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PERPETUAL HELP COLLEGE OF MANILA
1240 V. Concepcion St., Sampaloc, Manila
College of Nursing
In partial fulfillment of the requirements for
NCM 204 RLE
Grand Case Presentation on
CHRONIC CALCULOUS CHOLECYSTITIS
Submitted by:
Nacis, Michiko Grace D.
Pascual, Garnet DSagun, Star M.
Sanuco, Janine Vittoria M.
l b h
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Si Eli b h C
I.CLIENTS DATA
PATIENT: PS
AGE: 40 years old
GENDER: MaleBIRTHDATE: August/7/1971
ADDRESS: 118 Barangay Sta. Cruz A.D Sapang Palay, Bulacan
CIVIL STATUS: Married
SPOUSE: AS (Housewife)
Children: PS (18 y/o) Third Year College
ES (17 y/o) Second Year College
DS (14 y/o) Second Year High School
OS (12 y/o) Grade VIRS (8 y/o) Grade III
EDUCATIONAL ATTAINMENT: High School Graduate
RELIGION: Catholic
NATIONALITY: Filipino
OCCUPATION: Jeepney Driver
ADMISSION DATA
DATE OF ADMISSION: July 5, 2011
INITIAL DIAGNOSIS Cholelithiasis
DIAGNOSIS: Chronic Calculous Cholecystitis
CHIEF COMPLAINT: Abdominal Pain, Right Upper Quadrant
DATE OF ASSESSMENT: July 8, 2011
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A2. PRESENT HEALTH HISTORY
Seven months prior to his admission, patient drinks 2-3 bottles of San Miguel a week and smokes 4-5 sticks of cigarette/day.( Dec, 28
2010) patient had his check up in Roquero General Hospital, Sapang Palay, San Jose Del Monte, Bulacan for having experienced of
jaundice and sudden onset of pain in the right upper quadrant of the abdomen with nausea and vomiting. Jaundice may also be seen as
yellowing of the skin, sclera (Icterus). He had an increased level of pain so he took Mefenamic acid as a pain reliever prescribed by the
doctor. He experienced the pain until 1-2 hours especially during after meal. He encouraged his self to socialize to others like
neighborhood because it helps to reduce or control pain.
Six months prior to his admission, he was still suffering from pain with the level of 6 out of 10. He also had insidious symptoms of
clay colored stool and dark yellow urine result from obstetric process without fever. He experienced mild to moderate pain with loss of
appetite. Low fat diet to prevent further pain of biliary colic. He experienced pruritus or burning sensation especially during bed time.
July 2, 2011 he was confined in Roquero General Hospital. The patient was still suffering with the level of 8 out of 10 severe pain
and he cant tolerate the pain. Duration of pain is 30 minutes -1 hour.
3 days PTA patient experienced severe pain on right upper quadrant so he consulted in Roquero General Hospital. He was
suffering a severe pain with a level of 8/10. On July 5, 2011, he was then transferred to East Avenue Memorial Medical Center for
further examination.
A1. PAST MEDICAL HISTORY
SP is fond of eating meats, salt cured foods, likes condiments (especially fish sauce), chicharon, oily foods. He drinks 2-3 bottles
of San Miguel beer per week and smokes 4-5 cigerettes per day.SP experienced common illness such as colds, cough, chicken pox, and fever during his childhood and had completed his
immunization. However he could not recall at what age he got the disease. He has an allergy on sea foods but no allergy on drugs. The
patient does not participate in any sports, exercises and routine.
SP goes to Roquero General Hospital for his check-ups.
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A3. FAMILY HEALTH HISTORY
The patients father is hypertensive which he inherited together with his youngest brother. He has 5 children (3 boys, 2 girls). His
first and fourth child has asthma which they inherited from their grandmother (mothers side). The patient is the only one in the family
who had a chronic calculous cholecystitis.
A4. SOCIAL HISTORY
Patient P.S is a High school graduate from Marcelo H. Del Pilar National High school. His occupation is a jeepney driver. Hes the
bread winner of his family. He drinks 2-3 bottles of San Miguel a week and smokes 4-5 sticks of cigarette per day. The patient does not
participate in any sports, exercises or routine. Patient is a Roman Catholic who usually goes to church every Sunday or whenever
possible to attend the mass or even just to offer a prayer. He have 5 children and they are all close to each other. They all live in Bulacan. Patient
is a very active and friendly person. He loves to socialize with his friends in their neighborhood during his free time. He considered his self as a holistichuman being as long as hes complete, healthy and his family is always there for him. Patient puts his self to sleep by watching primetime television
programs. He does not have usual time of sleep. He sleeps for a long period of time.
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GENOGRAM
Father Mother Father Mother
Asthma hypertension
v
Brother Sister Wife Sister Patient Sister Sister Brother Sister
Brother
Asthma Asthma hypertension
hypertension
Chronic Calculos Cholecystitis
39 yrs old
Asthma Asthma
Wifes side
Patients side
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The patient, his father and his youngest brother is hypertensive
The patient is married to Ms. AN on June 8 1995. He is a high school graduate from Marcelo H. Del Pilar Natinal High
Shool, Bulacan. They live in the same household together with his parents. They have five children. He is the only one in
his family who got Chronic Calculous Cholecystitis.
Two of his children got asthma from their mother side.
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B.Risk Factors Associated with Disease
B1. Non- modifiable
Age
B2. Modifiable Risk Factors
lifestyle
high- fat diet (chicharon, meat specially pork)
Drinking liquor
Smoking
Fond of eating salty foods
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III. PHYSICAL ASSESSMENT
GENERAL SURVEY:
The patient was admitted at East Avenue Memorial Medical Center Male Surgical Ward Room4019D.The patientt appeared
weak with yellowish skin color. His hair is well groomed and no body odor being noted during assessment. He is cooperative and
responds to questions appropriately with weak voice and low tone.
Initial Assessment: Taking of Vital Signs
DATE OF ADMISSION: July 5, 2011 (Tuesday)DATE OF ASSESSMENT: July 8, 2011 (Friday)
DIET: NPO
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PRE OPERATIVE
Vital Sign TechniqueNormal
FindingsActual findings Analysis Interpretation
Temp Digital
Thermometer
via Axilla
35.8-37.0C 37.2C Normal The normal axillary
temperature is
between 35.8 to
37.0C
(Udan, 2009, p.249).
In other literature,
the usual range of
normal is 36.0 to
37.8 [without routes
indicated].
(Kozier, 2008, p.528)
Pulse Rate Taken in radial
artery (thumb
side of the
inner aspect of
the wrist)
60-100bpm 80bpm, regular
rhythm, normal
strength,
bilaterally equal
on radial pulses
Normal The normal pulse
rate for adults is
between 60 to 100
beats per minute.
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(Udan, 2009, p.251)
Respiratory
Rate
Inspection of
the rise and fall
of chest cavity
over 1 minute
12-20 cpm 32cpm Elevated RR Tachypnea is rapid
respiration above 20
breaths per minute
in an adult.
(Udan, 2009, p. 253)
Due to abdominal
pain
B/P
Rate
Auscultation
and BP
apparatus, left
arm
Systolic:
90-120 mmHg
Diastolic
60-80mm Hg
150/90mm Hg Hypertensiv
e
Factors associated
with hypertension
include thickening
of the arterial walls,
which reduces the
size of the arterial
lumen, and
inelasticity of the
arteries as well as
such lifestyle factors
cigarette smoking,
heavy alcohol
consumption, lack of
physical
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Appearance and mental status
Assessment Techniques Normal findings Actual findings Analysis
Body built, height and
weight
Inspection Proportionate
BMI= 18.5-24.9
Proportionate
BMI= 24.5
Within Normal Range
Posture Gait, standing,
seating and walking
Inspection Relaxed, erect posture;
coordinated movement
Patient is lying on bed in
a fetal position
Due to RUQ pain
Over all hygiene and
grooming body and
breath odor
Inspection No body order or minor
body odor relative to
work or exercise; no
breath odor
No presence of body or
breath odor noted;
patient is well groomed
and neat appearance
Normal
Signs of distress in
posture or facial
Inspection No distress noted With facial grimace Due to RUQ pain
exercise,high blood
cholesterol level and
continued exposure
to stress
Ref. Fundamental by
Kozier 8th
edition, p.
552
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expression
Quantity of speech;
quality and organization
Inspection Understandable,
moderate phase, clear
tone and inflection;exhibits thoughts
association
With weak voice and
low tone.
Patient cant speak
clearly because he was
disturbed by the pain hefelt
Obvious signs of health
or illnesses
Healthy appearance Patient is jaundice and
exhibited signs of
weakness; there are no
visible lessions noted
Jaundice or icterus, is
the yellow pigmentation
of the sclerae, skin, and
deeper tissues caused
by excessive
accumulation of bile
pigments in the blood. It
is a common
manifestation of a
variety of liver and
biliary diseases and
serves as a starting
point for evaluating
many of these disorders
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Integumentary (skin)
Body part Technique used Normal findings Actual findings Analysis
Color
Uniformity of color
Inspection
Inspection
Varies from light to deep
brown, from ruddy pink to
light pink, from yellow
overtones to olive
Generally uniform except
for those areas exposed
to sun, pigmentation.
Yellowish
Yellowish
Jaundice appears when
there is an obstruction in
the common bile duct. It
results from the impaired
bilirubin transport and
excretion in the biliary
system. In this case, the
problem arises from
obstruction of an extra
hepatic bile duct by
gallstones.
Ref. Medical- Surgical
Nursing 6th
Edition Vol.2, by
Joyce M. Black
Skin moisture Inspection
Palpation
Moisture in the skin folds
and axillae.
Moisture skin Normal
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Skin
temperature
Skin turgor
Skin Itching
Inspection
Palpation
Inspection
Palpation
Inspection
Uniform within the normal
range.
When the skin is pinched,
brings back to previous
state.
Skin temperature is
uniform throughout the
body.
Poor skin turgor
(+) Pruritus
Normal
This indicate that the person
is dehydrated
(+) vomiting
Ref. Fundamental by Kozier
p. 580
Pruritus is the most
common skin symptoms;
occurs with dry skin, aging,
drug reactions, allergy,
obstructive jaundice,
uremia. Presence or absence
of pruritus may be
significant for diagnosis.Scratching may cause
excoriation of primary
lesion.
Ref. Physical Examination
and Health Assessment 3rd
Edition by Carolyn Jarvis,
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p.218)
Integumentary (nails)
Body part Technique used Normal findings Actual findings AnalysisFingernail plate
shape and
curvature
Fingernail and toenail
texture and color
Inspection
Inspection
Palpation
Convex
structure and
160
Smooth
Texture and color
Convex
structure and
160
Smooth in texture, and
slowly returns to pink or
usual color upon
performing blanch test
Normal
Due to low hematocrit value
usually indicates the person
has anemia
(fundamental by Kozier,
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of capillary refill. p.800)
Arterial insufficiency
(fundamental by Kozier,
p.800)
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Head
Body part Technique used Normal findings Actual findings Analysis
Skull Inspection
Palpation
Smooth, no lumps,
Absence of nodules or
masses, No area of
tenderness,Symmetrical
with protrusions on the
lateral part of parietal
forehead and occipital
bone.Rounded, andnormocephalic and
symmetrical.
Smooth, no lumps,
absence of nodules or
masses, no area of
tenderness, symmetrical,
rounded, and
normocephalic
Normal
Scalp Inspection
Palpation
Lighter in color than
complexion, no scars, no
lesions, no masses, no
depression upon
palpation.
Lighter in color than
complexion, no scars is
noted, no lesions, no
masses, no depression
upon palpation. No nits,
no lice and no dandruff
Normal
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Hair Inspection Evenly
distributed
hair Black or Brown in
color, hair is evenly
distributed, No area of
baldness, thick,
fine.Curly/kinky/straight,
Dry/oily/shiny hair
Black in color, straight
hair and evenly
distributed
Normal
Face Inspection Appearance, symmetrical
facial expressions and well
coordinated facial
movements.
Facial Grimace.
aundice.
Facial grimace due to his
pain at right upper
abdominal quadrant.
Jaundice appearance is
cause by excessive
accumulation of bile
pigment in the blood. It is
common manifestation of a
variety of liver and biliary
diseases and serve as a
starting point for evaluatingmany of this disorder (Med-
surg black, p.1135)
Eyes
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Body part Technique used Normal findings Actual findings Analysis
Eyebrows
Eyelashes
Inspection
Inspection
Hair evenly
distributed; skin intact
Equally
distributed,
curled slightly
outward
Hair evenly
distributed,
aligned, color black andwell-coordinated
movement
Evenly
distributed
and slightly curved
outward.
Normal
Normal
Eyelids Inspection Skin intact, no discharge,
no discoloration.
Lids close symmetrically.
Approximately 15 to 20
involuntary blinks per
minute; bilateral blinking
-Skin is intact and lids
close symmetrically. The
eyelids blink within the
normal range
Normal
Conjunctiva Inspection Shiny, smooth, moist,
pinky, shiny, with visible
blood vessels and no
discharge
Yellowish Resulting from the
increased levels of bilirubin
in the blood
(hyperbilirubinemia)
Reference (Virginia L.
Cassmeyer p.1496)
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Body part Technique used Normal findings Actual findings Analysis
Sclera Inspection Appears white,clear
and vascular
yellowish Deviationfrom normal due
to effect of bilirubin in the
blood stream.
Reference (Virginia L.
Cassmeyer p.1496)
With yellowing of the sclera
of the eyes resulting from
the accumulation of the bile
pigments in those tissues.
(essentials of anatomy and
physiology by seely page
474)
Sclera of the eye, which
contains considerable elastic
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fiber in which jaundice can
be affected because
bilirubin has a special
affinity for elastic tissue.
(Pathophysiology by
Lipincott, Page 850, Fourth
Edition)
Cornea Inspection Transparent, shiny and
smooth; details of the iris
are visible
Transparent, shiny and
smooth.
Normal
Iris Inspection No shadows of light, brown
and no cloudiness.
Symmetrical, round,
transparent/ shiny
No shadows of light,
brown and no
cloudiness. Symmetrical
round, transparent and
shiny
Normal
Pupil Inspection 3mm-7mm in diameter.
Black in color, equal in size,
round, smooth border.
illuminated pupil constricts
while non
The technique used is
Direct and Consensual
reaction to light. 3mm-
7mm in diameter. Black
in color, equal in size,
round, smooth border.
Illuminated pupil
constricts while
Normal
normal
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illuminated dilates
Pupil constricts
when looking near object
while when looking distant
objects, it dilates.
non illuminated
dilates
Pupil constricts
when looking near
object while when
looking distant
objects, it dilates
Extra ocular
Muscles
Visual Fields
Inspection
Inspection
Both eyes are
coordinated,
move in unison
with parallel
alignment
When looking straight
ahead, client can see
objects periphery.
Both eyes are
coordinated,
move in unison
with parallel
alignment
When looking straight
ahead, client can
partially see objects
periphery. 20/20 both
eyes
Normal
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Ears
Body part Technique used Normal findings Actual findings Analysis
Auricles Inspection
Palpation
Color same as
in facial skin
Auricle is aligned in with
the outer canthus of eye
Mobile, firm, and not
tender;
pinna recoils
back after it is
folded
Ear lobes are bean
shaped, parallel and
symmetrical.
The upper connection is
parallel with the outer
canthus of the eye same
in color as complexion,
no lesions.
Has a firm cartilage.
Pinna
recoils when
folded. No pain or
tenderness.
normal
External ear
canal and
Tympanic
membrane
Inspection Contains hair
follicles, moist waxy
cerumen and no foreign
body
Presence of wet
cerumen in both ear, no
skin
lesions, no pus
and no blood and have
presence of hair follicles
Normal
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Nose
Body part Technique used Normal findings Actual findings Analysis
Nose
Nasal
Cavities
Nasal
Septum
InspectionPalpation
Symmetric,straight, uniform in color,
No discharge or flaring, no
tenderness, no lesions,
presence of cilia
Not tender, no
lesions, mucosa is pink,
clear and no lesions
Intact and in
midline
Uniform in colorin facial skin,
straight, presence of cilia
and no
discharge
No swelling, no presence
of discharges. No
lesions and pink
mucosal layer
Intact between the nasal
chambers
normal
Normal
Normal
Normal
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Patency
Sinuses
Air moves freely when
breathing
No tenderness on maxillary
and frontal sinuses
Patency shallow
breathing
No tenderness on
maxillary and
frontal sinuses
Due to abdominal pain
Normal
Mouth
Body part Technique used Normal findings Actual findings Analysis
Lips Inspection Uniform pink in
color, soft,
moist, smooth texture,
symmetry of contour,
ability to purse lips and no
tenderness
symmetrical, dark in
color
Abnormal findings due to
poor
oral hygiene, smoking
caused by nicotine.
- Fundamentals of Nursing
by
Taylor,Lillis,LeMone,
Copyright
2005, (p.583)
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Buccal
Mucosa
Inspection
Palpation
Pinkish in
color, Moist,
smooth, and
elastic
structure, no
lesions
Pinkish in
color, Moist,
smooth, and
elastic
structure, no
lesions
Normal
Teeth Inspection 32 adult teeth,
smooth and
white
Has incomplete adult
teeth 18 (10 teeth at the
upper area of the mouth
and 8 teeth at the lower
part)
with yellow
discoloration
of teeth. Presence of
tartar
Dark in discoloration of
teeth due to cigarette
smoking. Nicotine plays a
part in discoloration of
teeth.
- Fundamentals of Nursing
by
Taylor,Lillis,LeMone,
Copyright
2005, (p.583)
Gums
Tongue /
Floor of the mouth
Inspection
Inspection
Palpation
No retraction of gums and
bleeding, pinkish in color.
Central position, pinkish in
color, no lesions and raised
papillae. It has prominent
No retraction of gum,
bleeding and moist. Dark
discoloration
Central position, whitish
in color, no lesions and
Dark discoloration due to
smoking, nicotine plays a
part in discoloration of the
gums.
A white coating on the
tongue from poor oral
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veins
Moves freely and no
tenderness,
smooth with no
palpable nodules
raised papillae. It has
prominent veins.
Moves freely and
no tenderness,
smooth with no
palpable nodules
hygiene, irritation and
smoking.
- Fundamentals of Nursing
by Taylor, Lillis, LeMone,
Copyright 2005, (p.583)
Palates
Uvula
Inspection Light pink, smooth palate.
Lighter pink
in hard palate than soft
palate
Positioned in the midline of
soft palate.
Palate: Yellowish soft
and hard palate
Uvula: moist, moist,
smooth texture
Jaundice is first noted in the
unction in the hard and soft
palate in the mouth and
sclera. It is due to rising
amounts of bilirubin in the
blood.
Ref. Physical Examination
and health Assessment 3rd
Edition by Carolyn Jarvis
p.225
Pharynx and Tonsils Inspection
Palpation
Tonsils, no discharge, pink,
smooth.
Tonsils, no discharge,
pink, smooth.
Normal
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Neck and Lymph nodes
Body part Technique used Normal findings Actual findings Analysis
Neck Muscles
Move the chin to the
chest
Move the head back so
that the chin points
upward.
Move the head so that
the ear is moved toward
the shoulder on each
side.
Turn the head to the
right and to the left
Inspection
Inspection
Inspection
Inspection
Inspection
Muscles equal in size; headcentered.
Head flexes 45
Head laterally 60
Head laterally
flexes 40
Head laterally
flexes 70
Muscles equal in size;head
centered.
Head flexes 45
Head laterally 60
Head laterally
flexes 40
Head laterally
This determines thefunction of the
sternocleidomastoid
muscle.
This determines thefunction of the trapezius
muscle.
This determines the
function of the
sternocleidomastoid
muscle.
This determines the
function of the
sternocleidomastoid
muscle.
- Fundamentals of Nursing
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flexes 70 8th edition vol. I by Kozier
& Erbs, Copyright 2008
(p.607)
Body part Technique used Normal findings Actual findings Analysis
Muscle Activity
Range of Motion
Inspection
Inspection
Equal strength
In both sides
Can perform freely
Decrease of strength
and tone
Cant perform freely
Due to lack of activities
Due to his presence
condition and pain felt by
the client
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Lymph Nodes Inspection
Palpation
All lymph
nodes are not
palpable
No palpable lymph nodes. Lymph nodes are small oval
clumps of lymphatic tissue
located at intervals along
the vessels. Most nodes are
arranged in groups, both
deep and superficial in the
body.
Ref. Physical Examination
and Health Assessment 2nd
Edition by Carolyn Jarvis, p.
574
Trachea Palpation Central
placement in
midline of the
neck
Central
placement in
midline of the
neck
A tube-like portion of the
breathing or "respiratory"
tract that connects the
"voice box" (larynx) with
the bronchial parts of the
lungs.
- Fundamentals of Nursing
8th edition vol. I by Kozier& Erbs, Copyright 2008
(p.608)
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Thyroid Gland Inspection
Palpation
Not visible in
inspection. Gland ascends
during swallowing.
lobes may not be palpated.
Not visible in
inspection.
No nodules noted upon
palpation
No indication of
hyperthyroidism,
hypothyroidism or endemic
goiter.
Ref. Fundamental of
Nursing 7th
Edition by
Kozier
Upper Extremities
Body part Technique used Normal findings Actual findings Analysis
Skin Inspection No presence of edema, skin
lesions.
No presence of edema
and skin lesions.
Yellowish in color
Jaundice is due to an
abnormally high
accumulation of bilirubin in
the blood, as a result of
which there is a yellowish
discoloration of the skin.
Jaundice develop when theplasma contains about
twice the normal amount
of bilirubin.
(Pathophysiology, Lipincott,
Page 850, Fourth Edition)
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Muscle Strength and
tone
Inspection
Palpation
Equal strength on each
body side
Decrease of strength and
tone
Due to lack of activity
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Joint range of motion Inspection Flexion:
Decreasing the angle of the
oint
Extension:
Increasing the angle of the
oint
Normal full movement of
oint.
Normal full movement of
oint.
The range of motion (ROM)
of a joint is the maximum
movement that is possible
for that joint. Joint range of
motion varies from
individual to individual and
is determined by genetic
makeup, developmental
patterns, the presence or
absence of disease, and the
amount of physical activity
in which the person
normally engages.
- Fundamentals of Nursing
8th edition vol.2 by Kozier
& Erbs,
Copyright 2008 (p.1107)
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Thorax
Body part Technique used Normal findings Actual findings Analysis
Posterior
Thorax
Inspection Chest
symmetric,
transverse
diameter of 3:5 skin intact;
uniform temperature, chest
wall intact
Anteroposterior
to transverse
diameter on ratio of 3:5;
chest symmetric
Normal
Respiratory
Excursion
Inspection
Palpation
Full/symmetric
chest expansion
Symmetric chest
expansion.Chest expand for about 3-
4 cm.
Normal
Percuss
Posterior
Thorax
Percussion Percussion notes resonate,
except over scapula
Resonance
/flatness over the lung
during percussion was
heard.
Normal
Auscultate
Posterior
Thorax
Auscultation Vesicular and
bronchovesicular breath
sounds
Vesicular and
bronchovesicular breath
sound
Vesicular breath sounds are
soft, low pitch sound, heard
best over base of the lungs
during inspiration, which is
longer than expiration.
Bronchovesicular are heard
over the main stem
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bronchus and are Moderate
blowing sounds, with
inspiration equal to
expiration.
- Fundamentals of Nursing
by
Taylor,Lillis,LeMone,
Copyright
2005, (p.587)
Body part Technique used Normal findings Actual findings Analysis
Breathing
patterns and sound
Inspection Quiet, rhythmic
and effortless
respiration
Shallow breathing Because of abdominal pain
Repiratory
Excursion
Inspection
Palpation
Full/ symmetric
Chest expansion
Symmetric chest, expand
for about 3-4cm
Full symmetric excursion;
thumbs normally separate 3-
5 cm.
- Fundamentals of Nursing
8th
edition vol.1 by Kozier &
Erbs,
Copyright 2008, (p.578)
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Percuss
Anterior
Thorax
Percussion Percussion notes
resonate down to sixth rib
at the level of diaphragm
but flat over areas of heavy
muscles and bone, dull on
areas over the
heart and liver,
tympanic over
the underlying
stomach
Resonance sounds which
is moderate and low, flat
sounds on the areas of
muscles and
bone, dull on the heart
and
liver and loud
tympanic on
the stomach
Normal- symmetry
percussion sounds on the
anterior thorax.
When a normal air filled
lung is percussed, the sound
is hollow, loud, low in pitch
and long of duration. This
percussion tone is known as
resonance. A flat tone is
heard over a bony or well
developed muscle tissue.
- Fundamentals of Nursingby
Taylor,Lillis,LeMone,
Copyright
2005, (p.586)
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Body part Technique used Normal findings Actual findings Analysis
Auscultate the aortic,
pulmonic,
tricuspid, and apicalvalve
Auscultation Usually heard at all sites
dystole:
silent interval;slightly shorter
duration than
diastole at normal heart
rate
Diastole:
silent interval;
slightly longer
duration than
systole at normal heart
rates
Usually heard at all sites
systole: silent interval;
slightlyshorter duration than
diastole at
normal heart
rate
Diastole:
silent interval;
slightly longer
duration than
systole at normal heart
rates
The normal first two heart
sounds are produced by
closure of the valves of theheart.
S is louder at the tricuspid
and apical areas and its a
dull, low pitched sound
described as lub. S
occurs at the termination
of systole and corresponds
to the onset of ventricular
diastole. Its louder at the
aortic and pulmonic areas
and has a higher pitch
than S and is shorter in
duration and sound as
dub.
- Fundamentals of Nursing
by
Taylor,Lillis,LeMone,
Copyright
2005, (p.591)
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- Fundamentals of Nursing
8th
edition vol.1 by Kozier &
Erbs,
Copyright 2008, (p.619)
Axillary Inspection
Palpation
no tenderness,
no masses, no
nodules
no tenderness,
no masses, no
nodules
The nodes are generally
not palpable; if palpable,
they should be small,mobile, smooth, and
nontender.
- Fundamentals of Nursing
by
Taylor,Lillis,LeMone,
Copyright
2005, (p.591)
Abdomen
for skin
integrity
Inspection
palpation
Unblemished
skin, uniform
color
Jaundice
(+) edema
Increased level of bilirubin
Due to water retention,
the liver and kidney are
compensated
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Body part Technique used Normal findings Actual findings Analysis
Abdominal
Contour
Inspection )No evidence of
enlargement
of the liver andspleen
Symmetric
Contour
Symmetric contour Normal
Movements Inspection Symmetric
movement
Slowed movements Limited movements be
due to pain
Vascular
Pattern
Inspection No vascular
pattern
No visible
vascular
pattern
Normal
Auscultation
of theabdomen
Auscultation Audible bowel
sounds, absence of arterialbruits,
absence of friction rub
Audible bowel
sounds, absence of arterialbruits, absence of friction
rub
They are heard as clicks
and gurgles & usuallyoccur every 5-20 seconds.
Bruits are low-pitched,
murmur-like sounds that
occur when blood flow of
an artery is obstructed.
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- Fundamentals of Nursing
by
Taylor,Lillis,LeMone
(p.596)
Muscoloskeletal System
Body part Technique used Normal findings Actual findings Analysis
Muscle size Inspection Equal size in both sides of
the body
Equal size in
both sides of
the body
Muscles groups are
observed forbilateral
symmetry. Normally, they
are symmetric in size.
- Fundamentals of Nursing
by
Taylor,Lillis,LeMone,
Copyright
2005, (p.597)
Muscle tremors Inspection No tremors No tremors Normal
Body part Technique used Normal findings Actual findings Analysis
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Muscle activity
Range of motion
Inspection
Inspection
Equal strength
In both sides
Can perform freely
Weak muscle
Limited movements
Due to his condition and
pain felt by the patient
Due to his present
condition and pain felt by
the patient
Bone
Structures
Bone
Tenderness
Inspection
Palpation
No deformities
No swelling,
no tenderness
No deformities
No swelling,
no tenderness
Bones is assessed for
normal form. Bones is
dense, hard and
somewhat flexible
connective
tissue constituting the
bones of the human
skeletal & it has normal
findings.
- Mosbys Pocket
Dictionary of
medicine, nursing & health
professionals (p.189)
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Neurologic System
Body part Technique used Normal findings Actual findings Analysis
NeurologicSystem
Inspection Good sensation, reflexes,speech and oriented with
time place and persons.
Good sensation, reflexesand oriented with time,
place and persons
Normal
Lower Extremities
Body part Technique used Normal findings Actual findings Analysis
Skin Inspection No presence of edema, skin
lesions.
No presence of edema, no
visible bleeding and no
discharge seen.Yellowish in color.
Jaundice is due to an
abnormally high
accumulation of bilirubin Ithe blood, as a result of
wich there is a yellowish
discoloration of the skin.
Jaundice develop when
the plasma contains about
twice the normal amount
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of bilirubin.
(Pathophysiology,
Lipincott, Page 850, Fourth
Edition)
GENITALIA: the patient refuses to be assessed
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Post-operative
Vital Sign TechniqueNormal
FindingsActual findings Analysis Interpretation
Temp Digital
Thermometer
via Axilla
35.8-37.0C 37.2C Normal The normal axillary
temperature is
between 35.8 to
37.0C
(Udan, 2009, p.249).
In other literature,the usual range of
normal is 36.0 to
37.8 [without routes
indicated].
(Kozier, 2008, p.528)
Pulse Rate Taken in radial
artery (thumbside of the
inner aspect of
the wrist)
60-100bpm 80bpm, regular
rhythm, normalstrength,
bilaterally equal
on radial pulses
Normal The normal pulse
rate for adults isbetween 60 to 100
beats per minute.
(Udan, 2009, p.251)
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Respiratory
Rate
Inspection of
the rise and fall
of chest cavity
over 1 minute
12-20 cpm 20cpm Normal Normal respiration
is between 12-20
Cpm in adults.
(Udan, 2009, p. 253)
B/P
Rate
Auscultation
and BP
apparatus, left
arm
Systolic:
90-120 mmHg
Diastolic
60-80mm Hg
130/80mm Hg Normal The normal blood
pressure is a systolic
pressure of 90-120
mmHg. and it is
diastolic between
60- 80mmHg.
(Udan, 2009, p. 253)
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POST OPERATIVE
General appearance
Method Normal finding Actual finding Analysis
Psture and gait InspectionObservation
Relaxed, erect posture,coordinated movement
Slouched,uncoordinated
movement
Deviation from normaldue to the pain @ the
incision on the right
upper quadrant of the
abdomen
Signs of Distress Inspection and
Observation
No signs of illness or
disease
Appears weak with
facial grimace
and guarding behavior
Deviation from normal
due to present
condition; Post
cholecystectomy
Emotional Status Inspection No facial grimace (+) facial grimace Deviation from normaldue to pain at the site of
incision at right upper
quadrant of the
abdomen
Affect/mood,
appropriateness of
Responses
Inspection Appropriate to the
situation
Responses are
appropriate to the
situation; irritated
Deviation from normal
due to pain at the site of
incision at right upper
quadrant of the
abdomen.
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Physical Assessment
Color Inspection Uniform in color Yellowish discoloration Deviation from normal
due to the effect ofbilirubin that is still
present at the blood
streams.
Presence of Edema Inspection and
Palpation
Absence of Edema (+) peripheral edema Deviation from normal
due to water retention
caused by fluid shifting
from intracellular to
intravascular.
Presence of Lesions Inspection No Lesions With incision at the rightupper
quadrant of abdomen
Deviation from normaldue to status post
cholecystectomy
Color Inspection Sclera appears white Yellowish Deviation from normal
due to effect of bilirubin
in the blood streams
Breathing Pattern Inspection Rhythmic; effortless Use of accessory
muscles upon
breathing; shallow
breathing
Deviation from normal
due to pain
(compensatory
mechanism)
Skin integrity Inspection Unblemished skin;
uniform color
Impaired skin integrity
with
incision on the right
upper
quadrant
Deviation from normal
due to Cholecystectomy
on the right upper
quadrant of the
abdomen.
Bowel sounds Auscultation Audible bowel sounds Hypoactive bowel
sounds
Deviation from normal
due to status post
cholecystectomy
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Areas of tenderness Palpation No tenderness; relaxed
abdomen
Presence of tenderness Deviation from normal
due to status post
cholecystectomy
CONTRAPTIONS
Body part Tecnique used Normall findings Actual findings Analysis
Genitalia Folley catheter is noted This tubing is then
advance until it reaches
the bladder.performed
to drain urine from the
bladder or to instill
solution into the bladder.
To drain the urine of thepatient who in
trautamized tp prevent
infection or bacteria into
the organ.
(Fundamental by Kozier)
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IV.DEFINITION OF THE DISEASE
Calculous cholecystitis is caused by obstruction of stone in the bile duct leading to inflammation of the gallbladder. The
gallbladder is an organ which aids in the digestive process. Its function is to store and concentrate bile. The bile in turn emulsifiesfats and neutralizes acids in partly digested food. Despite its importance in the digestion of fat, many people are unaware of their
gallbladder. Fortunately enough, the gallbladder is an organ that people can live without. Perhaps, this fact contributes to the laxity
of the majority. The gallbladder tends to be taken for granted or ignored of the proper care and conditioning. Lifestyle together with
heredity, sex, race and age are just some factors that leave a room for gallbladder complications to occur. Gallstone disease is a
disease of hepato-biliary system, caused by cholesterol and/or bilirubin metabolic disorder, and characterized by formation of
stones in the gallbladder and/or the biliary tract.
Gallstones are categorized as cholesterol, mixed, black pigment, or brown pigment stones. Cholesterol gallstones are the
main type of gallstones and contain cholesterol as the major chemical constituent. Mixed cholesterol gallstones are composed of
more than 50% cholesterol. Cholesterol and mixed gallstones are formed from biliary sludge, which stays for a long time in the
gallbladder lumen. Biliary sludge consists of calcium bilirubinate granules, cholesterol monohydrate crystals, and biliary polymerized
glycoprotein mucin. The dynamics of the transformation of biliary sludge into cholesterol stones has been shown as follows: diffused
biliary sludge surface biliary sludge precipitating biliary sludge a cholesterol gallstone without acoustic shadow. The time of
formation of cholesterol stones depends on the intensity of the precipitation processes of cholesterol monohydrate crystals in biliary
sludge, and equals 3 to 36 months. Transformation proportion varies from 5 to 50% depending on the cause. Black pigment stones
are composed of either pure calcium bilirubinate or polymer-like complexes consisting of calcium, cooper, and large amounts of
mucin glycoproteins. Brown pigment stones are composed of calcium salts of unconjugated bilirubin, with varying amounts ofcholesterol and protein. These stones are usually associated with infection.
The natural history of gallstones is typically defined in two separate groups of patients: those with symptomatic gallstones
and those who are asymptomatic. The vast majorities of gallstones are asymptomatic and remain asymptomatic. As a rule, gallstone
disease is asymptomatic, which is called silent stones. The rate of development of biliary pain is approximately 2% per year for 5
years and then decreases over time. The incidence of complications in patients with asymptomatic stones is low, and prophylactic
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removal of the gallbladder for this condition is not necessary. Patients who had an episode of uncomplicated biliary pain in the year,
38% per year had recurrent biliary pain. An incidence of recurrent biliary pain as high as 50% per year in those with symptomatic
gallstones. 30% of patients with one episode of biliary pain will not have a recurrent episode. The estimated risk of developing biliary
complications is estimated to be 1% to 2% per year and is thought to remain relatively constant over time .
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V.Anatomy and Pathophysiology
LIVER
Largest organ in the body Lies under the diaphragm; occupies most of the right hypochondrium and part of the epigastrium. Weighing 1.5 kgs.
LIVER LOBES AND LOBULES
The liver has two lobes, separated by the falciform ligament Left lobe- about one sixth of the liver Right lobe- about five sixth of the liver.
BILE DUCTS
Right hepatic duct- drains bile from the right functional lobe of the liver
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Left hepatic duct- drains bile from the left functional lobe of the liver Common hepatic duct-is the duct formed by the convergence of the right hepatic duct and the left hepatic duct ; Length:
Usually 6 8 cm. Approximate width:
6 mm in adults; merges with cystic duct to form common bile duct, which opens into the duodenum.
Cystic duct- is the short duct that joins the gall bladder to the common bile duct. Common bile duct- formed by the union of the common hepatic duct and the cystic duct (from the gall bladder).
FUNCTIONS OF THE LIVER
The liver stores a multitude of substances, including glucose (in the form of glycogen), vitamin A (1 2 years' supply), vitaminD (1 4 months' supply),
vitamin B12, iron, and copper.Glucose metabolism- after meal, glucose is taken up from the portal venous blood by the liver and converted into glycogen
(glycogenesis), which is stored in
the hepatocytes. Glycogen is converted back to glucose (glycogenolysis) and release as needed into the blood stream tomaintain normal level of the blood
glucose Ammonia conversion- use of amino acid from protein for glycogenesis results in the formation of ammonia as a byproduct.
Liver converts ammonia to urea.
Protein metabolism- liver synthesizes almost all of the plasmas protein including albumin, alpha and betaglobulins, bloodclotting factor plasma lipoproteins.
Fat metabolism- fatty acid can be broken down for production of energy and production of ketone bodies. Bile formation- bile is formed by the hepatocytes
Composed of water, electrolytes such as sodium, potassium, calcium, bicarbonate, lecithin, fatty acids, cholesterol,bile salts
Collected and stored in the gallbladder and emptied in the intestine when needed for digestion.BILE
Bile is the greenish-yellow fluid (consisting of waste products, cholesterol, and bile salts) that is secreted by the liver cells toperform two primary functions,
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including the following: to carry away waste to break down fats during digestion Bile salt is the actual component which helps break down and absorb fats. Bile, which is excreted from the body in the form
of feces, bile gives feces its dark brown color.TRANSPORT BILE
1. When the liver cells secrete bile, it is collected by a system of ducts that flow from the liver through the right and left hepatic
ducts.
2. These ducts ultimately drain into the common hepatic duct.
3. The common hepatic duct then joins with the cystic duct from the gallbladder to form the common bile duct, which runs from the
liver to the duodenum (the
first section of the small intestine).
4. However, not all bile runs directly into the duodenum. About 50 percent of the bile produced by the liver is first stored in thegallbladder, a pear-shaped
organ located directly below the liver.
5. Then, when food is eaten, the gallbladder contracts and releases stored bile into the duodenum to help break down the fats.
GALLBLADDER
The gallbladder is a small organ whose function in the body is to store bile and aid in the digestive process. A hallow pear- shaped sac from 7- 10 cm (3-4 inches) long and 3 cm broad. It consists of a fundus, body and a neck. Fundus - the lower free and the expanded end of the Gall bladder. Body - the body of the gall bladder is the portion that is lying between that of the fundus and also the neck. The direction of
the body is upwards, backwards,
and to the left. Neck- takes a turn and becomes downwards and backwards. It can hold 30 to 50 ml of bile. right lobe and attached there by areolar connective tissue.
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The cystic duct connects the gallbladder to the common hepatic duct to form common bile duct.FUNCTION OF THE GALLBLADDER
Stores bile enters to the gallbladder by way of the hepatic and cystic duct. During this time the gallbladder concentrates bile five
folds to ten folds. Then later whendigestion occurs in the stomach and in the intestines, the gallbladder contracts, ejecting the concentrated bile into the duodenum.
Jaundice, a yellow discoloration of
the skin and the mucosa, results when obstruction of bile flow into the duodenum occurs. Bile is thereby denied its normal exit from
the body in the feces. Instead, it
absorbed in the blood, and an excess of bile pigments with a yellow hue enters the blood and is deposited in the tissues.
The gallbladder stores bile, which is released when food containing fat enters the digestive tract, stimulating the secretion of
cholecystokinin (CCK). The bile,
which is produced in the liver, emulsifies fats and neutralizes acids in partly digested foods.
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Pathophisiology
Book base
Concentration and storage of bile
Stasis of bile
Stone formation
Obstruction of bile flow
Smooth muscle contractions
Impairment of fat absorption
Acute or chronic inflammation or infection of gallbladder
perforation
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Reference (Virginia L. Cassmeyer p.P1500)
VI. Diagnostic Procedure
COMPLETE BLOOD COUNT
COMPONENT NORMAL FINDINGS ACTUAL FINDINGS INTERPRETATION
WBC Count 5- 10 X 10q/L 10.9 WBC is slightly elevated based
on the normal value which
confirms the presence of
infection
HEMATOCRIT 0.40-0.50 0.38 A low hematocrit value usually
indicates the person has
anemia, overhydration,
hyperthyroidism, and dietary
deficiency.
(Fundamentals of Nursing by
Kozier, page 759)
. Hematocrit is the one that
control the level of space
(volume) red blood cells takes
up in the blood.
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NEUTROPHILS 55-70 50 A low neutrophils indicate that
the person has Aplastic
Anemia, dietary deficiency,
radiation therapy.
(Fundamentals of Nursing byKozier, page 759)
Neutrophils are one of the
first-responders of
inflammatory cells to migrate
towards the site of
inflammation
LYMPHOCYTES 20-40 40 The lymphocytes helps
provide a specific response to
attack the invading organisms.
MONOCYTES 2-8 0.6 Monocytes helps the WBC to
remove damage tissues,
destroy cells and regulate
immunity against foreign
substances.
EOSINOPHIL 1-4 0.4 Eosinophils become active
when you have certain allergic
diseases, infections, and other
medical conditions. The result
showed normal level of
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eosinophils.
BASOPHIL 0.5-1 0.5-1 Normal
PLATELETS 150-400x 10/ml 283 Platelets play a fundamental
role in hemostatis and are
natural source of growthfactors. They are involved in
hemostatis leading to the
information og blood clots.
Mean Corpuscular
Volume
80-95 87.9 The result shows MCV is in
normal range,it is measure of
the average red blood cell
volume that is reported as
part of a standard completeblood count.
Mean Corpuscular
Hemoglobin
27-31pg 27.9 The average amount of
hemoglobin (MCH) is
calculated value derived from
the measurement of
hemoglobin and the red cell
count.
Mean Corpuscular
Hemoglobin
Concentration
320-360 g/dl 317 Decrease level may indicate
iron deficiency anemia or
hemoglobinopathy.
(Medical-surgical,Workman,
page 882)
It is a measure of the
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concentration ofhemoglobin
in a given volume of packed
red blood cells. It is reported
as part of a standard complete
blood count.
URINALYSIS
Urinalysis is a physical, microscopic, or chemical examination of urine . The specimen is physically examined for color, turbidity,
specific gravity, and pH. The it is spun in a centrifuge to allow collection of a small amount of sediment that is examined
microscopically for blood cell, casts, crystals, pus and bacteria. Chemical analysis may be done to identify and quantify any of a large
number of substances, most often for ketones, sugar, protein, and blood.
MACROSCOPIC
Result Normal values Interpretation
Color Dark yellow color Straw; amber The excretion of the bile
pigments by the kidney
gives the urine a very
dark color
There is a presence ofpus cells in the urine
which means that there
is also the presence of
infection.
Transparency Clear Clear Normal
Specific gravity 1.013 1.010- 1.025 The result indicated
http://en.wikipedia.org/wiki/Hemoglobinhttp://en.wikipedia.org/wiki/Red_blood_cellshttp://en.wikipedia.org/wiki/Complete_blood_counthttp://en.wikipedia.org/wiki/Complete_blood_counthttp://en.wikipedia.org/wiki/Complete_blood_counthttp://en.wikipedia.org/wiki/Complete_blood_counthttp://en.wikipedia.org/wiki/Red_blood_cellshttp://en.wikipedia.org/wiki/Hemoglobin -
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normal value. Specific
gravity is an indication
of urine concentration,
or the amount of solutes
( metabolic waste andelectrolytes) present in
the urine (Kozier, p.770)
Ph 3.5 4.6- 8 Acidic( decrease pH) is
due to inability of the
kidney to excrete
hydrogen ions.
Associated with the
dehydration, and with adiet high in protein
fruits
(Kozier, p.770)
MICROSCOPIC
RESULT NORMAL VALUES INTERPRETATION
RBC 0.3/ hpf 0-3hpf RBC is only present inglomerulonephritis,
lupusnephritis, urinary tract
disease, and heart failure.
WBC 1.5/hpf 0-4 hpf WBC is only present in acute
UTI, fever and strenuous
exercise.
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Epithelial Cells Many None Epithelial cells in urine indicate
presence of infections,
inflammation and
malignancies.
Bacteria Few None Bacteria are common in urinespecimen because of presence
of infection and their ability to
rapidly multiply in urine.
CHEMICAL TEST
RESULT NORMAL FINDINGS INTERPRATAION
SUGAR Negative Negative The result indicated that thereis no presence of sugar in the
urine. Normally, the amount of
glucose in the urine is
negligible, although individuals
who have ingested large
amount of sugar may show
small amounts of glucose in
their urine.(Kozier,p771)
ALBUMIN Negative Negative Albumin is only presence in
glomerular damage in renal
disease, including
glomerulonephritis, kidney
stones.
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Is a protein produced by the
liver.
(Fundamental by Kozier,8th
edition,p. 803)
CRYSTALS
RESULT NORMAL VALUES INTERPRETATION
Amorphous urates Few None Urates in the urine are
sign that your urine had
gotten solidified
through the process of
dehydration and have
lodge themselves in
your urinary tract.
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SERUM EXAM
TEST NAME RESULTS NORMAL VALUES INTERPRETATION
Alkaline phosphate 187.6-high 50.00-136.00U/L High alkaline phosphate isvaluable in differentiating
obstructive from hepato
cellular jaundice. Alkaline
phosphate level rise with post
hepatic obstruction (obstructive
jaundice) or in intra hepatic
cholestatis hepatocanalicular
jaundice.Cholesterol 6.5-high 0-5.2mmol/L when there is bilary obstruction
the total cholesterol level is
elevated. It is because of the
diet of the patient.
Triglycerides 3.2-high 0.4-1.7mmol/L A high triglycerides level
combined with low HDL
cholesterol or high LDL
cholesterol seems maybegenetics (hereditary) induced
Total protein 76.4 64-82g/L A total serum protein test
measures the total amount of
protein in the blood. It also
measures the amounts of two
major groups of proteins in the
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blood, albumin and globulin.
Albumin 36.6 34-50g/L Albumin helps move many
small molecules through the
blood, including bilirubin,
calcium, progesterone, and
medications. It plays an
important role in keeping the
fluid from the blood from
leaking out into the tissues.
Globulin 39.9-high 30-32g/L Globulin high. Its have a
disturbances in beta lipoprotein
metabolism are seen in patients
with obstructive jaundice.
A/G ratio 0.92-low 1.1-1.6 The usefulness of A/G ratio is
limited, since it gives only the
proportion of the two types of
protein measure.
A/G ratio low. There maybe a
low ratio that might have
occurred because of either anunchanged albumin with an
increased globulin.
Total bilirubin 144.8-high 0.00-17.1Umol/L Increase in conjugated
hyperbilirubinemia may result
from impaired excretion of
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bilirubin from the liver due to
hepato cellular disease, or extra
hepatic biliary obstruction.
Reference: medical-surgicalnursing volume 2, 6
thedition by
joyce black
Indirect bilirubin 25.77-high 12.1-15.1Umol/L Increase level because jaundice
is caused by hepato cellular
dysfunction (hepatitis) results
in elevated the levels of indirect
bilirubin. When the formation
of unconjugated bilirubin
exceeds the liners capacity to
conjugate and excrete it.
Jaundice results the term
hemolytic jaundice is often
used to describe this condition.
AST
Aspartate aminotransferase
236-high 15.00-37.00U/L AST exist in large amounts in
liver and myocardial cells and in
smaller but significant amounts
in kidneys, pancreas and the
brain. Serum AST are usually
associated with hepatocellular
diseases in an acute phase.
ALT 501-high 30-65U/L High ALT because jaundice
patients an abnormal ALT will
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Alanine transaminase incriminate the liver rather than
RBC, hemolysis as a source of
the jaundice. Diseases affecting
the liver parenchyma will cause
a release of this hepatocellularenzymes into the blood stream,
thus elevating serum ALT levels.
COAGULATION REPORT
COMPONENTS RESULT NORMAL VALUES INTERPRETATION
PT
Prothrombine time
12.9 12.9-15.7seconds The test of prothrombine time
determines defects in extrinsicclotting mechanism by
reflecting the activity of
fibrinogen and prothrombine.
INR 0.89 PT evaluation can now be
based on an INR using
standardized thromboplastin
reagent to assist in making
decisions regarding oral anti-
coagulation therapy.
APTT
Activated partial
thromboplastin time
34.0 26-31 seconds Increase in hepato cellular
damage (increase risk for
bleeding)
Control 28.0 Seconds
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TEST NAME RESULT NORMAL VALUES INTERPRETATION
Cholesterol 7.5-high 0-5.2mmol/L When there is biliary
obstruction the total
cholesterol level is elevated. It
is because of the diet of the
patient.
Triglycerides 3.8-high 0.4-1.7mmol/L A high triglycerides level
combine with low HDL
cholesterol or high ADL
cholesterol since may be
genetics (hereditary) induced.
HDL cholesterol 0.45-low 0.91-1.56mmol/L Low HDL cholesterol is a
caused of his obesity and
cholestasis.
LDL 5.3-high 1.89-3.09mmol/L High LDL cholesterol is a
caused of his acute stress and
illness.
COMPONENT INDICATION NORMAL FINDINGS ACTUAL FINDINGS Possible Causes of AbnormalFindings
Creatinine This is the indicator of the renal
function
0.60-1.7mg/dl 1.0 Normal
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Fecalysis Result
MACROSCOPIC
COMPONENTS RESULTS Normal value INTERPRETATION
RBC NONE/ HDF None Normally there is no
red cell in the urine.
WBC 1-2/ HDF Negative It caused by
inflammation of the
intestines, such as a
bacterial infection.
COMPONENTS RESULTS Normal
Value
INTERPRETATION
COLOR Clay colored Brown Absence of bile
pigment (bile
obstruction)
Reference: Kozier
1227
CONSISTENCY Soft Soft
CROSS PLUS Negative Negative
CROSS BLOOD Negative Negative
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REPORT OF ULTRASOUND EXAMINATION
Name: Mr. SP Date: July 06, 2011
Age: 39 years old OPD WARD
Upper Abdominal Sonography
contains two strong shadowing echoes of less than 0.9 cm and two intra abdominal nodules of less than 0.6 cm. Biliary duct
are not diluted. Great vessel are normal in caliber. Para aortic and primary retopenial areas are clear. Gastro intestinal pattern is
unremarkable. Anterior abdominal wall is intact.
Urinary Tract and Prostatic Sonography
Both kidneys are normal in size and echo texture. Right and left kidneys measure 9.8 x3.6 cm and 8.9 x 4.1 cm respectively.
Pelvis and ureters are not dilated. Urinary bladder is physiologically distended with normal anechoeic lumen. Prostate is normal in
size measuring 3.2 x 3.1 x 3.1 cm and weight 17 grams. remainder is unremarkable.
IMPRESSION:
Gallstone, multiple
Gallbladder polyps, multiple
Negative, KUB and prostatic sonography
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VII. Medical Management
ReducePain. Pain may arise from contraction of the gallbladder during transient obstruction of the cystic duct by gallstones.
Analgesic may be administered intramuscularly or intravenously with a patient-controlled analgesia or as needed for pain.
During an acute attack of biliary colic, the client remains on NPO status, with IV fluids administered to maintain hydration(D5LR 1L x
8 @31gtts). The client is advised to avoid foods that precipitate biliary colic.
Antibiotics are administered to reduce the likelihood of infection.
Other medications ordered such as:
Pre- operative Medication:
Omeprazole 4g OD
Ceftriaxone 750mg OD
Tramadol 10 mg !V
Fentanyl 50 mg IV
Mefenamin Acid 500mg (PRN)
Surgical Management
Laparoscopic Cholecystectomy has become the treatment of choice of asymptomatic gallbladder disease. The procedure is suitable
tor most clients, because there is minimal trauma to the abdominal wall.(Med-surgical, Black page 1124)
Cholecystectomy consist of excising the gallbladder from the posterior liver wall and ligating the cystic duct.When stone are
susoected in the common duct, operative cholangioraphy my be performed.(Med-surgical, Black page 1125)
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A conventional open cholecystectomy is indicated when a laparoscopic cholecystectomy does not allow for retrieval of astone in the common bile duct and and when the clients physique does not allow access to the gallbladder.(Med-surgical,
Black page 1125)
VIII. Statement of the Problem
-ineffective breathing patter related to abdominal pain
- Risk For Infection r/t inadequate Primary defenses
-Acute pain r/t inflammation of the gallbladder as evidenced by guarding behavior, facial mask, sleep disturbance, and expressive
behavior such as fetal position.
-risk for bleeding
-fluid and electrolyte imbalance
-risk for aspiration
-hyperthermia
-hypertension
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IX. Nursing Care Plan
Assessment Nursing
Diagnosis
Inference Goal Nursing Intervention Rationale Evaluation
Subject:
Sumasakit
ang tyan ko
kapag
humihinga
ako
Objective:
-Shallow
Breathing
-Respiratory
Rate IS 32
Ineffective
Breathing
Pattern
R/T
Abdominal
Pain
Super
saturation of
bile
Bile stasis
Cholelithias
Obstruction
of cystic duct
Inflammation
of gallbladder
Wall
Irritation of
gallbladderwall
Inflammatory
response
Cholecystitis
After 4 hours of
nursing
interventions,
the client will
be able to
establish
normal/effective
respiratory
pattern
INDEPENDENT:
- Assess respiratory
rate and depth by
listening to lung
sounds.
- Encourage
sustained deep
breaths by
emphasizing slow
inhalation, holding
end inspiration)
-Elevelate head of
bed; maintain low-
fowlers position.
Support
Abdomen when
coughing,
ambulating.
- Respiratory rate and
rhythm changes are
early warning signs of
impending respiratory
difficulties
- these promote deep
inspiration & ventilation
of all lung segments
-Facilitates lung
expansion. Splinting
provides incisionalsupport/decreases
muscle tension to
promote cooperation
with therapeutic
regimen
After 4 hours of
nursing
Interventions,
the client was
able to establish
normal/effective
respiratory
pattern
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Abdominal
pain
Ineffective
breathing
pattern
- pace and schedule
activities providing
adequate rest
periods
-Stress importance of
good posture and
effective use of
accessory muscles
COLLABORATIVE:
>Tramadol
10 mg IV
-Assess for
Hypersensitivity
to tramadol; acute
intoxication with
alcohol, opioids,
psychotropic drugs
or other centrally
acting analgesics;
past or presenthistory
of opioid addiction
-Tell patient that he
may experience
these side effects:
Dizziness, sedation,
- This prevents dyspnea
resulting from fatigue
-To maximize respiratory
effort
-Relief of moderate tomoderately to severe
pain.
-Binds to mu-opioid
receptors and inhibits
the reuptake of
norepinephrine and
serotonin; causes many
effects similar to the
opioids- dizziness,
somnolence, nausea,constipation- but does
not have the respiratory
depressant effects.
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drowsiness, impaired
visual acuity (avoid
driving or performing
tasks that require
alertness); nausea,
loss of appetite(lie quietly, eat
frequent small
meals).
>Mefenamin Acid
500mg (PRN)
-tell patient to take
drug with food.-Assess patient for
allergies and history
of liver disease,
diabetes, or stomach
or bowel
Problems.
-Discontinue drugand consult your
health care provider
if rash, diarrhea, or
digestive problems
occur.
- Anti-inflammatory,
analgesic and antipyretic
activities related to
inhibition of
prostaglandinsynthesis;
exact mechanisms ofaction are not known.
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-Tell patient that
Dizziness or
drowsiness can
occur.
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Assessment Nursing
diagnosis
Inference Goal Nursing
Intervention
Rationale Evaluation
Objectives:
>With a
temperature
of 38.2 C
>(+)
Drainage on
the incision
>IncreasedWBC of 10.9
g/l. normal
value 5-
10x10g/l
>Wet
dressing
Risk For
Infection r/tinadequate
Primary
defenses
Super saturation
of bile
Bile stasis
Cholelithiasis
Obstruction of
cystic duct
Inflammation ofGallbladder
Irritation of
gallbladder wall
Inflammatory
response
Cholecystitis
Cholecystectomy
Risk for infection
After 30 mins.
of nursingintervention
the patient will
be able to
identify
interventions
to
prevent/reduce
risk of infection
> establish rapport
> assess Patients
general condition
> Teach patient to
wash hands often,
especially before
toileting , before
meals and before
and
after administering
self-care.> Discuss
to patients the
following signs of
infection -
redness, swelling,
increased pain ,or
purulent drainage
on the site and
fever
> Gain Patients trust and
cooperation ofthe patient
>To provide proper
Nursing intervention.
>Hand washing reduces
the risks for infection
and also in transmitting
pathogens from one area
of the body to another as
well as from one patient
to another.
>To provide early
detection of infection
and to provide earlynursing management.
After 30 mins
of nursingintervention,
the patient was
able to identify
interventions
to
prevent/reduce
risk of infection
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>Monitor wound
for Redness,
swelling, increased
pain, or purulent
drainage .
> Monitor
temperature and
the presence of
sweating and
chills.
> Maintain strict
aseptic technique
with all dressingchanges
> Encourage intake
of protein and
calorie rich foods.
Provide enteral
> Redness, swelling,
increased pain, or
purulent drainage is
suspicious of infection
and should be cultured.
> In the first 24-48 hours
fever up to 38 degrees C
(100.4F) is related to the
stress of surgery. After
48 hours fever above
37.7C (99.8F) suggests
infection. High fever with
sweating and chills
suggests septicemia.
> Strict asepsis is
necessary to prevent
cross-contamination and
nosocomial infections.
> Optimal nutritional
status promotes wound
healing.
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feeding in patients
who are NPO.
COLLABORATIVE:
> Administer Anti
microbial drug asprescribed or
ordered by the
physician
>to fight further
infection
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ASSESSMENT DIAGNOSIS INFERENCE GOAL INTERVENTION RATIONALE EVALUATION
S: Masakit po
yung tiyan ko sa
may bandang
kanan na
tumatagal ng15-30 minuto.
7/10 po yung
sakit niya as
verbalized by
the pt.
O:
>guarding
behavior>(+) facial mask
>(+) sleep
disturbance
>(+) expressive
behavior; fetal
position
Acute pain r/t
inflammation of
the gallbladder
as evidenced by
guardingbehavior, facial
mask, sleep
disturbance,
and expressive
behavior such
as fetal
position.
Super
saturation of
bile
Bile stasis
Cholelithiasis
Obstruction of
cystic duct
Inflammation of
gallbladder
Irritation of
gallbladder wall
Inflammatory
response
Cholecystitis
Acute Pain
After 30
minutes of
nursing
intervention,
the pt. will beable to
verbalize that
pain is relieved/
controlled.
Independent:
>Assess the pts
level of pain.
observe and
document location,severity (0- 10
scale), and
character of pain
>promote bed rest,
allowing patient to
assume position of
comfort
> encourage use of
relaxation
technique (deep
breathing exercise)
provide diversional
>assist in
differentiating
cause of pain,
and providesinformation
about diseases
progression or
resolution,
development of
complications
and
effectiveness of
interventions
>promote bed
rest in low-
fowlers position
reduces intra-
abdominal
pressure ;
however,
patient will
naturallyassume least
painful position.
>promotes rest,
redirects
attention may
After 30
minutes of
nursing
intervention,
the pt. was ableto verbalize that
pain is relieved/
controlled.
Goal partially
met, with a pain
scale of 3/10.
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activities
> make time to
listen to and
maintain frequent
contact with patient
Collaborative:
>Administered the
following meds as
ordered by the
physician:
Tramadol 10mg IV
Nursing
considerations:
Assess onset, type,
location, and
duration of pain.
Effect of medication
is reduced if full
pain recurs before
next dose.
Assess drug history
enhance coping
>Helpful in
alleviating
anxiety &
refocusing
attention, which
can relieve pain
> Analgesic
Centrally acting
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especially
carbamazepine, CNS
depressant
medication, MAOIs.
Review past medical
history, especially
epilepsy or seizures.
Assess renal or
hepatic function
laboratory values.
Give without
regards to meals
Monitor pulse and
blood pressure.
Assist with
ambulation if
dizziness or vertigo
occurs.
Dry crackers or cola
may relieve nausea.
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Palpate bladder for
urinary retention.
Monitor pattern of
daily bowel activityand stool
consistency.
Sips of tepid water
may relieve dry
mouth.
Assess for clinical
improvement and
record onset of
relief from pain.
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X. Discharge Planning
A. MedicationTramadol 10 mg !V
Fentanyl 50 mg IV
Omeprazole 4g OD
Ceftriaxone 750 mg OD
Mefenamin Acid 500mg (PRN)
B. Exercise Maintaining mobility to improve the overall function status, an appropriate program of exercise will help to decrease pain
and improve function.
.
C. Treatment The major goal for the treatment of patient include
Increase knowledge about the disease and treatment regimen, adherence to the medication and activity and observed for
complication. Practicing proper hygiene. Consuming nutritious and adequate rest Participating in appropriate level of activity Taking medication as prescribed Teach patient and family about infection control behaviour Emphasize importance of completing antibiotic regimen
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D. Health Teaching Maintain body hygiene Advice the client to avoid extraneous activity like running, jumping and high impact exercise
Advice the patient to increase high fiber diet and high protein diet Remind the patient to take medication as exactly doctors prescribeE. Out Patient Instruct the client for follow up check-up referral Doctor Ceverero at EAMMCF. Diet Emphasize the strict low calorie diet Emphasize high fiber diet especially vegetable
Advise patient on the importance of an individualized meal plan in maintaining the appropriate weight. Assist patient to identify problems that may have an impact on dietary adherence and possible solutions to these problems. Emphasize that lifestyle changes should be maintainable for life. Each meal should consist of a balance of carbohydrates, proteins, and fats. Consistency in timing of meals and amounts of food eaten on a day-to-day basis help regulate blood glucose levels. Increase the intake of soluble and insoluble fiber. Avoid salt whenever possible. Prepare foods to retain vitamins and minerals and reduce fats.
Distribute snacks in the meal plan Prohibit use of alcohol.G. Spiritual Provide emotional support coming from the family. Encourage the patient to participate in family affairs.
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