PANPACIFIC UNIVERSITY NORTH PHILIPPINES

Urdaneta City, Pangasinan

Ascending Cholangitis

CASE STUDY
(Tarlac Provincial Hospital)

In Partial Fulfillment of the Requirements

For General Case Presentation

Submitted by:
Tarlac Group
(October Rotation)

October 2009
I. PATIENT ASSESSMENT DATA BASE

A. GENERAL DATA
1. Patient’s Name: Patient XYZ
2. Address: Tarlac City, Tarlac
3. Age: 42 y/o
4. Sex: Male
5. Birth Date: May 7, 1968
6. Rank in the Family: Eldest
7. Nationality: Filipino
8. Civil Status: Married (Widower)
9. Date of Admission: October 3, 2009
10. Order of Admission: 4:04pm
11. Attending Physician: Dr. Roedel Dizon

B. CHIEF COMPLAINT

Patient had fever and complaint of epigastric pain prompting immediately his family
members to consult. The client was weak and pale in appearance and noted to have facial
grimacing. Patient XYZ has been guarding the affected area, furthermore, cold clammy sweat
has been observed.

C. HISTORY OF PRESENT ILLNESS

Patient’s condition started 1 week prior to admission with epigastric pain with on and
off fever. He went to Cagayan Valley Medical Center for consult on September with a
diagnosis of dyspepsia. After medical interventions, patient was then discharged and
apparently well. Until few hours prior to admission, patient had fever and complaint of
right upper quadrant (RUQ) abdominal pain so they immediately went to Tarlac Provincial
Hospital for consult and was admitted. He has been given medications such as Dobutamine and
has had his initial laboratory exams.

D. PAST HEALTH HISTORY/STATUS

Patient had chicken pox, measles and mumps when he was a child. However, he and his
watcher could not remember how old he was when he got them. He verbalized that his
immunization was complete. When he was in grade one, he had a perforating eye injury that
caused the blindness of his right eye.

E. FAMILY ASSESSMENT

Name Relation Age Sex Occupation Educational

Attainment

Sergio Maniti Father 63 Male none 3rd Year High School

2nd Year High School

Imelda Maniti Mother --- Female ----

High School graduate

Graduate of Automotive
Shiela Bimeda Sister 41 Female Government Vocational Course
Employee

4th Year Highschool

Ambulance
 Sergie Maniti Brother 39 Male Driver High School
Graduate

High School Graduate

Housewife

Shirly Macasiog Sister 36 Female

Housewife

Sharon Tanhueco Sister 26 Female

Service Crew

Shalee Jonnales Sister 26 Female

F. SYSTEMS REVIEW – GORDON’S 11 FUNCTIONAL HEALTH PATTERNS ASSESSMENT

1. Health Perception - Health Management Function

Patient XYZ had stated that being healthy is free from sickness and the absence
of disease. He refers to doctors whenever he or one of his family members gets
sick. He managed his health by following medical treatment being given by his
health care providers. In addition, he perceived that he is not totally
healthy because his right eye has been blind since on the first grade.

2. Nutrition – Metabolic Pattern

 The client eats thrice a day with adequate amount of food. He has good appetite.
His usual daily menu includes meat and vegetables. He drinks 12-15 glasses of water and
up to 2 cups of coffee a day.

3. Elimination Pattern

He urinates 3-4 times a day with amber-colored urine. He further stated that
urinating is not a problem. Defecation pattern has been reported to be seven
times a week most occurring in the morning with a semi-solid consistency and
brownish in color. No difficulty of defecating has been stated and did not have to
use laxatives and other stool softeners.

4. Activity – Exercise Pattern

_0_ Feeding _0_ Dressing _0_ Grooming

_0_ Bathing _0_ Toileting _0_ Cooking
_0_ Bed Mobility _0_ Home Maintenance

Legend:
0 – Full care
I – Requires use of equipment
II – Requires assistance or supervision from others
III- Requires assistance or supervision from another equipment and a device
IV – Dependent; doesn’t participate

5. Cognitive – Perceptual Pattern

Hearing: No hearing abnormalities as state by the client

Vision: His left eye functions normally and does not need to use eyeglasses
when reading.
Sensory Perception: No sensory perceptual abnormalities
 Learning Styles: He learns upon doing it by himself. Understands more when there
are illustrations

6. Sleep – Rest Pattern

He sleeps 6-8 hours a day. He does not need any relaxation techniques for him to
fall asleep easily. He does not have any sleeping difficulty. When travelling,
they would request for the vehicle to stop if it’s already time for them to sleep.
Approximately, they would sleep up to 5 hours.

7. Self-Perception And Self-Concept Pattern

He does not consider himself as a burden to his Aunt’s family. He even said that
he helps in their daily expenses by giving some of his earnings to them. As a
patient, he said it’s normal that family members take care of him especially he
doesn’t have a family of his own. He considers himself as simple and hardworking
person. At work, he is the one who cooks for the whole crew. He said he is good in
cooking. He is also a good mechanic though he wasn’t able to learn how to drive.
He said, he is too afraid to drive.
8. Role – Relationship Pattern

He is a good brother and a good son to his parents. He had proven being a
responsible family member when he decided to work immediately for them after
graduating from high school. He is in good terms with his Aunt’s family.

At work, he is a dependable co-worker. He said, whenever a co-worker needs help,

he tries to help him. When conflict arises, he initiates to resolve it
immediately.

9. Sexuality – Reproductive Pattern

 He said he is still sexually active, though he does not practice safe sex. He
admits that he doesn’t want to use condom. He practices withdrawal method. He is
aware of the circumstances of not practicing safe sex but he said it’s a matter of
fate whatever will happen to him like acquiring sexually transmitted infections.

10. Coping – Stress Tolerance Pattern

When he has problems, he solves it by himself. He does not bother other family
members to help him solve it especially if it is manageable. Sometimes, he drinks
alcohol to cope from his problem.

11. Value – Belief Pattern

He is a Catholic. He would go to church if there is time. He still believes that

God would help him to solve his problems. He prays to ask for assistance and
guidance especially when they are travelling.

G. Heredo-Familial Illness

Father Mother
(TB, HPN) (Diabetes)

Patient XYZ 2nd 3rd 4th 5th 6th 7th

(Ascending Child Child Child Child Child Child
Cholangitis)
 H. DEVELOPMENTAL HISTORY

Theorist Age Sex Patient Description

Erik Erikson’s 40 – 65 y/o for both male The patient did not have a child of his
Psychosocial and female own. He was not able to fulfill his role
Theory Generativity as a parent. He wanted to have a child but
vs. Stagnation unfortunately his wife died. He said he
had no luck but was contented with his
immediate family. It seems that he is
being passive and feels lack of purpose
and productivity.
James Fowler’s for both male The patient verbalized that it is better
Stages of Faith and female that he had no family so he could work and
Development travel without worrying about them when
he’s away. He added that he don’t have
future plans to have his own family. I
Conjunctive observed that this might be contradictory
Faith Stage to what he really wants. He also said that
he wanted to have his own child,
(mid-life)
therefore, it seems he only want to
confine himself to the reality that he
might not be able to have his own family
at this stage of his life.

I. PHYSICAL ASSESSMENT

A. General Survey

Patient XYZ was awake, lying on bed, conscious and coherent, and weak in
appearance. A nasogastric tube was inserted at the right nares aseptically.
Oxygen inhalation was given regulated @ 3 LPM. An IVF of DsW + 2 ampules of
Dobutamine was infused at his right hand as venoclisis. An IFC has been inserted
connecting to a urine bag inplace.

B. Vital Signs

1st Day 2nd Day 3rd Day

BP: 110/80 mm Hg 120/80 mm Hg 110/90 mm Hg
T : 39.6 °C 37.8 °C 37.7 °C
RR: 32 bpm 30 bpm 28 bpm
CR: 100 bpm 98 bpm 95 bpm

C. Regional Exams

Area Assessed Techniques Used Findings

Skin
> color inspection dark-skinned with
hyperpigmentations
> texture palpation rough and dry
> temperature palpation warm to touch
> moisture palpation dry

Nails
> color of nailbed inspection pink, not clean
> texture palpation slightly rough
> shape inspection convex curvature
> nail base inspection firm
Hair
> color inspection black
> distribution inspection evenly distributed
> moisture inspection oily
> texture inspection fine

Eyes
> eyebrows inspection symmetrically aligned,
equal movement
> eyelashes inspection slightly straight
> ability to blink inspection blinks voluntarily
eyes move freely (both)
> ocular movement inspection icteric (jaundice)
> sclera inspection round, reactive to light,
> pupils inspection constricts briefly (L eye)

Nose
> symmetry, shape, inspection
size and color symmetrical, smooth, tan
> mucosa color inspection
> nasal septum inspection pinkish
> sinuses palpation oval and symmetrical nares
not tender

Mouth and Throat

> lips inspection slightly brown,
symmetrical, dry,
> sublingual area inspection icteric (jaundice)
> tongue inspection pinkish, dry
> teeth inspection 19 teeth, with dental
caries
> throat inspection no swelling noted
palpation no pain when palpated

Cardiovascular
> heart rate auscultation 100 bpm
> heart sounds auscultation clear

Thorax and Lungs

> symmetry inspection symmetrical
> respiratory rate inspection 32 bpm, tachypneic
> breathing inspection rapid and shallow
pattern
> lung/breath auscultation vesicular
sounds

Abdomen
> contour inspection globular
> texture palpation mild tenderness on right
upper quadrant
> frequency and auscultation soft gurgling sound
character

Upper Extremities
> skin color inspection dark-skinned
> size inspection equal and appropriate for
his body
> symmetry inspection symmetrical

Lower Extremities
 > skin color inspection dark-skinned
> size inspection equal and appropriate for
his body
> symmetry inspection symmetrical

Neurologic
> level of interview responds quickly but he
consciousness inspection, needs to ask again the
question
> behavior and interview poor eye contact, does not
appearance pay attention to questions
and tells his sister to
answer
> mood and affect inspection, quite irritable
interview blunted affect
>thought process inspection, there are questions that
interview pertains to him that he
cannot recall

II. PERSONAL/ SOCIAL HISTORY

The patient drinks 2 cups of coffee everyday. He could consume a pack of cigarette in
one day. He started smoking when he was 25 years old. He can drink 1 bottle of Ginebra
almost each day and he drinks more when he is with his co-workers and friends.

He spends more time travelling because of the nature of his work. They deliver
religious icons and images from Northern Luzon to Central Visayas region. His last travel
was in Cagayan. There was limited time for him to socialize or to attend family gatherings.
 He is the eldest child in their family. He was only a high school graduate but he
decided to work immediately for his family.

III. ENVIRONMENTAL HISTORY (LIVING/NEIGHBORHOOD/CIRCUMSTANCES)

The family is not well-off but they can manage to survive and meet their basic needs.
He lives with his aunt’s family in a subdivision. The neighborhood is quiet and peaceful.
The patient said there are no circumstances that could endanger their lives. There were no
incidents of crime or illegal activities in the vicinity. There were no piggeries or poultry
that could be a health hazard for them.

IV. INTRODUCTION

Ascending Cholangitis or acute cholangitis is an infection of the bile duct, usually

caused by a bacteria ascending from its junction with the duodenum (first part of the small
intestine. It tends to occur if the bile ducts are already partially obstructed by
gallstones.
In 1877, Charcot described cholangitis as a triad of findings of right upper quadrant
(RUQ) pain, fever, and jaundice. The Reynolds pentad adds mental status changes and sepsis
to the triad. A spectrum of cholangitis exists, ranging from mild symptoms to fulminant
overwhelming sepsis. With septic shock, the diagnosis can be missed in up to 25% of
patients. Consider cholangitis in any patient who appears septic, especially in patients who
are elderly, jaundiced, or who have abdominal pain. A history of abdominal pain or
symptoms of gallbladder colic may be a clue to the diagnosis.
Cholangitis can be life-threatening and is regarded as a medical emergency.
Characteristic symptoms include jaundice, fever, abdominal pain, and in severe cases, low
blood pressure and confusion. Initial treatment with intravenous fluids and antibiotics, but
there is often an underlying problem (such as gallstones or narrowing in the bile duct) for
 which further tests and treatments may be necessary, usually in the form of endoscopy to
relieve obstruction of the bile duct.
Bile duct obstruction, which is usually present in acute cholangitis is generally due
to gallstones. 10-30% of cases, however, are due to other caused as benign stricturing
(narrowing of the bile duct without an underlying tumor), postoperative damage or an altered
structure of the bile ducts such as narrowing at the site of an anastomosis (surgical
connection) and various tumors (cancer of the bile duct, gallbladder cancer, cancer of the
ampulla of Vater, pancreatic cancer or cancer of the duodenum). Cholangitis may also
complicate medical procedures involving the bile duct, especially ERCP. To prevent this, it
is recommended that those undergoing ERCP for any indication receive prophylactic
(preventive) antibiotics.

VI. ANATOMY AND PHYSIOLOGY

Anatomy of the Biliary System:
The biliary system consists of the organs and ducts (bile ducts, gallbladder, and associated
structures) that are involved in the production and transportation of bile. The
transportation of bile follows this sequence:
1. When the liver cells secrete bile, it is collected by a system of ducts that flow from
the liver through the right and left hepatic ducts.
2. These ducts ultimately drain into the common hepatic duct.
 3. The common hepatic duct then joins with the cystic duct from the gallbladder to form
the common bile duct, which runs from the liver to the duodenum (the first section of
the small intestine).
4. However, not all bile runs directly into the duodenum. About 50 percent of the bile
produced by the liver is first stored in the gallbladder, a pear-shaped organ located
directly below the liver.
5. Then, when food is eaten, the gallbladder contracts and releases stored bile into the
duodenum to help break down the fats.
Functions of the Biliary System:
The biliary system's main function includes the following:
• to drain waste products from the liver into the duodenum
• to help in digestion with the controlled release of bile
Bile is the greenish-yellow fluid (consisting of waste products, cholesterol, and bile
salts) that is secreted by the liver cells to perform two primary functions, including the
following:
• to carry away waste
• to break down fats during digestion
VIII. LABORATORY AND DIAGNOSTIC EXAMINATIONS

Date: October 3, 2009

Prothrombin Time (PT)

Patient’s Time Normal Values Significance

17.1 seconds (done twice) 10-14 seconds prolonged PT my suggest

hepatic disease,
deficiencies in fibrinogen,
prothrombin, Vit K or
 factors V, VII, or X

Activated Partial Thromboplastin Time (APTT)

Patient’s Time Normal Values Significance

52.1 seconds (done twice) 26 - 36 seconds prolonged APPT my suggest

deficiencies in coagulation
factors (Vit. K)

Date: October 5, 2009

Blood Results Normal Values Significance

Chemistry

BUN 6.89 mmol/L 2.9 – 8.2 mmol/L within normal range

Creatinine 176.8 µmol/L 53 -106 µmol/L an increase may suggest

renal disease

Hepatic Results Normal Values Significance

Enzymes

SGOT/AST 7.1 U/L 8 – 33 U/L low levels suggests lack

of Vitamin B6

Date: October 6, 2009

Whole Abdominal Ultrasound

R Mid-hepatic Length = 17.9 cm

L Mid-hepatic Length = 12.4 cm
Common Bile Duct = 1.5 cm
Main Portal Vein = 1.3 cm
Spleen = 8.7 x 3.8 cm
R Kidney = 10.2 x 4.9 x 4.7 cm
L Kidney = 10.6 x 5.1 x 5.3 cm
Prostate Gland = 2.5 x 2.9 x 3.1 cm (11.6 gms)

• The liver is enlarged without focal lesion. Common bile duct and intrahepatic ducts are
dilated. Extrahepatic portions of the common bile duct are obscured by bowel gas.
• Markedly distended gallbladder is noted
• Gallbladder is adequately distended without intraluminal echoes or wall thickening
• Pancreas cannot be properly evaluated due to presence of bowel gas
• Spleen is unremarkable
• Both kidneys are within normal size configuration, parenchymal echopattern, and
cortical thickness. No focal lesion, ectasis, or lithiasis noted
• Prostate gland is normal in size without calcifications
• Urinary bladder is underfilled with note of foley catheter

Impression:
Hepatomegaly with biliary obstruction
Markedly distended gallbladder vs. bowel loop
Underfilled urinary bladder

Date: October 7, 2009

 Blood Chemistry Results Normal Values Significance

Total Bilirubin 47.5 2 - 21 mmol/L increased values may

suggest hepatitis,
biliary stricture

increased values may

suggest biliary
Direct Bilirubin 17 <5 µmol/L
obstruction
(B1)

increased values may

suggest hepatic damage

Indirect Bilirubin 30.5 2 – 17 µmol/L

Electrolytes Results Normal Values Significance

Sodium 152.4 mmol/L 136 - 142 mmol/L increased values may

suggest impaired renal
function

decreased values may

suggest gastrointestinal
Potassium 2.90 mmol/L 3.8 – 5.0 mmol/L
and renal disorders
 increased values may
suggest severe
Chloride 121.7 mg/L 95 – 103 mg/L dehydration or complete
renal shutdown

Hematology Results Normal Values Significance

Blood Type Type O+

WBC 17.6 G/L 4.1 – 10.9 G/L -increased values may suggest
infection

-decreased values may suggest

RBC 3.68 T/L 4.2 – 6.30 T/L anemia

-decreased values may suggest

HGB 112 g/L 120 – 180 g/L anemia, recent hemorrhage or
fluid retention

-decreased values may suggest

anemia, hemodilution
HCT 360 L/L 370 – 510 L/L

-decreased values may suggest

immune disorders, Vit B12

Platelet 66 g/L 140 – 440 G/L deficiencies
XI. DRUG STUDY

Generic Name: Cefuroxime

Dosage: 750 mg IVP q 8°
Indication: it is used as an anti-infective agent for urinary tract infections and severe
infections
 Mechanism of Side Effects Contraindications Adverse Reactions Nursing
Action Considerations

Inhibits diarrhea, nausea Hypersensitivity Allergic reactions • Determine

bacterial cell and vomiting, gas to cephalosporins like skin rash, history of
wall synthesis, or heartburn and related itching or hives, hypersensitivi
rendering cell antibiotics; swelling of the ty reactions
wall osmotically pregnancy face, lips or to
unstable, (category B), tongue, dark cephalosporins
leading to cell lactation urine, difficulty , penicillins,
death of breathing, and history of
irregular allergies,
heartbeat or chest particularly
pain, seizures, to drugs,
unusual bleeding
or bruising, white • Inspect IM and
patches or sores IV injection
inside the mouth sites
frequently for
signs of
phlebitis.
• Monitor I&O
rates and
pattern:
• Monitor for
bleeding

Generic Name: Metronidazole

Dosage: 500 mg IV infusion q 8°
 Indications: It is used for the treatment of serious infection caused by susceptible
anaerobic bacteria in intra-abdominal infections, skin infections,
gynecologic infections, septicemia, and for preoperative and
postoperative prophylaxis

Mechanism of Side Effects Contraindications Adverse Nursing

Action Reactions Considerations

It binds to GI discomfort, Blood dyscrasias. Convulsive • Obtain baseline

bacterial and anorexia, nausea, Active CNS seizures; information on
protozoal DNA to furred tongue, diseases. peripheral patient’s
cause loss of dry mouth and Hypersensitivity neuropathy; infection:
helical unpleasant to imidazole. rash, pruritus. fever, wound
structure, metallic taste, Tuberculosis to Burning and characteristics,
strand breakage, headache, less mucous membranes skin irritation WBC count
inhibition of frequently and certain viral (>100,000mm3)
nucleic acid vomiting, conditions. 1st and regularly
synthesis and diarrhea, trimester of assess during
cell death. weakness, pregnancy. treatment.
dizziness and Lactation. • Assess for
darkening of the Children. allergic
urine. Watery Leukopenia. reactions:
(tearing) eyes if Peripheral rash ,
applied near to neuropathy (long urticaria,
eye area, term therapy). pruritus.
transient redness Psychiatric • Monitor renal
and mild dryness. disorders. function: urine
output, input-
output ration,
polyuria,dysuria
, pyuria, BUN
and creatinine.
Decreasing
 output and
increasing BUN,
creatinine may
indicate
nephrotoxicity.
• Monitor bowel
pattern,
discontinue drug
if severe
diarrhea occurs.
• Assess for over
growth of
infection:
peripheral
itching, fever
malaise,
redness,
swelling,
drainage, rash
and change in
cough/sputum.
 Generic Name: Paracetamol
Dosage: 300mg IVP q 4° for temp ≥ 38.5 °C
Indication: To relieve mild to moderate pain due to things such as headache, muscle and
joint pain, backache and period pains. It is also used to bring down a high
temperature.

Mechanism of Side Effects Contraindications Adverse Reactions Nursing

Action Considerations

Decrease fever Side effects are Hypersensitivity Skin rashes, • Assess patients
by inhibiting rare with to acetaminophen blood disorders fever or pain:
the effect of paracetamol when or phenacetin; use and acute type of pain,
pyrogens of the it is taken at with alcohol. inflammation of location,
hypothalamic the recommended the pancreas have intensity,
heat regulating doses. occasionally duration,
centers by a occurred in temperature,
hypothalaminc people taking the diaphoresis
action leading drug on a regular • Assess allergic
to sweating nd basis for a long reactions: rash,
vasodilation time. One urticaria; if
relieves pain by advantage of this occur, drug
inhibiting paracetamol over may have to
prostagalandin aspirin and discontinued
synthesis in CNS NSAIDs is that it • Assess
does not have doesn't irritate hepatotoxicity;
inflammatory the stomach or dark urine, clay-
action because causing it to colored stools,
of its minimal bleed, potential yellowing of skin
effect Side effects of and sclera;
aspirin and itching,
NSAIDs. abdominal pain,
fever, diarrhea
if patient is on
 long term
therapy.

• Monitor liver and

renal function.
AST, ALT
bilirubin, pro-
time, BUN, CREA
• Check input and
output ratio;
decreasing output
may indicate
renal failures
(long-term
therapy)

• Assess for
chronic
poisoning: rapid,
weak pulse;
dyspnea: cold,
clammy
extremities;
report
immediately to
prescriber
 Generic Name: Pantoprazole
Dosage: 80 mg IV infusion
Indications: Gastric acid pump inhibitor

Mechanism of Side Effects Contraindications Adverse Nursing Considerations

Action Reactions

Inhibits both Headache, Hypersensitivity. Insomnia, • Assess for

basal and diarrhea, Moderate to severe flatulence, underlying
stimulated abdominal pain, hepatic or renal hyperglycemia condition before
gastric rash dysfunction. therapy and
secretions by regularly
suppressing the thereafter to
final step in monitor drug
acids effectiveness.
production, • Assess GI symptoms:
through the epigastric/abdomina
inhibition of l pain, bleeding
the proton pump and anorexia.
by binding to • Monitor for
and inhibiting possible drug-
hydrogen- induced adverse
potassium reactions
adenosine • Monitor hepatic
triphosphatase, enzymes: AST, ALT,
the enzyme alkaline
system located phosphatase during
at the treatment
secretory • Assess patient and
surface of the family’s knowledge
gastric
parietal cell. on drug therapy.

Generic: Vitamin K/ Phytomenadione

Dosage: 1 amp IVP q 8°
Indication: Used in the treatment and prevention of hemorrhage associated with Vitamin K
deficiency

Mechanism of Side Effects Contraindications Adverse Reactions Nursing Considerations

Action

Synthetic Hypotension, Pronounced Urticaria. • Assess for patients

analog of cyanosis, allergic Hyperbilirubinemia condition before
Vit. K w/c headache, diathesis. including therapy and regularly
is essential dizziness, Infants<1 yr. kernicterus. In thereafter to monitor
to hepatic rash. newborns. death drug effectiveness.
synthesis of Anaphylactoid after IV • Assess for bleeding:
blood reactions; injection. bruising, hematouria,
clotting pain, Pruritic black- tarry stools and
factors II, swelling erythematous hematemesis.
VII, IX, X. plaques at IM • Monitor for possible
injection site. drug- induced adverse
reactions
• Assess patient and
family’s knowledge on
 drug therapy

X. Identified Problems According to Priority

1. Ineffective breathing pattern related to decreased lung expansion secondary to liver

enlargement
 2. Acute pain related to ductal spasm secondary to biliary duct obstruction
3. Hyperthermia related to presence of disease process

XI. NURSING CARE PLAN

Assessment Nursing Scientific Goals Interventions Rationale Evaluation

Background
Diagnosis
S> Ineffective The liver is After 2-3 > assess and > serve as Goal partially
breathing located hours of monitor vital baseline data met. After 3
“hinahabol ko pattern immediately rendering signs hours of
ang aking related to below the proper rendering
hininga” as decreased diaphragm proper nursing
verbalized by lung which is the nursing intervention,
the client > monitor
expansion major muscle > to note for the client
intervention respiratory
of worsening of demonstrated
O> secondary to , the client status
respiration. tachypnea easier
liver will
- rapid and Upon respiration
enlargement demonstrate
shallow enlargement and
easier
breathing of the > place client respiratory
respiration > it allows good
liver, it in rate decreased
and lung excursion
-nasal compresses sitting/high from 32 bpm to
respiratory and chest
flaring noted the fowler’s 25 bpm
rate will expansion
diaphragm position
-use of decrease
upward thus
accessory from 32 bpm
decreasing
muscles to 22 bpm
lung
> provide
expansion
adequate
during > to facilitate
ventilation
Vital Signs: inspiration effective
resulting to breathing
rapid and
RR: 32 bpm shallow > ensure O2
breathing delivery
BP: pattern system is > so that
applied to the appropriate
110/80 mm Hg amount of oxygen
patient
is continuously
CR: 100 bpm
delivered
T: 39.6°C
> refer to
physician
accordingly
during
> to assess
tachyneic
respiratory
episodes
status

> explain
effects of
wearing
restrictive
clothing

> use of tight

or restrictive
clothing
compromises
> teach
respiratory
patient
excursion
appropriate
breathing
techniques by
demonstration > appropriate
breathing
emphasizing techniques are
slow important in
inhalation, maintaining
holding end adequate gas
inspiration exchange
for a few
seconds and
passive
inhalation
 Assessment Nursing Scientific Goals Interventions Rationale Evaluation
Background
Diagnosis
S> Acute pain As the After 4 > monitor > to monitor any Goal partially
related to biliary duct hours of vital signs changes from the met. After 4
“masakit ang ductal becomes rendering previous to hours of
tiyan ko” as spasm obstructed, proper present data. rendering
verbalized by secondary the pressure Serve as proper nursing
the client to biliary within the nursing baseline data intervention,
duct bile duct the patient’s
intervention
obstruction increases level of pain
, the
O> thus subsided from
patient’s > to assess
producing 7/10 to 4/10
level of etiology/
- facial involuntary
pain of 7/10 contributing
grimace contraction
will subside > perform a factors
usually
- with to 3/10 comprehensive
accompanied
guarding by pain that assessment of
behavior noted may last pain to
from seconds include
- restlessness location,
to minutes
onset/
- pale and
duration,
weak in
quality,
appearance
severity and
- rated pain precipitating
as 6/10 in a factors
pain scale of
1-10; 1 as the
lowest and 10 > determine
as the highest possible
pathophysiolog
ical causes of
> to assess
pain
precipitating
factors
Vital Signs:
> perform pain
BP:
assessment
110/80 mm Hg each time pain
occurs
RR: 32 bpm
> to rule out
CR: 100 bpm worsening of
> provide
underlying
T: 39.6°C comfort
condition
measures

> to provide
non-
> provide calm pharmacological
and quiet pain management
environment

> to prevent
> administer anxiety
analgesics as
indicated

> to maintain
> instruct the
acceptable level
patient to
of pain
report pain
 > so that
immediate relief
> explain measures may be
cause of pain, instituted
if known

> this will

contribute to
patient’s
understanding to
> instruct the his condition
patient to
evaluate and
report > it will
effectiveness determine if
of measures measures used
used were not
effective to
facilitate
better
interventions
 Assessment Nursing Scientific Goals Interventions Rationale Evaluation
Background
Diagnosis
S> Hyperthermia During After 1-2 > monitor > to monitor any Goal met.
related to inflammation hours of vital signs changes from the After 1-2
“sobrang init disease or rendering previous to hours of
ko” as process infection, proper present data. rendering
verbalized by the area of Serve as proper nursing
the patient infection or nursing baseline data intervention,
infection the patient’s
intervention
phagocyte temperature
, the
O> releases subsided from
patient’s > to promote
endogenous 39.6°C to
temperature heat loss
- febrile pyrogens 37.5°C.
will subside through
(39.6 °C) (fever-
from 39.6°C > remove evaporation
causing
- flushed to 37°C or excess clothes
substance).
skin maintain or blanket
These will
body
act as > TSB opens the
- warm to temperature
receptors in skin pores
touch within
the therefore
normal range
-diaphoretic hypothalamus facilitating
(36.5°C –
to cause > perform TSB conduction and
37.5°C)
> pale and upward evaporation of
weak in alteration heat from a warm
appearance of its surface to a
temperature cool surface
set point

Vital Signs:
> to reduce
metabolic
BP: demands

110/80 mm Hg

RR: 32 bpm > to support

circulating
CR: 100 bpm volume and
tissue
T: 39.6°C
perfusion
> provide
adequate rest

> to treat
underlying cause
> administer
fluid an
electrolyte
replacement

> this will

provide patients
knowledge how to
assess their
> administer
temperature;
medications as
this will
indicated
provide
information on
how to prevent
or control
temperatures
> explain especially when
temperature they were
measurements already
 and all discharged
treatments

> provide
information
regarding
normal
temperature
and control

> discuss
precipitating
factors and
preventive
measures

XII. ONGOING APPRAISAL

October 8, 2009
Patient XYZ’s condition has improved. He is not experiencing abdominal pain. His NGT
and IFC were removed. He is already allowed to have general liquids on his diet. Patient
is with ongoing Pantoprazole drip.

October 9, 2009
The patient is allowed to have soft diet. Pantoprazole drip was discontinued.
Medications are still continued.

October 10, 2009

Patient is requested to have another abdominal ultrasound to confirm bile duct
obstruction. If confirmed, the patient may be transferred to surgery ward.

October 11, 2009

 The patient is not experiencing abdominal pain, fever and shortness of breath. The
patient is still for abdominal ultrasound.
October 12, 2009
The patient may be transferred to regular ward. The patient is still for abdominal
ultrasound for confirmation of common bile duct obstruction.

XIII. DISCHARGE PLAN

M – Medicine
- advise patient to continue his prescribed medicines

E – Environment and Exercise

- maintain a quiet environment to promote relaxation
- provide clean and comfortable environment
- encourage walking everyday

T – Treatment
- continue home medications
- advise patient to take multivitamins for increased immunity
- teach patient about wound care

H – Health Teachings
- provide oral and written instructions about wound care, activity, diet
recommendations, medications, and follow-ups

O – Out-Patient Follow-Up
- patient will be advised to go back to the hospital in a specific date to have a
follow-up check-up after discharge

D – Diet and Danger Signs

- encourage patient to increase protein intake for tissue repair
 - advise patient and family members to immediately consult if the patient is
experiencing any likely symptoms, or changes that may occur when the patient is
at home.
VII. PATHOPHYSIOLOGY
(Ascending Cholangitis)

Biliary tract obstruction (gall

stone, neoplasm, or stricture)

(Main Factor of Pathogenesis)

Elevated Intraluminal Pressure

Walls of biliary tract become

distended

Occlusion of lymphatic
channels then the venous
return and arterial supply to Diminished host
the biliary tract becomes antibacterial defenses
undermined

Reduced blood supply to the Immune System Dysfunction

biliary tract

Decreased oxygenation

Walls of biliary tract starts

to break

Bacteria gain
access to the
biliary tree
 Bacteremia
Bacteria start to multiply

Invasion of bacteria (E.coli

27%, Klebsiella species 16%,
Enterococcus species
15%,Sreptococcus species 8%,
Enterobacter species 7%,
Pseudomonas aeruginosa 7%
Retrograde ascend from duodenum
or from portal venous blood to
the hepatic ducts, biliary
canaliculi, hepatic veins and
perihepatic lymphatics

Charcot’s triad:fever, RUQ

pain,jaundice

Reynold’s pentad:altered mental

status, hypotension,RUQ pain,
fever and jaundice

Unclassical signs:pruritus,
malaise and tacycardia