NURSING CARE PLAN

ON
Ca Gall Bladder

Submitted to:
Mrs.Anita D’Souza,
Prof. cum Principal,
TMC, Mumbai.

Submitted by:
Mr. Sourabh Mehra,
M Sc Nursing 2st year student,
TMC, Mumbai
 BIOGRAPHICAL DATA

Name of the patient: Mrs. Asha Burman

Age: 45 Yrs
Sex: Female
Marital status: Married
Education: Graduation
Occupation: Housewife
Mother Tongue: Hindi
Religion: Hindu
Address: Bhopal, M.P.
Nationality: Indian
Name of the Hospital: TMH, Mumbai
Ward: General Female Ward
Dept: Gastrointestinal (B)
Bed Number: 37
Registration No.: CS/24808
Date of admission: 07/08/2019
Date of surgery: 10/08/2019
Diagnosis: Ca Gall Bladder
Surgery: - Radical Cholecystectomy.

PRESENT COMPLAINTS

 Upper abdominal pain for past 6 months.

 Regurgitation for past 6 months.

PRESENT HISTORY OF ILLNESS

Patient had pain in abdomen and acidity after eating meal from last 6 months. She had
consulted with family physician in Bhopal but pain was still even after the treatment. Then
family doctor refer patient to the gastroenterologist in Bansal Hospital, Bhopal. On
investigation found moderate enhancing soft tissue mass filling GB. They refer to TMH,
Mumbai for further evaluation and treatment.

PAST HISTORY OF ILLNESS

 No past medical history.

 History of left breast lump excision 13 years ago for ?Galactocele

PERSONAL HISTORY

 HABITS
 o No history of smoking, tobacco chewing and alcohol intake.

 DIET
o All family members have vegetarian and non vegetarian taking meals and also have no
any allergic to any food items.

 SLEEP AND REST PATTERN

o Sleep timing of family members is around 10pm daily and have sleep duration of 7 to 8
hrs daily.

 ACTIVITIES OF DAILY LIVING (ADL’S)

o Members taking care by self like eating, grooming, dressing etc.

 RECREATIONAL AND HABITS

o For recreational they attend social gathering, sometimes go for outing etc.

 SOCIO-ECONOMIC STATUS
o Family relationship is good and cooperative.
o Marital relationship is also satisfactory.
o Family monthly income is Rs. 10000 per month.

FAMILY HISTORY

There is no family history of cancer. His husband is a farmer and having two children.

Mr. Chandra Prakash, 47 years Mrs. Asha, 45years

Mr. Suresh, 16 years

Patient Male

S.No Name of the family Age Relation Education Remark

. member with the
patient
1 Mr. Chandra Prakash 47 years Husband Tax Advocate Healthy
Burman
2 Mrs. Asha Burman 45 years Self Housewife Unhealthy
3 Mr. Suresh Burman 16 years Son Student Healthy
 HISTORY OF HEALTH PROBLEM/CHRONIC ILLNESS

 No any congenital problem and psychological problem.

ENVIRONMENTAL HISTORY

Patient and his family members living in own house (Pakka) with adequate lighting and
ventilation, have municipal water supply, kitchen and bathroom, proper drainage and disposal
of garbage system.

PHYSICAL EXAMINATION

1) BASELINE DATA
i. Weight:- 53 kg
ii. Height:- 157cm
iii. Temperature:- 37.6 C
iv. Pulse:- 94 / min
v. Respiration:- 20 / min
vi. Blood pressure:- 110 / 70 mm of Hg
vii. BSA: - 1.60m2
viii. BMI: - 24.3

2) GENERAL APPEARANCE
i. Nourishment – Nourished
ii. Activity- Dull.
iii. Facial expression- Tense.
iv. Body language- Eye contact maintained.

3) MENTAL STATUS
i. Level of alertness: - Conscious
ii. Orientation: - Oriented to time, place and person.
iii. Responsiveness: - responds to verbal stimuli and slow.

4) POSTURE
i. Body curve: - Normal.
ii. Movement: - Active movement of limbs.

5) SKIN CONDITION
i. Color: - skin colour is pallor.
ii. Temperature and moisture: - Warmth and Moist.
iii. Texture: - smooth.
iv. Turgor and mobility: - moderate skin elasticity.

6) HEAD AND NECK

 i. Skull: - round shape.
ii. Hair: - long, dry, thick and evenly distributed.
iii. Face: - Symmetrical facial expression.
iv. Scalp condition is clean.
v. No facial puffiness.
vi. No enlargement of lymph nodes.

7) EYES
i. Symmetric eye brows and in line with each other.
ii. Eye lashes is short.
iii. Eye lid is symmetrical, covers upper portion of cornea, when looking straight and not
drooping of upper eyelids.
iv. Pupils- 2 to 4 mm in diameter, equal, round and reactive to light.
v. Eye conjunctiva: - pink.
vi. Sclera: - white in colour and clear.
vii. Iris: - round.
viii. Visual field is intact.
ix. Visual acuity is good.
x. She is able to read the newspaper and time in clock from distance.

8) EARS
i. Pinnae: - small in size, small lobes, symmetrical and proportion to face.
ii. Canal is clean and having no discharge.
iii. No infection, wax is present.
iv. Hearing: - she can able to hear normally.

9) NOSE
i. Size and shape: - short in shape and proportion to face.
ii. Nostrils: - NJT tube (14 FR) present in left nostril.
iii. Nasal Septum: - presented in midline
iv. Mucosa: - pink, moist and no discharge.

10) ORAL CAVITY

i. Lips: - pink in colour and not swollen.
ii. Gums: - pink in colour, moist, no bleeding and sensitivity.
iii. Tongue: - thick, symmetrical and tongue movement present.
iv. Oral mucosa: - moist and intact.
v. Gag reflex is present.
vi. Able to move the tongue freely and with strength.

11) THORAX AND LUNG

i. Bilaterally symmetrical in shape.
ii. Diaphragmatic exertion is dull.
iii. Wheezing sound on auscultation due to accumulation of secretion.
12) ABDOMEN
i. Suture is present in sub costal incision site approximately 15cm in length.
ii. Redness and pain around the surgical suture site.
iii. Mild distension.
iv. Abdominal girth is 36cm.
v. JP drain present at the surgical site (about 40 ml fluid collected in drain)
vi. Abdominal tenderness is present.
vii. Peristalsis movement is present.
viii. Mild abdominal distension.

13) CARDIOVASCULAR EXAMINATION

i. Apical impulses present.
ii. Heart rate is 86/min.
iii. Heart Sound: - S1 and S2 sound present.
iv. Murmur sound is absent.
v. Capillary refill time is normal 10 sec.
vi. No varicosities and thrombophelbitis.

14) EXTREMITIES
i. Both extremities are equal in size and having range of motion is present.
ii. Body curve is normal as well as spine also found normal.
iii. No swelling over the upper and lower limbs.
INVESTIGATION (ON DATED 22/07/ 2019)

COMPLETE BLOOD COUNT

S.NO INVESTIGATION OBSERVED OBSERVED

NORMAL RANGE
. TYPE VALUE

1 HAEMOGLOBIN LOW 9.9 12.0-15.0 g/dL

2 RBC COUNT NORMAL 4.08 3.8-4.8x 10e12/L

LOW
3 HAEMATOCRIT 32.4 36-46%
LOW
4 MEAN CORPUSCULAR VOLUME (MCV) 79.4 83-101fL
LOW
MEAN CORPUSCULAR HEMOGLOBIN 24.3
5 27-35pg
(MCH)
LOW
MEAN CORPUSCULAR HEMOGLOBIN 30.6
6 31.5-34.5g/dL
CONCENTRATION (MCHC)
LOW
CELL HEMOGLOBIN CONCENTRATION 30.4
7 33-37g/dL
MEAN (CHCM)

RED BLOOD CELL DISTRIBUTION HIGH 17.7

8 11.6-14.0%CV
WIDTH (RDW)

HEMOGLOBIN DISTRIBUTION WIDTH 3.03

9 NORMAL 2.2-3.2g/dL
(HDW)

10 CH LOW 23.9 24-35pg

NORMAL
11 CHDW 4.04 3.01-4.07pg
NORMAL
12 PLATELETS 222 150-400x10e9/L
NORMAL
13 MEAN PLATELET VOLUME (MPV) 7.8 7.5-10.5 fL
NORMAL
PLATELET DISTRIBUTION WIDTH 25.5
14 25-65%
(PDW)
NORMAL
15 PROCALCITONIN (PCT) 0.17 0.12-0.36%
NORMAL
16 WBC COUNT 7.20 4.0-10.0x10e9/L
NORMAL
17 NEUTROPHILS % 64.5 40.0-80.0%
NORMAL
18 LYMPHOCYTE % 26.4 20.0-40.0%
NORMAL
19 MONOCYTE % 5.5 2.0-10.0%
LOW
20 ESINOPHIL % 0.5 1.0-6.0%
LOW
21 BASOPHIL % 0.9 1.0-2.0%
NORMAL
22 LARGE UNSTAINED CELL % (LUC) 2.1 0-4%
23 NUCLEATED RBC’S % (NRBCS) NORMAL - 0.0-2.0 NRBCS/100

24 NORMAL
NEUTROPHILS ABS (ANC) 4.644 2.0-7.0 x10e9/L
 NORMAL
25 LYMPHOCYTE ABS 1.9008 1.0-3.0 x10e9/L
NORMAL
26 MONOCYTE ABS 0.396 0.2-1.0 x10e9/L
LOW
27 BASOPHIL ABS 0.0648 0.02-0.1 x10e9/L
NORMAL
28 LARGE UNSTAINED CELLS (LUC) ABS 0.36 0.0-0.4 x10e9/L
NORMAL
29 EOSINOPHIL ABS 0.1512 0.02-0.5 x10e9/L
HIGH
ESR (ERYTHROCYTE SEDIMENTATION 40 0-10 mm/hr for men and
30
RATE) 0-20 mm/hr for women

CHEMISTRY PROFILE (22/07/2019)

S.NO INVESTIGATION OBSERVED VALUE

OBSERVED TYPE NORMAL RANGE
.

1 RBS NORMAL 105 70-200mg/dL

2 SERUM SODIUM NORMAL 137 136-145 mmol/L

3 SERUM POTASSIUM NORMAL 3.6 3.5-5.1 mmol/L

4 SERUM CHLORIDES NORMAL 106 98-107 mmol/L

5 SERUM BICARBONATES NORMAL 27.3 22-29 mmol/L

6 SERUM UREA NORMAL 20 12.38-42.8 mg/dL

NORMAL
7 SERUM URIC ACID 3.3 2.6-6.0 mg/dL
LOW
8 SERUM CREATININE 0.5 0.6-1.1 mg/dL
LOW
9 SERUM PROTEIN 4.7 6.6-8.3 g/dL
LOW
10 SERUM ALBUMIN 2.5 3.5-5.2 g/dL
NORMAL
11 SERUM GLOBULIN 2.2 1.7-3.5 g/dL
NORMAL
12 SERUM ALKALINE PHOSPHATE 62 30-120 U/L
NORMAL
13 TOTAL BILIRUBIN 0.92 0.3-1.2 mg/dL
HIGH
14 DIRECT BILIRUBIN 5.23 0.0-0.2 mg/dL
HIGH
15 INDIRECT BILIRUBIN 4.95 0.3-1.0 mg/dL
HIGH
16 SERUM AST 192 <35 U/L
HIGH
17 SERUM ALT 218 <35 U/L
LOW
18 SERUM PHOSPHATE 2.4 2.7-4.5 mg/dL
 RH TYPING & COAGULATION PROFILE (22/07/2019)

S.NO INVESTIGATION OBSERVED VALUE

OBSERVED TYPE
.

1 INR HIGH 1.449

2 PT HIGH 19.500

3 APTT NORMAL 24.300

BLOOD GROUPING (22/07/2019)

S.NO. INVESTIGATION OBSERVED VALUE

1 BLOOD GROUPING AND RH TYPING B +ive

VIRAL MARKER (23/07/2019)

S.NO. INVESTIGATION OBSERVED VALUE

1 HEPATITIS B ANTIGEN (HBSAG) NON REACTIVE

2 HEPATITITS C ANTIBODIES (HCV) NON REACTIVE

3 HIV ANTIBODIES NON REACTIVE

TUMOR MARKER TEST (22-07-2019)

S.NO INVESTIGATION OBSERVED VALUE

OBSERVED TYPE NORMAL RANGE
.

1 SERUM IRON LOW 16 60-80 ug/dL

2 SERUM TIBC HIGH 444.0 250-425 ug/dL

LOW 2.47 Male: 21.81-274.66 ng/dL

3 SERUM FERRITIN
Female: 4.63-204.00ng/dL

4 SERUM CA-19.9 NORMAL <2.00 0-37U/mL

URINE MACROSCOPY AND MICROSCOPY EXAMINATION (22/07/2019)

S. NO. INVESTIGATION OBSERVED VALUE

1 COLOR Pale yellow

2 pH Acidic
 3 GLUCOSE Negative

4 BILIRUBIN Negative

5 BLOOD -

6 SPECIFIC GRAVITY 1.015

7 PROTEINS Negative

8 KETONES Negative

9 UROBILINOGEN Negative

10 WBC Occasional

11 RBC 1-2

12 CASTS -

13 BACTERIA Absent

14 SQUAMOUS EPITHELIAL CELLS Occasional

OTHER INVESTIGATIONS
Date Investigation Report

13-07-2019 USG ABDOMEN Distended GB relatively hyperechoiec lesion filling up

(OUTSIDE) lumen extending in neck and cystic duct.
16-07-2019 CECT ABDOMEN STM filling GB, cystic duct, proximal CBD with mild
dilatation of EHBR & Central IHBR, CHD: 12.3mm,
RHD: 7mm, LHD: 5.6mm, increased periGB
vascularity, no obvious hepatic infiltration, hepatic
artery and portal vein is normal, few suprapancreatic
LN, largest 6mm SAD.
23/07/2019 USG ABDOMEN Gall bladder is distended and large heterogeneous mass
(TMH) filling entire body and neck measuring 6 x 4 cm. It
reveals distended gall bladder with mass-HPR
29-07-2019 BILATERAL No dominant mass, suspicious calcification or
DIGITAL architectural distortion seen. No suspicious lesion is
MAMMOGRAPHY appreciated.
02/08/2019 GALL BLADDER Smear show groups of epithelial cells showing mild to
MASS FNAC (3 moderate nuclear atypia and nuclear overlapping. Cell
SMEARS) degeneration is also seen. Nuclear membrane
irregularity is seen. Features are consistent with
 adenocarcinoma cells.
07/08/2019 MRI MRCP Mass in GB extending into cystic duct, proximal CBD

SURGICAL DETAILS (10/08/2019)

Operative procedure: Radical Cholecystectomy: Gall bladder along with a wedge of the
liver segment 4 and 5 resected and removed. Cystic duct cut margin sent for frozen section.
Portal structures cleared of all lymphatic and fibro fatty tissue. Retroduodenal lymph node
dissection done along with retropancreatic nodal clearance done.

INTRAOPERATIVE FINDINGS

Residual Disease: R0

Organ/site: Gall bladder and bile ducts.

Surgical Staging: T: 3 N: 0 M: 0

T3: The tumor extends beyond the gallbladder and/or has invaded the liver and/or 1 other
adjacent organ or structure, such as the stomach, duodenum (part of the small bowel), colon,
or pancreas.

N0: There is no regional lymph node metastasis.

M0: There is no distant metastasis.

Complication Desc: Nil

Intent of procedure: Curative

Drain: Abdominal

TREATMENT

 Inj. Supacef. 1.5gm IV BD

 Inj. Paracetamol 500mg IV TDS

 Inj. Pantop 40mg IV OD

 Inj. Clexone 0.4 ml S/C OD Weekly

 Inj. Vit K 10mg IV OD.

 Tab. Diclo 50 mg SOS

 Nebulization with duolin and budecort TDS

NURSING CARE PLAN

 NURSING DIAGNOSIS

 Ineffective breathing pattern related to muscular impairment as evidenced by reduced vital

capacity.

 Acute pain related to surgical intervention as evidenced by patient’s verbalisation.

 Risk for infection related surgical intervention.

 Imbalanced nutrition less than body weight related to surgical intervention as evidenced by
presence of NJ tube.

 Activity intolerance related to prolonged immobilization as evidenced by generalized

weakness.

 Knowledge deficit related to disease condition as evidenced by request for information.

 Anxiety related disease condition as evidenced by patient’s verbalisation.

 HEALTH EDUCATION

 Take proper rest and sleep.

 Instruct the patient to follow exercise plan.
 Teach the patient about active and passive range of motion exercise.
 Instruct the patient not to do stair climbing, and not to perform any heavy activity.
 Encourage to have well balanced diet, including green leafy vegetables, pulses, cereals, oat,
meals, and whole grain etc.
 Advice to have plenty of fluids in the form of fruit and vegetables juices or soups daily.
 Maintain personal hygiene like daily bath, hand washing, oral care etc.
 Consume 8-10 glasses of water daily.
 Adhere to medical regimen and not miss the dose as per advice.
 Report the symptoms such as leakage, heavy pain, undigestion etc to the health professionals.
 Regularly follow –up.

SUMMARY

On oncology clinical training, I had been posted in General Ward (Female), TMH Hospital,
Parel, Mumbai for one week. I took Mrs. Asha Burman, 45yrs of age as my case. He admitted
in hospital on dated 07/08/2019 with complaint of pain in abdomen after eating meals and
acidity by investigation found moderate enhancing soft tissue mass filling GB. On dated 10-
08-2019 she operated with Radical Cholecystectomy. She responded well to the treatment,
discharge teaching given to the patient and their relatives regarding the home care of the
patient. Explained to the patient and their relatives for the follow up informed to them.
Throughout my posting patient and their relatives was very co-operative.

REFERENCES

 Connie, Y.H. & Debra, W. “Cancer Nursing: Principles and Practice”, Jones and Bartlet
Publications, 7th Ed.
 Frederik, S. O. & Carl, A. “Basics of Oncology”, Springer Publications, 5th Ed.
 https://tmc.gov.in