evaluates the hemoglobin contents of erythrocytes. It measures the oxygen carrying capacity of the blood since hemoglobin is the primary component of the blood which carries oxygen.

125 g/L 120-160 g/L The client’s result of Hemoglobin is within normal range.

> Hematocrit 12-05-1012-05-10

It is used to measure the volume of RBC in whole blood expressed as percentage. The hematocrit value is roughly three times the hemoglobin concentration.

0.37 0.38-0.40 The client’s result of hematocrit is slightly below range which indicates that the patient’s RBC is low in proportion to whole blood.

> Platelet count

12-05-1012-05-10

It is done to examine the capability of the blood to clot

275 150-400x10^9/L The result is within normal range.

> WBC

> Neutrophils

12-05-1012-05-10

12-05-1012-05-10

A white blood cell count is a determination of number of WBC or leukocytes/unit volume in a sample of venous blood. The test is used to detect infection or inflammation and leukemia, also used to help monitor the body’s response to various treatments and to monitor bone marrow function, and to determine the need for further tests, such as differential count.

12.2

0.78

5.0-10.0

0.18-0.70

The result is above normal which indicates infection.

The result is above normal limits. Neutrophils is greater in amount as compared to other WBC component because in a normal inflammatory response, the neutrophils are the first ones to be release and act on the

> Lymphocytes 12-05-1012-05-10

0.22 0.10-0.48

injured site. Hence, they are greater in number.

The result is within normal range.

> Creatinine

12-05-1012-05-10

More specific to assess renal function because it is not affected by dietary consumption & hydration status.

77.6 umol/L 60-120 umol/L The result is within normal range.

> Potassium 12-05-1012-05-10

To monitor serum K+ level, a determinant of water balance and essential for myocardial contraction.

4.32 mmol/L 3.5-5 mmol/L The result is within normal range.

> Sodium 12-05-1012-05-10

To monitor serum Na level, a determinant of water balance.

132.4 mmol/L 136-145 mmol/L The result is below normal range which may indicate that the patient is dehydrated or has lost fluids due to the disease condition.

Nursing Responsibilities:

Before:

Explain the procedure to the patient.

Tell the patient that no fasting is required.

Inform the patient that this test requires a blood sample and he/she may experience transient discomfort from the

needle puncture and the pressure of the tourniquet.

During:

Collect approximately 5 to 7 ml of venous blood in a lavender-top tube.

Avoid hemolysis.

List on the laboratory slip any drugs that may affect test results.

After:

Apply pressure to the puncture site.

If hematoma develops at the venipuncture site, apply warm soaks. If the hematoma is large, monitor pulses distal

to the venipuncture site.

Ensure that subdermal bleeding has stopped before removing pressure.

Diagnostic or Laboratory Procedures

Date orderedDate

result(s) in

Indication(s) orPurposes

Results Normal Values Analysisand Interpretation of Results

> Urinalysis 12-06-1012-06-10

To monitor fluid imbalances or factor for fluid imbalances.

Color: yellow

Transparency:Slightly turbid

Specific Gravity: 1.015

Sugar: (-)

Reaction: acidic

RBC: 8-12 / HPF

Pus cells:8-10 / HPF

Yellow or Amber

Clear

1.010-1.035

Negative

Acidic

0-3

0-3

Urine color is normal

Turbid urine may contain RBC, WBC, bacteria or fat and may reflect renal infection

Urine specific gravity is normal

There is no sugar present in the urine

The result is normal

RBC in urine is slightly elevated which means there is an infection

This further proves that there is infection.

Nursing Responsibilities:

Before:

Check doctor’s order

Inform the patient about the procedure and explain the importance of the procedure to be done.

Inform the patient that there are no restrictions in food and fluid before the test.

Explain to the patient that this procedure is non invasive; no pain will be felt.

During:

Assist patient by giving him a bed pan.

Advise patient to clean the genitalia first.

Describe the procedure for collecting a clean- catch or midstream specimen.

After:

Chart time of collection of urine specimen.

Attach results to the chart as soon as they are available.

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.

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 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.

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.

IV. The Patient’s Illness

Precipitating Factors:

Factors Rationale

Diet (high cholesterol,

high calorie, high

sodium)

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.

Medications and Oral

Contraceptives

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.

Total Parenteral

Nutrition

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.

Spinal Cord Injury 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.

Primary Biliary

Cirrhosis

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.

Diabetes Mellitus 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.

Hemolytic Syndromes 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.

Ileal Disease,

Resection, and Bypass

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.

Biliary Infection 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 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.

Rapid Weight Loss/

Fasting diets

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 Rationale

Gender 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.

Advancing Age 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.

Race 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 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.

Parity/ Pregnancy 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 Rationale

Biliary Colic/ Moderate to

Severe Pain

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.

Tenderness Palpation of the abdomen frequently elicits

localized tenderness in the right upper

quadrant which is associated with guarding

and rebound tenderness.

Murphy’s Sign 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.

Nausea and Vomiting These signs and symptoms may accompany a

gallbladder attack. Pain is usually

accompanied by nausea and vomiting.

Fever and chills 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

Loss of appetite and

Anorexia

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

Risk factor Heredity Obesity Rapid Weight Loss, through diet or surgery Age Over 60 Female Gender Diet-Very low calorie diets, prolonged fasting,

and low-fiber/high-cholesterol/high-starch diets.

Bile must become supersaturated with

cholesterol and calcium

Bile must become supersaturated with

cholesterol and calcium

The solute precipitate from solution as solid

crystals

The solute precipitate from solution as solid

crystals

Crystals must come together

and fuse to form stones

Crystals must come together

and fuse to form stones

Gallstones

Gallstones

Obstruction of the cystic duct and common bile duct

Jaundice Jaundice Sharp pain in the right part of

abdomen

Sharp pain in the right part of

abdomen

Distention of the gall bladder

Venous and lymphatic drainage

is impaired

Venous and lymphatic drainage

is impaired

Proliferation of bacteria

Proliferation of bacteria

Localized cellular irritation or infiltration or both take place

Localized cellular irritation or infiltration or both take place

Areas of ischemia

may occur

Areas of ischemia

may occur

Cause of fever Cause of fever

Inflammation of gall bladder

Cholecystitis

Cholecystotomy

The operation of making an opening in the gall bladder, as for the removal of a gallstone.

Surgical Incision

Disruption of skin, tissue and muscle integrity

Stimulation of sensory nerve endings

PainPain

Destruction of skin layers

Impaired Skin integrity

Impaired Skin integrity

Broken skin and traumatized tissue

Destruction of Skin Layers

Increased risk for environmental exposure

to pathogens

Risk for InfectionRisk for Infection

Broken Skin and traumatized tissue

V. The Patient’s Care

IVF:

INTRAVENOUSFLUID

DATE ORDERED/DISCONTINUED

GENERALDESCRIPTION

INDICATION CLIENT’S RESPONSE TO TREATMENT

D5W x KVO via microset

Date ordered:12-05-10

Date discontinued:12-06-10

D5W is an isotonic solution which neither causes cells to swell nor shrink. However, the dextrose component is easily metabolized by the body making the solution hypotonic later on causing cells to swell.

It is used in repairing electrolyte and acid/base imbalances, and also includes total and partial, parenteral nutrition solutions.

The patient tolerated the IVF well.

Nursing Responsibilities:

Before starting IV therapy, consider duration of therapy, type of infusion, condition of veins and medical condition

of the patient to assist in choosing IV site.

Explain the procedure and its purpose to the patient.

After initiation of IV therapy, monitor patient frequently for signs of infiltration, phlebitis, sins of fluid overload or

dehydration.

OXYGEN THERAPY

DATE ORDERED/DISCONTINUED

GENERALDESCRIPTION

INDICATION CLIENT’S RESPONSE TO TREATMENT

O2 inhalation at 2-3LPM via nasal cannula

Date ordered:12-05-10

Date discontinued:12-05-10

Oxygen is an odorless, tasteless, colorless, transparent gas that is slightly heavier than air. It can be dispensed from a cylinder, piped-in system, liquid O2 reservoir or O2 concentration. It is generally prescribed when the amount of O2 in the blood and tissues are not sufficient to meet the body’s need.The most common intervention to improve gas exchange between the alveoli and the blood by increasing the concentration of oxygen in the inspired air and to assist the patient to meet cellular oxygen demand.

To treat the harmful and possible lethal effects of hypoxemia, and to decrease myocardial workload.

Relief in discomfort brought by difficulty of breathing.

Nursing Responsibilities:

Inform the patient that the oxygen therapy may be done to reduce risk of complications.

Be sure that you are giving the right amount and regulation to the right patient.

Instruct the client and the visitors about the hazard of smoking with oxygen use.

Make sure that the electrical devices are in good working condition to prevent the occurrence of short-circuit

sparks.

Drugs:

GENERIC/BRAND NAME

DATE ORDERED/ DISCONTINUED

DOSAGE, ROUTE AND

FREQUENCY

GENERALACTION

MECHANISM OFACTION

INDICATION/PURPOSE

CLIENT’S RESPONSE

Meperidine HCl / Demerol

Dates given:12-05-1012-06-10

25 mg IV PRN for pain

Opioid agonist analgesic

Acts as agonist at specific opioid receptors in the CNS to produce analgesia, euphoria, sedation; the receptors mediating these effects are thought to be the same as those mediating the effects of endogenous opioids.

Relief of moderate to severe acute pain.

The patient was relieved of pain.

Ampicillin + Sulbactam

Dates given:12-05-1012-06-10

750mg + 50cc D5W to run in soluset BID

Antibiotic, Penicillin

Bactericidal action against sensitive organisms; inhibits synthesis of bacterial cell wall, causing cell death.

Treatment of infections cause by susceptible strains of Shigella, Salmonella, E. coli, H. influenzae, P. mirabilis, N. gonorrhoeae, enterococci, gram-positive organisms

Signs of infection such as fever were prevented.

Nursing Responsibilities:

Prepare the medication with correct dosage.

Administer the medication on the right route.

Clean the IV line where the drug is being administered.

Observe the patient for any reaction to the drug.

Advise patient to report fever, diarrhea and allergy.

To enhance absorption, give drug with meals.

Protect drug from light.

Monitor electrolyte levels, fluid intake and output, weight and blood pressure.

Inform the patient that eggs and milk, coffee and tea consumed with a meal or 1 hour after may significantly inhibit

absorption.

Do not crush or chew sustained release products.

Inform that it may cause change in stool color, abdominal cramps, diarrhea, or constipation.

Inform patient that citrus fruits enhance iron absorption.

Diet:

DIET REGIMEN

*DATE ORDERED/ **DISCONTINUED

GENERAL DESCRIPTION

INDICATIONSSPECIFIC FOODS

TAKENCLIENT’S RESPONSE

NPO*12-05-10**12-06-10

The patient is not allowed to eat or drink anything, including oral meds.

NPO status is prescribed because the patient’s chief complaint was vomiting. NPO status would prevent complications with regards to the patient’s GI.

Patient followed the diet.

Activity and Exercise:

EXERCISE REGIMEN *DATE ORDERED/ **DISCONTINUED

GENERAL DESCRIPTION

INDICATIONS CLIENT’S RESPONSE

Complete Bed Rest with Bathroom Privileges

*12-05-10**12-06-10

CBR with BRP is wherein the patient is instructed to stay in bed without any kind of strenuous activity except for going to the bathroom.

This is to reduce the metabolic demand of the body, especially the organs when a patient is experiencing a disease condition that requires rest.

Patient was cooperative with the activity.

A. Nursing Management

a) NCP (Nursing Care Plan)

a. Acute Pain

b. Risk for Hyperthermia

c. Risk for Impaired skin integrity r/t mechanical process (surgery)

d. Self-care deficit related to pain or discomfort

e. Risk for Infection r/t inadequate primary defenses

1. Acute Pain

ASSESSMENTNURSING

DIAGNOSIS

SCIENTIFIC

EXPLANATIONPLANNING

NURSING

INTERVENTIONSRATIONALE

EXPECTED

OUTCOME

S> Patient may

report:

-pain in the

surgical

incision site

- pain is felt

post

operatively

- dyspnea

O>Patient may

manifest:

-pain scale

greater than

5/10

-altered v/s

-restlessness

-fatigue

-elevated PR

-guarding

Acute pain Fracture itself

causes pain, but

in addition to this,

surgical

intervention also

leads to

stimulation of

pain receptors.

Pain is one of the

common

symptoms of post

operative

patients. Noxious

stimuli (bleeding)

causes release of

biochemical

mediators

(prostaglandin,

bradykinin,

Short-term:

After 4 hrs.

of NI, the

patient’s

pain scale

will

decrease

Long-term:

After 2 days

of NI, the

patient will

demonstrate

techniques

on how to

manage the

pain, if pain

occurs such

>Monitor and

record vital signs

>Assess pt’s

condition, perform

a comprehensive

assessment of

pain to include

location,

characteristics,

onset/duration,

frequency, quality

or severity and

precipitating or

aggravating

factors

>position in

comfortable

position

>Perform pain

>To obtain

baseline data

>To determine

extent of

condition, have a

basis for future

comparison, and

determine

appropriate

nursing

interventions to be

carried out to

alleviate the pain

>to provide non-

pharmacological

Short-term:

the patient’s

pain scale

shall have

decreased

Long-term:

The patient

shall have

demonstrated

techniques on

how to

manage the

pain, if pain

occurs such

behavior

-facial mask

-sleep

disturbance

-autonomic

alteration in

muscle tone

serotomin,

histamine,

substance P)

which then lead

to sensitization of

nociceptors

(receptors

responsible for

pain).

Transmission of

this pain

impulses will

occur in the

peripheral nerve

fibers to spinal

cord through the

spinothalamic

tract to brainstem

and thalamus

then to somatic

sensory cortex

where pain

as

relaxation

techniques

(deep

breathing

exercises).

assessment each

time pain occurs.

>Encourage pt. to

take a nap.

>plan care with

rest periods

>encourage

verbalization of

pain

>Encourage use

of relaxation

techniques like

deep breathing

>Instruct pt. to

increase intake of

foods, rich in vit.

C, CHON and

iron

>Instruct the

patient to

increase oral fluid

intake as ordered

pain

management.

>to know if the

pain is

progressing or

not.

>to divert feeling

of pain

> To

lessen/prevent

fatigue

>to assess pain

and involve

patient in plan of

care

>To provide

nonpharmacologic

management

>To provide

adequate nutrition

as relaxation

techniques

(deep

breathing

exercises).

perception

occurs. The client

becomes

conscious to pain

when it reaches

the cortical

structure. Then

for the client to

elicit a reaction it

will travel down

from neurons of

brainstem to the

spinal cord which

releases

biochemical

mediators

(opioids,

serotonin, and

norepinephrine).

>administer

analgesics as

ordered >To prevent

dehydration

>to decrease

painful sensation

2. Risk for Hyperthermia

Assessme

nt

Nursing

Diagnosis

Scientific

Explanation

Objectives Nursing

Intervention

Rationale Evaluation

S>Ø

O>The

patient

may

manifest:

increased

body

temp.

above

normal

range

(38)

flushed

skin

increased

RR

(tachypn

ea)

Risk for

Hyperthermia

It is caused by the

fever producing

substance known as

“pyrogens.” These

pyrogens are

secreted by toxic

bacteria or released

by degenerating

tissue of the body. It

is believed that this

substance stimulate

the release of the

second substance

known as leukocyte

which have been

drawn. This

leukocyre pyrogens

goes to the

bloodstream and

Short term:

After 4 hours of

Nursing

Interventions,

the patient’s

temperature

will decrease

from 38 to the

normal range

(36.5 C- 37.5

C)

Long term:

Patient will

maintain a

normal

temperature

>Establish rapport

>Assess patient’s

condition

>Monitor vital signs

> Perform TSB

>Loosen the

constrictive clothing

>Place cold

compress in the

forehead.

>Keep patient’s

>To gain

patient’s trust

>To monitor

physiologic

condition

>To have a

baseline data

>To facilitate

loss of heat

through the

process of

conduction and

evaporation

> To improve

ventilation

>Heat is lost

through

conduction

Short term:

Patient’s

body

temperature

shall have

decreased

from 38 to

37.5

Long term:

Patient shall

have

maintained

a normal

temperature

seizures stimulates the heat

regulating center, the

thermostat which is

the hypothalamus

and set it to a febrile

state, Febrile level of

the hypothalamus in

which there will be an

increase in

epinephrine

vasoconstriction.

back dry

>Provide adequate

ventilation

>Encourage

adequate fluid

intake

>Encourage

adequate rest.

>Provide

comfortable

beddings/ linens

> Administer drugs

such as anti-

pyretics as ordered

>Provide

supplementary

>To prevent

further

complication

>To promote

heat loss by

means of

convection

>To prevent

dehydration

>To reduce

oxygen demand

and

consumption.

>To promote

comfort and

prevent skin

irritations

>To aid in re-

setting core

temperature.

>To offset

.

oxygen as needed

and ordered

increased

oxygen demands

and consumption

3. Risk for Impaired skin integrity r/t mechanical process (surgery)

ASSESSMEN

T

NURSING

DIAGNOSIS

SCIENTIFIC

EXPLANATIO

N

PLANNINGNURSING

INTERVENTIONSRATIONALE

EXPECTED

OUTCOME

S> Patient

may report:

-itching

-numbness of

surrounding

area

O>pt may

manifest:

-edema or

inflammation

of the

surrounding

Impaired skin

integrity r/t

mechanical

process

(surgery).

Because of the

surgery, the

patient is

expected to

have an

incision site.

Thus impairing

the integrity of

the skin,

making it more

prone to

invasion of

microorganism

Short term:

After 4hrs, of

NI, the

patient will

be able to

participate in

preventive

measures to

improve skin

integrity

Long term:

After 2 days

> Assess pt’s

condition. Monitor

and record VS

>Assess for dry

scaling skin

>Assess for pruritus

>Note changes in

skin color, texture

> to gather

baseline data

> Uremic skin

does not have the

usual amount of oil

because of

decreased sweat

and oil glands

>Pruritus can be

caused by dry skin

or accumulation of

nitrogenous waste

Short term:

The patient

shall have

participated in

preventive

measures to

improved skin

integrity

Long term:

A The patient

shall have

area

-poor skin

turgor

-dry, scaly

skin

-erythema

-disruption of

skin surface

(epidermis)

-destruction

of skin layers

(dermis)

-invasion of

body

structures

s. of NI, the

patient will

display

timely

healing of

skin lesions/

wounds

without

complication

s

and turgor.

>Periodically

measure affected

area.

>Keep area clean,

dry and stimulate

circulation.

>Use appropriate

padding devices.

>Encourage early

ambulation or

mobilization.

>Instruct the patient

to wear loose fitting

clothing when

in the blood

>restrictive

clothing can

increase risk of

skin breakdown

>To determine

severity of the

condition.

>To monitor

progress of

healing.

>To decrease

potential skin

breakdown.

>To reduce

pressure and

enhance

circulation to

compromised

area.

>To promote

circulation and

displayed

timely healing

of skin

lesions/woun

ds without

complications

edema is present

>Stress the

importance of not

scratching skin and

keeping fingernails

short

>Instruct patient to

perform proper hand

washing

>Suggest use of

TSB for bathing

reduce risk

associated with

immobility.

>Scratching can

cause lesions and

open sores

> To prevent

transmission of

micro organism

>Increased

warmth can

increase the

itching

4. Self-care deficit related to pain or discomfort

Assessmen

t

Diagnosis Scientific

Explanation

Objectives Interventions Rationale Desired

Outcomes

S = Ø

O = Patient

Self care

deficit

related to

Due to the

different factors

namely pain,

SHORT

TERM:

After 5 hours

> establish

rapport

> to gain the trust

and compliance of

the client

SHORT

TERM:

The patient

may

manifest:

> inability to

prepare

food for

ingestion

>inability to

wash body

or body

parts

>impaired

ability to

obtain or

replace

articles of

clothing

>inability to

carry out

proper toilet

function and

hygiene

pain or

discomfort

discomfort and

musculoskeletal

impairment that

the surgical

procedures can

produce, the

ability of the

patient to move

and perform

activities will be

impaired. Such

impairment to

mobility and

activities may

prevent the client

from performing

his self care

activities hence

deficit on self

care can occur.

of nursing

interventions,

the patient will

be able to

identify

individual

areas of

weakness.

LONG TERM:

After a week

of nursing

interventions,

the patient will

be able to

demonstrate

technique/lifes

tyle changes

to meet self-

care needs.

> monitor vital

signs

>identify degree

of individual

impairment

>assess skills and

strengths of the

client

>Promote

client/SO

participation in

problem

identification and

decision making

>assist with

rehabilitation

program

>provide privacy

during personal

>to establish

baseline data

>to help in the

determination of

the measures to be

implemented

>to capitalize on

this strenght when

formulating plan of

care

> enhances

commitment to

plan optimizing

outcomes

>to enhance

capabilities

>to decrease the

anxiety of the

patient

will have

been able

to identify

individual

areas of

weakness

LONG

TERM:

The patient

will have

been able

to

demonstrat

e

technique/li

festyle

changes to

meet self-

care

needs.

care activities

>assist with

necessary

adaptations to

accomplish

ADL’s; begin with

easily

accomplished

tasks

>identify energy

saving behaviors

>review safety

concerns and

modify activities

or environment

>to encourage

client and build on

success

>to prevent fatigue

>to prevent injuries

5. Risk for Infection r/t inadequate primary defenses

ASSESSMEN

T

NURSING

DIAGNOSIS

SCIENTIFIC

EXPLANATIO

N

PLANNINGNURSING

INTERVENTIONSRATIONALE

EXPECTE

D

OUTCOM

E

S>Ø

O>The

patient may

manifest:

>increase in

body

temperature

>fatigue

>weakness of

muscles

>restlessness

>erythema

and

inflammation

Risk for

infection

related to

inadequate

primary

defenses

The skin is the

largest organ

in the body, it

is our physical

barrier against

friction and

shearing

forces and

protection

against

infection,

chemicals,

ultraviolet

irradiation,

particles. Due

Short term:

After 4 hours

of nursing

intervention

the patient

will verbalize

understandin

g of

individual

causative/risk

factors

>Monitor vital

signs.

>Assess patient for

causative factors.

>Wash hands

thoroughly with

warm water, soap,

and friction before

and after providing

client care. Teach

client to wash her

>To have a baseline

data

>To determine which

areas will be given

more attention to in

preventing

aggravation of the

condition.

>Effective hand

washing removes

pathogenic

organisms from the

hands thus

preventing the

transmission of micro

Short

term:

After 4

hours of

nursing

interventio

n the

patient

shall

verbalize

understand

ing of

individual

causative/ri

sk factors

of incision site to the surgical

incision,

pathogens or

microorganism

s that

contaminates

in the skin can

freely enter the

body cavity

and can cause

harmful effects

of infection.

Long term:

After 3 days

of nursing

intervention

the patient

will

demonstrate

techniques.

Lifestyle

changes to

promote safe

environment

hands before and

after using the

bathroom,etc.

>Monitor lab values

as obtained. Notify

caregiver of any

abnormal values.

>Instruct patient to

maintain dry and

clean environment.

>Teach client of

infection to report:

fever, abdominal

tenderness, foul

vaginal discharge.

>Administer

medications as

ordered.

organisms.

>Allows early

identification of

infectious and allows

prompt treatment.

>Decreases dark

moist environment,

which enhances

growth of micro-

organisms.

>Provides

information the client

needs to identify

infections early.

>To prevent

infection.

Long

term:

After 3

days of

nursing

interventio

n the

patient

shall

demonstrat

e

techniques

. Lifestyle

changes to

promote

safe

environme

nt

b) Actual SOAPIERs

FIRST STUDENT-NURSE INTERACTION, 2nd Hospital day (December 6,

2010)

S > O

O > Received patient on bed on supine position, conscious and coherent, with an

ongoing IVF of D5W x KVO via microset @ 100 cc level regulated infusing well

on the left hand, with good skin turgor; with an initial VS of the following: T=

36.8°C (axilla); PR= 82 bpm; RR=27 bpm; BP= 100/70 mmHg

A >Acute Pain

P > After 2 hours of nursing interventions, the patient will decrease pain

sensation from 7/10 to 5/10

I > established rapport.

> Assessed general condition/appearance.

> Ascertained knowledge of safety needs and injury prevention.

> Assessed pain sensory

> Monitored and recorded vital signs

> PM care rendered

> Provided regular skin and oral care

> Repositioned client every 2 hours

>Provided safety and comfort measures

> Instructed patient to request assistance as needed.

> identified energy-conserving techniques.

E > Goal Met; the patient decreased pain sensation

SECOND STUDENT-NURSE INTERACTION, 3rd Hospital day (December

7, 2010)

S > O

O > Received patient on bed on supine position, conscious and coherent, with no

IV fluid attached, with good skin turgor; with an initial VS of the following: T=

37.1°C (axilla); PR= 86 bpm; RR=20 bpm; BP= 110/80 mmHg

A > Acute Pain

P > After 2 hours of nursing intervention, the patient’s pain scale will decrease

from 10/10 to 7/10.

I > Established rapport.

> Assessed general condition/appearance.

> Assessed for referred pain

> Encouraged use of relaxation techniques

> Encouraged diversional activities

> repositioned every 2 hours

> Encouraged adequate rest periods

> encouraged early ambulation

> Maintained adequate hydration

E > Goal Met AEB patient’s pain scale of 7/10.

VI. CLIENT’S DAILY PROGRESS IN THE HOSPITAL 

1.      Client’s daily progress chart (From admission to discharge)

 

  DAYS

(Specific date)

Admission

(12/05/10)

2

(12/06/10)

3

(12/07/10)

Nursing problems

a. Acute Pain

b. Risk for Hyperthermia

c. Risk for Impaired skin integrity r/t mechanical

process (surgery)

d. Self-care deficit related to pain or discomfort

e. Risk for Infection r/t inadequate primary defenses

*

*

*

*

*

*

Vital Signs

1. Temperature

2. Pulse Rate

3. Respiratory rate

4. Blood pressure

No records found T= 36.8°C

(axilla)

; PR= 82 bpm;

RR=27 bpm;

BP= 100/70

mmHg

T= 37.1°C (axilla);

PR= 86 bpm;

RR=20 bpm;

BP= 110/80

mmHg

DIAGNOSTICS/ LAB procedures

1. CBC

2. Urinalysis

*

*

Medical Mgmt.

1 D5W x KVO via microset

2. O2 inhalation

*

*

*

Drugs

1. Meperidine HCl / Demerol

2. Ampicillin + Sulbactam

*

*

*

*

Diet

1. NPO* *

Activity/ exercise

1. CBR with BRP * *

 

 

VII. CONCLUSION

 

After doing such case, the group have conclude and learned that

Cholecystitis, which has long been considered an adult disease, is quickly

gaining recognition in medical practice because of the significant documented

increase in nonhemolytic cases over the last 20 years. Gallbladder disease is

common throughout the adult population. Most information related to morbidity

and mortality in gallstone disease is related to the adult population, although

some trends can be extracted and applied to the pediatric population.

The physical examination in acute cholecystitis usually reveals right upper

quadrant tenderness. The classic triad is right upper quadrant pain, fever, and

leukocytosis. The patient may have abdominal guarding and a positive Murphy

sign (ie, arrest of inspiration on deep palpation of the gallbladder in the right

upper quadrant of the abdomen). Omental adherence to the inflamed gallbladder

combined with distension may create a palpable mass between the 9th and 10th

costal cartilages.

Surgery is one of the most medical/surgical interventions needed to be

done so as to remove the inflammation. Preventing of it such as low salt low

fat diet or balanced diet is the top priority to prevent the occurrence of the

disease process.