Calculous Cholecystitis Case Study Sample

Calculous Cholecystitis A Case Study Presented to the Faculty, Ateneo de Davao Universi ty College of Nursing

Submitted to: Daphny Grace Peneza, R.N., R.M., M.N. Clinical Instructor – Panelist for the Case Study Submitted by: Gino Gregor Palaca Marvin Rey Andrew Pepino Rio Remonde Kevin Melvin Roa Krystle Rustia BSN-3H-4a

May 25, 2010

TABLE OF CONTENTS

I.Introduction ................................................................................................... 1 II.Objectives (General & Specific) ................................................................... 3 III.Patient’s Data ................................................................................................. 6 IV.Family Background and Health History ..................................................... 7 V.Definition of Complete Diagnosis................................................................. 14 VI.Developmental Data ...................................................................................... 17 VII.Physical Assessment ...................................................................................... 26 VIII.Anatomy and Physiology .............................................................................. 34 IX.Etiology and Symptomatology ..................................................................... 37 X.Pathophysiology ............................................................................................. 47 XI.Doctor’s Order ............................................................................................... 50 XII.Diagnostic Exam ............................................................................................ 62 XIII.Drug Study ..................................................................................................... 72 XIV.Procedural Report ......................................................................................... 87 XV.Nursing Theories ........................................................................................... 94 XVI.Nursing Care Plan ......................................................................................... 100 XVII.Discharge Plan (M. E. T. H. O. D.) & Prognosis ........................................ 123 XVIII.Recommendation ........................................................................................... 130 XIX.References ...................................................................................................... 133

ACKNOWLEDGMENT

The Group 4-1 of section 3H, would like to acknowledge the contributions of the following groups and individuals to the development of this case presentation. To the Almighty God for blessing them with wisdom, competence and genuine passion and giving them the strength to finish this presentation. The group dedicates to Him the fruits of their hard-earned achievement. To the staff of the Davao Medical School Foundation Hospital-3C for being accommodating to the students and for giving them additional teachings during their exposure in the said hospital. They have also been very willing to allow the students to obtain records necessary for this presentation. To their respected clinical instructor for this rotation, Daphny Grace Peneza, R.N., R.M., M.N., for her support and guidance to the group. She has imparted knowledge that would furthermore enhance the student’s understanding of their patient’s case, thus making them ready to present this case presentation. To their client, Meg, and her family, for being open and

generous

enough

to

disclose personal information that would be helpful for this study. The group would also like to thank them for their patience throughout the duration of the study and for giving the group the opportunity to care for Selecta and apply what they have learned. To the proponents’ respective family and friends for their prayers as well as their financial support. They have also been a source of inspiration of the students. To the members of this group for working hard and giving their efforts, time and resources in conducting the study and for the completion of the written output.

INTRODUCTION One of the body organs that we can live without is the gallbladder. However, does this mean it is of no use to the body? The gallbladder is a pearshaped organ situated underneath the liver. Its function is to store bile and release it as needed for digestion. Bile emulsifies the fats in food, breaking them to small fragments so they can be further digested and absorbed in the small intestine. If the gallbladder is not working as it should, the digestion of fats can be seriously impaired. One of the common gallbladder diseases is calculous cholecystitis. Calculous cholecystitis is a condition wherein gallstones obstruct the gallbladder outlet leading to poor drainage of bile. Trapped bile can irritate and inflame the walls of the bladder, thus leading to inflammation. Calculous cholecystitis is the cause of more than 90% of cases of acute cholecystitis (Feldman, Friedman & Brandt, 2006). It affects women more often than men and is more likely to occur at the age of 20-50 or over 60. Asians are also more prone to develop pigment stones. Moreover, people who are obese and those who had had low fat diet are at an increased risk for developing cholelithiasis. In the United States, it is estimated that 6.3 million men and 14.2 million women aged 20 to74 had gallbladder disease (Everhart, Khare, Hill, Maurer, 1999). In the Philippines, an extrapolated prevalence of 5, 073, 040 people are affected by the disease (http://digestive.niddk.nih.gov/statistics). Gallstones that do not cause symptoms do not require treatment. However, if gallstones cause, disruptive, recurring episodes of pain, surgical removal of the gallbladder is recommended. Recently, the Group 3H-4a had a patient who was diagnosed with symptomatic

calculous

cholecystitis

and

underwent

laparoscopic

cholecystectomy. The group chose this case for they see it fit for their perioperative concept. Rarely do they interact with patients who had minimally invasive surgery. The proponents are hoping that through this case study, they will be more knowledgeable and aware about such gallbladder disorder and the surgical procedure done for the said disease. They are also interested to know Page | 1

the proper and necessary nursing management that will be given to a patient affected by the disease. Moreover, they would also like to impart their learning to their families and their community regarding the prevention and care if ever such condition will arise in the scenario. As nursing students, they are hoping that this study will help them become more efficient and better nurses in the future. The student nurses also hope to apply their learning in taking care not only of their patients but of themselves as well.

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OBJECTIVES General objective: Within 2 weeks exposure to various clinical areas, the group should have been able to present a comprehensive case study which explains the pathology, the treatment and the appropriate medical and nursing management regarding the condition of their chosen client. The group also aims to perform the necessary nursing interventions to help alleviate the patient’s condition and improve her health. Specific Objectives: The proponents also created certain aims that will help them in achieving their general objectives. Within 2 weeks of exposure, the proponents aim to: Cognitive:  Gather pertinent data regarding the past and present health history of the patient through interview and assessment;  Draw the family genogram of the patient;  Define the complete diagnosis of the patient by directly citing it from three different sources;  Ascertain the patient’s developmental status using the theories of Robert Havighurst, Erik Erikson and Lawrence Kohlberg;  Conduct a thorough cephalocaudal assessment obtained from the client;  Review the anatomy and physiology of the organs affected in the patient’s disease;  Present the etiology and symptomatology of the disease;  Trace the pathophysiology of the patient’s disease;  Obtain the doctor’s orders and make rationales for each order;

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 Obtain, analyze and interpret laboratory and diagnostic procedures done on the patient and include the normal and abnormal values and findings for comparison, and the specific nursing responsibilities associated with each diagnostic procedure;  Make drug studies on each drug given to the client, correlate them with the disease process, explain why such drugs were ordered, and present important interventions in administering the drug;  Identify three nursing theories that can be applied to the patient’s condition;  Present specific, measurable, attainable, realistic, and time-bounded nursing care plans for the patient;  Correlate the different nursing theories with the nursing care plans that are presented in this case study;  Make a discharge plan for the patient with the use of M.E.T.H.O.D.;  Validate patient’s prognosis according to the following categories: onset of illness, duration of illness, precipitating factors, willingness to take medications and treatment, age, environmental factors and family support;  Broaden our scope of knowledge about the disease and the appropriate Nursing Care for the patient with the disease; Psychomotor:  Find a patient who will be the subject of their case presentation;  Render health teachings to the patient and her significant others to promote health;  Provide care based on the various nursing care plans formulated by the researchers and the patient herself;

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 Share information about calculous cholecystitis and the factors that cause the development of such disease and its complications;  Share how the disease affects those affected by it and the systems involved in its occurrence; Affective:  Establish rapport with the patient and significant others;  Show genuine concern and willingness in serving the client;  Be aware of the client’s progress on the succeeding interactions;  Appropriately state the bibliography of all resources used in order to prevent plagiarism and promote honesty.

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PATIENT’S DATA Client’s Code Name:

Meg

Age:

38 years old

Gender:

Female

Birth date:

November 6, 1971

Address:

Upper Sirib, Calinan Davao City

Nationality:

Filipino

Religion (Denomination):

Christian (Roman Catholic)

Civil Status:

Married

Spouse:

Bobong

Educational Attainment:

4th year high School

Occupation:

House keeper

Height:

5ft 2inches

Weight:

62 kgs.

Health Insurance:

Phil Care

Hospital:

Davao Medical School Foundation (DMSF)

Vital Signs on Admission:

BP: 130/80 mmHg PR: 79 bpm RR: 19 cpm T: 37 ºC

Unit:

3C- 324-5

Chief Complaint:

Pain at right upper quadrant

Admitting Physician:

Dr. Walter Batucan

Admitting Diagnosis:

Acute Cholelithiasis

Final diagnosis

Calculous Cholecystitis

Surgical procedure

Laparoscopic cholecystectomy

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FAMILY BACKGROUND AND HEALTH HISTORY A. Family Background Meg is the second child among Mamang and Papang’s four children. All children of Mamang were born through Normal Spontaneous Vaginal Delivery without any complications. She delivered all her children at their house with the help of ―mananabang‖. The family has been residing in Sirib, Calinan Davao City since the marriage of Papang and Mamang. Their home is near their farm. The client, Meg has 3 siblings namely: Kenny (Male, deceased), Luigi (Male, 30, married), and Dora (Female, 28, married). Meg graduated high school and didn’t to proceed to college because she helped her family tend their farm. According to the patient, her father and mother are still alive and they suffer from hypertension and diabetes. She said that the family lineage of her mother also suffers from heart problems as well as kidney problems. Two of her uncles on father’s side underwent surgery, cholecystectomy, and had the same condition as Meg. Her older brother died due to motorcycle accident. Luigi was diagnosed with hypertension and Dora had a history of UTI. There was no one else in her immediate family that suffered cholecystitis aside from Meg herself. Meg got married to Bobong in the 1998. They were blessed with 3 children. Her 3 children were delivered through Normal Spontaneous Vaginal Delivery, all were born in the Maternity clinic in Calinan. Her eldest child is now studying in 4th grade. So far, none of her children suffer a serious illness. In terms of their expenses, Bobong is the one that provides money for their daily expenses. Bobong is a Supervisor at DABCO and has a wage of approximately 10,000 a month. Meg said that they budget the Page | 7

money well for them to have food and to provide the necessary daily needs and expenses. By helping tend to the 2 hectare farm of the patient’s parents, they also get their share. They plant coconut trees, bananas, and pineapples in their farm.

Lifestyle The patient has sedentary lifestyle. When Meg stopped going to school, she helped her mother with household chores. Right now, she is busy taking care of Bobong and their 3 children. She is the one who cooks, cleans the house, and does the laundry of the whole family. Sometimes, she does gardening in their backyard. According to her, she only works in the house, but still, she experiences fatigue from doing household chores especially since she is the only one who does the laundry. She reported that she doesn’t smoke, but her husband does; he smokes almost one pack a day. Meg said that she drinks liquor very seldom; she only consumes a half of glass or a glass of liquor occasionally. The family has good relationship. At night, they watch television together and this serves as their bonding time. Occasionally, they gather together with her relatives when there are fiestas, birthday celebrations and other special occasions. She is not so active in terms of social organizations such as GKK (Gagmay’ng Kristohanong Katilingban), but she sometimes joins in the events in their community like the fiesta. She sometimes goes to church on Sundays together with her children.

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Meg sleeps around 9:00 o’clock at night and wakes up around 5:00 o’clock in the morning to prepare things needed of her husband. She is the one who cooks the ―baon‖ of her husband for work. Meg said that she eats at least two times a day in small meals. She said “naga-diet diet man ko kay tabaan nako sa akoang lawas, nagsugod ko katong 36 years old pako, pero karong tuiga giundangan na nako ang pagdiet-diet”. For breakfast she usually eats, ―bulad‖, ―bagoong‖, ―ginamos‖ and bread. Every morning, she always drinks coffee. In a day, she can consume at least 3 cups of coffee. Her lunch and supper are sometimes vegetables that are found in their backyard such as ―kamunggay‖, ―upo‖, ―okra‖, ―talong‖ and ―tinangkong‖. She is not fond of eating pork and beef. She said that before, she limits herself from eating fatty foods since she aimed to lose weight because she was afraid of becoming obese. Also, she is so fond of drinking soft drinks. In a day she can consume 4 glasses of coke. But she also drinks approximately 5-6 glasses of water. She also loves to eat salty foods, especially junk foods. According to her, she has no allergy from any form of food.

B. Past Health History Meg and her husband preferred to have artificial family planning than natural family planning. She started using birth control pills since she was 36 years old. She said that she is not sure if she completed her immunizations. Her mother forgot already and the records were lost. They only avail of the services of the health center very seldom. She said that their house was far from the health center so they weren’t able to avail of all of the services. She also experienced common illnesses such as cough, colds, fever, measles and even chickenpox. They only treated it at home, since her mother knows how to make use of different herbal medicines such as Page | 9

kalabo, mayana, buyo, gabon, and tawa-tawa. Also, they sometimes bought over-the-counter drugs such as paracetamol, Neozep, and Medicol. With regards to how long she experienced those usual illnesses, she said “dili man jud ko maabtan ug simana sa akoang kalintura ug bisan ubo”. She experienced measles when she was a 1-year old and had chickenpox when she was 10-year old. Meg had her menarche when she was 11 years old. Meg reported that she got pregnant with her 1 st child at the age of 28; unfortunately, she had miscarriage on the 1st week of pregnancy. She was hospitalized at Robillo Hospital, Calinan Davao City. Completion curettage was performed to her. Again, on her 3 rd pregnancy, she had a miscarriage and was hospitalized on the maternity clinic and underwent completion curettage. She reported that in almost all her pregnancies, she experienced an increased blood pressure, usually 140/90. After delivering her third child at the age of 36, Bobong and Meg decided to make use of family planning. Meg started to take birth control pills until now to prevent unexpected pregnancy.

C. History of Present Illness On the second week of December 2009, Meg felt mild pain at the right upper quadrant of her abdomen. She neglected it thinking that it’s nothing serious and might be just an episode of indigestion. After three days, the pain went away. But after two weeks, pain recurred at a higher scale (5/10). Because of this, she was forced to seek medical advice. She went to Isaac T. Robillo Memorial Hospital Calinan, Davao City and was asked to have ultrasound of the whole abdomen. After 2 days, the result was released and they found out that there were stones in her gallbladder. She was advised by the doctor to undergo surgery, cholecystectomy. However, Page | 10

the patient resisted the doctor’s advice due to fear of surgery. She was given medications as an alternative (the patient already forgot the name of medications prescribed). She was instructed by the doctor to increase water intake and have a low fat diet, unfortunately, she wasn’t able to follow the doctor’s order and still continued with her usual lifestyle. Meg said that she still felt the pain after the check-up but she could still tolerate it. She just took medications that were prescribed by the doctors to alleviate the pain she felt. Last May 5 this year, three days prior to admission, the patient again experienced right upper quadrant pain which lasted until the present condition. This was characterized to be progressive pain with a pain scale of 8 out of 10. There was no radiation noted and no associated symptoms. Two days prior to admission, pain recurred with a pain scale of 10 out of 10. This prompted Meg to seek consultation, hence, admission.

On May 8, 2010, the patient was admitted at Davao Medical School Foundation at Surgical Ward, room 324 bed 5 under the service of Dr. Batucan, with admitting diagnosis of Acute Cholelithiasis.

D. Effects/Expectations of Illness to Self/Family

Biological: When Meg knew about her condition that she needs to undergo surgery, she didn’t know what to do. She was very worried about herself because she has fear of not waking up after surgery. She feared having complications of not having a gall bladder anymore.

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Psychosocial: Also, she is worried about her 3 children, who still need care and guidance from their mother. This made her decide not to go through with the surgery before. Meg wants to overcome her illness so that she can still spend time with her family and friends. Furthermore, she said that she wants to be in good condition as much as possible so that she can do her daily task in everyday life for her family. The client is worried about her condition because she has many plans in life together with her family. Spiritual: Still, Meg is still hopeful to overcome her challenges in life. The client still has faith in the Creator, and she continues to pray to Him. She believes that everything will be alright with the help of the creator. Also, her children were worried about their mother, who’s suffering from such condition. Her husband, Bobong is trying his best to support his wife. Bobong was worried about Meg because for him, it makes him suffer seeing his wife suffering. In addition, their relatives are also extending their care and prayers for Meg because they are worried and concerned for her. The client is also very thankful because her family, relatives and friends are still there giving support to her for her fast recovery. They are always there and look after her in the hospital and to aid her physically, mentally, emotionally, and spiritually.

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Genogram

Maternal

Side

Mamita, †,

Lolo, K ,†

Ana, , 70

Lala, K,

Paternal Side Lola, †, o

Sis, ,

67

Papito, †



Po, c, 67

Mamang, 60, D

64

Jose, c, , D,

Papang, 62

64

- Female Kenny, a, †

-Male

Luigi, 30,  Dora, 28, K

#- age - Heart problems †-deceased

Meg, , Bobong, 45,

c, 38



D- diabetic K- Kidney problem o- old age c- cholelithiasis a- accident

Bebe three, 2

Bebe two, 7

Bebe one, 10

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DEFINITION OF COMPLETE DIAGNOSIS Complete Diagnosis: Calculous Cholecystitis

Calculous

Calculi, or gallstones, usually form in the gallbladder from the solid constituents of bile; they vary greatly in size, shape and composition. Source: Boyer, M. (2006). Brunner and Suddarth’s Textbook of MedicalSurgical Nursing, 11th ed., p. 1347. Lippincott Williams & Wilkins.

Calculus (pl. calculi) is also called stone; an abnormal stone formed in body tissues by accumulation of mineral salts. Calculi are usually found in the biliary and urinary tracts.

Source: http://medical-dictionary.thefreedictionary.com/calculi. Retrieved May 15, 2010. Calculi (stones) can be divided into two groups—renal calculi and gallstones. The majority of gallstones are composed principally of cholesterol and other calcium salts.

Source: Iyengar, V. Elemental Analysis of Biological Systems: Biomedical, Environmental, Compositional and Methodological Aspects of Trace Elements, Vol. 1, p. 49.

Cholecystitis

Cholecystitis is the inflammation of the gallbladder. In more than 90% of the cases, gallstones are present.

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Source: White, L. Foundations of Nursing: Caring for the Whole Person, p. 832.

Inflammation of the gallbladder is called cholecystitis (chole = bile +cyst = bladder + itis = inflammation)

Source: Crowley, L. (2010). An Introduction to Human Disease: Pathology and Pathophysiology Correlations, 8th ed., p. 563. USA: Jones and Bartlett Publishers.

Inflammation of the bladder which may be either acute or chronic.

In

an

acute cholecystitis, the blood flow to the gallbladder may become compromised which in turn will cause problems with the filling and emptying of the gallbladder. A stone may block the cystic duct which will result in bile becoming trapped within the bladder due to inflammation around the stone within the duct. Chronic cholecystitis occurs when there have been recurrent episodes of blockage of cystic duct.

Source: Digiulio, M. & Jackson, D.(2007). Medical-Surgical Nursing Demystified, p. 288. USA: McGraw-Hill.

Calculous Cholecystitis

Acute cholecystitis is inflammation of the gallbladder. There are two major types of acute cholecystitis— calculous and acalculous. In calculous cholecystitis, gallstones obstruct the gallbladder outlet leading to poor drainage of bile. In physical exam, patients may exhibit Murphy’s sign— right upper quadrant pain elicited by palpation under the right costal margin when the patient inspires.

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Source: Ginsber, G. & Ahmad, N. (2006) The Clinician’s Guide to Pancreaticobiliary Disorders, p. 121-123. USA: SLACK Incorporated.

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DEVELOPMENTAL DATA According to Taylor, Lillis, LeMone and Lynn (2008), growth and development are orderly and sequential as well as continuous and complex. All humans experience the same growth patterns and developmental levels, but, because these patterns and levels are individualized, a wide variation in biologic and behavioral changes is considered normal. Within each developmental level, certain milestones can be identified; for example, the time the infant rolls over, crawls, walks, or says his or her first words. Although growth and development occur in individual ways for different people, certain generalizations can be made about the nature of human development for everyone. Robert Havighurst’s Developmental Task Theory Robert Havighurst believed that living and growing are based on learning, and that a person must continuously learn to adjust to changing societal conditions. He described learned behaviors as developmental tasks that occur at certain periods in life. Successful achievement leads to happiness and success in late tasks, whereas unsuccessful achievement leads to unhappiness, societal disapproval, and difficulty in later tasks. The developmental tasks arise from maturation, personal motives, and values that determine occupational and family choices, and civic responsibility. (Taylor, et al. 2008)

Stage

Description

Middle

In the middle years, men and women reach

Age(30-40)

the peak of their influence upon society, and

Result

Justification

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at the same time the society makes its maximum demands upon them for social and civic responsibility. It is the period of life to which they have looked forward during their adolescence and early adulthood. And the time passes so quickly during these full and active middle years that most people arrive at the end of middle age and the beginning of later maturity with surprise and a sense of having finished the journey while they were still preparing to commence it.  Selecting a mate

The patient married and started a Achieved

family last 1998. She is happy with her

 Learning to live with a partner

husband since she receives care and

 Starting family

unconditional love from him. She works

 Rearing children

together with her husband in taking care of and rearing their children by providing

their

physiological,

psychological, and emotional needs.

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The patient has no job, however, she is the one managing the house, by cleaning, washing clothes, doing other  Managing home

Achieved

 Getting started in occupation

household

chores

and

being

a

peacemaker when trouble happens among her children. managing

the

She is the one

house

to

have

a

peaceful and organized home. Meg is also responsible for budgeting their money needed to sustain them in their everyday living. She sees to it that her husband’s salary is well budgeted and not put into waste.

 Taking on civic responsibility

Achieved

The patient is doing her responsibilities as a Filipino citizen by following laws in our country such as not throwing garbage anywhere, and following traffic rules. She is also a registered voter.

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Patient verbalized that if she were not admitted in the hospital, she would really vote in the 2010 Presidential elections.

She

also

pays

taxes

(property tax and cedula) as part of her responsibility as a citizen.

Erik Erikson’s Psychosocial Development Theory Erikson emphasized developmental change throughout the human life span. In Erikson’s theory, eight stages of development unfold as we go through the life span. Each stage consists of a crisis that must be faced. According to Erikson, this crisis is not a catastrophe but a turning point of increased vulnerability and enhanced potential. The more an individual resolves the crises successfully, the healthier development will be. It is patterned to the Psychosexual Development of Sigmund Freud but more concentrated on what task and conflict should a person be able to manage in a certain age group. That is termed psychosocial development. He described eight stage of development: 1. Infancy

5. Adolescence

2. Early childhood

6. Young adulthood

3. Late childhood

7. Adulthood

4. School age

8. Maturity Page | 20

Each stage signals a task that must be accomplished. The resolution of the task can be complete, partial, or unsuccessful.

Stage

Description

Result

Justification

Middle Adulthood: 25-65 years

The significant task is to perpetuate culture and transmit values of the culture through the family (taming the kids) and working to establish a stable

Ego Development Outcome: Generativity vs.

Self

absorption or Stagnation

Basic Strengths:

environment. Strength comes through care of others and production of something that contributes to the

Working

As a wife and a mother of three children, she is

towards

the one who inculcates values in the family

achieving

whom she acquired from her parents. She

goal

makes sure that her children will be raised with good attitude and as good Filipino Citizens.

betterment of society, which Erikson

As of now, her children are dependent and still

calls generativity, so when a person is

with them, she still doesn’t know what her

in this stage, she often fear inactivity

feelings will be when her children will leave

and meaninglessness.

home someday. Today, she is busy taking care

As the children leave home, or the person’s

relationships

or

goals

of her children and her husband as those are the responsibilities of a mother and wife.

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Production

changes, she may be faced with major

and Care

life changes—the mid-life crisis—and struggle with finding new meanings and purposes. If a person doesn't get through this stage successfully, she can

becomes

self-absorbed

and

stagnate. Significant relationships are within the workplace, the community and the family. Creativity, productivity, concern for others concern,

or

self-indulgence,

lack

of

interests

selfand

commitments

Kozier and Erbs, Fundamentals of Nursing, Chap. 20, page 352 http://www.learningplaceonline.com/st

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ages/organize/Erikson.htm

Lawrence Kohlberg’s Levels of Moral Development Lawrence Kohlberg outlined the different planes of moral adequacy, based on his continued interest in how children would react to varying moral dilemmas. Kohlberg stated that ethical behavior was based on moral reasoning, which in turn could be broken down into six specific developmental stages. The stages are progressive, in that it is highly improbable for someone to regress backwards. Once a person acquires the functionalities of higher stages of moral development, it will be difficult for him to lose these abilities and revert to lower levels of growth. Every stage follows another, making it difficult for a person to jump forward and virtually skip an entire stage.

The levels and stages are as follows: Level 1: Preconventional

Level 2: Conventional

Level 3: Postconventional

Stage1: Punishment/obedience

Stage3: Approval Seeking

Stage5: Social Contract

Stage2: Instrumental/relativist

Stage4: Law and order

Stage6: Universal-ethical

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Stage

Description

Result

Justification

Postconventional Level

At stage 5 social contract and utilitarian

orientation,

Achieved

She sees that most of the laws are correct and worth to

correct

be followed. She said that she follows the rules of the

Stage

5: behavior is defined in terms of

country and the city she lives in. She doesn’t want

Social

society’s law. Laws can be

nuisance in the society because she believes that to be

Contract

changed, however, to meet

able to live in a serene place, people must maintain and

society’s

establish respect with themselves and then to others.

needs,

while

maintaining respect for self and others.

Stage Stage6: Universalethical

6,

universal

ethical

principle orientation, represents the

person’s

concern

for

equality for all human beings, guided by personal values and

Working towards achieving goal

She knows about universal laws, specifically about justice. She is concerning about justice, “malooy gyud ko sa mga tao nga dili matagaan ug hustisya, labaw na ng mga kabus” , as verbalized by the patient.

standards regardless of those Page | 24

set by society or laws. Justice might be internalized at an even higher level than society. Few adults ever reach this stage of development. (Taylor et. al, 2008)

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PHYSICAL ASSESSMENT Patient’s Name: Meg Age: 38 yrs. old Sex: Female Admitting Diagnosis: Acute Cholelithiasis Final Diagnosis: Calculous Cholecystitis Chief Complaint: right upper quadrant pain Date of Assessment: May 12, 2010 Time of Assessment: 4:00 pm Location of Assessment: DMSF Hospital, 3C, Room 324-5 Vital Signs upon physical assessment: Temperature :

36.6 °C

Pulse Rate:

82 bpm

Respiratory Rate:

18 cpm

Blood Pressure:

130/80 mmHg

I. General Survey The patient was received lying on bed, awake, conscious, coherent, afebrile and without IVF. She has three 0.5-cm long incisions at her epigastric and right lower rib cage areas and a 1-cm incision under her umbilicus. Incision site is dry and intact. Each incision is covered with dry and intact dressing. Patient complains of pain on the incision site and rated this pain as 6 out of 10 in the pain scale. She is oriented to time (verbalized it was late in the afternoon), person (identified watcher correctly), place (verbalized she’s in the hospital) and

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reason for admission (stated that she was admitted due to right upper quadrant abdominal pain). Patient is not in respiratory distress. Patient appears appropriate for her stated age. She stands 5 feet and 2 inches tall and weighs 62 kg. Her body mass index (BMI) is 24.9 which is normal. She has an endomorphic body type. Patient is in fair grooming as evidenced by unsoiled t-shirt she is wearing, well-kept hair and clean linens and pillows. However, it was noted that patient has halitosis. Nails were long but clean. Through the course of the physical assessment, it was observed that the patient is cooperative and has an accommodating attitude towards the student. The patient is calm. Patient’s speech was audible, comprehensible and in moderate pace.

II. Skin Skin is fair in color, intact and with hairs, except in the palms, soles and dorsa of the distal phalanges. Skin is dry and slightly warm upon palpation. It returns quickly to its normal state when picked up between two fingers and released. Skin texture is soft and fine while extensor surfaces such as the elbows have coarser skin. The palms and the soles are calloused. No skin breaks present aside from the incision sites on her abdomen. No edema present.

III. Hairs and Nails Upon inspection, hair was noted to be black. It is thick, oily, straight, long and well-kept. Hair is also evenly distributed as evidenced by absence of bald spots. Dandruff or flaking was not present. Other infestations, such as lice, were not noted. The color of scalp is lighter than the color of skin. Nails on both hands and feet are long but clean. Nail polish was removed. Client has a capillary refill time of 2 seconds. No clubbing of the nailbeds noted. Page | 27

IV. Head Patient’s head is round and normocephalic in configuration with smooth skull contour. There were no palpated masses, nodules, deformities or fractures. Facial features are symmetric as evidenced by palpebral fissures being equal in size and symmetric nasolabial folds. Facial movements are symmetrical and patient is able to perform different kinds of expression effortlessly and without any obstructions. Patient can move her head up and down and side to side. No lesions noted on the face.

V. Eyes Hairs of eyebrows are thick and evenly distributed. Eyebrows are symmetrically aligned and there’s equal movement as evidenced by the patient’s ability to elevate and lower the eyebrows. No edema, lesions, puffiness or tenderness noted upon inspection and palpation of the periorbital area. Eyelashes are equally distributed and curled slightly outward with no ectropion or entropion. Eyelids’ surface is intact with no discharges and no discoloration but with noted eye bags on the lower surface. No lid lag noted. Blink reflex is present. Palpebral fissure is equal in both eyes. Bulbar conjunctiva is pale pink. Cornea is transparent and without cloudiness. Sclera is anicteric. Eyeballs are symmetrical with no bulging observed. Pupils were black in color, equally round, 3mm in size and reactive to light and accommodation. Pupils quickly constrict when a penlight is shone towards the pupil from a lateral position. Iris is dark brown in color. Client has central and peripheral vision. She can see things on the side of her eye, like the adjacent bed, even when looking straight ahead. Moreover, pupils constrict when looking at near objects and dilate when looking at far objects. During ocular motility testing, patient was asked to follow the examiner’s Page | 28

finger in the six cardinal fields of gaze. There was smooth, parallel movement of eyes in all direction. Both eyes move in unison. No nystagmus noted. To test her visual acuity, the students asked her to read their nameplates placed about 1 ½ feet away from her. She was able to correctly read the names without any difficulty. Patient verbalized she doesn’t use any corrective aids. She also did not report any vision difficulty or eye pain.

VI. Ears The color of the patient’s ears is the same as her facial skin. The skin behind the ear in the crevice is smooth and without breaks. The left and right pinna are symmetrical and aligned with the inner canthus of the eye. Pinna recoils after it is folded. Auricle is nontender upon palpation. Mastoid process is smooth and hard and no tenderness or swelling noted. External canals have minimal cerumen. No sanguinous discharges noted on the meatus. Patient was able to hear a soft whisper equally in both ears. She can also hear normal voice tones as evidenced by prompt responses to questions asked.

VII. Nose It was noted that the nostrils were symmetrical and the nasal septum is midline. There were no observed discharges draining from the client’s nose. Hair is noted on the nares. Nares are patent since patient is able to breathe normally on both nostrils without difficulty when one nose is closed with digital compression and patient inhaled with mouth closed. No lesions on the external nose structure were seen. There was no tenderness over the maxillary and frontal sinuses upon palpation of the cheeks and supraorbital ridges. Client’s gross smell was functional as she could identify the scent of alcohol.

Page | 29

VIII.

Mouth Mouth is proportional and symmetrical. Lips are cracked, dry, pink in

color and with no masses or congenital defect. Buccal mucosa was uniform pale pink in color and moist. The patient’s gum was, moist, firm and pinkish in color. No gum retraction or bleeding was noted. Teeth are of complete set. There are no spaces in between teeth. Dental carries are evident in lower right and left molar. Teeth are yellow in color. Patient has no dentures. Tongue is pink, moist, slightly rough and has thin whitish color on the surface. It is also in central position and moves freely. The base of tongue is smooth with prominent veins. No tenderness, lesions or any unusualness noted. Soft palate is light pink in color. On the other hand, hard palate is much lighter and more irregular in texture. Uvula is positioned in midline of soft palate and rises when the patient says ―ah‖. Tonsils are not inflamed. No ulcerations and exudates present. Patient has no difficulty of masticating and swallowing. Halitosis was noted. Patient has no speech disorders.

IX.

Neck Neck is symmetrical with no masses or unusual swelling upon

palpation. No jugular vein distention noted. Pulsation at carotid arteries is strong and regular in rhythm. Range of motion is normal and no pain elicited upon flexion, extension, and rotation of head. Thyroid is not enlarged upon palpation with no nodules, masses or irregularities upon palpation. Thyroid also rises when patient was asked to swallow. Trachea is symmetrical and in midline without deviation. No lymph adenopathies appreciated. No torticollis present.

Page | 30

X. Breast Breast is conical, symmetrical and skin color is lighter than exposed areas. No lesions, redness, or edema and texture is even. No dimpling or retraction. Nipples are in midline and everted pointing in the same direction. Areola and nipples are dark brown in color and has no discharges, crusting and masses.

XI. Chest/Lungs Chest skin integrity is good and intact. Patient has symmetrical chest wall movement. Point of maximal impulse is at 5th intercostal space left midclavicular line. Apical pulse is 84bpm. Patient has distinct heart sounds, with S1 louder than S2; negative for murmurs. There were no noted deformities in the client’s thoracic area. There are no bulges or retraction of the intercostal spaces. Client’s respiratory rate is 18 cycles per minute. Patient did not complain of chest pain or chest tightness. Guarding of the chest noted upon respiration due to the proximity of the incision site to the diaphragm. Patient is not in respiratory distress. Coughing episodes were also not observed. Vesicular breath sounds are soft and low pitched. Her breathing is deep, regular and slow with a long inspiratory phase and a short expiratory phase. With no adventitious sounds, lungs are clear to auscultation and no crackles, wheezes or rubs. It was observed that vocal fremitus is present both at the back and front of the chest when the patient says ―ninety-nine‖.

XII. Abdomen Abdomen is round. Color of skin in abdomen is slightly lighter than the rest of the body. A 0.5-cm incision was noted at the subxyphoid area. Another two 0.5-cm incisions are seen at her right lower rib cage. A 1-cm incision is also present just below her umbilicus. All four incisions are covered with dry and intact dressing. Patient complains of pain on the surgical site and verbalized, Page | 31

―Nagangulngol tong gioperhan. Pwede makahingi ug tambal para sa sakit?” Patient reported a pain scale of 6 out of 10. Aortic pulsations are not visible. Umbilicus is midline and inverted. Symmetrical movement of abdomen upon respiration was noted. Upon auscultation of the abdomen, it was noted that patient has normal bowel sounds—high-pitched and occurred 16 times per minute. Abdomen is soft and there is no point tenderness. Patient was on DAT as ordered.

XIII. Back and Extremities Peripheral pulse of the patient was symmetrical and regular in rhythm; radial pulse is 82bpm. Patient has normal capillary refill of 2 seconds. The nails were pinkish in color without cyanosis and clubbing. Patient is able to ambulate freely. She was able to sit up on bed and perform range of motion on both upper and lower extremities. However, it was noted that patient has guarded and slow movement for she feels pain on her abdomen. Client’s grasping ability was moderately strong on both hands. No edema or cyanosis was noted on both upper and lower extremities. There is no swelling, tenderness or nodules palpated on each joint. The shoulders, arms, elbows and forearms are free of nodules, swelling, deformities and atrophy. The skin at the back of the patient is uniform in color. Symmetrical chest expansion with respirations noted. No spinal tenderness noted. There are no skin breaks present. The back is also symmetrical with the spinal cord aligning from the neck down to the buttocks. There were no deformities or abnormalities on the bone such as scoliosis, osteoporosis and alike to be noted.

XIV.

Genito-urinary Pubic hair is present, thick in each strand, curly and equally distributed

on the mons pubis. No vaginal bleeding or any other unusual discharges noted. Page | 32

Patient voids freely. She has no difficulty urinating and did not report dysuria. She verbalized her urine is amber in color.

XV.

Neurological Patient was received lying on bed, awake, conscious, coherent and

afebrile. Reflexes are normal and symmetrical bilaterally in both extremities. Patient is oriented to person, place and time. She has a Glasgow coma scale of 15: 4 from eye opening, 5 for verbal resoponse and 6 for motor response. She is also alert and attentive.

Page | 33

ANATOMY AND PHYSIOLOGY

GALLBLADDER The gallbladder is a hollow organ that sits just beneath the liver. In adults, the

gallbladder

measures

approximately

8 cm in length and 4 cm in diameter when fully distended. It is divided into three sections: fundus, body, and neck. The neck tapers and connects to the biliary tree via the cystic duct, which then joins the common hepatic duct to become the common bile duct. Its function is to store and release bile, a fluid made by the liver.

Page | 34

CYSTIC DUCT The cystic

duct is

the

short duct that joins the gall bladder to the common bile duct. The cystic duct varies from 2 to 3 cm in length and terminates

in

the gallbladder.

Throughout its length, the cystic duct is lined by a spiral mucosal elevation, called the valvula spiralis (valve of Heister)

which

is

a series of crescentic folds of mucous membrane in

the upper part

of

the cystic

duct,

arranged

in

a

somewhat spiral manner. Its length is variable and usually ranges from 2 to 4 cm. The cystic duct is usually 2-3 mm wide. It can dilate in the presence of pathology (stones or passed stones). The duct and spiral folds contain muscle fibers responsive to pharmacologic, hormonal, and neural stimuli. There is, however, no convincing evidence of a discrete muscular sphincter within the duct. Although the cystic duct is unlikely to play a major role in gallbladder filling and emptying, it appears to function as more than a passive conduit. Coordinated, graded muscular activity in the cystic duct in response to hormonal and neural stimuli may facilitate gallbladder emptying. The principal function of the internal spiral folds that are found in man may be to preserve patency of this narrow, tortuous tube rather than to regulate bile flow.

BILE The main components of bile include contains water, cholesterol, fats, bile salts, proteins, and bilirubin.

Page | 35

Bile, is produced by hepatocytes in the liver and and then flows into the common hepatic duct, which joins with the cystic duct from the gallbladder to form the common bile duct. The common bile duct in turn joins with the pancreatic duct to empty into the duodenum. If the sphincter of Oddi, a muscular valve that controls the flow of digestive juices (bile and pancreatic juice) through the ampulla of Vater into the second part of the duodenum, is closed, bile is prevented from draining into the intestine and instead flows into the gallbladder, where it is stored and concentrated to up to five times its original potency between meals. This concentration occurs through the absorption of water and small electrolytes, while retaining all the original organic molecules. When food is released by the stomach into the duodenum in the form of chyme, the duodenum releases cholecystokinin, which causes the gallbladder to release the concentrated bile to complete digestion. Bile helps to emulsify the fats in the food. Besides its digestive function, bile serves also as the route of excretion for bilirubin, a byproduct of red blood cells recycled by the liver. The alkaline bile also has the function of neutralizing any excess stomach acid before it enters the ileum, the final section of the small intestine. Bile salts also act as bactericides, destroying many of the microbes that may be present in the food. In the absence of bile, fats become indigestible and are instead excreted in feces, a condition called steatorrhea.

Page | 36

ETIOLOGY AND SYMPTOMATOLOGY Etiology Predisposing Factors

Female

Present/ Absent

Rationale

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

Justification

The patient is female.

gallstones as men. Estrogen increases cholesterol levels in bile and decrease gallbladder movement, both of which can lead to gallstones. Sources: Harrison’s Principles of Internal Medicine, Tenth Edition 1983 page 1822 Lippincott Williams and Wilkins Handbook of Diseases Third Edition, page 184 http://www.diabetesmonitor.com/learningcenter/gallstones.htm

Diabetes mellitus

ABSENT

People with diabetes generally have

The patient

high levels of fatty acids called

is not

triglycerides. These fatty acids

diabetic.

increase the risk of gallstones. Sources: Harrison’s Principles of Internal Medicine,

Page | 37

Tenth Edition 1983 page 1823 Lippincott Williams and Wilkins Handbook of Diseases Third Edition, page 184

Age

PRESENT

(20-50; over age 60)

Many of the body’s systems and

The patient

protective mechanisms become less

is 38 years

efficient with age. Body systems and

old.

processes become sluggish. Sources: Harrison’s Principles of Internal Medicine, Tenth Edition 1983 page 1823 Lippincott Williams and Wilkins Handbook of Diseases Third Edition, page 184

Ethnicity (Native American, Mexican American) (Asian)

PRESENT

Native Americans have a genetic

The patient

predisposition to secrete high levels

is Filipino.

of cholesterol in bile. In fact, they

She is

have the highest rate of gallstones

predisposed

in the United States. A majority of

to having

Native American men have

pigment

gallstones by age 60. Mexican

stones.

American men and women of all ages also have high rates of gallstones. Asians are more genetically predisposed to having pigment stones as compared to those living

Page | 38

in the Western countries Sources: Lippincott Williams and Wilkins Handbook of Diseases Third Edition, page 184 http://www.diabetesmonitor.com/learningcenter/gallstones.htm

Precipitating Factors Pregnancy

Present/ Absent

ABSENT

Rationale

Justification

Excess estrogen from pregnancy, hormone replacement therapy, or birth control pills appears to increase cholesterol levels in bile and decrease gallbladder movement, both of which can lead to gallstones.

The patient is not pregnant.

Source: http://www.fbhc.org/Patients/Modul es/gallstns.cfm

Rapid weight loss

ABSENT

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

No rapid weight loss was noted by the patient.

Sources: Lippincott Williams and Wilkins Handbook of Diseases Third Edition, page 184 http://www.fbhc.org/Patients/Modul es/gallstns.cfm Page | 39

Obesity

ABSENT

The most likely reason is that obesity tends to reduce the amount of bile salts in bile, resulting in more cholesterol. Obesity also decreases gallbladder emptying.

The patient is not obese.

Sources: Harrison’s Principles of Internal Medicine, Tenth Edition 1983 page 1823 Lippincott Williams and Wilkins Handbook of Diseases Third Edition, page 184 http://www.fbhc.org/Patients/Modul es/gallstns.cfm

Fasting

ABSENT

Fasting decreases gallbladder movement, causing the bile to become overconcentrated with cholesterol, which can lead to gallstones.

The patient doesn’t fast.

Source: http://www.diabetesmonitor.com/lea rning-center/gallstones.htm

Hormone replacement therapy, or birth control pills

PRESENT

Excess estrogen from pregnancy, hormone replacement therapy, or birth control pills appears to increase cholesterol levels in bile and decrease gallbladder movement, both of which can lead to gallstones.

The patient has been on birth control pills since she was 36 years old.

Page | 40

Source: Lippincott Williams and Wilkins Handbook of Diseases Third Edition, page 184 http://www.diabetesmonitor.com/lea rning-center/gallstones.htm

Low Fat Diet

PRESENT

Before dietary fat can be digested, it has to be emulsified. Bile is used for this purpose. The liver makes bile continuously and stores it in the gall bladder until such time as it is needed. However, if a low-fat diet is eaten, that bile remains in the gall bladder.

The patient avoids fatty foods.

Gallstones are formed when the gall bladder is not emptied on a regular basis. In people who continually resort to low-fat diets, bile is stored for long periods in the gall bladder — and it stagnates. In time — and it is really quite a short time — a 'sludge' begins to form.

Source: http://www.secondopinions.co.uk/gallstones.html

Page | 41

Symptomatology Signs and Symptoms

Present/ Absent

Right upper

PRESENT

quadrant pain

Rationale

patient ducts The into connected to the gallbladder came Obstruction

will

(may radiate

cause

produced

to right

Justification

of

inflammation DMSF by increased complaining

intraluminal pressure and of RUQ pain.

scapula, shoulder, or

distension

interscapular

gallbladder.

area)

of

the

Sources:

“biliary colic”

Harrison’s Principles of Internal Medicine, Tenth Edition 1983 page 1825

Fever (low grade)

ABSENT

patient nonspecific The not response that is mediated was by endogenous pyrogens febrile. Fever

is

a

released from host cells in response to infectious or non-infections disorders. It may be brought about by prostaglandins

released

during inflammation. Source: Carol Mattson Page | 42

Porth (2005. Pathophysiology, Seventh edition page 205)

Murphy's sign (abrupt interruption of deep inspiration)

PRESENT

Classically Murphy's sign is The tested for during was

patient positive

the an abdominal examination; for it is performed by asking the Murphy’s patient to breathe out and Sign. then gently placing the hand below the costal margin on the right side at the midclavicular line approximate

(the location

of

the gallbladder). The patient is then instructed to inspire (breathe

in).

during

Normally, inspiration,

the abdominal contents are pushed

downward

as

the diaphragm moves down (and lungs expand). If the patient stops breathing in (as

the

is tender and, downward,

gallbladder in

moving

comes

in

contact with the examiner's fingers) and winces with a 'catch' in breath, the test is

Page | 43

considered

positive.

A

positive test also requires no pain on performing the maneuver on the patient's left hand side. Source: http://www.turnerwhite.com/pdf/hp_nov00_m urphy.pdf

Nausea and

ABSENT

Nausea

and

vomiting The

patient

sometimes occur with biliary didn’t

vomiting

colic. The inflammation of complain

of

the gallbladder causes pain nausea

or

and

spasms

of

the vomiting.

abdominal muscles which may

make

one

feel

nauseated. Source: Understanding Surgical

Medical

Nursing

by

Williams and Hopper page 742

Mildly elevated

ABSENT

Biliary obstruction causes The patient’s suppression of bile flow, bilirubin

was

Page | 44

serum

and

bilirubin

regurgitation

of not increased.

conjugated bilirubin into the bloodstream. Sources: Harrison’s Principles of Internal Medicine, Tenth Edition 1983 page 1829

Elevated SGPT and SGOT enzymes

PRESENT

SGOT (AST) and (ALT) is The patient’s an enzyme found mostly in lab

tests

the liver but also in the reveal heart,

the

muscles,

an

the elevated level

kidneys, the pancreas and of SGPT and in red blood cells. High SGOT elevations

may

associated

with

be enzymes. liver

disease or muscle trauma. Elevations

may

also

be

associated with a variety of conditions

including

myocardial infarction (heart attack),

pancreatitis,

bile

duct obstruction and more. Abnormalities enzymes

of

liver

including

Page | 45

AST/SGOT and ALT/SGPT are indicative of problems such as Mirrizi syndrome, or a stone in the bile duct causing

infection/liver

inflammation. Sources http://my.diabetovalens.com /apollo/sgot.asp

Page | 46

PATHOPHYSIOLOGY Precipitating Factors: Predisposing Factors:    



    

Female Age 38 Ethnicity Diabetes Mellitus

Birth control pills Low Fat Diet Pregnancy Rapid weight loss Obesity fasting

Bile stagnates in the gallbladder

Pigment solute precipitate as solid crystals

Crystals clump together and form stones Gallstones

Gallbladder contracts after intake of fat to release bile Upon contraction, a stone is moved and becomes impacted on the cystic duct

CHOLELITHIASIS Lumen is obstructed by stones Bile stasis

Page | 47

Chemical reaction inside gallbladder triggers the release of inflammatory enzymes (Prostaglandins)

Fluids leak into gallbladder

Inflammation of the gallbladder

Edema

Increased intraluminal pressure and distention of the gallbladder

Constriction of blood vessels

Biliary Colic (RUQ pain)

Murphy’s Sign

ACUTE CHOLECYSTITIS If not treated If treated with:

Surgery, proper diet (low fat, high fiber), compliance to medications

Continued lack of blood supply to gallbladder

Continued increase in intraluminal pressure of gallbladder

Necrosis Rupture of gallbladder

Good prognosis

Gangrene and empyema

Perforation of gallbladder

Spread of bile indigenous microorganisms peritoneal cavity Page | 48

and into

Sepsis

Death

Page | 49

DOCTOR’S ORDER Date

Order

Rationale

Remarks

5/8/10

Admit under the care

Admitted under the care of

Done.

@ 11pm

of Dr. Batucan

Dr. Batucan, a surgeon, for

Patient was

his specialties on surgical

placed in

procedures (Laparoscopic

ward 324

cholecystectomy)

bed 5

Secure consent to

Consent is an agreement

Done

care

between client and health care provider to give proper quality care. It is also to protect the client from harmful procedures and the institution from law suits

Low fat diet

Doctors were not sure

Done

whether the gallstones are either cholesterol or pigment stones. Thus, this is done to prevent any further damage to the gallbladder. Monitor VSqShift and

Monitoring vital signs is

record

important in order to note any

Done

unusualities and to refer these as follows. Labs:

CBC

A complete blood count

Done

(CBC) is a series of tests used to evaluate the composition and

Page | 50

concentration of the cellular components of blood. It consists of the following tests: red blood cell (RBC) count, white blood cell (WBC) count, and platelet count; measurement of hemoglobin and mean red cell volume; classification of white blood cells (WBC differential); and calculation of hematocrit and red blood cell

Platelet

Platelet count is to determine

Done

the number of platelets; If the number of platelets is too low, excessive bleeding can occur. However, if the number of platelets is too high, blood clots can form (thrombosis), which may obstruct blood vessels.

Urinalysis

It is done to detect urinary

Done

tract infection. It also measures the level of ketones, sugar, protein, blood components and many other substances Venoclysis: PNSS 1L

PNSS is an isotonic solution

Done. IVF

@ 100cc/hr

to provide hydration since it

infusing well Page | 51

was found out that the

at right

specific gravity for urine is in

metacarpal

the borderline (1.010). It is

vein.

also to provide electrolytes, and as a medium for IVTT meds

Meds:

Demerol 50mg IVTT

Acts as agonist at specific

now then prn for

opioid receptors in the CNS to

abdominal pain

produce analgesia, euphoria,

Given

sedation for relief of moderate to severe pain

HNBB (Hyoscine N-

It's a competitive antagonist

Butyl Bromide) 20mg

of the actions of acetylcholine

1amp IVTT now

and other muscarinic agonists

Given

causing smooth muscle relaxation indicated for her abdominal pain MHBR

Moderate high back rest is to

Done

elevate the upper portion of the body to increase lung expansion thus promoting gas exchange. This is also to prevent ascending infection that could be caused by possible rupture of the gallbladder. Refer any

In order for the patient to be

Done Page | 52

unusualities: severe

assessed and evaluated

abdominal pain,

properly and be managed

vomiting

accordingly.

5/9/10

Start Cefoxitin

Cefoxitin inhibits synthesis of

Done. Result

8:10am

(Monowel) 1g IVTT

bacterial cell wall causing cell

for skin test

q8 ANST

death which acts as a

is negative.

perioperative prophylaxis for

Cefoxitin

surgical procedures. ANST or

may be

after negative skin test is to

given to the

check whether the client is

patient.

not allergic to the antibiotic. For ultrasound

This is done to visualize

Not able to

tomorrow morning

internal organs, to capture

comply.

their size, structure and any

Patient had

pathological lesions with real

her

time tomographic images.

ultrasound

This is also to know the

on May 11,

condition of the gallbladder

2010.

whether it ruptured or not. For total bilirubin,

Bilirubin is elvated if

Done.

hepatocytes are injured and

Results are

cannot metabolize or excrete

normal

bilirubin

Direct bilirubin,

Increases in conjugated bilirubin are highly specific for disease of the liver or bile ducts

Indirect bilirubin

Increase in unconjugated bilirubin may be caused by Page | 53

hepatic disease, cholestasis, and hemolysis

Alkaline phosphatise

High levels of alkaline phosphatise indicates liver disease

SGPT

SGPT is released into blood

Done.

(Serum glutamic

when the liver or heart is

Patients

pyruvic

damaged; thus, this is to

SGPT

transaminase)

determine liver function.

results are

Elevation of this may possibly

high

mean liver problems

SGOT (Serum glutamic oxaloacetic transaminase)

AST (aspartate aminotransferase) or SGOT is an enzyme found in high

Done. SGOT results are also high

amounts in heart muscle and liver and skeletal muscle cells. It is also found in lesser amounts in other tissues. Elevated levels may be caused by liver or heart disease

Schedule for

Lap Chole was to surgically

Done.

laparoscopic

remove the gallbladder with

Surgery was

cholecystectomy on

only a small incision.

done on

Tuesday (4/11/10)

4/11/10 @

2pm

4pm

Secure consent/AC

Patient has the right to be

Done.

Page | 54

consented in all procedures to be done, and for legal purposes. Anesthesia clearance is for the patient to be evaluated whether he/she is fit to undergo the operation. It is also for the anaesthesiologist to predict the operative risk and the appropriateness of the anaesthesia to be induced during operation. Inform OR

For the OR to know that such

Done

case will be performed and to prepare the necessary instruments and room. This is also to coordinate availability of staff and surgeon Refer

In order for the patient to be

Done

assessed and evaluated properly and be managed accordingly. 5/9/10

May have ultrasound

This was to visualize internal

Done.

5:00pm

on Tuesday 5/11/10

organs, to capture their size,

Ultrasound

structure and any pathological result lesions with real time

retrieved on

tomographic images. It is also

5/11/10.

to know whether the

Impression:

gallbladder has ruptured or

Cholelithiasi

not.

s; Sonographic Page | 55

ally normal liver and pancreas 5/10/10

To reschedule OR

To inform the OR that the

Done.

1:00pm

tomorrow from 2pm

procedure will be moved from

Patient had

to 4pm

2pm to 4pm

her surgery at 4pm of May 11, 2010.

IVF TF: PNSS 1L @

PNSS is an isotonic solution

KVO

for hydration and as a

Done

medium for IVTT meds; KVO was done since patient’s hydration was good. 9:15pm

Please facilitate AC

AC is to assess patient’s rate

Done

of survival and check for what anesthetics is right for the patient, making sure that the patient isn’t allergic to the anesthetic For Lap Chole tom

This was to surgically remove

4pm

the gallbladder with only a

Done.

small incision. Patient can undergo laparoscopic cholecystectomy since gallbladder has not ruptured yet as seen on the ultrasound result. For blood chem. and

Blood tests are used to

Ultrasound tom

determine physiological and

Done.

biochemical states, such as Page | 56

disease, mineral content, drug effectiveness, and organ function. 9:30pm

Pre-op orders:

NPO after light

NPO is to prevent peristalsis,

breakfast (8am)

aspiration and injury during

Done

surgery

Assess VS prior to

as baseline data and to detect Done

OR

any unusualities

General oral hygiene

Oral hygiene is the practice of

Done

keeping the mouth clean and healthy by brushing and flossing to prevent tooth decay and gum disease.

IVF: D5NSS 1L @

Intravenous solutions with

120cc/hr

reduced saline concentrations

Done

typically have dextrose added to maintain a safe osmolality while providing less sodium chloride; to hydrate before surgery in preparation for disruption of homeostasis

Meds:

Diazepam 10mg 1

Potentiates the effects of

Given Page | 57

tab 2am

GABA; Act in spinal cord and at supraspinal sites to produce skeletal muscle relaxation; it is also used as adjunct to General anesthesia Given

Ranitidine 150mg

Inhibits basal gastric acid

1tab 2am

secretion and gastric acid secretion; patient was placed on NPO

Vitamin K

For the liver to activate

Given

clotting factors such as prothrombin, proconvertin, thromboplasstin, and stuart factor. 5/11/10

NPO

1:30pm

NPO is to prevent peristalsis,

Done

aspiration and injury to the GI tract during surgery. Post op orders:

To PACU then to

Patient must first be stabilized Done

room

before transfer to the ward; PACU is a place with complete gadgets and staff for emergency purposes after post op.

NPO for 4 hrs then

Patient not yet fully conscious

may have SD

due to anesthetics, thus this

Done

Page | 58

is to prevent aspiration.

Monitor VS q15 until

Monitoring vital signs is to

stable then q30 for

detect any unusualities after

2hrs then q2

the operation.

Done

Meds:

Etoricoxib 120mg PO

Half life is 22hrs. Etoricoxib

12mn

blocks COX2 thus relieving

Given

pain and inflammation.

Tramadol 100mg

Half life is 5-7hrs

1tab 12mn

Inhibits the reuptake of

Given

norepinephrine and serotonin; causes many effects similar to opioids – analgesic

Demerol 50mg IVTT

Half life is 3-5hrs

Given

Causes analgesia, euphoria, sedation; thus reducing pain

Sultamicillin 375mg

Inhibits synthesis of bacterial

PO TID

cell wall causing cell death;

Given

this was indicated due to possible intra – abdominal infections O2 inhalation @ 4pm

This ensures optimum

until fully awake

oxygenation of cells gearing

Done

towards achieving balance or homeostasis. Also this was Page | 59

for optimum respiratory level; prevents lung collapse. MHBR

Moderate high back rest is to

Done

elevate the upper portion of the body to increase lung expansion thus promoting gas exchange. Deep breathing

Post op exercise is indicated

exercises for 15mins

To prevent lung collapse and

TID

to eliminate anesthetic gases

Done

introduced to the body 5/12/10

May have DAT

Patient may eat anything as

Done.

long as it can’t harm her

11:15am

current condition Continue meds

For the patient to complete

Done

the medication regimen and for continuity of care

Wound care

Daily routine wound care is

Done

indicated in order to promote healing and/or prevent infection 5/13/10

MGH

9:00am

Patient may go home after

Done

the doctor decides if unusualities are absent Home meds:

Etoricoxib 90mg PO

Half life is 22hrs. Etoricoxib

Done.

BID

blocks COX2 thus relieving

Patient was

pain and inflammation.

informed

Page | 60

Tramadol 100mg ½

Half life is 5-7hrs

tab PO BID

Inhibits the reuptake of norepinephrine and serotonin; causes many effects similar to opioids – analgesic

Sultamicillin 375mg

Inhibits synthesis of bacterial

PO BID

cell wall causing cell death

C/D IVF

Terminate IVF when IVF is

IVF

about 50cc

discontinued

ff. up check at

Follow up check up is for the

Patient to

5/18/10

patient to be assessed and

come back

evaluated properly and be

at 5/18/10

managed accordingly.

Page | 61

DIAGNOSTIC EXAM CBC – a determination of red and white blood cells per cubic millimeter of blood. It helps health professional check any symptoms such as weakness, fatigue, or bruising. It also helps diagnose conditions such as anemia, infection and other disorders May 8, 2010 Test Hemoglobin

Normal Result Remark Rationale Values 115.0- 137.0 Normal Hemoglobin carries 155.0

Hematocrit

0.36-

oxygen to and removes

0.42

Normal

0.52

Interpretation Within normal

Nursing Responsibilities There is very little risk

range

associated with taking

carbon dioxide from red

blood from a vein in the

blood cells. It measures

arm, although there is a

total amount of

slight risk of infection

hemoglobin in the blood

anytime the skin is

Hematocrit measures the percentage of red blood

Within normal range

broken. Strict asepsis should be observed

cells in the total blood volume RBC

4.2-6.1

4.47

Normal

Measures the number o RBCs per cubic millimeter

The patient may feel Within normal

discomfort when blood is

range

Page | 62

of the whole blood. WBC

5.0-

14.1

High

10.0

Determines the number of

55-75

74

Normal

20-35

21

Normal

a

vein.

Bruising may occur at

may be caused by the puncture site, or the

millimeter of the whole

acute infections –

person may feel dizzy or

tuberculosis,

faint. Pressure should be

pneumonia,

applied to the puncture

meningitis,

site until the bleeding

tonsillitis,

stops to reduce bruising.

appendicitis,

Warm packs can also be

colitis, etc.

placed over the puncture

Within normal

site to relieve discomfort

Phagocytes engulfing bacteria and cellular

Lymphocytes

Elevated levels

from

circulating WBCs per cubic

blood.

Neutrophil

drawn

levels.

debris. It prevents or limits

Instruct patient in dietary

bacterial infections.

sources of iron such as

Cells present in the blood

Within normal

red meat, organ meats,

and lymphatic tissue that

range

clean green vegetable

provide the main means of

and fortified grains

immunity for the body. There are three types of

Protect the patient from

lymphocytes: the natural

potential sources of

Page | 63

killer (NK), thymus-derived

infection, monitor for

lymphocytes (T cells), and

signs of infection.

bone marrow-derived

Provide soft, bland diet

lymphocytes (B cells). NK

high in protein, vitamins,

cells are found in the

and calories. Meticulous

blood, red bone marrow,

hand washing and strict

lymph nodes and spleen

asepsis are mandatory

and are able to destroy

Monocytes

2-10

4

Normal

many kinds of infected

Institute

protective

body cells and tumor cells.

isolation

measures

The T cells and B cells are

immediately if there is

involved in specific

neutrophil disorder. Also

immune responses.

instruct the patient to

This type of granular leukocyte functions in the

Eosinophil

1-8

1

Normal

Within normal range

observe

aseptic

technique and to take

ingestion of bacteria and

caution most especially

other foreign particles

if immunocompromised.

Functions in allergic responses and in resisting infections. Eosinophils

Within normal

Inflammatory responses

range

involve more than one body

system.

Monitor

Page | 64

mount on attack against

the patient for worsening

parasitic invaders by

of

attacking to their bodies

condition,

and discharging toxic

respiratory

molecules from their

compromised.

the

inflammatory particularly

cytoplasmic granules. Platelet

150.0400.0

278

Normal

A test that direct count of

Within normal

platelets in whole blood.

range

Platelets number from 100,000-500,000 per cubic millimeter and are important in triggering the sequence of events that

Encourage patient to rest between activities. Encourage patient to plan ahead and save energy for the most important activities.

leads to the formation of blood clots.

Encourage patient to void or stop activities that make short of breath or make heart beat faster. Encourage patient to Eat Page | 65

a diet with adequate protein and vitamins. Drink plenty of noncaffeinated and nonalcoholic fluids.

Urinalysis - Urinalysis is a physical, microscopic, or chemical examination of the urine. It is done to detect urinary tract infection. It also measures the level of ketones, sugar, protein, blood components and many other substances May 8, 2010 TEST

RESULT

NORMAL

CLINICAL SIGNIFICANCE

Glucose

Negative