178352604 case-presentation-2012-chole

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N. INTRODUCTION
Cholecystitis is an inflammation of the gallbladder wall and nearby abdominal
lining. Cholecystitis is usually caused by a gallstone in the cystic duct, the duct that
connects the gallbladder to the hepatic duct. The presence of gallstones in the
gallbladder is called cholelithiasis. Cholelithiasis is the pathologic state of stones or
calculi within the gallbladder lumen.
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Calculouscholecystitis is the cause of more than 90% of cases of acute
cholecystitis (Feldman, Friedman and Brandt,2006).
Gallstones are crystalline structures formed by hardening or adherence of
particles of normal or abnormal bile constituents. According to various theories, there
are four possible explanations for stone formation. First, bile may undergo a change in
composition. Second, gallbladder4 stasis may lead to bile stasis. Third, infection may
predispose a person to stone formation. Fourth, genetics and demography can affect
stone formation.
Sometimes, persons with gallbladder disease have few or no symptoms. Others,
however, will eventually develop one or more of the ff. symptoms; (1.) Frequent bouts of
indigestion, especially after eating fatty or greasy foods, or certain vegetables such as
cabbage, radishes, or pickles, (2.)Nausea and bloating (3.) attacks of sharp pains in the
upper right part of the abdomen.This pain occurs when a gallstone causes a blockage
that prevents the gallbladder from emptying (usually by obstructing the cystic duct). (4)
Jaundice may occur if a gallstone becomes stuck in the common bile duct, which leads
into the intestine blocking the flow of bile from both the gallbladder and the liver. This is
a serious complication and usually requires immediate treatment.
The only treatment that cues gallbladder disease is surgical removal of the
gallbladder, called cholecystectomy. Generally, when stones are present and causing
symptoms, or when the gallbladder is infected and inflamed, removal of the organ is
usually necessary. When the gallbladder is removed, the surgeon may examine the bile
ducts, sometimes with x-rays, and remove any stones that may be lodged there. The
ducts are not removed so that the liver can continue to secrete bile into the intestine.
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Most patients experience no further symptoms after cholecystectomy. However, mild
residual symptoms can occur, which can usually be controlled with a special diet and
medication.
I. DEMOGRAPHIC DATA
A. Initials of Client’s Name: E.Q.
B. Address: Blk 2 Lot 3 Section 35 Bellview Meadows Subd. Brgy.BagtasTanza Cavite
C. Age: 61 years old
D. Birth date: August 24, 1951
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E. Birthplace: Albay, Bicol
F. Gender: Female
G. Civil status: Widowed
H. Religion: Roman Catholic
I. Educational attainment: 2nd
Year High School
J. Usual Source of Medical Care: San Lazaro Hospital, UST and KP
K. Date of Admission: December 5, 2012
L. Time of Admission: 11:50 am
M. Hospital: Korea-Philippines Friendship Hospital
N. Date of Interview: December 7, 2012
O. Primary Informant: Patient (E.Q.)
P. Secondary Informant: None
Q. Other Data Source: Patient’s chart and health care provider
Occupation: Vegetable Stand Vendor
Monthly Income: 3,000 Php
II. REASON FOR SEEKING HEALTH CARE
Prior to admission, client had fever for 1 day and experienced abdominal pain for
3 days with a pain scale of 10 out 10 on Right Upper Quadrant radiating from front to
back upon admission which cause the patient to seek for medical assistance.
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III. HISTORY OF PRESENT ILLNESS
According to the patient she experienced the pain since 2003( month and date
not stated) and she had an check-up on the same year at University of Sto. Tomas
Medical Center with Dr. Alvin Quino as her physician. She had a request for ultrasound
and given a medication of Buscopan for 3 days.
The client also mentioned that she uses boiled guava leaves and she drinks it.
She even calls for midwife for massage regarding her pain. At first clients perception
about her disease is “ang alam ko kasi lamig lang siya eh” as verbalized by the patient.
At present upon occurring of pain she was on their house lying on bed when it
triggers again and tend the patient to have consultation at Korea-Philippines Friendship
Hospital under Dr.Calma as her attending physician last November 27, 2012. She have
undergone for ultrasound at Divine Grace last Dec. 4 2012. And after the result has
being read, she was diagnosed to have Cholecystolithiasis or presence of stone on the
gall bladder. Her physician decided her to be admitted at KP on Dec. 5, 2012 and was
scheduled for Cholecystectomy on Dec. 7, 2012.
IV. PAST MEDICAL HISTORY
According to the patient, she was diagnosed to have a mass on her
xyphoidprocesswhen she was 15 years old at San Lazaro Hospital Manila. She doesn’t
remember the name of the doctor who prescribed her to take Kremil-S and Tetralac
during that time. After that, the patient didn’t hesitate to return to any health institution
for further check-ups or assessments. She used herbal medicines ofFeligayonProducts
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since year 2000 up to now as her pain reliever. Moreover, the patient said that she
doesn’t experience any incidence of injury and accidents. She was never been
hospitalized. In regards on her immunization, patient stated that she was fully
immunized before she reached one year old. According to her, she has the possibility to
be allergic to contraceptive pills because according to her observation, her baby got
rashes when she breastfeeds her which she thought to be due to her intake of pills. The
patient also stated that she had a history of taking multivitamins (Revicon) regularly
when she was 30 years old up to when she turned 40. The patient also stated that she
takes B6B12 for her joints twice a day irregularly. The patient had her last check-up this
November 27 at KPFH with Dr.Calma.
V.OBSTETRIC GYNECOLOGICAL HISTORY
The patent stated that she had her menarche when she was 15 years old.She
have a regular cycle of 28 days with a usual amount of 3 pads/ day for 5 days she
sometimes experienced dysmenorrhea client usually take Midol and herbal medicine for
menstruation. But when patient is at age of 45 years old her menstruation stops for 9
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months which is not normal but after 9 months she experience menorrhagia. The client
experiences her menopause when she was 55 years old.
G5 P5 T5 P0 L5 M0
VI. HEREDO-FAMILIAL HISTORY
MATERNAL SIDE
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BA
83 y/0
HPN
DA
83 y/o
MA
HPN

INTERPRETATION
As seen above the genogram, patient has history
of hypertension on both sides. Other than that,
patient has no known diseases that can
contribute to her present condition.
VII. SOCIO-ECONOMIC
The type of family structure is extended client lives with her grand children and in
laws. Since client EQ’s husband died the breadwinner of the family is her eldest son who
is working in Makati. Upon the interview, the patient stated that their average monthly
income is Php 6,000 and they usually spends Php100 per day for their food, 2000 for
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46 yrs old
HPN
DA
HPN
PA
83 yrs old
EQ
61 yrs old

electricity, and health maintenance varies depending upon the condition but is not
consistent. They owned the house in which they were residing. They were also affiliated to
Phil Health in order to suffice the patient’s hospitalization.
Below is the estimated breakdown of their expenditures as of the month of
November.
Expenses:
Food: 100 php
Electricity: 2000 php
Food: 100 Php/ day
x 30 days
3000 Php
VIII. DEVELOPMENTAL HISTORY
Erik Erickson’s Psychosocial Development
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Erik Erikson's theory of psychosocial development is one of the best-known
theories of personality in psychology. Erikson believed that personality develops in a
series of stages it describes the impact of social experience across the whole lifespan.
Elements of Erikson’s psychosocial stage theory are the development of ego
identity. Ego identity is the conscious sense of self that we develop through social
interaction. According to Erikson, our ego identity is constantly changing due to new
experiences and information we acquire in our daily interactions with others. In addition
to ego identity, Erikson also believed that a sense of competence motivates behaviors
and actions. Each stage in Erikson's theory is concerned with becoming competent in
an area of life. If the stage is handled well, the person will feel a sense of mastery,
which is sometimes referred to as ego strength or ego quality. If the stage is managed
poorly, the person will emerge with a sense of inadequacy.
In each stage, Erikson believed people experience conflict that serves as a
turning point in development. In Erikson's view, these conflicts are centered on either
developing a psychological quality or failing to develop that quality. During these times,
the potential for personal growth is high, but so is the potential for failure.
Stage 1: Trust vs. Mistrust: Infancy (Birth to 18 Months)
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The patient grows up living with her Grandmother. According to her she was very
close to her Lola. Upon questioning the client reminisces about her childhood days, she
stated that, “Sabi saakin ng Lola ko dati, hindi daw ako lumalapit sa ibang tao sa mama
ko at sakanya lang kasi pag iba na humahawak sakin iyak na daw ako ng iyak .” She
was a breastfed baby during her birth until she got 1year old.
The patient verbalized that, “Isang beses daw wala yung Lola ko tapos ang
kasama lang ni mama ay yung kaibigan nya, tapos tinakot takot daw ako nun kaya lalo
daw akong di sumama at di nasanay sa ibang tao.” In her case, the patient developed
mistrust with other people because of what she experienced when she was child. if we
Failing to build trust because our needs are not met, we may end up with a
subconscious feeling of unimportance and a mistrust of other people around us.
Stage 2: Autonomy vs. Shame: Early Childhood (18 Months to 3 Years)
During this stage the patient learn to master some skills for her. She learned to
walk, talk and feed herself through the help of her mother and her sisters. She was
learning finer motor development as well as the much appreciated toilet training. The
patient recalls that when she was 3 years old, she knew how to say “NO” if she did not
want to do certain activities and normally her Lola is the one who’s choosing what
clothes she will wear even if she doesn’t like it. Her parents allowed her to do as she
pleased. Though if she did something wrong they would commend her in her actions.
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It concludes that, the patient is in the process having disgrace of doing things or
in learning other important skills; she may feel great shame and hesitation of her
capabilities and experience low confidence as a result.
Stage 3: Initiative vs. Guilt: Play Age (3 to 5 Years)
During this period, the patient experiences a desire to copy the adults around us
and take initiative in creating play situations. In this stage a child will begun to explore
the world by using a wonderful word "WHY?”. As she verbalized, “sabi saakin nung
Lola ko, dati daw pag may ginagawa sya ginagaya ko daw madalas pag nagwawalis
sya o nagliligpit, yung Lola ko naman hinahayaan lang ako para daw paglaki ko
masipag ako.” She also verbalized that after school she and her playmates used to play
“bahay-bahayan” or playing there dolls. The patient also begun to use that wonderful
word for exploring the world – She commonly asked her Grandmother “Lola bakit
pobinigay ako nila mama sayo?” or “Mahal po ba ako nila?”. The client is in the process
of asking many questions to know the truth and to adopt on the reality. Her
Grandmother answers her questions honestly and it came up to positive outcome. If a
child’s questions treat as insignificant, it will result to embarrassing or may develop
negative behaviour then the child may have feelings of guilt for “being an irritant”. Too
much guilt can make the child slow to interact with others and may inhibit their creativity,
it can also effect the child to exercise self control or have a conscience. A healthy
balance between initiative and guilt is important. Success in this stage will lead to the
virtue of purpose.
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Stage 4: Industry (competence) vs. Inferiority (6 - 12 years)
The patient at this stage learned to read and write, to do sums, to make things
on their own. The patient verbalized that, “Naaalala ko pa nun yung guro naming
magaling sya pero minsan may pag ka sadista, uso naman yun dati pag mali ginawa o
ginagawa mo pinapalo ka pero ok lang naman yun mas natuto ako na magsipag sa
pag-aaral para di mapalo.” She also stated that, her Grandmother is always there for
her to encourage, to educate and also to give advices in a nice way every time she was
having trouble in her studies.
If children are encouraged and reinforced for their initiative, they begin to feel
industrious and feel confident in their ability to achieve goals. If this initiative is not
encouraged, if it is restricted by parents or teacher, then the child begins to feel inferior,
doubting his own abilities and therefore may not reach his potential.
Stage 5: Identity vs. Confusion: Adolescents (13 – 19 years)
In this stage, adolescence, children explore their independence and
develop sense of self. Those who receive proper encouragement and reinforcement
through personal exploration will emerge from this stage with a strong sense of self and
a feeling of independence and control. Those who remain unsure of their beliefs and
desires will feel insecure and confused about themselves and the future. According to
the client she was aware in her appearance as a female, she knew where group of
friends she belongs. Her Grandmother is strict when it comes to handling herself, on
how to act as a female and sometimes discouraging her to make friends with boys. The
patient didn’t have any confusion about her identity.
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Stage 6: Intimacy vs. Isolation: Young Adult (20 – 24 years)
This stage covers the period of early adulthood when people are exploring
personal relationships. Erikson believed it was vital that people develop close,
committed relationships with other people. Those who are successful at this step will
form relationships that are committed and secure. Remember that each step builds on
skills learned in previous steps. Erikson believed that a strong sense of personal
identity was important for developing intimate relationships. Studies have demonstrated
that those with a poor sense of self tend to have less committed relationships and are
more likely to suffer emotional isolation, loneliness, and depression.
The patient in this stage feels loved and beloved. This is the time that she really made a
decision in her life to have a serious relationship with her first husband. She decided to
have a commitment that will last forever. So what she did she come to her true friends
to ask some advices. This is also a stage that the patient seeks stable job for her family.
Love and affiliation was shown by the patient.
Stage 7: Generativity vs.Stagnation: Mid-adult (25-64 years)
During this period, patient is already having her own family. Her love with her
husband resulted to ___ childrens. As the mother of the family, she gets the obligations
and responsibilities that she was able to show. However, she sometimes feels
unproductive due to her long stay at the hospital. With that, she does not have any
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source of income thus making it hard for her to withstand the responsibility in the family
that made her feel dissatisfaction.
The patient had developed sense of generativity or the sense of being
productivity and accomplishment during this stage. At this stage of middle adulthood
one is preoccupied with establishing and guiding the new generation. Constructing a
life, a career, to have founded a family and to contribute to society are the most
important elements of this stage. Someone who lacks those attributes might feel at the
margin of the world, passive and with a lack of purpose and productivity. Generativity is
the concern of establishing and guiding the next generation. Socially-valued work and
disciplines are expressions of generativity. During Middle Ages the primary
developmental task is one of contributing to society and helping to guide future
generations. When a person makes a contribution during this period, perhaps by raising
a family or working toward the betterment of society, a sense of generativity – a sence
of productivity and accomplishment results. In contrast, a person who is self-centered
and unable or unwilling to help society move forward develops a feeling of stagnation –
dissatifiscation with the relative lack of productivity. (Pilliteri, 5th
edition)
In regards with this stage, during adulthood, we continue to build our lives,
focusing on our career and family. Those who are successful during this phase will feel
that they are contributing to the world by being active in their home and community.
Those who fail to attain this skill will feel unproductive and uninvolved in the world.
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IX. GORDON’S FUNCTIONAL ASSESSMENT
A. HEALTH PERCEPTION – HEALTH MANAGEMENT
T he patient verbalized that the most important factors for a healthy life is just
eating nutritious foods, having a balance diet and having enough hours of sleep. She
does not smoke nor drinks alcohol. She doesn’t believe in faith healer but believes in
herbal medicines.
Prior to hospitalization, E.Q stated that she thought that she was alright. She also
stated that she seldom get sick and have coughs and colds. She did not consult any
medical help until she could no longer tolerate her symptoms. She only took herbal
medicines like Feligayon Products as pain reliever. She was a fully immunized child.
The patient has been in the hospital since December 5, 2012 and had undergone
an operation on December 7, 2012. Prior to operation, she stated, “Mahina po ako
ngayon. Sana pagkatapos ng operasyon magaling na ako.” After the operation, she
verbalized wellness even though there is pain in the incision site.
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O. NUTRITIONAL METABOLIC
MEALS December
5, 2012
December 6,
2012
December 7,
2012
BREAKFAST
2 pcs of
Bread
1 cup of
coffee
2 pcs of Bread
1 cup of coffee
½ cup of
Lugaw
1 glass of
water (120 ml)
LUNCH
½ cup of
Lugaw
1 glass of
water (120
ml)
1 cup of rice
1 pc.
Ginataang
Tilapia
1 glass of water
NPO
DINNER ½ cup of
Lugaw
1 glass of
water (120
ml)
½ cup of
Lugaw
1 glass of water
(120 ml)
NPO
TOTAL FLUID
INTAKE
300 ml 300 ml 120 ml
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The patient had her diet as tolerated but is ordered in nothing perm orem diet
prior to operation. According to the patient, her meal before hospitalization usually
includes vegetables, fish and rice. She stated that she likes to eat gata. She only
weighs 52 kgs and verified no weight loss or weight gain. There are no changes in
appetite or eating discomfort. According to her when he has wound it heals well. He
doesn’t have any dentures.
The patient daily meal doesn’t meet the nutritional guides for adult. An adult
should have at least 5 ½ cup of rice and alternative daily (Nutritional Guidelines for
Filipino, 2000 ed. P.13 FNRI-DOST). She may have imbalanced nutrition less than body
requirements since she use to eat lugaw in her hospitalization.
P. ELIMINATION
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The patient usually urinates 7 times a day (840mL): 5 times on day and 2 times
on night. Her urine color is orange. Catheter was inserted before the operation and
passes out orange color. She defecates once a day regularly without any difficulties or
using of laxatives. The color of her stool is golden brown. She doesn’t exhibit excessive
perspiration.
D. ACTIVITY-EXERCISE
The patient stated that her usual activities during her stay at the hospital are just
lying in bed and having conversations with her son. She seldom does anything because
she experiences body weakness. She just stay on her bed, sleeping. Her only exercise
would be her walk to the bathroom if needed.
According to her, her usual activities before her illness were taking care of her
grandchildren.
E. SLEEP REST
E.Q stated that she usually sleep at night at around 8 pm and wakes up at
around 2:00 to 3:00 am. She stated that even though she sleeps early or late at night
she stills wakes up early in the morning. However, she feels quite rested upon waking
up and ready for the day.
But during hospitalization, the patient sleeps for about 4 to 5 hours at night. Her
sleep is disrupted due to pain felt on her incision site.
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CONSTRUCTS MON TUES WED THURS FRI SAT SUN
HOURS OF
SLEEP
7hours 7hours 7hour
s
7hours 7hour
s
7hours 7hours
SLEEPING TIME 8pm 8pm 8pm 8pm 8pm 8pm 8pm
WAKING TIME 3am 3am 3am 3am 3am 3am 3am
BEDTIME
RITUALS
pray pray pray pray pray pray pray
FEELING UPON
WAKING UP
Feels
rested
Feels
rested
Feels
rested
Feels
rested
Feels
rested
Feels
rested
Feels rested
PROBLEMS
ENCOUNTERED
NONE NONE NONE NONE NONE NONE NONE
F. COGNITIVE PERCEPTUAL
Upon the interview, the patient was able to answer all the questions coherently
and appropriately. She stated that she had blurred vision but stopped wearing reading
glass nor hearing aids though she experienced slight difficulty in hearing. As observed,
the patient is able to read the sample reading materials with little difficulty. As Tic Tac
Test was performed, the patient heard the ticking of the watch after 5 seconds. She
doesn’t complain any changes in taste. Other than that, there are no significant changes
in patient’s perception. She shows good memory and was able to remember recent and
past events. She easily learned something by responding and asking follow-up
questions.
She had no difficulty in making decisions because according to her, her children
were the one who is responsible in decision making. She stopped her studies when she
was 2nd
year high school due to her own reasons. After that, she started selling
vegetables in Bicol.
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G. SELF PERCEPTUAL – SELF PATTERN
Upon assessment, the patient appeared calm. When asked how she would
describe herself, she stated that she was approachable person and can easily deal with
others. She experienced lesser problems because all her children were in stable life and
all of them support her in financial especially during hospitalization..
The patient sees herself as a friendly person. When we asked her what she feels
about being hospitalized she told us that she feels fine and she added that he wants to
go home already. When asked about her illness, she verbalizes, at first it was alright for
her because she doesn’t know that it was serious. But after explaining it to her, she
accepted her condition and wanted to cure and get well soon.
H. ROLE RELATIONSHIP
The patient was widowed since her husband died due to hypertension on 1992.
As of now, she lives with her eldest and youngest son together with their own family.
They usually spend time watching television and eating meals together. She enjoys
taking care of her grandchildren. She stated that she and some of her siblings weren’t
able to see each other again, only her mom and eldest son are there when she is
visiting their hometown in Bicol. She misses them a lot.
I. SEXUALITY REPRODUCTIVE
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She stated that she had her menarche when she was 15 years old. She have a
regular cycle of 28 days with a usual amount of 3 pads/ day for 5 days she sometimes
experienced dysmenorrheal client usually take Midol and herbal medicine for
menstruation. But when patient reached the of 45 years old her menstruation stops for
9 months which is not normal but after 9 months she experience menorrhagia. She had
given birth to five live children.
The patient verbalizes that since her husband died; she never had another
sexual partner.
J. COPING STRESS
E.Q experienced lesser problems because all her children were in stable life and
all of them support her in financial. But whenever there are problems, she just talks to
her children to take things over.The big change in her life is when he found out that she
has gallstones. When he has problem he usually share it with her friends and family
and according to him it is effective
K. VALUE BELIEF PATTERN
Patient E.Q grew in a Roman Catholic faith. She always attends mass every
Sunday together with her family. She believes in God as her saviour and puts
everything in Him. She prays at night before sleeping to ask God for good health.
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According to her, her family is the most important thing in her life. She verbalized,
“Sila ang nagsisilbing buhay ko at nagbibigay ng lakas ng loob sa araw-araw.”
X. COMPREHENSIVE PHYSICAL EXAMINATION
A. Vital Signs
T= 36.1 C⁰
PR= 84 bpm
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RR= 19 cpm
BP= 120/80 mmHg
B. Anthropometric Data
Weight = 52 kg
Height = 5’3’’
C. General Appearance
Upon assessment the patient was observed that her body build is proportionate
to her weight and height. Due to major surgical procedure done, the patient still at bed
rest. When moving or sitting she needs support from her relative however, the patient is
relaxed.
In regards to her over all hygiene and grooming the patient was observed neat
and clean. There is a quite breath odor but there is no body odor noted.
The patient does not shown any signs of distress but slightly looks weak in
appearance. Mentally, the patient is conscious and coherent.
Upon interview the patient is very cooperative in answering all the questions that
is being asked to her. Her responses are appropriate to the questions and logical in
sequence. The speech that is being delivered was audible and easy to understand and
moderate in pace. All her statements are correlated to the previous information that she
said.
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Q. Physical Assessment
Body Part
Examined
Review of
System
Actual Finding Normal Finding Clinical
Significance
Integument
SKIN
“Nangangati
ang skin
kosa parte
ngtiyan” as
verbalized by
the patient.
I: Even and uniform
slight brown
complexion
-longitudinal incision
site in the RUQ of
abdomen.
P: normal skin turgor
Varies from light to
deep brown; from
ruddy pink to light
pink, generally
uniform, no
edema, no
abrasions or other
lesions
-Incision site is
due to the
surgical
operation done
to the patient
called
Cholecystectom
y. It is the
removal of
gallbladder as a
management of
Cholecystitis.
(Brunner
&Suddarth’s
Medical-
Surgical
Nursing; 10th
ed.
Vol.1, page
1177)
-Can cause
infection if
wound dressing
was not taken
care properly.
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Hair “Walanaman
akongkuto’
as verbalized
by the
patient
I: short, straight, thick
-evenly distributed
-patches of white hair
near the scalp.
-without infestation
Evenly distributed.
Thick, silky and
resilient hair.
No infection or
infestation.
Presence of
white hair is
related to old
age.
(Fundamentals
of Nursing
5th
Edition,
Kozier and Erbs,
page 478)
Nail “Nag
gugupitnama
nakongkuko
lingo-linggo”
as verbalized
by the
patient.
I: Convex curvature;
160°
Smooth texture
-pinkish nail bed
-surrounding tissues
still intact.
P - color comes back
4 seconds when
pinched(blanch test)
Convex curvature;
angle of nail plate
about 160°
Smooth texture
Nail bed pinkish in
light-skinned
clients; dark-
skinned clients
may have brown
or black
pigmentation
Intact epidermis
Prompt return of
pink or usual color
(generally less
than 4 seconds)
NORMAL
Head “Di
namannasak
itanguloko”
as verbalized
by the
patient.
I: symmetrically round
P:smooth skull
contour
-no nodules or
masses
Rounded and
smooth skull
contour
Uniform
consistency;
absence of
NORMAL
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nodules or
masses.
Eyes and
Vision
“Malabo
naangmatak
o, di
naakomasya
dongmakapa
gbasapagwal
angsalamin”
as verbalized
by the
patient.
I: Eyebrows
symmetrically aligned;
equal movement
Eyelashes equally
distributed; curled
slightly outward
-corneas are clear,
transparent and
sensitive.
-Pupils are equally
round, reactive to light
and accommodation.
-sclera appears
yellowish
P: No edema or
tearing
Blinks when the
cornea is touched.
Visual Acuity: wearing
eyeglasses with grade
of R eye- 200-250
L eye- 300
Hair evenly
distributed; skin
intact
Equally
distributed, curled
slightly outward.
PERRLA.
Elderly patients
usually occur
visual changes
due to loss of
elasticity and
transparency of
the lens.
(Fundamentals
of Nursing 5th
Edition, Kozier
and Erbs, page
490)
Ears and
Hearing
“Medyomahi
nana din
angpandinig
ko” as
verbalized by
the patient.
-Symmetrically
aligned auricles, firm
and not tender; pinna
recoils after it is folded
Watch Tick Test: able
to hear ticking in both
ears after 5 secs.
Have no tenderness.
Color is same as
the facial feature,
aligned with the
outer cantus of the
eye, elastic and
can
be folded.
Elderly patients
can occur mild
sensorineural
hearing loss.
(Fundamentals
of Nursing 5th
Edition, Kozier
and Erbs, page
27 | P a g e

494)
Nose and
Sinuses
“Ayosnaman
ang pang-
amoyko’ as
verbalized by
the patient.
I: Uniform in color,
symmetrical and no
discharge
Pink nasal mucosa
P: Sinuses not tender
Symmetric and
straight, no
discharge,
tenderness or
lesions
NORMAL
Mouth and
Oropharynx
“Di pa
koakonakaka
pagtooth
brush,
dalawangara
wna” as
verbalized by
the patient.
I: Lips slightly dry,
symmetrical
Buccal mucosa,
oropharynx and uvula
are pinkish.
Teeth: 3 missing teeth
on upper (molar) and
5 on lower teeth
(molar)
Pinkish gums
Tongue is in central
position, can move
freely
No discharges
Uniform in color,
elastic and
symmetric in
contour.
Should be 32 teeth
for adult, shiny
tooth enamel, pink
gums, and without
lesions.
Central position of
the tongue, pink in
color, smooth and
no lesions.
Tooth loss can
occur as a result
of gum disease
but is
preventable if a
good dental
hygiene is being
maintained.
(Fundamentals
of Nursing 5th
Edition, Kozier
and Erbs, page
503)
NECK
Neck
Muscles
Lymph
Nodes
“ Wala
naming
nasakitsalee
gko” as
verbalized by
the patient.
Neck muscles equal in
size, no swelling
Coordinated
movements
No palpable lymph
nodes
Placed in the midline
of neck
Ascends during
Muscles are equal
in size,
coordinated,
smooth in
movement with no
discomfort.
Central placement
in midline of the
neck, not visible
NORMAL
28 | P a g e

Trachea
Thyroid
Gland
swallowing on inspection,
lobes may not be
palpated
THORAX
and LUNGS
Posterior
Thorax
Anterior
Thorax
“Hindi
namanakona
hihirapanghu
minga” as
verbalized by
the patient.
Chest symmetric, skin
intact; uniform
temperature
Chest wall intact; no
tenderness; no
masses;
Symmetric chest
expansion and vocal
fremitus
Absence of
adventitious sounds.
Effortless respiration
Full symmetric
excursion
Same as posterior
vocal fremitus
Structure is
symmetric, no
tenderness.
NORMAL
Breast and
Axillae
“Walanaman
gmasakitsap
artengyan”
as verbalized
by the
patient.
Rounded in shape;
generally symmetric,
uniform in color
-minimal striae
present
Everted nipple, dark
brown in color
No tenderness,
masses and nipple
Rounded shape;
skin uniform in
color
Nipple is round;
everted and equal
in size, similar in
color
No masses,
nodules,
NORMAL
29 | P a g e

discharge. tenderness, or
nipple discharge.
ABDOMEN “Hindi
nakatuladdat
iyungsakit,
ngayonnasa
kitnalangdahi
lsatahi” as
verbalized by
the patient.
Minimal striae visible
Flat, rounded and no
evidence of
enlargement
Longitudinal incision
site at RUQ about 3
inches long
normoactive bowel
sounds
P- no tenderness or
rebound tenderness
noted
Uniform color, flat
rounded; no
evidence of
enlargement of
liver or spleen;
Symmetric
contour; audible
bowel sounds; No
tenderness
-Incision site is
due to the
surgical
operation done
to the patient
called
Cholecystectom
y. It is the
removal of
gallbladder as a
management of
Cholecystitis.
(Brunner
&Suddarth’s
Medical-
Surgical
Nursing; 10th
ed.
Vol.1, page
1177)
-Can cause
infection if
wound dressing
was not taken
care properly.
GENITALS Hair distributed in the
shape of an inverse
triangle some part of
white hair
Pubic hair
distributed in the
shape of an
inverse triangle,
NORMAL
30 | P a g e

Skin of vulva slightly
darker than the rest of
the body
No inflammation,
swelling, or discharge
hair growth should
not extend over
the abdomen
RECTUM
AND ANUS
Intact perineal skin,
anal sphincter has
good tone.
Intact perineal
skin; usually
slightly more
pigmented than
the skin of the
buttocks
Anal sphincter has
good tone.
NORMAL
XI. ANATOMY AND PHYSIOLOGY
ANATOMY AND PHYSIOLOGY
Gastrointestinal Tract
The gastrointestinal tract (GIT) consists of a hollow muscular tube starting from
the oral cavity, where food entersthe mouth, continuing through the pharynx,
esophagus, stomach and intestines to the rectum and anus, where food
isexpelled. There are various accessory organs that assist the tract by secreting
enzymes to help break down food into itscomponent nutrients. Thus the salivary glands,
liver, pancreas and gall bladder have important functions in the digestivesystem. Food
is propelled along the length of the GIT by peristaltic movements of the
muscular walls. The primarypurpose of the gastrointestinal tract is to break down
food into nutrients, which can be absorbed into the body to provideenergy.
31 | P a g e

Function of Liver
The liver has many functions. Some of the functions are: to produce substances
that break down fats, convert glucose to glycogen, produce urea (the main substance of
urine), make certain amino acids (the building blocks of proteins), and filter harmful
substances from the blood (such as alcohol), storage of vitamins and minerals (vitamins
A, D, K and B12) and maintain a proper level or glucose in the blood. The liver is also
responsible for producing cholesterol. It produces about 80% of the cholesterol in your
body.
Function of duodenum
The duodenum is largely responsible for the breakdown of food in the small
intestine. Brunner’s glands, which secrete mucus, are found in the duodenum. The
duodenum is composed of a very thin layer of cells that form the muscularis mucosae.
The duodenum is almost entirely retroperitoneal. The pH in the duodenum is
approximately six. It also regulates the rate of emptying of the stomach via hormonal
pathways.
Function of Pancreas
The pancreas is a small organ located near the lower part of the stomach and the
beginning of the small intestine. This organ has two main functions. It functions as an
exocrine organ by producing digestive enzymes, and as endocrine organ by producing
hormones, with insulin being the most important hormone produced by the pancreas.
32 | P a g e

The pancreas secretes its digestive enzymes, through a system of ducts into the
digestive tract, while it secretes its variety of hormones directly into the bloodstream.
Abnormal pancreatic function can lead to pancreatitis or diabetes mellitus.
Function of cystic duct
Bile can flow in both directions between the gallbladder and the common hepatic
duct and the (common) bile duct.
In this way, bile is stored in the gallbladder in between meal times and released
after a fatty meal.
Function of traverse colon
The large intestine comes after the small intestine in the digestive tract and
measures approximately 1.5 meters in length. Although there are differences in the
large intestine between different organisms, the large intestine is mainly responsible for
storing waste, reclaiming water, maintaining the water balance, and absorbing some
vitamins, such as vitamin K.
Function of gall bladder
The gallbladder (or cholecyst) is a small organwhose function in the body is to
harbor bileand aid in the digestive process.
The function of the gallbladder is to store bile and concentrate. Bile is a digestive
liquid continually secreted by the liver. The bile emulsifies fats and neutralizes acids in
partly digested food. A muscular valve in the common bile opens, and the bile flows
from the gallbladder into the cystic duct, along the common bile duct, and into the
duodenum (part of the small intestine).
33 | P a g e

The different layers of the gallbladder are as follows:
• The gallbladder has a simple columnar epithelial lining characterized by
Recessescalled Aschoff's recesses, which are pouches inside the lining.
• Under the epithelium there is a layer of connective tissue (lamina propria).
• Beneath the connective tissue is a wall of smooth muscle(muscularisexterna)
that contracts in response tocholecystokinin, a peptide hormonesecreted by
theduodenum.
• There is essentially nosubmucosaseparating the connective tissue
fromserosaandadventitia.
Size and Location of the Gallbladder
The gallbladder is a hollow, pear-shaped sac from 7 to 10 cm (3-4 inches) long
and 3 cm broad at its widest point. It consists of a fundus, body and neck. It can hold 30
to 50 ml of bile. It lies on the undersurface of the liver’s right lobe and is attached there
by areolar connective tissue.
Structure of the Gallbladder
Serous, muscular, and mucous layers compose the wall of the gallbladder. The
mucosal lining is arranged in folds called rugae, similar in structure to those of the
stomach.
Causes of Cholelithiasis
Cholelithiasis is the presence of stones in the gallbladder. From the Greek roots
chole means bile and lithos means stone.
Different kinds of stones have different causes and different risk factors.Cholesterol
stones are believed to be more common among Fat and FertileFemales of Forty years
and above.
• Obesity is a major risk factor. Obese people produce and secrete higher amounts
of cholesterol. This increases the risk for development of cholesterol stones.
• Women who have experienced multiple pregnancies are more prone to
gallstones because of the high levels of the hormone progesterone during
pregnancy. This hormone reduces the contractility of the gallbladder and leads to
retention of bile. Prolonged retention can lead to cholesterol stones.
34 | P a g e

• Birth control pills and hormone replacement therapy: The hormonal changes with
these drugs mimic pregnancy and therefore increase the risk of gallstones.
• Females, especially in the reproductive age, are more likely to develop
cholesterol stones than males. The female-to-male ratio is 4:1 this is due to the
female hormone estrogen that increases cholesterol secretion. However, with
age this difference between the two sex’s decreases.
• Gallstones continue to form throughout life and the prevalence is greatest in the
elderly age group.
• Predisposition to cholesterol stones is hereditary in 25% of cases. There are
many different genes that contribute to this risk.
• Diet rich in refined carbohydrates and saturated fats is associated with a higher
risk for gallstones.
Black pigment gallstones are seen more often in individuals whose hemoglobin
breaks down rapidly leading to increased production of the bile pigment bilirubin. This
includes those with following:
• Bleeding disorders such as sickle cell anemia, hereditary spherocytosis and beta
thalassemia.
• Liver cirrhosis
Brown pigment stones are formed when cholesterol stones are colonized with
bacteria. Enzymes from these bacteria react with bilirubin conjugates and fatty acids.
Over time, calcium salts may accumulate on these cholesterol stones to produce mixed
stones. Both men and women are equally at risk of developing pigment stones.
Complications of Cholelithiasis
Inflammation of the gallbladder. A gallstone that becomes lodged in the neck of the
gallbladder can cause inflammation of the gallbladder (cholecystitis). Cholecystitis can
cause severe pain and fever.
Blockage of the common bile duct. Gallstones can block the tubes (ducts) through
which bile flows from your gallbladder or liver to your small intestine. Jaundice and bile
duct infection can result.
Blockage of the pancreatic duct. The pancreatic duct is a tube that runs from the
pancreas to the common bile duct. Pancreatic juices, which aid in digestion, flow
through the pancreatic duct. A gallstone can cause a blockage in the pancreatic duct,
35 | P a g e

which can lead to inflammation of the pancreas (pancreatitis). Pancreatitis causes
intense, constant abdominal pain and usually requires hospitalization.
Gallbladder cancer. People with a history of gallstones have an increased risk of
gallbladder cancer. But gallbladder cancer is very rare, so even though the risk of
cancer is elevated, the likelihood of gallbladder cancer is still very small.
XII.PATHOPHYSIOLOGY
PATHO-PHYSIOLOGY OF CHOLECYSTOLITHIASIS
Decreased Contractility
Delayed Emptying
Bile Stasis
Viscosity of the bile
36 | P a g e
Modifiable Factors
 Age (61 y/o)
 Food rich in CHO and Fat (habit
of eating gata viands)
 Multiple pregnancies (5
children)
Non-modifiable factors
 Hormonal Factors
Estrogen Female Production

Bile acid synthesis cholesterol synthesis on the liver
Supersaturated bile
Precipitation of bile
Releasing of protein which lately crystalize
Stone formation
Prevention of Bile from entering SI Obstruction on Common Hepatic Bile Duct
Pus Accumulation / Cystic Duct
Pressure on liver cells Blocks Digestive enzymes
Bile salts and Pigments enter blood stream Inflammation / spasm of Biliary Duct Fever 37.7°C
Circulation of Bile pigment Pressure on Auto digestion organ
Circulation of bile through blood Pancreatitis / Cholecystitis
Jaundice (yellow schlera) and Abdominal pain (RUQ)
Pruritus (itching of skin on RUQ)
XIII. MEDICAL MANAGEMENT
A. Laboratory Test
Name: E.Q. Hospital no.: 333231
Age/sex: 61/F Date of test: Dec. 5, 2012
Birthdate: 24-Aug-51 Physician: CALMA
HEMATOLOGY
Lab Test Indications Normal Findings Actual
Finding
s
Clinical Significance Nursing Responsibilities
37 | P a g e
Acute abdominal pain,
N&V, chills related to
fever, jaundice, low
grade fever

ERYTHROCYTES
HEMOGLOBIN
HEMATOCRIT
LEUKOCYTE
NEUTROPHILS
EOSINOPHILS (P)
BASOPHILS (P)
LYMPHOCYTES(P)
MCH
MCV
MCHC
RDW
MPV
Platelets
This test is
used to
evaluate
anemia,
leukemia,
reaction to
inflammation
and
infections,
peripheral
blood cellular
characters,
State of
hydration and
dehydration,
Polycythemia,
Hemolytic
disease of the
newborn, to
manage
chemotherapy
decisions.
M: 4.6 – 6.2
F: 4.2 - 5.4
M: 140 – 180
F: 120 – 140
M: 42.0 – 52.0
F: 37.0 – 47.0
50.0 – 70.0
1.0 – 4.0
0.0 – 1.0
25.0 – 40.0
27.0 – 31.0
M: 80 – 94;
F: 81 – 99
33.0 – 37.0
11.5 – 14.5
7.2 – 11.1
150 - 450
4. 82
144.0
42.9
74.2
0.1
0.1
15.0
31.5
87.7
35.9
12.8
10.2
177 %
The result of the test
shows that the
client has low
eosinophils
(eosinopenia),
high neutrophils
(neutrophilia) and
high MCH or Mean
corpuscular
hemoglobin.
Neutrophils increased
with acute
infections, trauma
or surgery,
leukemia,
malignant
disease, necrosis.
Eosinophils decreased
with stress, use
of some
medications.
Increased in
macrolytic
anemias,
decreased in
microcytic
anemia.
Pretest:
-Check for doctor’s order.
-Identify the patient using at
least two unique identifiers
before providing care,
treatment, or services.
-Inform the patient this test
can assist in evaluating the
amount of hemoglobin in
the blood to assist in
diagnosis and monitor
therapy.
Intratest:
- Instruct the patient to
cooperate fully and to follow
directions. Direct the patient
to breathe normally and to
avoid unnecessary
movement.
-Remove the needle and
apply direct pressure with
dry gauze to stop bleeding.
-Observe/assess
venipuncture site for
bleeding or hematoma
formation and secure
gauze with adhesive
bandage.
-Promptly transport the
specimen to the laboratory
for processing and
analysis.
PostTest:
-A report of the results will
be sent to the requesting
physician, who will discuss
the results with the patient.
-Depending on the results
of this procedure, additional
testing may be performed
to evaluate or monitor
progression of the disease
process and determine the
need for a change in
therapy. Evaluate test
results in relation to the
patient's symptoms and
other tests performed.
38 | P a g e

Age/sex: 61/F Date of test: Nov. 30, 2012
ULTRASOUND
Findings:
 Liver is not enlarged with increased parenchymal echogenicity
 Intrahepatic ducts are not dilated
 No focal masses or calcifications seen
 Gallbladder is normal in size with at least two reflective echoes measuring about seventeen and fourteen
mm
 Gallbladder wall is thin
 Common bile duct is not dilated
 Pancreas and spleen are homogeneous and not enlarged—there are no focal masses seen
 Both kidneys are normal in size with homogenous echo pattern
 Right kidney measures 99 x 42 mm while the left kidney measures 111 x 49 mm
 Central echo complexes of both kidneys are intact
 No renal stones or masses seen
 corticom edullary borders are distinct
 the urinary bladder is moderately distended with no intra luminal echoes seen
 the bladder wall is smooth
 the abdominal aorta measures 40 mm in its widest diameter with no abnormal dilatation 100% - there are
no enlarged para-aortic nodes seen
 there are no masses or free fluid
IMPRESSION:
40 | P a g e

UNREMARKABLE ULTRASOUND OF THE PANCREAS, SPLEEN, KIDNEYS, URINARY BLADDER AND
ABDOMINAL AORTA
CHOLELITHIASIS, AS DESCRIBED
CONSIDER FATTY INFILTRATION OF THE LIVER
Age/sex: 61/F Date of test: Dec. 7, 2012
CLINICAL CHEMISTRY
TEST RESULT REFERENCE
RANGE
CLINICAL SIGNIFICANCE
Glucose (random) 3.75 2.75 – 4.13 mmol/L Normal
Creatinine 53.8 M: 62-106 mmol/L
F: 44-90 mmol/L
Normal
SGOT (AST) 36.1 M: up to 40 u/L
F: up to 39 u/L
Normal
SGPT (ALT) 44.7 M: 0.17-0.68 mckat/L
F: 7-35 U/L or 0.12-
0.60 mckat/L
High levels of ALT may be caused
by:
• Liver damage from conditions
such as hepatitis or cirrhosis.
• Lead poisoning.
• Exposure to carbon
tetrachloride.
• Decay of a large tumor
(necrosis).
41 | P a g e

• Many medicines, such
as statins, antibiotics, chemotherapy,
aspirin, narcotics, and barbiturates.
• Mononucleosis.
• Growth spurts, especially in
young children. Rapid growth can
cause mildly elevated levels of ALT.
Sodium 136.2 75 -200 mmol/L Normal
Potassium 3.21 3.6-5.5 mmol/L Diarrhea, Adrenocortical
insufficiency
42 | P a g e

44 | P a g e
Name of drug Indications Action Contraindicati
on
Side
effects
Adverse
effects
Nursing Management
Generic:
kalium durule
Brand name:
Potassium
Chloride
Form: tablet
Route: oral
Dose: 4doses
up to AM
Frequency:
TID
Classification
:
Electrolyte
Prevention
and
correction
of
potassium
deficiency;
when
associated
with
alkalosis,
use
potassium
chloride;
when
associated
with
acidosis,
use
potassium
acetate,
bicarbonate
, citrate, or
gluconate
Principal
intracellular
cation of
most body
tissues,
participates
in a number
of
physiologic
processes—
maintaining
intracellular
tonicity,
transmission
of nerve
impulses,
contraction
of cardiac,
skeletal, and
smooth
muscle,
maintenance
of normal
renal
function;
also plays a
role in
carbohydrate
metabolism
and various
enzymatic
reactions.
Contraindi-
cated with
allergy to
tartrazine,
aspirin
(tartrazine is
found in some
preparations
marketed as
Kaon-Cl, Klor-
Con); severe
renal
impairment
with oliguria,
anuria,
azotemia;
untreated
Addison’s
disease;
hyperkalemia;
adynamia
episodica
hereditaria;
acute
dehydration;
heat cramps;
GI disorders
that delay
passage in the
GI tract. Use
cautiously with
cardiac
disorders,
especially if
treated with
digitalis
Arrythmias
-heart block
hypotension
-cardiac
arrest
- respiratory
paralysis,
-nausea
and
vomiting
-abdominal
pain
-Rash
-GI obstruction
-GI bleeding
-GI ulceration
or perforation
Hyperkalemia
-ECG changes
(peaking of T
waves, loss of
P waves,
depression of
ST segment,
prolongation of
QTc interval)
-Tissue
sloughing
-local necrosis
-local phlebitis
-venospasm
with injection
PRE:
 Verify doctors order
 Watch out for levelsofpotassium
electrolyte level to prevent
hyperkalemia.
 Observe 10 rightsofgiving
medication.
 Watch out for possibleadverse
reaction of the patient
INTRA:
 Arrange for serial serum
potassium levels before and
during therapy.
 Administer oral drug after
meals or with food and a full
glass of water to decrease GI
upset.
 Dissolve effervescent tablets
completely in 3–8 oz of cold
water, juice, or other suitable
beverage, and have patient
drink it slowly.
 Caution patient not to chew or
crush tablets; have patient
swallow tablet whole.
POST:
 Teach patient that they may
find wax matrix capsules in
the stool. The wax matrix is
not absorbed in the GI tract.
 Have periodic blood tests and
medical evaluation.
 Watch out for these side
effects: Nausea, vomiting,
diarrhea (taking the drugs with
meals, diluting them further
may help).

46 | P a g e
Name of drug Indications Action Contraindica
tion
Side effects Adverse effects Nursing Management
Generic:
Metoclopramide
Brand name:
reglan
Form: liquid
Route: IV
Dose: 10mg
Frequency:
single dose
PTOR
Classification:GI
stimulant,
Antiemetic,
Dopaminergic
blocker
Prophylaxis
of postoperati
ve nauseaand
vomitingwhen
nasogastric
suctionis
undesirable
Stimulates
motility
of upper GI
tract with
out
stimulating
gastric,
biliary,
or pancreat
ic secretions;
Contraindicate
d with allergyto
metoclopramide
GIhemorrhage
Mechanical
obstruction
or perforation
Epilepsy
restlessness
-drowsiness
–fatigue
-insomnia
-dizziness
-anxiety
-transient
hypertension
-nauseaand
diarrhea
-extra pyramidal
reactions
-Neuroleptic
malignant
syndrome
-anxiety
-depression
-irritability
-tardive
dyskinesia.
-arrhythmias
(supraventricular
tachycardia, brad
ycardia)
-hypertension
-hypotension
-constipation
-dry mouth,
- gynecomastia.
–methemoglo
binemia
-neutropenia
-leucopenia
-agranulocytosis
PRE:
 Check the doctor's order
 Check the expiration date of
the drug
 Assess the client's
understanding about the
drug
 Observe 10 rights in drug
administration.
 Assess for allergy to
metoclopramide.
 Assess for other
contraindications.
 Keep diphenhydramine
injection readily available in
case extra pyramidal
reactions occur (50 mg IM).
 Have phentolamine readily
available in case of
hypertensive crisis.
INTRA:
 Monitor BP carefully during
IV administration.
 Monitor for extra pyramidal
reactions, and consult
physician if they occur.
 Give direct IV doses slowly
over 1-2minutes.
 For IV infusion, give over at
least 15minutes.
POST:
 Dispose of used materials
properly.
 Educate patient about side
effects.
 Instruct to report involuntary
movement of the face, eyes,
or limbs, severe depression,
and severe diarrhea.

47 | P a g e
Name of drug Indications Action Contraindi
cation
Side
effects
Adverse
effects
Nursing Management
Generic:
omeprazole
Brand name:
Form: tablet
Route: oral
Dose: 10mg
Frequency:
OD
treatment of
active
duodenal
ulcer,
gastroesop
hageal
reflux
disease
(GERD),
including
erosive
esophagitis
and
symptomati
c GERD
Hough to
be a
gastric
pump
inhibitor
and that it
blocks the
final step
of acid
production
. By
inhibiting
the
Hydrogen/
Potassium
ATP-ase
system at
the
secretory
surface of
the gastric
parietal
cell..
Contraindicate
d with
hypersensitivit
y to
omeprazole or
its components
Depres
sion
-agitation
-aggres
sion
–hallucina
tions
-confu
sion
-headache
-dizziness
-asthenia
-vertigo
-insomnia
-apathy
-anxiety
-paresthesias,
-dream
abnormalities
rash,
inflammation,
urticaria, pruritu
s,alopecia,
dryskin
diarrhea,
abdominal pain,
nausea,vomiting,
constipation,
drymouth
,tongue atrophy
,URI symptoms,
cough, epistaxis
PRE:
 Check the expiration date of the
drug
 Assess the client's understanding
about the drug
INTRA:
 The capsule should be taken 30
minutes before eating and is to be
swallowed whole.
 Antacid can be administered with
Omeprazole.
 Monitor vital signs
POST:
 Monitor for adverse effect.
 Report to the physician if chest
pain, abdominal pain and fecal
discoloration occurred
 Report severe headache,
worsening of symptoms, fever,
chills.
Name of drug Indications Action Contraindicat
ion
Side
effects
Adverse
effects
Nursing Management
Generic:
metronidazole
Brand name:
flagyl
Form: liquid
Acute
infection
with
susceptible
anaerobic
bacteria
Disrupts
DNA and
protein
synthesis
in
suscepti
ble
organisms
Contraindicated
in
patients hyper
sensitive to
drug or other
nitroimidazole
derivatives
-Use cautiously
-stomach
-pain
-diarrhea
-dizziness
-loss of
balance
-vaginal
itching or
-Seizures
-dizziness
-headache
-Tearing
(topicalonly)
-abdominal
pain,
-anorexia,
PRE:
drug
 assess patient’s and family’s
knowledge of drug therapy
 assess patient infection
 watch carefully for edema because

Name of drug Indications Action Contraindica
tion
Side
effects
Adverse
effects
Nursing Management
Generic:
Ranitidine
Brand name:
Zantac
Form: liquid
Route: Intravenous
Dose: 50mg
Frequency: q8
CLASSIFICATION
Therapeutic:
Anti-ulcer agents
Pharmacologic:
Histamine H2
antagonists
•Treatment
and
prevention
of
heartburn,
acid
indigestion,
and sour
stomach.
• Inhibits the
action of
histamine at
the H2
receptor site
located
primarily in
gastric
parietal cells,
resulting in
inhibition of
gastric acid
secretion.
• In addition,
ranitidine
bismuth
citrate has
some
antibacterial
action
against H.
pylori.
Contraindicat
ed in patient
hypersensitivi
ty, Cross-
sensitivity
may occur;
some oral
liquids
contain
alcohol and
should be
avoided in
patients with
known
intolerance.
Use
Cautiously in
patient with
Renal
impairment,
geriatric
patients
-headache
–consti
pation
-diarrhea
-upset
stomach
-dizziness
-difficulty
-sleeping
-blurred
vision
-Confusion
-dizziness
-drowsiness
-hallucination
s
-headache
-Arrhythmias
-Altered taste
-black tongue
-constipation
-dark stools
-diarrhea
-drug-induced
hepatitis
-nausea
-Decreased
sperm count
impotence
-Gyneco
mastia
-Agranulo
cytosis
-Aplastic
Anemia
-neutropenia
-thrombo
cytopenia
PRE:
drug
understanding about the drug
 Assess patient for epigastric or
abdominal pain and frank or
occult blood in the stool,
emesis, or gastric aspirate.
INTRA:
 Administer drug through IV
 Inform patient that it may cause
drowsiness or dizziness.
 Inform patient that increased
fluid and fiber intake may
minimize constipation.
 Inform patient that medication
may temporarily cause stools
and tongue to appear gray
black. POST
 Advise patient to report onset of
black, tarry stools; fever, sore
throat; diarrhea; dizziness;
rash; confusion; or
48 | P a g e

hallucinations to health care
professional promptly.
49 | P a g e

Name of drug Indications Action Contraindic
ation
Side
effects
Adverse effects Nursing Management
Generic:
ketorolac
Brand name:
Toradol
Form: liquid
Route:
Intravenous
Dose: 30mg
Frequency: q8
CLASSIFICATION
Analgesic,
antipyretic, anti-
inflammatory
Short term
manageme
nt of pain in
the surgical
site (up to
5days)
Anti-
inflammatory
andanalgesic
activity;
inhibits prosta
glandinsand
leukotriene
synthesis
Contraindica
ted with
significant
renal
impairment, ,
aspirin
allergy,
recent
GI bleed
or perforatio
n.Use
cautiously
with impaired
hearing;
allergies;
hepatic
conditions
-Headache
-dizziness
-somnolenc
-insomnia
-fatigue
-tinnitus
-ophthal
mologic
effects
-constipa
tioh
-heartburn
-drowsiness
-abnormal thinking
-euphoria
-asthma
-dyspnea
-edema
-pallor
-vasodilation
-GI Bleeding
-abnormal taste
-diarrhea
-dry mouth
-dyspepsia
-GI pain
-nausea
- oliguria
-renal toxicity
-pruritis
-purpura
-sweating
-urticaria
-prolonged
bleeding time
-injection site
paresthesia
allergic reaction,
anaphylaxis
PRE:
 Check the expiration date of
the drug
understanding about the drug
 Assesspain(notetype, location,
andintensity) priorto and1-2hr
following administration
 Checksensitivity,ANST(-)
INTRA:
 Administer drug through IV
route.
 Monitor vital signs
 Caution patient to avoid
concurrent use of alcohol,
aspirin, NSAIDs,
acetaminophen, or other OTC
medications without
consulting health care
professional.
 Watch out for bleeding
POST:
 Advisepatient to report if rash,
itching, visualdisturbances,
tinnitus,weightgain,edema,black
stools,persistent headache,
orinfluenza-like syndromes
(chills,fever,musclesachesand
pain)occur
50 | P a g e

C. MEDICAL MANAGEMENT
Procedures Indication Nursing Responsibilities
Oxygen via Nasal
Cannula regulated @
2-3 L/min
Oxygen therapy is the
administration of oxygen at a
concentration greater than that
found in the environmental
atmosphere. The goal of this is
to provide adequate transport
of oxygen in the blood while
decreasing the work breathing
Pre:
Determine the need for
oxygen therapy by verifying
the doctor’s order.
Ensure precautions ad safety
measures to be used when
52 | P a g e
Name of drug Indications Action Contraindicati
on
Side effects Adverse effects Nursing Ma
Generic:
cefuroxime
Brand name:
Yurocef
Form: powder.
Route:
Intravenous
Dose: 750 mg
Frequency: q8
Classification:
anti-infective
Used in the
treatment of
susceptible
surgical
infections,
and urinary
tract
infections.
- anti-
infective-
a 2nd
generation
cephalospo
rin that
inhibits
cell-wall
synthesis,
promoting
osmotic
instability;
usually
bactericidal
.
contraindicated
in patients with
renal
impairment, ,
elderly and in
rare cases it
causes
hypersensitive
ty.
-nausea
-vomiting
-diarrhea
-stomach pain
-headache
-dizziness
-fussiness
-Diarrhea
-Decreased
-Hgb/Hct
-Eosinophilia
Nausea/vomiting
Vaginitis
-Transient rise in
hepatic
transaminases
Thrombophlebitis
-Transient
neutropenia &
leucopenia
-Increase in BUN
& creatinine
-Rash
PRE:
 Check
 Check
of the
 Asses
under
drug
 Asses
INTRA:
 Inspe
injecti
for sig
 Monit
manif
hyper
 Recon
with 8
 Slowl
over 3
POST:
 Evalu
adver
 Repo
persis
signs
Anem

and reducing stress on the
myocardium. Uses to relief
hypoxemia and prevention of
damage to the tissue cells as a
result of oxygen lack.
oxygen is in use.
Intra:
Monitor and maintain the
prescribed flow rate.
Post:
Assess the patient’s tolerance
to breath effectively without
support or oxygen.
Jackson Pratt a medical device that is
commonly used as a post-
operative drain for collecting
bodily fluids from surgical sites.
The device consists of an
internal drain connected to a
grenade-shaped bulb via
plastic tubing. The flexible bulb
has a plug that can be opened
to pour off collected fluid. Each
time fluid is removed, the
patient, caregiver or healthcare
provider squeezes the air out of
the bulb and replaces the plug.
The resulting vacuum creates
suction in the drainage tubing,
which draws fluid from the
surgical site.
Pre:
 The drainage tube must
be connected immediate to a
drainage receptacle.
Intra:
 Measure how much
fluid you collected. Write the
amount of drainage, and the
date and time you collected it,
 Watch the skin around
the drain for these signs of
infection:
 increased redness
 increased pain
 increased swelling
Other signs of
infection:
 fe
ver greater than 101 ºF
 cl
oudy yellow, tan, or foul-
smelling drainage
Post
 Check for incision site.
Observe for signs of bleeding
and infection.
 Keep incision dry and
intact.
53 | P a g e

 Practice proper wound
dressing to prevent cross
contamination.
D. SURGICAL MANAGEMENT
Procedures Indication Nursing Responsibilities
Cholecystectomy For acute and chronic
cholecystitis.
It is a common treatment
of symptomatic gallstones
and other gallbladder
conditions.
Pre:
 Monitor vital signs.
 Reviews previous
obtained laboratory result to
obtain information about the
patient’s nutritional status.
54 | P a g e

Performed when patient’s
condition precludes more
extensive surgery or
when an acute
inflammatory reaction is
severe.
Intra:
 Check for vital signs and
assess skin for paleness.
Post:
 Monitor vital signs and
inspect the surgical incision
site and any drains for
bleeding.
 Instruct patient and family
to report any change in the
color of the stools, because
this may indicate
complications.
55 | P a g e

XIV. NURSING MANAGEMENT
a. Problem List
Actual Nursing Problems
1. Deficient Knowledge
2. Fear
3. Acute Pain
4. Impaired Tissue Integrity
5. Impaired Physical Mobility
6. Activity Intolerance
Potential Nursing Problems
1. Risk For Aspiration
2. Risk For Aspiratio
56 | P a g e

b. Nursing Care plan
Table 1: Deficient Knowledge
Assessment Diagnosis Background
Knowledge
Planning Implementation Rationale Evaluation
Subjective:
“Paano ba ang
gagawin sa akin sa
operating room?
Objective:
• Anxiety
noted
• Restlessnes
s observed
Deficient
knowledge
related to
unfamiliarity with
information
resources as
manifested by
verbalization of
request for
information
Cholecystectomy
is the surgical
removal of the
gallbladder,
which is located
in the abdomen.
Gallbladder
problems are
usually the result
of gallstones that
can block the
gallbladder
causing the organ
to swell
Goal:
After the shift, the
client will be
knowledgeable about
the upcoming
procedure
Planning:
After nursing
intervention the
client will be able to:
• Participate in
learning process
• Exhibit
increased interest
and assume
• Assess client’s
level of knowledge
• Provide
information relevant
only to the situation
• Provide
positive
reinforcement
• Use short,
simple sentences and
concepts. Repeat and
summarized as
needed.
• Discuss one
topic at a time; avoid
giving too much
information
• Begin with
information the client
already knows and
• To determine
factors pertinent to
the learning process
• To prevent
overload
• Can
encourage
continuation of
efforts
• To facilitate
learning
• Can arouse
interest or limit sense
of being
After nursing
intervention, the goal
was met as evidenced by
understanding of the
patient about her
condition and upcoming
operation
57 | P a g e

responsibility for own
learning by beginning
to look for
information and asks
questions
• Verbalized
understanding of
condition, disease
process and
treatment
move to what the
client does not know,
progressing from
simple to complex
• Deal with the
client’s anxiety or
other strong
emotions
• Provide for
feedback or positive
reinforcement and
evaluation of learning
and acquisition
overwhelmed
• It may
interfere with the
client’s ability to
learn
Table 2: Fear
Assessment Diagnosis Background Planning Implementation Rationale Evaluation
58 | P a g e

knowledge
Subjective:
“Hindi ba delikado
ang gagawin sa
aking operasyon?”,
as verbalized by the
patient
Objective:
• Apprehensio
n
• Tense
observed
• Increase
tension
• Worry
• restlessness
Fear related to
surgical procedure
as manifested by
non verbal
evidenced of fear
such as worry and
tense
Undergoing
cholecystectomy
, patient may
perceive threat
like the outcome
of the surgery
that is
consciously
recognized by
the patient as
danger
After 8 hours of
nursing
intervention, the
client will be able
to:
1) Acknowledg
e and discuss
fears, recognizing
healthy versus
unhealthy fears
2) Demonstrat
e through use of
effective coping
behaviors
3) Lessened
fear
• Monitor vital signs
• Ascertain client’s
perception of what is
occurring and how this
affects life
• Discuss client’s
perceptions and fearful
feelings
• Provide appropriate
information about the
procedure
• Provide opportunity
to questions and answer
honestly
• Explain procedure
within level of client’s ability
of understanding
• Instruct deep
• This can be
altered when fear is
present
• Fear is a
defensive mechanism
in protecting oneself
but, if left unchecked,
can become disabling
to the client’s life
• Promotes
atmosphere of caring
and permits
explanation or
correction of
misperceptions
• Facilitates
understanding of the
situation
• Enhances sense
of trust
• To prevent
confusion of
information overload
• To promote
relaxation
After nursing
intervention, the
goal was met as
evidenced by
patient’s fear
was lessened
and more
relaxed behavior
59 | P a g e

breathing exercises
Table 3: Acute Pain
knowledge
60 | P a g e

Subjective:
“Masakit ang
inoperahan sa
akin”, as
verbalized by
the patient
Objective:
• 9 out of
10 level of pain
• Facial
grimace noted
• Guarding
behavior
observed
• With
protective
gestures
Acute pain
related to post
surgical incision
as manifested
by verbalization
of feelings and
observed
evidence of pain
In performing
cholecystectomy,
surgical incision is
done. By which,
the incision
causes direct
irritation to the
nerve endings by
chemical
mediators
released at the
site such as
bradykinin. The
irritation will
send signal to the
cortex and
thalamus of the
brain, thus
producing pain
perception
After nursing 8
hours of nursing
intervention, the
1) Report pain
is relieved or
controlled
2) Verbalized
non pharmacological
methods that
provide relief
3) Demonstrate
use of relaxation
skills and diversional
activities, as
indicated, for
individual situation
• Assess clients
assessment of pain
• Use pain
rating scale
• Observe non
verbal cues of pain
• Provide
comfort measures
and calm activities
•
• Instruct in
and encourage
relaxation
techniques, such as
watching TV or
listening to music
• Identify ways
of avoiding or
minimizing pain such
as splinting incision
• Encourage
adequate rest
• To have baseline
data
• To measure the
quantity of pain
• Observations may
not be congruent with
verbal reports o may be
only indicator present
when client is unable to
verbalize
• To promote non
pharmacological pain
management
• To distract
attention and reduce
tension
• To prevent fatigue
After nursing
was met as evidenced
by
1) Pain scale of 7
from 9
2) Verbalization of
nonpharmacological
methods
3) Demostration
of relaxation
techniques such as
chatting to others
61 | P a g e

periods
• Identify
specific
signs/symptoms and
changes in pain
characteristic
requiring immediate
attention
Table 4: Impaired Tissue Integrity
Knowledge
Objective:
• Incision at
right upper
quadrant of the
abdomen
• With
Jackson Pratt
Impaired
tissue integrity
related to
incision
secondary to
surgical
procedure
Cholecystecto
my is the
surgical
removal of the
gallbladder,
which is
located in the
abdomen.
Gallbladder
problems are
After the shift,
the client will be:
• Verbalize
understanding of
condition and
causative factors
• Demonstra
te behaviors and
lifestyle changes
• Assess client’s
condition
• Note poor
hygiene or health
practices
• Determine
nutritional status
• Change
dressing as often as
needed
• Check the
incision daily to
• To have
baseline data
• It may interfere
with the healing
• To avoid cross-
contamination
After all the nursing
intervention, the goal was
met as evidenced by the
following:
• Understanding about
her conditions
• Knowledgeable on
ways to promote healing
And prevent complications
62 | P a g e

usually the
result of
gallstones that
can block the
gallbladder
causing the
organ to swell
to promote
healing and
prevent
complications or
recurrence
inspect for signs of
infection,
complications and
healing
• Instruct the
patient to practice
aseptic technique, for
cleansing, dressing,
or medicating lesions.
• Promote early
mobility
• Monitor
laboratory studies
• Emphasize for
need of adequate
nutrition and fluid
intake
• Promotes
timely intervention
and revision of plan
care
• Reduce risk for
cross-contamination
• To promote
circulation
• Detection for
presence of infection
and contamination
• To optimized
tissue healing
Table 5: Impaired Physical Mobility
Assessment Diagnosis Background Planning Implementation Rationale Evaluation
63 | P a g e

knowledge
Subjective:
“Hindi pa ako
masyadong nagkikilos,
kasi sumasakit ang
sugat ko. At baka
bumuka pag
pinuwersa ko ang sarili
ko”, as verbalized by
the patient
Objective:
• Pain upon
assessment
• Weakness
observed
• Pallor noted
• Slowed
movement
• Postural
instability
• Uncoordinated
movements
Impaired
physical
mobility
related to pain
as manifested
by pain
verbalization
and weakness
Presence of
surgical incision
procedures the
patient to be
reluctant in doing
movements such
as ROM, because
they may induce
pain sensation
After 3 hours of
nursing
intervention, the
client will be able
to:
• Verbalize
understanding of
situation and
individual
treatment regimen
and safety
measures
• Participate
in ADLs and desired
activities
• Assess
patient’s over all
condition
 Determine
situations that
contributes
immobility
 Assess degree
of pain
 Assess
nutritional status
• Instruct in use
of side rails and other
safety aids
• Assist wit
treatment of
underlying condition
causing pain
• Instruct to
have adequate rest
periods
• Encourage
participation in self
care, diversional
• Encourage
adequate intake of
fluids and nutritious
foods
• To have
baseline data
• To ensure
safety
• To reduce
fatigue
• Enhances
self concept and
sense of
After nursing
was met as evidenced
by the verbalization of
understanding of
safety measures and
participation in ADLs
with evidenced of well
being.
64 | P a g e

independence
• Promotes
well being and
maximizes energy
production
65 | P a g e

Table 6: Activity Intolerance
66 | P a g e

67 | P a g e
knowledge
Subjective:
“Nanghihina pa
din ako at hindi pa
ako masyadong
nagalaw kasi
masakit pa din
ang sugat ko”, as
verbalized by the
patient
Objective:
• Pallor
noted
• Pain upon
assessment(facial
grimace, guarding
behavior)
• Weakness
observed
• Fatigue
noted
Activity
intolerance
related to pain as
manifested by the
patient’s
verbalization of
weakness and
pain
Post-operative
patient usually is
under bed rest
for few days that
may hinder them
to their usual
activity. Presence
of surgical
incision
procedures
causes the
patient to be
reluctant in doing
personal
activities,
because this may
result in the
stimulation of
nerve endings,
thus, increase
pain reception
After 8 hours of
nursing
intervention, the
client will be able
to:
1) Use
identified
technique to
enhance activity
tolerance
2) Participate
willingly in
necessary/desired
activities
3) Report
measurable
increase in activity
• Assess
patient’s condition
• Note presence
of factors
contributing activity
intolerance
• Note
treatment-related
factors, such as side
effects and
interactions of
medications
• Increase
activity gradually
• Assist client
with activities
• Promote
comfort measures
and provide for relief
of pain
• Encourage
client to maintain
positive attitude
• Encourage to
eat nutritious foods
• To have
baseline data
• To
conserve energy
• To protect
client from
energy
• To
enhance ability to
participate in
activities
After nursing
ttentive participation of
the patient of planned
activities

Table 7: Risk for Aspiration
knowledge
Objective:
• Reduced
level of
consciousness
• Impaired
swallowing
• Evidenced
of excess secretions
on the mouth while
in sedation
• Loud
snoring(noisy
respiration)
Risk for aspiration
related to induction of
general anesthesia as
manifested by
reduced level of
consciousness and
presence of secretions
Prior to any surgical
procedure, general
anesthesia is
induced. It relaxes
the muscles of the
body and depresses
the sensation of
pain, thus the gag
and swallowing
reflexes is
temporarily
suppressed and
may lead to
aspiration
After 4 hours of
nursing
intervention, the
• The patient
will be maintained in
safe and
homeostasis
condition
• Assess
patient’s condition
• Monitor
vital signs
• Note
patient’s level of
consciousness and
awareness of
surrounding
• Assist with
postural drainage
• Assist with
assistive breathing
devices (oxygen
cannula)
• For baseline
data
• As
impairment in
these areas
increase patient’s
risk for aspiration
• To
mobilized
thickened
secretions that may
interfere with
swallowing
• To clear
secretions in the
airway
After 4 hours of
nursing
intervention, the
goal was met as the
patient was
maintained in safe
and homeostasis
condition as
evidenced by:
• Noiseless
respiration
• Decrease
secretions on
airways
68 | P a g e

• Instruct the
patient to cough
• Watch out
for increase
secretions and
difficulty of
breathing
69 | P a g e

Table 8: Risk for Infection
Knowledge
Objective:
• Inadequate
secondary
defenses
 Post surgical
incision
Risk for infection
related to
inadequate
secondary defenses
as manifested by
surgical incision
The patient is at
risk of acquiring
infection due to
the break in the
continuity of the
first line defense
which is the
skin. The patient
shall have
undergone
cholecystectomy
, thus there is an
incision and
suture made in
the abdomen. If
there is a
breakage in the
skin, the
pathogens will
easily invade the
body’s immune
system, thus
Short term goal:
After nursing
intervention, the
client will be
knowledgeable in
reducing or
preventing
infection
• Assess
client’s condition
• Stress
proper hand
hygiene
• Change
surgical or other
wound dressings,
as indicated, using
proper technique
for
changing/disposin
g of contaminated
materials
• Keep side
rails up
• Assist in
ADL’s
• Emphasize
for proper hygiene
of the wound
• To have
baseline data
• A first-line
defense against
health-care
associated
infections
• To limit
cross-
contamination
• To avoid
injury
After nursing
intervention the goal
the patient
knowledgeable about
preventing the spread of
infection
70 | P a g e

increasing risk
for infection.
• To prevent
spread of infection
71 | P a g e

C. Ongoing Appraisal
PROGRESS NOTES
December 7, 2012
2:00 pm to 10:00 pm
Received patient lying on bed, conscious
and cooperative. Initial vital signs are as
follows: T:___ºC, PR:___ bpm, RR: ___ cpm
and BP:___ mmHg with IV fluid on ®
metacarpal vein D5LR 1L x 8 hrs in 30-31
gtts/min. The client was on DAT (diet as
tolerated).
On the first contact with the patient, we
established rapport to promote trust and good
communication with the patient. The patient
was cooperative during the assessment. We
easily gathered information concerning to her
condition.
Nursing interventions were rendered such
as monitoring vital signs positioning and health
teachings. Patient shows willingness to learn by
asking questions regarding the operation
performed and her condition.
December 8, 2012
10 2:00 pm to 10:00 pm
On our second interaction, good nurse patient
relationship was rendered within the ward. We
had follow-up interview to the patient regarding
the post-op and other information related to the
patient. The patient was more vocal and shares
her experiences after the surgery. We observed
that during the interview, the patient shows
positive outlook after the surgery. She was able
to answer the questions.
DECEMBER 10, 2012 Our last day of meeting with the patient. We
visited the patient for evaluations. The patient
was still in recovery. We ask some questions
and she was able to answer those. Patient
showed positive behaviour and cooperation for
the improvement of her condition.
72 | P a g e

Summary of Client health status as Last Day of Contact
On our last day of meeting, the patient was conscious and well cooperative. We
visited the patient for evaluations. The patient was still in recovery. We ask some
questions and she was able to answer those. We had also added health teachings to
improve her status. Patient showed positive behavior and cooperation for the
improvement of her condition.
73 | P a g e

XV. BIBLIOGRAPHY
 2002, Kozier, Erbs, Blais and Wilkinson; Fundamentals of Nursing ; 5th
Edition,
pp. 478, 490, 494, 503,
 Brunner &Suddarth’s Medical- Surgical Nursing; 10th
Edition, Vol.1, page 1177)
74 | P a g e

178352604 case-presentation-2012-chole

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