I.

INTRODUCTION

Cholecystolithiasis refers to gallstones within the gall bladder. The most common type of stone is cholesterol, though less common causes exist. Cholesterol stones form, as one might guess, when cholesterol levels are high enough in the bile that crystals form, then tiny stones which go on to grow. These can escape with the bile after a fatty meal and pass into the intestines and go out of the body or they can obstruct the outlet of the gallbladder causing pain in the right upper quadrant of the abdomen as well as nausea. These symptoms usually occur after a fatty meal. This pain can be short-lived or can last several hours. Our patient is Ms V.G. 39 y/o who was admitted at the Surgery Ward of Jose B. Lingad Memorial General Hospital last January 6, 2010. She was scheduled to have an Cholecystectomy. She underwent Choledochotomy on the year 2009. a.) Current trends about disease condition: Typically, the incidence of cholecystolithiasis increases with age. The greatest incidence occurs in female sex and in individuals between the ages of 40 and 60 years. In an Italian study, 20% of women had stones, and 14% of men had stones. In a Danish study, gallstone prevalence in persons aged 30 years was 1.8% for men and 4.8% for women; gallstone prevalence in persons aged 60 years was 12.9% for men and 22.4% for women. Adult male-to-female ratio is 1:2-3, presumably in part because of the effect of estrogen on cholesterol metabolism. Cholecystolithiasis is the fifth leading cause of hospitalization among adults and accounts for 90% of all gallbladder and duct diseases. b.) Reason for choosing case study: The main reason why we decided to choose Cholecystolithiasis as our topic in this said case study is because we want to expand our knowledge about Cholecytolithiasis. This will definitely help us to provide correct and efficient data that will help us in our future accomplishments. c.) General Objectives: To aim for effective nursing care and disease familiarity to a client diagnosed with Cholecystolithiasis through a comprehensive review on the patients condition and the disease process.

Specific Objectives a.) 1.) 2.) 3.) 4.) 5.) 6.) Student-based Objectives: To have a basic knowledge about Cholecystolithiasis To gain knowledge about the patients medication and its implications. To know about the laboratory findings and why such things occur. To have a basic knowledge about the predisposing factors associated with cholecystolithiasis. To properly formulate the appropriate nursing diagnosis for the nursing care plans that is gathered through effective nurse-patient interaction. To fully understand the anatomy and physiology together with the pathophysiology of the disease process.

b.) Client-based Objectives 1.) 2.) 3.) 4.) To identify special nursing needs for patient with Cholecystolithiasis. To promote care and implement Preventive measures for further complications. To provide Health Teaching to patient related to Cholecystolithiasis. To help the client in dealing with his disease and help her cope together with his family.

II. NURSING HEALTH HISTORY A. Biographic Data Name: Veronica Gozo Address: Mt. View Balibago Angeles, Pampanga Age: 39 y/o Gender: Female Race: Filipino Marital Status: Cohabiting Occupation: Housewife Religion: Catholic Health Care Financing: None B. Chief Complaint Pinabalik kasi ako ng doctor para tanggalin yung apdo ko, as verbalized by the patient. C. Present History of Illness It was 1991 when the symptoms started. The patient experienced sudden pain in the right upper quadrant, the patient seek for consultations and the doctor diagnosed that she had an ulcer, the doctor prescribed Maalox, but the pain continued for 3 months. It was 1997 when the symptoms started again. The same pain was felt by the patient, she became worried and unsatisfied at the previous diagnosis and consult again a different doctor for another opinion at Jose B. Lingad Hospital (JBL), and the doctor diagnosed that she had a stone in her gallbladder, the doctor advice her to undergo surgery but she refused and the only thing that the doctor did is to prescribed her with medicine that can partially ease the pain and possibly cure the disease. The pain became more severe, accompanied by stomachache, sudden nausea and vomiting that happen for several times. It was September 15, 2009 when the symptoms started again that made her decide to immediately rush at JBL. The doctor prescribed medicines to manage the pain, and scheduled her for surgery. It was September 18, 2009 when the surgery was done. She was confined at the surgery ward with contraptions of T-tube and Jackson Pratt drain. It was lat October 2, 2009 when the patient was discharged and was allowed to rest at home. She was noted to come back at the hospital to change her t-tube drain. Her T-tube was changed twice

on the course of her stay at home prior to her operation. January 6, 2010 when she was admitted again at JBL with the diagnosis of cholecystolithiasis S/P Ttube, choledochotomy for cholecystectomy. She was admitted for the removal of her gallbladder. D. Past History of Illness According to the patient, chickenpox was the only disease that she remembered that she had at her childhood. She acquired a complete vaccine for immunization. She had no previous and present allergies. She cannot recall any significant accident or injury that she had experienced in the past. And this previous hospitalizations due to her present illness was the only hospitalization she had experienced. No other significant drugs were given to her that was out of her present condition except from Maalox that was administered for ulcer that was a misdiagnosis. E. Family History of Illness The father of the patient together with her aunt died because of hypertension. She has 3 brothers and 4 sisters and she was the 5 th eldest. There were no other familial incidences of mental illnesses. Refer to the genogram for a detailed history of the patient.

GORDONS FUNCTIONAL HEALTH PATTERN PRIOR According to the patient she does a lot of things, she cleans their house, cooked food for her family and others. She didnt felt weak. She always forgotten to eat food when she was hungry because she is busy doing many things. She does not have a proper diet. The patient believes in kulam and hilot and takes herbal medicines. It is easy for her to follow the orders of the doctor. DURING When it comes to the general health, she said that she feels weak and uncomfortable because her disease greatly interferes with her daily activities. She cannot perform the things she likes and usually do. According to her the most important things to keep her self healthy are to have enough rest, drink a lot of water and have a well balanced diet. The patient believes in kulam and hilot and takes herbal medicines. It is easy for her to follow the orders of the doctor.

F. Health Perception and Health Management Pattern

G. Nutritional and Metabolic Pattern

The clients typical food intake prior her first operation is more of fatty foods like pork, fried rice, and fried dry fish. She drinks a little amount of water. But because of the advice of the doctor, the patient decided to limit fat intake and drink plenty of water. 72 HOURS DIET RECALL PRIOR TO HOSPITALIZATION
1ST Day (January 3, 2010) 2pcs biscuit cracker 2 glasses of water 1 cup of rice 1 pc porkchop 4 glasses of water 1 cup rice 1 whole grilled tilapia 3 glasses of water 3rd Day (January 5, 2010) 3pcs. Pandesals 2glasses water 1 cup of 1cup of rice rice 1small bowl 1 small of sabaw plate of ng sinigang pakbet 3glasses of 3 glasses of water water 1 cup of 1cup rice rice fried 1 pc bangus pangat na 2glasses of sapsap water 3 glasses of water 2nd Day (January 4, 2010) NONE

At the beginning of her hospitalization her diet was NPO as preparation for the surgery. Last January 10 she started to eat soft food like sopas and rice porridge. Furthermore last January 15 her diet was changed to DAT meaning she can eat whatever she wants. 72 HOURS DIET RECALL DURING HOSPITALIZATION
1st (January 11, 2010) BREAKFAS T 1 small bowl of lugaw 3 glasses of water NONE 2nd (January 12,2010) 1 small bowl of lugaw 2 glasses of water 1 small cup of nissin noodles 2 glasses of water 3 tablespoon of rice 1 small cup of soup 3rd (January 13,2010) 1 small bowl of lugaw 3 glasses of water NONE

BREAKFAST

LUNCH

LUNCH

DINNER

DINNER

1 small bowl of sabaw ng nilagang manok 2 tablespoon of rice 4 glasses of water

1 pc biscuit cracker 3 glasses of water

H. Elimination Pattern

The patient defecates once a day. Her stool was color brown dry During her hospitalization the patient did not defecate from January and formed. She urinates 3 times a day orange in color, she doesnt 6-13, but she urinates 4 times a day orange in color. have any problems in her elimination pattern and she doesnt ELIMINATION PATTERN DURING HOSPITALIZATION FREQUEN COLOR/ DISCOMFO experienced painful urination and defecation. CY CONSISTEN RT ELIMINATION PATTERN PRIOR TO HOSPITALIZATION
FREQUEN CY BOWEL ELIMINATI ON Once a day COLOR/ CONSISTEN CY brown DISCOMFO RT No discomfort No discomfort BOWEL NONE ELIMINATI ON URINATION 4 times a day CY NONE NONE With pain before urination

orange

URINATION 3 times a day

orange

I. Activity and Exercise Pattern

Prior to hospitalization the patient already feels weak because of her previous operation. O Feeding II Toileting Grooming II Mobility Cooking Level: O- Full self care I- Requires equipment/ devices II- Requires assistance from others III- Requires assistance from others and devices II Bathing II Dressing N/A Shopping IV Home maintenance II II

The patient had limited activities because she feels weak and she easily gets tired. She cannot walk and she cant even go to the bath room. She only use bed pan when she urinates. O Feeding IV Bathing III Toileting II Dressing II Grooming N/A Shopping II Mobility N/A Home maintenance N/A Cooking Level: O- Full self care I- Requires equipment/ devices II- Requires assistance from others III- Requires assistance from others and devices IV- Dependent and does not participate

IV- Dependent and does not participate

J. Sleep and Rest Pattern

Prior to hospitalization, the patient sleeps regularly. He usually sleeps at 11:00 pm and wakes up at 7am. Patient does not experience difficulty in falling asleep. Sometimes she takes a nap every afternoon. Watching T.V is the way of her relaxation.

During hospitalization, the patient finds it difficult to sleep because of the change in environmental setting. She only sleeps 3 hours at night. She also takes a nap upon admission to the hospital.

K. Role and relationship Pattern L. Sexuality Reproductive

Prior to hospitalization, she was able to work and do some household chores. Also she was able to take care of her family. Sometimes she can also hang out with her sister and friends. Prior to hospitalization, her menstruation are regular without feeling of dysmenorrhea. Prior to hospitalization, if their a problem they talk about it with her family and also she ask for an advise to her sister and relatives. She also does household chores to divert herself from thinking about her problem.

During hospitalization, her husband assures her responsibility and attends all of her needs in the hospital. During hospitalization, her menstruation is normal without feeling of dysmenorrehea. During hospitalization, she cant able to help in their problem, the only thing she can do is to pray to overcome their problem.

M. Coping Stress Tolerance

N. Values and Beliefs

They do not attend masses every Sunday and day seldom go to church, they still believe that God has purpose for everything thats happening.

They became more prayerful and diligent in praying to God.

GROWTH AND DEVELOPMENT Psychosocial development Based on Erik Ericksons stages of psychosocial development, our client Ms. VG fall under Generativity vs. Stagnation. This occurs in the Middle age. Generativity is concern for establishing and guiding the next generation. It is the ability to look beyond oneself and to be concentrated to others. In that matter, our client is very much concern for her children in molding them to be a good person. She is concerned on the situation of her children if anything goes wrong with her. Spiritual development In spiritual development, older adult can consider new religion and philosophical views. In our client, she is very God Fearing. She always pray rosary for her complete recovery. She always seeks Gods help whenever she has problems in life.

III ANATOMY AND PHYSIOLOGY Human Digestive System The human digestive system is a complex series of organs and glands that processes food. In order to use the food we eat, our body has to break the food down into smaller molecules that it can process; it also has to excrete waste. Most of the digestive organs (like the stomach and intestines) are tube-like and contain the food as it makes its way through the body. The digestive system is essentially a long, twisting tube that runs from the mouth to the anus, plus a few other organs (like the liver and pancreas) that produce or store digestive chemicals. The Digestive Process: The start of the process - the mouth: The digestive process begins in the mouth. Food is partly broken down by the process of chewing and by the chemical action of salivary enzymes (these enzymes are produced by the salivary glands and break down starches into smaller molecules).

On the way to the stomach: the esophagus: After being chewed and swallowed, the food enters the esophagus. The esophagus is a long tube that runs from the mouth to the stomach. It uses rhythmic, wave-like muscle movements (called peristalsis) to force food from the throat into the stomach. This muscle movement gives us the ability to eat or drink even when we're upside-down. In the stomach: The stomach is a large, sack-like organ that churns the food and bathes it in a very strong acid (gastric acid). Food in the stomach that is partly digested and mixed with stomach acids is called chyme. In the small intestine: After being in the stomach, food enters the duodenum, the first part of the small intestine. It then enters the jejunum and then the ileum (the final part of the small intestine). In the small intestine, bile (produced in the liver and stored in the gall bladder), pancreatic enzymes, and other digestive enzymes produced by the inner wall of the small intestine help in the breakdown of food In the large intestine: After passing through the small intestine, food passes into the large intestine. In the large intestine, some of the water and electrolytes (chemicals like sodium) are removed from the food. Many microbes (bacteria like Bacteroides, Lactobacillus acidophilus, Escherichia coli, and Klebsiella) in the large intestine

help in the digestion process. The first part of the large intestine is called the cecum (the appendix is connected to the cecum). Food then travels upward in the ascending colon. The food travels across the abdomen in the transverse colon, goes back down the other side of the body in the descending colon, and then through the sigmoid colon. The end of the process: Solid waste is then stored in the rectum until it is excreted via the anus. Two main groups: 1. Alimentary canal performs the whole menu of the digestive function (ingest, digest, absorbs, and defecate). Also called the gastrointestinal tract. A continuous, coiled, hollow, muscular tube that winds through the ventral body cavity and is open at the both ends. 2. Accessory organ assist the process of digestive breakdown in various ways, Organs of the Alimentary Canal 1. Mouth 2. Pharynx 3. Esophagus 4. Stomach 5. Small Intestine 6. Large Intestine Mouth - Where foods enters the Digestive Tract. a. b. c. d. e. f. g. h. i. Mouth or oral cavity a mucous membrane lined cavity. Lips protect its anterior opening Cheeks forms its lateral wall Hard Palate forms its anterior roof. Soft Palate forms its posterior roof. Uvula is a fleshy fingerlike protection of the soft palate Tongue occupies the floors of the mouth. Palatine Tonsil paired masses of lymphatic tissue at the posterior of oral cavity. Lingual Tonsil covers the base of the tongue just beyond.

Pharynx - Passage for food fluid and air. Subdivided: a. Nasopharynx respiratory passage b. Orapharynnx posterior to the oral cavity. c. Laryngopharynx which continuous with the esophagus. Esophagus - Also called gullet. - Runs from the pharynx through the diaphragm to the stomach. - About 25 cm (10 inches) long. Four basic tissue layers: 1. Mucosa the innermost layer. It is a moist membrane that lines the cavity or lumen of the organ. 2. Submucosa found just beneath the mucosa. It is a soft connective tissue layer containing blood vessel, nerve endings, lymph nodes, and lymphatic vessels. 3. Muscularis externa is a muscle layer typically made up of an inner circular layer and an outer longitudinal layer of smooth muscle cells. 4. Serosa the outermost layer of the wall. Stomach - C Shaped stomach is on the left side of the abdominal cavity. Different Regions of the stomach: a. Cardiac region named for its position near the heart. Cardioesophageal sphincter food enters the stomach from the esophagus. b. c. d. e. Fundus the expanded part of the stomach lateral to the cardiac region. Body the midportion Pyloric antrum narrow inferior of the body Pylorus a funnel shape. The terminal part of the stomach.

Pyloric sphincter food enters from the pylorus to the small intestine. Small Intestine - The bodys major digestive organ. - A muscular tube extending from the pyloric sphincter to the ileocecal valve. - Longest section of the alimentary tube, with an average length of 2.5cm to 7m (8 18 feet). Three subdivisions: 1. Duodenum a twelve finger widths; largely responsible for the breakdown of food in the small intestine, using enzymes. 2. Jejunum 4-7 feet in length, the jejunum is where chemical breakdown of the food chyme is completed. 3. Ileum 7-5 feet in length, the ileum is the final section of the small intestine, linked to the large intestine by the ileocecal valve. The main function of the ileum is to absorb nutrients. Bile is also absorbed here and returns to the liver through blood vessels in the intestinal walls. Large Intestine - Is much larger in diameter than the small intestine. - About 1.5m (5 feet) long, it extends from the ileocecal valve to the anus. - Its major function is to dry out the ingestible food residue by absorbing water and to eliminate this residue from the body as feces. Subdivision: 1. Cecum first part of the large intestine. The cecum receives chyme from the small bowel (ileum) which opens into it. 2. Appendix a wormlike hanging from the cecum which potential troubles spot. 3. Colon it extracts water and salt from solid wastes before they are eliminated from the body, and is the site in which flora-aided (largely bacteria) fermentation of unabsorbed material occurs. Several Regions: a. Ascending Colon travels up the right side of the abdominal cavity. b. Transverse Colon The right colic (hepatic) flexure, to travel across the abdominal cavity. c. Descending Colon It turns again at the left colic (splenic) flexure, and continues down to the left side. d. Sigmoid the S shaped that enter the pelvis. 4. Rectum acts as a temporary storage site for feces.

5. Anal Canal It is situated between the rectum and anus, below the level of the pelvic diaphragm. It is approximately 2.5 to 4 cm long, extending from the anorectal junction to the anus. Sphincter: a. External voluntary sphincter also called as external anal sphincter, composed of skeletal muscle. b. Internal involuntary sphincter composed of smooth muscle. Accessory Digestive Organ a. Salivary Glands Three pairs of salivary glands: 1. Parotid Glands Lie anterior to the teeth. 2. Submandibular Glands 3. Sublingual Glands

b. Teeth help for mechanical digestion through mastication. c. Classification of teeth: 1. Incisor chisel shaped used for cutting. 2. Canines fanglike used for tearing and or piercing. 3. Premolars bicuspid broad crowns best for griding. 4. Molars broad crowns with rounded cups are best suited for grinding. d. Pancreas a soft, pink, triangular gland that extends across the abdomen from the spleen to the duodenum. Its secreted pancreatic enzyme in an alkaline fluid, which neutralizes the acidic chyme coming in from the stomach. The pancreas also has an endocrine function; it produces the hormones insulin and glucagons. e. Liver The largest gland in the body. It is located under the diaphragm. Its produces bile f. Gallbladder is a small, thin walled green sac that snuggles in a shallow fossa in the inferior surface of the liver. Storage of bile.

Function of the Digestive System: The major functions of the digestive tract are usually summarized in two words digestion and absorption. 1. Ingestion Food must be placed into the mouth before it can be acted on. 2. Propulsion Food are to be processed by more that one digestive organ and indeed they must be propelled from one organ to the next. Peristalsis is involuntary and involves alternating waves of contraction and relaxation of the muscle in the organ wall. Segmentation the foods move back and forth across the internal wall of the organ. 3. Food breakdown: Mechanical digestion Prepares food for further degradation by enzymes by physically fragmenting the foods into smaller particles. 4. Food breakdown: Chemical digestion The sequence of step in which large food molecules are broken down to their building blocks by enzymes. 5. Absorption Transport of digested end products from the lumen of the GI tract to the blood or lymph. 6. Defecation The elimination of indigestible residue from the GI tract via the anus in the form of feces. Focused Organ: Gallbladder, Cystic Duct and Bile Duct Gallbladder- is a saclike structure on the inferior surface of the liver that is about 8cm long and 4cm wide. 3 Tunics Form the Gallbladder wall: 1. An inner mucosa folded into rugae that allow the gallbladder to expand. 2. A muscularis, which is a layer of smooth muscle that allows the gallbladder to contract 3. An outer covering of serosa. Cystic Duct- connects the gallbladder to the common bile duct. Bile- is a continually secreted by the liver and flows to the gall bladder, where 40-70 mL of bile can stored.

Function: 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 the common bile duct 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).

in

Conditions and Diseases of the gallbladder: Sometimes the substances contained in bile crystallize in the gallbladder, forming gallstones. They can cause inflammation of the gallbladder, a disorder that produces symptoms similar to those of indigestion, especially after a fatty meal is consumed. If a stone becomes lodged in the bile duct, it produces severe pain. Gallstones may pass out of the body spontaneously; however, serious blockage is treated by removing the gallbladder surgically. Removal of the Gallbladder In some cases, the gallbladder must be removed. The surgery to remove the gallbladder is called a cholecystectomy. In a cholecystectomy, the gallbladder is removed through a 5- to 8-inch long cut in your abdomen. Once the gallbladder is removed, bile is delivered directly from the liver ducts to the upper part of the intestine.

IV THE PATIENT AND HIS ILLNESS Definition of the disease Cholecystolithiasis refers to the presence of one or more calculi (gallstones) in the gallbladder. Gallstones are hard, pebble-like deposits that form inside the gallbladder. Gallstones may be as small as a grain of sand or as large as a golf ball. Predisposing and Precipitating Factors Prediposing Factors: Gender ( Female) Age (39 yrs.old) Lifestyle (sedentary; without exercise)

Precipitating Factor: Diet (increased intake of foods high in cholesterol)

Physical Assessment AREAS TO BE ASSESSED Vital Signs 1. Body Temperature 2. Pulse Rate Inspection, Palpation 3. Respiratory Rate Inspection A. General Survey 20(15-25) cycles/min 27 cycles/min 100(75-120) beats/min 121 beats/min METHOD Inspection NORMAL FINDINGS 37 C ACTUAL FINDINGS 37.9 C ANALYSIS Deviation from normal due to infection Deviation from normal due to bodys compensation from infection Deviation from normal due to bodys compensation from infection

1. 2.

Body built, height and weight

Inspection Inspection Inspection Inspection Inspection Inspection Inspection Inspection Inspection

Proportionate Relaxed, erect posture, coordinated movement Clean, neat No body odor, no breath odor No distress Healthy appearance Cooperative Appropriate to situation Understandable, moderate pace Generally uniform in color except for areas most expose to sun, No edema, No lesions, Moisture on skin folds and when pinched should spring back to previous state Nail curvature is convex; pink nail bed; blood brings back after performing a blanch test of less than 3 seconds Normocephalic; symmetric; no nodules and depressions

Proportionate Relaxed, erect posture, needs assistance when standing in bed Neat appearance No unusual body odor Facial grimace and weakness observed Appears healthy cooperative Responses are appropriate to situation Speech is understandable and in moderate pace Pale but uniform in color; without lesions; uniform temperature, moist on axillae ; skin springs back to previous state Nail bed is pale in color; capillary refill of 4 seconds Small, rounded with smooth skull contour; no nodules, masses, and

Normal Normal Normal Normal Deviation from normal due to pain Normal Normal Normal Normal

Posture and gait, standing, sitting and walking 3. Overall hygiene and grooming 4. Body and breathe odor 5. Signs of distress, in posture or facial expression 6. Obvious signs of health or sickness 7. Attitude 8. Affect/mood, appropriateness of responses 9. Quantity and quality of speech B. Integumentary 1. Skin

Inspection, Palpation

Deviation from normal due to blood loss after surgery

2. Nails Inspection, Palpation 3. Skull Inspection, Palpation

Deviation from normal due to blood loss from surgery Normal

depressions noted 4. Hair and Scalp Inspection, Palpation 5. Face C. Eyes 1. Eyebrows Inspection 2. Eyelashes 3. Bulbar and Palpebral Conjunctiva 4. Sclera 5. Cornea 6. Iris 7. Pupil Inspection 8. Lacrimal Gland 9. Extraocular Muscles 10. Visual Fields Inspection/ Palpation Inspection Inspection Inspection, Palpation Inspection Inspection Inspection Inspection Thick and resilient hair, evenly distributed ; Scalp must have no redness, rashes, lice, nits, ringworm, or dandruff Facial movements are symmetric Hair evenly distributed; skin intact; symmetrically aligned; equal movements Evenly distributed; downward or outward curl Bulbar: transparent: capillaries sometimes present Palpebral: shiny and smooth White Transparent Round; dark in color and flat Black in color, equal in size and round; reactive to light and accommodation No edema or tearing Coordinated movement The client can see the object in periphery Hair evenly distributed to the scalp; thin hair; no tenderness or masses; Facial movements are symmetric Hair evenly distributed and properly aligned: thick hair; intact skin; symmetric movements Evenly distributed; downward curl Bulbar: transparent: capillaries are present Palpebral: shiny and smooth and pale in color White Transparent Round; dark in color and flat Reactive to light and accommodation; black in color, round and smooth No nodules, masses, and lesions; no tenderness Coordinated movement and in good alignment The client can see the object in periphery Normal Normal

Normal Normal Deviation from normal due to blood loss after surgery Normal Normal Normal Normal Normal Normal Normal

D. Ears 1. Auricle Inspection / Palpation 2. External Ear Canal 3. Hearing Acuity E. Nose 1. Nasal Septum Inspection 2. Patency of Airways 3. Sinuses F. Mouth 1. Lips 2. Buccal Mucosa 3. Teeth 4. Gums 5. Tongue 6. Palate and Uvula 7. Oropharynx and Tonsils Palpation Palpation Inspection Inspection Inspection Inspection / Palpation Inspection/ palpation Inspection Inspection Inspection Inspection

Color same as the facial skin; symmetrical; aligned with the outer canthus of the eyes No discharges Normal voice tone audible Symmetric and straight; no discharge or flaring; uniform color Air moves freely in and out of the nasal cavities Not tender Pink,unmoist. soft, unsmooth Uniform pink color Smooth, shiny, white teeth enamel Pink gums, smooth and firm texture Central position, pink color, moves freely Uvula vibrates when speaking; midline position Pink, smooth, no discharges

Uniform in color same with the facial skin; aligned with outer canthus of the eyes With presence of earwax Respond normally to normal voice tone No discharge or flaring Air moves freely in and out of the nasal cavities No note of tenderness Pink,unmoist. soft, unsmooth Pinkish in color Has intact dentures Pink gums, smooth and firm texture Pink in color ; Has raised papillae Uvula vibrates when speaking; midline position Has no discharges from tonsils; presence of gag reflex; tonsils not

Normal Normal Normal

Normal Normal Normal Normal Normal Normal Normal Normal Normal Normal

swollen and tender G. Neck and Lymph Nodes 1. Lymph Nodes Inspection/ palpation 2. Trachea 3. Thyroid Gland H. Thorax 1. Posterior Thorax Inspection/ palpation / Auscultation Inspection/ palpation Inspection/ palpation No tenderness and masses Midline of the neck Lobes are not palpable Has no swollen lymph nodes and tenderness; no nodules and masses Located midline in neck No visible masses or enlargement

Normal Normal Normal

Symmetric; ratio of 1:2 to the anteroposterior part; spine laterally aligned; no tenderness; equal respiratory excursion; bilateral vocal fremitus no abnormal breath sounds Quiet, rhythmic and effortless breathing; Symmetric; no tenderness; with equal respiratory excursion; bilateral vocal fremitus no abnormal breath sounds No pulsations and abnormal sounds No pulsations and abnormal sounds No pulsations and abnormal sounds

Symmetric; ratio of 1:2 to the anteroposterior part; no tenderness; equal respiratory excursion

Normal

2. Anterior Thorax Inspection/ palpation / Auscultation I. Cardiovascular 1. Aortic area 2. Pulmonic area 3. Tricuspid area

Symmetric, effortless breathing; bilateral vocal fremitus no abnormal breath sounds

Normal

Inspection / Palpation Inspection / Palpation Inspection / Palpation

No pulsations and abnormal sounds No pulsations and abnormal sounds No pulsations and abnormal sounds

Normal Normal Normal

4. Apical area 5. Epigastric area 6. Carotid arteries 7. Jugular veins J. Abdomen

Inspection / Palpation Palpation / Palpation Inspection / Palpation Inspection

Pulsations present; normal interval of pulsations Aortic pulsations present Presence of pulsation; no abnormal sounds No distention Uniform color; symmetric contour; no lesions, no deformities, audible bowel sounds; no tenderness; Equal strength on each body side Normally firm No lesions; no deformities; no tenderness;

Inspection

Pulsations present; normal interval of pulsations Aortic pulsations present Presence of pulsation; no abnormal sounds no distention Uniform color; symmetric contour; no lesions, no deformities, audible bowel sounds; impaired skin integrity; pain scale of 6/10 Equal strength on each body side Firm muscle tone Has no lesions on both arms; no deformities; no tenderness.

Normal Normal Normal Normal Deviation from normal due to the operation and presence of drain systems

UPPER EXTEMETIES 1. Motor strength 2. Muscle Tone 3.Presence of lesions, deformities and varicosities LOWER EXTREMITIES 1. Motor strength 2. Muscle Tone 3. Presence of lesions, deformities and varicosities

Inspection Palpation Inspection

Normal Normal Normal

Inspection Palpation Inspection

Equal strength on each body side Normally firm No lesions; no deformities; no tenderness; no edema

Equal strength on each body side Firm muscle tone No lesions; no deformities; no tenderness; no edema

Normal Normal Normal

SIGNS AND SYMPTOMS DATE OF OCCURANCE September 15, 2009 September 16, 2009 SIGNS AND SYMPTOMS 1.Nausea and Vomiting 2.Jaundice RATIONALE Less or absence of bile acid in the duodenum means less or no digestion of fats May occurs if a gallstone become stock in the common bile duct, which leads into the intestine blocking the flow of bile from the gallbladder and the liver, it results from an abnormally high accumulation of bilirubin in the blood as a result of which there is a yellow discoloration to the skin and deep tissues, jaundice becomes evident when the serum bilirubin level rises above 2.0 to 2.5 mg/dl. Because of the loss of blood after undergoing an operation Due to the trauma to the skin during the operation and presence of drain systems on the right upper quadrant of the abdomen REFERENCE Medical-Surgical Nursing by Priscilla Lemone 5th Edition Medical-Surgical Nursing by Priscilla Lemone 5th Edition

January 8, 2010 January 15, 2010

3.Pallor 4.Pain

Medical-Surgical Nursing by Priscilla Lemone 5th Edition Medical-Surgical Nursing by Priscilla Lemone 5th Edition

REVIEW OF SYSTEMS DIGESTIVE SYSTEM Nausea and vomiting that happened due to less or absence of bile acid in the duodenum. INTEGUMENTARY SYSTEM Patient manifested jaundice due to an abnormally high accumulation of bilirubin in the blood (serum bilirubin level rises above 2.0 to 2.5 mg/dl.) Pallor was also manifested due to blood loss after she undergone an operation as the value of hemoglobin and hematocrit decreases. CIRCULATORY SYSTEM Decrease blood volume due to blood loss after she undergone an operation. LYMPHATIC SYSTEM As infections arise in our body our lymphatic system starts to secrete white blood cells to fight the infection in our body which can cause a sudden change in our body temperature. NEUROLOGIC SYSTEM The patient experiences pain, few days after undergoing an operation.

LAB FINDINGS Diagnostic Laboratory Procedure Hematology or Complete Blood Count Date Ordered and Date Result in Date 1st Result in: 01-0610 Date 2nd Result in: 01-0910 Date 3rd Result in: 01-1310

Indications or Purpose As a preoperative test to ensure both adequate oxygen carrying capacity and hemostasis Anemia detection. Infection diagnosis.

Result (1st, 2nd, 3rd) 1st Hemoglobin: 129 Hematocrit: 0.39 WBC: 10.5 Neutrophils: 0.68 Lymphocytes: 0.30 Monocytes: 0.02 2nd Hemoglobin: 103 Hematocrit: 0.31 Neutrophils: 0.82 Lymphocytes: 0.18 Platelet Count: 276 3rd Hemoglobin: 60 /L Hematocrit: 1.8 WBC: 15.0 Neutrophils: 0.63

Normal Values (unit used in the Hospital) M:125-175 g/L;F:115-155 g/l M:0.40-0.52;F:0.38-0.48 5-10 x 1 / L 0.45-0.65 0.20-0.35 0.25-0.4 M:125-175 g/L;F:115-155 g/l M:0.40-0.52;F:0.38-0.48 0.45-0.65 0.20-0.35 150-450 M:125-175 g/L;F:115-155 g/l M:0.40-0.52;F:0.38-0.48 5-10 x 1 / L 0.45-0.65

Analysis and interpretation of the results The results indicate increased and decreased in blood components such as hemoglobin, hematocrit, neutrophils, monocytes, lymphocytes, and mean corpuscular hemoglobin concentration, which is due to limited amount of hemoglobin that will fit inside a red blood cell during the first, second and third test of complete blood count. The rest is normal. The peripheral smear indicated a normal in size but has pale cells or hypochromic and

Lymphocytes: 0.33 MCH: 32.3 MCV: 86.5 MCHC: 37.3 Reticulocyte Count: 3.0% Peripheral Smear: normocytic; hypochromic; adequate platelet count Nursing Responsibilities Prior to procedure: Verify the doctors order. Prepare the client

0.20-0.35 27-33 pg 82-92 fl 31-36 g/dl 1-5% Normal size, shape, color, normal quantity, normal count

adequate platelet count.

During the procedure: Place an elastic band Draw the blood from the vein

After the procedure: Apply pressure to the puncture site until bleeding stops. Encourage the patient to rest. Secure the specimen and bring immediately to the laboratory for testing.

Diagnostic Laboratory Procedure Prothrombine Time

Date Ordered and Date Result in Date Result in: 01-17-10

Indications or Purpose Check for a low level of vitamin K. Check how well the liver is working.

Result (1st, 2nd, 3rd) Patient: 12.8 sec Control: 13.3 sec Activity: 83.7% INR: 1.07

Normal Values (unit used in the Hospital) 12-15 sec 70-100% 1.01.4

Analysis and interpretation of the results Normal Normal Normal

Diagnostic Laboratory Procedure Partial Thromboplastin Time

Date Ordered and Date Result in Date Result in: 01-17-10

Indications or Purpose Check for low levels of blood clotting factors.

Result (1st, 2nd, 3rd) 28.8

Normal Values (unit used in the Hospital) 25-35 sec

Analysis and interpretation of the results Normal

Nursing Responsibilities Prior to procedure: Verify the doctors order. Be sure to tell the doctor about all the nonprescription and prescription medicines the patient taking.

During the procedure: Wrap an elastic band around the upper arm Clean the needle site with alcohol Withdraw the blood from the vein

After the procedure: Put pressure to the site then place a bandage. Secure the specimen and bring immediately to the laboratory for testing. Watch for signs of bleeding.

Diagnostic Laboratory Procedure Hepatobiliary Sonography

Date Ordered and Date Result in Date Result in: 01-07-10

Indications or Purpose Allows visualization of the gallbladder and ducts in patient with

Result (1st, 2nd, 3rd) Right Hepatic Lobe: 14.2 cm Left Hepatic Lobe:

Normal Values (unit used in the Hospital)

Analysis and interpretation of the results The liver is normal in size and tissue echo pattern. No focal lesion seen in

impaired liver function.

10.0

the liver, hepatic margins are regular and smooth. Biliary ducts both intrahepatic and extrahepatic are normal in caliber CBD measures 4mm in diameter. Gallbladder is small in size and difficult to demonstrate shadowing echos are observed in the gallbladder lumen.

V. THE PATIENT AND HIS CARE 1. Medical Management a. IVF MEDICAL MANAGEMENT/ TREATMENT Dextrose 5% Lactated Ringers Solution (D5LRS) D5LRS 1000cc at 30 - 31 gtts/min DATE ORDERED DATE PERFORMED DATE CHANGED DO: 01-06-10 DC: 01-06-10 GENERAL DESCRIPTION This medication is a solution given by vein (through an IV). The solutions are parenteral fluid and nutrient replenishers. INDICATION(S)/ PURPOSE(S) Intravenous solutions containing dextrose are indicated for parenteral replenishment of fluid and CLIENTS RESPONSE TO THE TREATMENT The patient responded well on his treatment by not showing any signs of dehydration while maintaining a better urine

It is used to supply water, electrolyte and calories to the body. It is also used as a mixing solution (diluent) for other IV medications. Dextrose is a natural sugar found in the body and serves as a major energy source. When used as an energy source, dextrose allows the body to preserve its muscle mass.

minimal carbohydrate calories output. as required by the clinical condition of the patient. It is capable of inducing diuresis depending on the clinical condition of the patient. This solution also contains lactate which produces a metabolic alkalinizing effect. It is also use as a mixing solution for other IV medication.

Nursing Responsibilities Prior: Verify with the doctors order. Explain the indication to the significant others. During: Label the IVF bottle and tubing indicating the date and time it was started with the ordered regulation. Maintain and regulate at the rate prescribed. Handle IVF site aseptically. Change solution and IVF tubing as per hospital policy.

After: Check the site for any signs/symptoms of infection.

MEDICAL MANAGEMENT/ TREATMENT Plain Normal Saline Solution (PNSS) 1000 cc at 10 gtts/min DATE ORDERED DATE PERFORMED DATE CHANGED DO: 01-13-10 DC: 01-14-10 GENERAL DESCRIPTION Isotonic solution has the same tonicity as that of body fluids. When this type of fluid is injected, fluids travel equally in both directions. INDICATION(S)/ PURPOSE(S) It is used as a solvent for drugs that are to be administered parenterally, to replace body fluids in dehydration, to go with blood transfusions, hyponatremia, and burn victims. CLIENTS RESPONSE TO THE TREATMENT The patient response well on his treatment by showing the sign of improving circulation and hydration.

Nursing Responsibilities Prior: Verify with the doctors order. Explain the indication to the significant others.

During:

 Label the IVF bottle and tubing indicating the date and time it was started with the ordered regulation. Maintain and regulate at the rate prescribed. Handle IVF site aseptically. Change solution and IVF tubing as per hospital policy. After: Check the clients vital signs. Check the site for any signs/symptoms of infection.

b. Blood Transfusion

DATE ORDERED/ DATE PERFORMED/ MEDICAL MANAGEMENT DATE CHANGED Unit no.1 Packed RBC 4 units Date ordered: January 13, 2010 Date performed: January 13-14 ,2010 Time started:

GENERAL DESCRIPTION Packed Red Blood Cells (PRBCs), also called packed cells primarily consist of RBCs, a small amount of plasma and approximately 100ml anticoagulant / preservative solution in a total

INDICATIONS/PURPOSES Used to increase the amount of hemoglobin, thus increasing the oxygen-carrying capacity of the blood. The physician ordered blood transfusion of packed RBC to our client due to the decreased Hemoglobin

CLIENTS RESPONSE TO THE TREATMENT Hemoglobin and Hematocrit levels rises and lies within normal normal limits, with the value of Hemoglobin= 135g/l and Hematocrit = 0.39g/l. Comparing to the previous results of haematology done

9:15 pm Time consumed: 2:00 am Unit no.2 Date ordered: January 14,2010 Date performed: January 14,2010 Time started: 2:00 am Time consumed: 7:00 am Unit no.3 Date ordered: January 14,2010 Date performed: January 14,2010 Time started: 9:00 am Time consumed: 1:00pm Unit no.4 Date ordered: January 14,2010 Date performed:

volume of approximately 250 to 300 ml/unit. This type of blood product is obtained by separating the cells from CPD anticoagulated whole blood. Cells are suspended in a solution of OPTISOL, a red cell preservative.

and Hematocrit which might be an indicator of surgical anemia or anemia due to blood loss during surgery. .

last January 13, 2010 wherein the hematocrit and haemoglobin levels are low The patient adhered well on her treatment. There are no significant or unusual reactions that are observed at her through out the procedure.

January 14, 2010 Time started: 6:30 pm Time consumed: 10:30 pm Nursing Responsibilities Prior: Verify with the doctors order. Verify that the client has signed a blood administration consent form Obtain a client history; know whether the client has allergies from previous transfusion. Check for the clients vital signs for baseline data Check also for any unusual signs and symptoms Assess for the status of the infusion site. The combining IVF should be PNSS/Normal saline solution, if the existing IVF is not a PNSS changed it with PNSS according to he agencys The needle must be at the appropriate gauge Explain the procedure to the client and its purpose. Instruct to report promptly any sudden chills, nausea, vomiting, dyspnea, itching and back pain As a nurse, we must be aware of the different transfusion reaction Check the requisition form and the blood bag label Observe the blood for any puncture, abnormal color, RBC clumping, gas bubbles and extraneous materials. Check for the expiration date Ask another nurse or any license health care team to check and compare the laboratory blood records. Then, sign an appropriate form Make sure that the blood is left at room temperature no more than 30 min. before starting the transfusion Swirl to mix the blood

During:

Prime the tubing of the blood before connecting to the y-tube of the IV line Regulate the blood drop rate at KVO for the first 15 mins. Observe the client closely for the first 15 mins. Note for any adverse reaction of the procedure Monitor the vital signs q15 mins for the first hour. Then, q1hr for the succeeding monitoring Regulate the drop rate according to the doctors order after 15mins monitoring if theres no reaction Do not transfuse blood longer than 4hrs

After: If no infusion is to follow, clamp the blood tubing and remove needle. If another transfusion is to follow, clamp the blood tubing and open saline infusion Discard the administration set and blood bags should be bagged and labeled before being sent for decontamination and processing Perform after care Document relevant data Still monitor clients vital signs Assist client in comfortable position c. Diet Type of Diet Date ordered, Date started , Date Changed General description Indication/Purposes Specific Foods taken Client response to diet

Nothing per orem (NPO)

January 6, 2009

Restriction to take food via mouth or oral route.

Nothing Per Orem is a type of diet modification as well as fluid restriction. This intervention is prescribed prior to surgery to rest the gastrointestinal tract. If client remains in NPO for longer than 3 to 4 days, he may be at nutritional risk if previously malnourished or acutely stressed Soft Diet Promotes the mechanical digestion of foods. Prescribed in pt with difficulty in chewing or swallowing.

None

The patient feels hungry and thirsty.

Soft Diet

January 13, 2010,

The patient is allowed to take soft foods as tolerated.

Lugaw

The patient feels relief.

DAT

January 14, 2010

The Patient is allowed to eat anything she wants.

Nursing Responsibilities Prior: Check for the doctors order Assess clients need Before prepare the appropriate diet for the patient be sure that proper hand washing is maintained

During: Give feedings with strict aspiration precaution After: Advice to eat slowly Monitor if the feeding is well-tolerated Note and document any untoward reaction. Advice to avoid salty and fatty foods

d. Drugs Name of Drug Generic and Brand Name Date Ordered Date Taken or given Route of Administration Dosage and General Action, Classification, Mechanism of Action Indications/ Purposes Clients Response to medication with actual side effects

Cefuroxime Axetil (Ceftin)

Date Changed DO: 01-06-10 DT/DG: 01-06-10

Frequency 750mg/ IV q 8 hours

Antibiotic (Cephalosporin, second generatrion) Bactericidal Inhibits synthesis of bacterial cell wall, causing cell death.

Antibiotics are used for treatment or prevention of bacterial infection. Other antibiotics may be useful in treating protozoal infections.

o The patient did not manifest any allergic or untoward reaction of the drug. o The patient did not develop any adverse effects. o The drug is sensitive to the microorganism found on his culture, making it effective as a treatment for his condition.

Nursing responsibilities: Prior: Verify the doctors order. Check the expiration date of the drug. Calculate the drug doses accurately. Explain the indication to the significant others. Check the patient if she have allergy on antibiotic. Check the IV solution if it is containing aminoglycosides. Obtain culture for culture and sensitivity if needed. Check the patient for impaired hepatic function and alcoholism. During: Identify the client.

 Administer the drug slowly over 3 5 minutes directly into the vein by IV administration. Record the drug administered. After: Assess the patient for any adverse effects of the drug. Name of Drug Date Ordered Route of General Action, Indications/ Purposes Generic and Date Taken or Administration Classification, Mechanism Brand Name given Dosage and of Action Date Changed Frequency Ranitidine DO: 01-06-10 50mg/ IV q 8 Histamine2 (H2) antagonist It is used to decrease the amount of Hydrochloride hours (Pre - op) acid produced by the stomach. DT/DG: 01-06-10 Competitively inhibits (once on NPO the action of histamine and in the at the H2 receptor of the morning prior to parietal cells of the OR) stomach, inhibiting basal gastric acid secretion and gastric acid secretion that is stimulated by food, insulin, histamine, cholinergic agonists, gastrin, and pentagastrin. Nursing responsibilities: Prior: Verify the doctors order. Check the expiration date of the drug. Clients Response to medication with actual side effects o The patient did not manifest any allergic or untoward reaction of the drug. o Did not develop any adverse effects.

 Calculate the drug doses accurately. Explain the indication to the significant others. Check the patient if she have allergy to ranitidine. Check the patient for impaired hepatic or renal function. During: Identify the client. Administer the drug slowly over 3 5 minutes directly into the vein by IV administration. Record the drug administered. After: Assess the patient for any adverse effects of the drug.

Name of Drug Generic and Brand Name Promethazine

Date Ordered Date Taken or given Date Changed DO: 01-06-10

Route of General Action, Administration Classification, Dosage and Mechanism of Action Frequency IM/ 50mg, on Antiemetic;

Indications/ Purposes

Clients Response to medication with actual side effects o The patient did not

As sedative used to induces sedation by

hydrochloride DT/DG: 01-06-10

call to OR.

Antihistamine; Anti reducing irritability or excitement. motion sickness drug; Dopaminergic blocker; Used for preoperative sedation and to Phenothiazine; Sedative counteract postnarcotic nausea. hypnotic. As antiallergic medication to combat hay Selectively blocks H1 fever, allergic rhinitis. To treat allergic reactions it can be given alone or in receptors, combination diminishing the with oral decongestants like pseudoephedrine. effects of histamine on cells of the upper respiratory tract and eyes and decreasing the sneezing, mucus production, itching, and tearing that accompany allergic reactions in sensitized people exposed to antigens. Blocks cholinergic receptors in the vomiting center that are believed to mediate the nausea and vomiting caused by gastric irritation, by input from the vestibular apparatus (motion sickness, nausea associated

manifest any allergic or untoward reaction of the drug. o Did not develop any adverse effects.

with vestibular neuritis), and by input from the chemoreceptor trigger zone (drug and radiation induced emesis). Depress the RAS, including the parts of the brain involved with wakefulness.

Nursing responsibilities: Prior: Verify the doctors order. Check the expiration date of the drug. Calculate the drug doses accurately. Explain the indication to the significant others. Check the client vital signs. Check the patient if she have hypersensitivity to antihistamine or phenothiazine.

During: Identify the client. Administer the drug slowly and deep IM.

 Record the drug administered. After: Assess the patient for any adverse effects of the drug. Name of Drug Generic and Brand Name Atropine Sulfate Date Ordered Date Taken or given Date Changed DO: 01-06-10 DT/DG: 01-06-10 Route of General Action, Indications/ Purposes Administration Classification, Mechanism Dosage and of Action Frequency IM/ 0.5 mg, on Anticholinergic; Antidote; It may be prescribed in the call to OR antimuscarinic; treatment of GI hypermotility. Antiparkinsonian; Parasympathologic. Used to decrease the tone of the detrusor muscle of the urinary bladder in urinary tract disorders. Competitively blocks the effects of Used as an adjunct to anesthesia. acetylcholine at muscarinic cholinergic receptors that mediate the effects of parasympathetic postganglionic impulses, depressing salivary and bronchial secretions, dilating the bronchi, inhibiting vagal influences on the heart, relax the GI and GU tracts, inhibiting gastric acid secretion, relaxing the pupil of the Clients Response to medication with actual side effects o The patient did not manifest any allergic or untoward reaction of the drug. o Did not develop any adverse effects.

eye. Also blocks the effects of the acetylcholine in the CNS.

Nursing responsibilities: Prior: Verify the doctors order. Check the expiration date of the drug. Calculate the drug doses accurately. Explain the indication to the significant others. Check the patient if she have hypersensitivity to anticholinergic drugs. Check the patient for impaired hepatic function. During: Identify the client. Administer the drug slowly. Record the drug administered. After: Assess the patient for any adverse effects of the drug. Name of Drug Date Ordered Route of General Action, Indications/ Purposes Clients Response to

Generic and Brand Name Famotidine

Date Taken or given Date Changed DO: 01-07-10 DT/DG: 01-07-10

Administration Classification, Mechanism Dosage and of Action Frequency 20mg/ IV q 12 Histamine2 (H2) receptor It is used to decrease the amount of hours antagonist. acid produced by the stomach. Competitively blocks the action of histamine at the H2 receptors of the parietal cells of the stomach. It inhibits basal gastric acid secretion and chemically induced gastric acid secretion.

medication with actual side effects o The patient did not manifest any allergic or untoward reaction of the drug. o Did not develop any adverse effects.

Nursing responsibilities: Prior: Verify the doctors order. Check the expiration date of the drug. Calculate the drug doses accurately. Explain the indication to the significant others. Check the patient if she have allergy to famotidine. Check the patient for impaired hepatic or renal function. During:

 Identify the client. Administer the drug slowly over 3 5 minutes directly into the vein by IV administration. Record the drug administered. After: Assess the patient for any adverse effects of the drug. Name of Drug Generic and Brand Name Vitamin K Date Ordered Date Taken or given Date Changed DO: 01-07-10 DT/DG: 01-07-10 Route of Administration Dosage and Frequency 1 ampule/ IV q 6 hours General Action, Classification, Mechanism of Action Indications/ Purposes Clients Response to medication with actual side effects o The patient did not manifest any allergic or untoward reaction of the drug. o Did not develop any adverse effects.

Vitamin K is known as the clotting vitamin, because of an essential role in the production of prothrombin (a clotting factor).

Nursing responsibilities: Prior: Verify the doctors order. Check the expiration date of the drug. Calculate the drug doses accurately. Explain the indication to the significant others. During: Identify the client.

 Administer the drug slowly over 3 5 minutes directly into the vein by IV administration. Record the drug administered. After: Assess the patient for any adverse effects of the drug. Name of Drug Generic and Brand Name Diclofenac Date Ordered Date Taken or given Date Changed DO: 01-07-10 DT/DG: 01-07-10 Route of General Action, Indications/ Purposes Administration Classification, Mechanism Dosage and of Action Frequency 75mg/ IM q 12 Analgesic (nonopiod); They may be used for treatment hours Anti-inflammatory; of post surgical pain and to make Antipyretic; NSAID. anesthetics work more effectively. Inhibits prostaglandin synthesize to cause antipyretic and antiinflammatory. Clients Response to medication with actual side effects o The patient did not manifest any allergic or untoward reaction of the drug. o Did not develop any adverse effects.

Nursing responsibilities: Prior: Verify the doctors order. Check the expiration date of the drug. Calculate the drug doses accurately. Explain the indication to the significant others. Check the patient if she have allergy to NSAIDs.

 Check the patient if she have hepatic problem, GI condition and cardiovascular condition. During: Identify the client. Administer the drug slowly. Record the drug administered. After: Assess the patient for any adverse effects of the drug. Name of Drug Generic and Brand Name Bupivacaine Date Ordered Date Taken or given Date Changed DO: 01-07-10 DT/DG: 01-07-10 Route of General Action, Administration Classification, Mechanism Dosage and of Action Frequency 0.125% 10ml Local Anesthetic via epidural catheter q 6 Bupivacaine blocks hours both the initiation and conduction of nerve impulses reducing the permeability of neuronal membranes to Na ions resulting in inhibition of depolarization with resultant blockade of conduction Indications/ Purposes Clients Response to medication with actual side effects o The patient did not manifest any allergic or untoward reaction of the drug. o Did not develop any adverse effects.

Used for peripheral nerve block, infiltration, sympathetic block, caudal or epidural block, retrobulbar block to reduce pain.

Nursing responsibilities: Prior:

 Verify the doctors order. Check the expiration date of the drug. Calculate the drug doses accurately. Explain the indication to the significant others. Check the patients vital signs. During: Identify the client. Administer the drug properly. Record the drug administered. After: Assess the patient for any adverse effects of the drug.

Name of Drug Generic and

Date Ordered Date Taken or

Route of Administration

General Action, Classification,

Indications/ Purposes

Clients Response to medication with actual side

Brand Name Paracetamol (acetaminophen)

given Date Changed DO: 01-13-10 DT/DG: 01-13-10

Dosage and Mechanism of Action Frequency 300mg/ IV PRN Analgesic (nonopiod); Antipyretic. As antipyretic it reduces fever by acting directly on the hypothalamic heat regulation center to cause vasodilation and sweating, this helps dissipate heat. As analgesic the site and mechanism of action is unclear.

effects It is used to relieve many kinds of o The patient did not manifest minor aches and pains, including the any allergic or untoward aches and pains that often reaction of the drug. accompany colds. o Did not develop any adverse effects. It is suitable for control of pain following minor surgery, or for post-surgical pain after the need for stronger pain relievers has been reduced. It is also used to relieved fever.

Nursing responsibilities: Prior: Verify the doctors order. Check the expiration date of the drug. Calculate the drug doses accurately. Explain the indication to the significant others. Check the patient if he have allergy to acetaminophen. Check the patient for impaired hepatic function and chronic alcoholism. During:

 Identify the client. Administer the drug slowly over 3 5 minutes directly into the vein by IV administration. Record the drug administered. After: Assess the patient for any adverse effects of the drug. Name of Drug Generic and Brand Name Diphenhydramine Date Ordered Date Taken or given Date Changed DO: 01-13-10 DT/DG: 01-13-10 01-14-10 Route of General Action, Administration Classification, Dosage and Mechanism of Action Frequency 50mg/ IV prior to Antihistamine Blood Transfusion Competitively blocks, the effects of histamine at H1 receptor sites, has atropine like, antipruritic, and sedative effects. Indications/ Purposes Clients Response to medication with actual side effects

Diphenhydramine is used to help o The patient did not manifest limit allergic reactions to transfused any allergic or untoward blood products. reaction of the drug. o Did not develop any It can induce sleep. adverse effects.

Nursing responsibilities:

Prior: Verify the doctors order. Check the expiration date of the drug. Calculate the drug doses accurately. Explain the indication to the significant others. Check the patient if she have allergy to antihistamine. Check the patient for impaired hepatic function and alcoholism. During: Identify the client. Administer the drug slowly over 3 5 minutes directly into the vein by IV administration. Record the drug administered. After: Assess the patient for any adverse effects of the drug.

Name of Drug

Date Ordered

Route of

General Action,

Indications/ Purposes

Clients Response to

Generic and Brand Name Multivitamins

Date Taken or given Date Changed DO: 01-15-10

Administration Dosage and Frequency 50mg/cap OD

Classification, Mechanism of Action Multivitamins can be a valuable tool for those with dietary imbalances or different nutritional needs.

medication with actual side effects o The patient did not manifest any allergic or untoward reaction of the drug.

Nursing responsibilities: Prior: Verify the doctors order. Check the expiration date of the drug. Calculate the drug doses accurately. Explain the indication to the significant others. During: Identify the client. Administer the drug properly. Record the drug administered. After: Assess the patient for any adverse effects of the dru

Name of Drug Generic and Brand Name Celecoxib

Date Ordered Date Taken or given Date Changed DO: 01-15-10

Route of Administration Dosage and Frequency 200mg/cap BID

General Action, Classification, Mechanism of Action Analgesic (nonopiod); NSAID; Specific COX 2 enzyme inhibitor. Analgesic and anti inflammatory activities related to inhibition of the COX 2 enzymes, which is activated in inflammation to cause the signs and symptoms associated with inflammation.

Indications/ Purposes

Clients Response to medication with actual side effects

It is used as therapeutic agents in o The patient did not manifest the treatment of pain, inflammation any allergic or untoward and fever without the side effects of reaction of the drug. gastric and renal toxicity and o Did not develop any inhibition of platelet function. adverse effects.

Nursing responsibilities: Prior: Verify the doctors order. Check the expiration date of the drug. Calculate the drug doses accurately. Explain the indication to the significant others. Check the patient if she have allergy to sulfonamides, celecoxid, and NSAIDs.

 Check the patient if she have hepatic problem and cardiovascular condition. During: Identify the client. Administer the drug properly. Record the drug administered. After: Assess the patient for any adverse effects of the drug.

SURGICAL INTERVENTION

The surgical procedure ordered on Ms. VG was to perform a cholecystectomy. Cholecystectomy was performed to the client last January 6, 2010. Cholecystectomy is a very common surgical procedure involving removal of the gallbladder for acute and chronic cholecystitis and also cholelithiasis. The procedure was done through open laparotomy or laparoscopy (small incision made to insert laparoscope and instruments used to manipulate and remove the gallbladder). The laparoscopic method decreases recovery time and risk of complications. After cholecystectomy, the bile ducts eventually dilate to accommodate the volume of bile once held by the gallbladder. A traditional open cholecystectomy is a major abdominal surgery in which the surgeon removes the gallbladder through a 10-18 cm (4-7 inch) incision. The surgeon made an incision in the upper right area of the abdomen. The gallbladder was separated from the surrounding structures, including the liver, bile ducts, and arteries. While the abdomen is open, the surgeon carefully examined the other organs and structures in the area. This was done to make sure that the patient does not have any other problems. The incision was closed with sutures. It was then covered with a bandage. The nursing responsibilities preoperatively are the following: Making sure that Ms. VG knows the reason in performing the cholecystectomy to her, what the procedure involves, and what to expect after the surgery. Patient must have nothing by mouth from midnight the night before surgery, and must void before surgery. Administer IV fluids before surgery to improve hydration status.

The nursing responsibilities intraoperatively as a circulating nurse are: To oversee the physical aspects of the operating room itself, including the equipment. To assist with the transferring and positioning the client, prepare the clients skin, ensures that no break in aseptic technique occurs, and counts all sponges and instruments. Assisting other members of the surgical team. Documenting intraoperative nursing activities, medications, blood administration, placement of drains and catheters, and length of the procedure. Formulates a care plan based on physiologic and psychosocial assessment to the client. Finally, the circulating nurse is at all times an advocate for the safety and well-being of the client. The responsibilities of a scrub nurse during the operation are the following: Handling of sutures, instruments, and other equipment immediately adjacent to the sterile field. The nursing responsibilities postoperatively are the following: Assess vital signs and level of consciousness of the patient. Administering prescribed pain medications or monitor patient-controlled analgesia. Promoting ambulation to the patient to prevent thromboembolus, facilitate voiding, decrease flatus and abdominal distension, and stimulate peristalsis. Encouraging splinting of incision when moving and coughing and deep breathing, encourage use of incentive spirometer. Assessing wound dressing and T-tube site for any drainage, noting the amount, color and odor. Assessing bile drainage from T-tube, report any increase or decrease in drainage. Maintaining T-Tube patency and security. Report if the client is experiencing right upper quadrant pain, abdominal distention, fever, chills or jaundice indicating bile duct injury. Administering antibiotics as prescribed. Assessing intake and output of the client, including T-tube drainage. Assessing for nausea and vomiting, and administer antiemetics as prescribed. Ensuring adequate replacement of fluids. Encouraging fluid intake and advance to regular diet as tolerated by the patient. Lastly is to clamp T-tube when ordered and assess tolerance of food and color of stools.

VI NURSING CARE PLANS Prioritization 1. 2. 3. 4. 5. Acute Pain Hyperthermia Impaired Skin Integrity Activity Intolerance Anxiety

PRIORITITY PROMBLEM NO.1: Acute Pain ASSESSMENT SUBJECTIVE CUES: ang sakit dito tagiliran ko pag biglang gumagalaw as verbalized by the client OBJECTIVE CUES: >Pain Scale: 6/10 >restless noted >irritable >guarding behavior over the abdomen observed >facial grimace noted >narrowed focus observed DIAGNOSIS Acute pain related to tissue trauma as manifested by a pain scale of 6 over 10 SCIENTIFIC KNOWLEDGE Trauma to the tissues Activation of inflammatory response vasodilation Increased capillary permeability Release of histamine kinins prostaglandins leukotrienes Activation of pain receptors Acute pain Reference: Lemone, Priscilla et.al. Principle of Medical PLANNING After 2hrs of intervention, the patient will be able to demonstrate nonpharmacologic ways of relieving pain. After 4hrs of intervention, the patient pain level will decrease from a pain scale of 6 to a pain scale of 2. INTERVENTION INDEPENDENT ACTIONS: >have a comprehensive assessment of the pain that includes location, characteristics, onset, duration, frequency, quality, intensity >provide an individualized relaxation therapy by asking the patients significant others for suggestions >provide a quiet, nonstimulating environment >pain is a subjective experience and must be described by the client RATIONALE EVALUATION After 2hrs of intervention, the patient was able to demonstrate nonpharmacologic ways of relieving pain. ___ goal met ___ partially met ___ unmet >each person prefers different approaches to relaxation After 4hrs of intervention, the patient pain level has decreased from pain scale of 6 to a pain scale of 2. ___ goal met ___ partially met ___ unmet

>manipulating the environment helps reduce noxious stimuli that increases pain

Surgical Nursing: critical thinkingin client care, 4th edition. Pearson Prentice Hall.2008 pg.304

>encourage patient to perform relaxation techniques such as deep-breathing exercises, music therapy and distraction of the mind >place patient in Fowlers position >advise client to withhold oral food and fluids during episodes of acute pain

>relaxation techniques help reduce skeletal muscle tension which also reduces the intensity of pain

>decreases pressure on the gallbladder >Emptying the stomach reduces the amount of chime entering the duodenum and the stimulus for gallbladder contractions, thus reducing pain >timely intervention is more likely to be successful in alleviating pain

>advise client to report pain as soon as it begins >provide health techings: -about the use of

-to give the patient

nonpharmacological techniques (music therapy, distraction, massage) before, after and during painful attacks -about the frequency of administration, side effects, interactions and specific precautions of the medications >discuss the relationship between fat intake and pain. Teach ways to reduce fat intake

preferences or choices minimizing dependence to drugs

-to reduce anxiety of patient

>Fat entering the duodenum initiates gallbladder contractions, causing pain when gallstones are present in the ducts

DEPENDENT ACTION: >Give analgesics as ordered, evaluating effectiveness and observing for any signs and symptoms of untoward effects.

>Pain medications are absorbed and metabolized differently by patients, so their effectiveness must be

evaluated from patient to patient. Analgesics may cause side effects that range from mild to lifethreatening. Reference: Lemone, Priscilla et.al. Principle of Medical Surgical Nursing: critical thinking in client care, 4th edition. Lemone, Priscilla et.al. Fundamentals of Nursing by Barbara Kozier

PRIORITITY PROMBLEM NO.2: Hyperthermia ASSESSMENT SCIENTIFIC DIAGNOSIS KNOWLEDGE SUBJECTIVE Hyperthermia related CUES: to the bodys primary Infectious agents mainit ung reaction to infection (Pyrogens) pakiramdam ko as as manifested by verbalized by the increased temperature Stimulates release of client (t=37.9C) monocytes OBJECTIVE CUES: Release of pyrogenic cytokines >weak in appearance >flushed skin noted Stimulates the >skin is warm to anterior touch hypothalamus to >restlessness increase observed thermoregulatory set >WBC count of point 15.0X10g/l >VS: Increased Heat Temp: 37.9 C production RR: 27 cpm PR: 121 bpm hyperthermia

PLANNING After 5hrs. of intervention, the patients temperature will decrease from 37.9 C to 37.5 C

INTERVENTION INDEPENDENT ACTIONS: >Monitor heart rate and rhythm

RATIONALE

EVALUATION After 5hrs. of intervention, the patients temperature decreased from 38.3 C to 37.5 C ___ goal met ___ partially met ___ unmet

>dysrhythmias are common due to the direct effect of hyperthermia on blood and cardiac tissues >for indications of infection or dehydration >to meet the increased in metabolic demand >to monitor for dehydration

>Assess skin color and temnperature >Monitor WBC and hematocrit value >Provide adequate nutrition and fluids >Measure intake and output

>Provide oral hygiene >Provide tepid sponge bath >provide dry clothing and linens >Wrap extremities with cotton blankets >Maintain bed rest

>to keep the mucous membranes moist >to increase heat loss through conduction

>to minimize shivering >To reduce metabolic demands and oxygen consumption

DEPENDENT ACTION: >Administer antipyretics as ordered >to relieve the patient from fever

PRIORITITY PROMBLEM NO.3: Impaired Skin Integrity ASSESSMENT DIAGNOSIS SCIENTIFIC PLANNING KNOWLEDGE Subjective: Objective: 1. Destruct ed skin layer 2. Destruct ed skin surface 3. Presence of t-tube and Jackson Pratt drains 4. The client undergone 3 surgical operation: Choledochoto my Choledocholit hotomy Cholecystecto Impaired Skin Integrity related to mechanical factor. Increase intake of foods high in cholesterol and slow and incomplete emptying of gallbladder Super saturation of bile with cholesterol or concentration of cholesterol Precipitate formation of gallstones Presence of gallstones in the gallbladder After 1hour of nursing intervention the client and the clients family will be able to utilize understanding on how to prevent postoperative wound infection.

INTERVENTION INDEPENDENT NURSING ACTION: 1. Established rapport

RATIONALE

EVALUATION After 1hr of nursing intervention the client and the clients family utilized understanding on how to prevent postoperative wound infection, as evidenced by demonstration of proper wound care and verbalization of understanding. ___ goal met ___ partially met ___ unmet

2. Make a comprehensive assessment on skin and wound condition that includes: Location, dimension and depth Inspection for any redness, swelling or signs of dehiscence and evisceration presence and characteristic of

1. To gain the clients trust so that the client would be cooperative and will believe to the teachings that will be rendered. 2. To be able to comprehensively check the clients condition so we could appropriately formulate a specific and individualized care to the client aiming to attain the goal of preventing infection.

my

Inflammation Increases the reabsorption of excess water and bile salts Increasing no. of gallstones Gallstones migrate to the bile duct Removal of gallstones in the gallbladder (CholedochoLithotomy and Choledochotomy) To prevent the formation of new stones Removal of gallbladder (Cholecystectomy)

exudates Presence of symptoms of infection Inspection of the dressings intactness and drainage 3. Discuss and demonstrate to the client and to the clients family how to clean and dress surgical incision site using the principles of sterility or medical asepsis: Wear disposable gloves Clean the site with normal saline solution or any antiseptic solution as ordered Clean the site from clean to dirty, using one swab per wipe

3.It is important for the client to observed and apply the principle of sterility to prevent post-operative wound infection

Clean around the sutures, using sterile cotton applicator Clean around the drain last, moving from center outward in circular motion 4. Keep the surrounding tissue free from excess moisture and drainage 5.Change the dressing at appropriate intervals and establish a skin and wound care routine 6. Advise the client and the clients family to monitor the wound dressings and report if there is profuse bleeding.

4. Moisture and excessive drainage can harbor microbes that contribute to infection.

5. Regular basis of wound care and dressing can prevent the possible growth of microorganism thus inhibiting infection.

6. Profuse bleeding must be monitored t prevent excessive blood loss. Pinkish liquid substance secreted in the incision site can be a sign of dehiscence and evisceration.

7.Reinforce to maintain the environment clean and neat 8.Encourage to reposition the client frequently 9.Assist client in positioning 10.Massage the area around the wound 11. Stress to them the importance of eating food rich in vitamin A,B complex, C, K, zinc, copper, iron and manganese. 12. Encourage client to eat food rich in protein.

7. Clean environment decreases the risk for infection.

8. For proper circulation thus fasten wound healing. 9. Post-operative patient usually cannot tolerate turning from side to side due to pain. 10. Massage stimulate circulation 11. Vitamin A is for collagen synthesis and epithelialization. Vitamin B complex serve as cofactor of enzyme reactions needed for wound healing. Vitamin C is for synthesis of prothrombin, clotting. Zinc, coper and iron assist in collagen synthesis and Manganese serves as an enzyme activator.this vitamins and minerals can prevent infection, fasten the wound healing and repair of tissue and skin that are

DEPENDENT NURSING ACTION: 1. Administer antiseptic ointment and antibiotic as prescribed. 2. Apply TENS(Transc utaneous electrical nerve stimulation )

damaged DEPENDENT NURSING ACTION: 1. Antibiotic inhibits synthesis of or activation of bacterial proliferation. 2. TENS is use post-operatively to stimulate circulation for faster healing. Shorter time of wound exposure to environment can decrease the incidence of infection.

VII HEALTH TEACHING

Date/Time/Venue Nov. 2009 9:00 am Jose B. Lingad Hospital

Objectives To provide knowledge to the patient ways for decreasing pain To emphasize the importance of communicatin g her pain

Learning Content about the use of nonpharmacol ogical techniques about the frequency of administration, side effects, interactions and specific precautions of the medications discuss the relationship between fat intake and pain.

Strategies Discussion and demonstratio n of the technique used to disseminate the learning contents of health teachings.

Target Our mai n targ et in this cour se of heal th teac hing is our clie nt

Resources Lemone, Priscilla et.al. Principle of Medical Surgical Nursing: critical thinking in client care, 4th edition. Lemone, Priscilla et.al. Fundamentals of Nursing by Barbara Kozier

Implementation Relaxation Technquies such as deep-breathing exercises, music therapy and distraction of the mind it help reduce skeletal muscle tension which also reduces the intensity of pain advise client to withhold oral food and fluids during episodes of acute pain

Evaluation The atie nt lear ned and perf orm ed prop erly way s to decr ease his pain

advise client to report pain as soon as it begins timely intervention is more likely to be successful in alleviating pain

Date/Time/Venue Nov. 2009 9:00 am Jose B. Lingad Hospital

Objectives

.To rovide the patient and SO:knowl edge about simple Conduction interventio n to rduce Tepid temperatur Sponge e bath To facilitate Convection proper interventio Loose tns to shirts educe temperatur Ways to e reduce metabolic demands

Learning Content Ways to reduce temperatur e by:

Strategies Discussion and demonstrat ion of the technique used to disseminat e the learning contents of health teachings.

Target Our main target in this course of health teaching is our client

Resources

Implementation emphasize adequate nutrition and fluids to meet the increased in metabolic demand stress the importance of oral hygiene to keep the mucous membranes moist demonstrate proper technique of tepid sponge bath assist to Maintain bed rest To reduce metabolic

Evaluation The patient learned and performed properly ways to decrease his temperature

demands and oxygen consumption Date/Time/Venue Nov. 2009 9:00 am Jose B. Lingad Hospital Objectives To teach ways to promote timely wound healing. To facilitate learning about proper wound care. Learning Content Importance of proper positioning to lessen the chance of further eradication of the wound. The factors that may affect wound healing. Changing and monitoring the dressing of the wound. Strategies Discussion and demonstration of the technique used to disseminate the learning contents of health teachings. Target Our main target in this course of health teaching is our client Resources Prentice Hall Nursing Diagnosis Handbook, 9th edition, Judith M. Wilkinson, Nancy R. Ahern Fundamental s of Nursing by Barbara Kozier Implementation Keep the surrounding tissue free from excess moisture and drainage Change the dressing at appropriate intervals and establish a skin and wound care routine Advise the client and the clients family to monitor the wound dressings and report if there is profuse bleeding. Encourage to reposition the client frequently Evaluation The patient learned and performe d properly ways to promote timely wound healing.

 Assist client in positioning Encourage client to eat food rich in protein. Stress to them the importance of eating food rich in vitamin A,B complex, C, K, zinc, copper, iron and manganese

VI. DISCHARGE PLANNING A. General Condition of the Client upon Discharge:

The patient was conscious but still has a general weakness upon discharge. The wound dressing was intact. The vital signs of the patient are within normal range.

B.

METHODS:

Medication The client is advised to take celexocib 200mg/cap two times a day for 5 days, multivitamins 500mg/cap once a day, cefuroxime 3 times a day for 1 week. Exercise Treatment The client is advised to maintain proper drainage of T-tube discharge. Instruct client to do deep breathing techniques and ROM exercises.

Health Teaching Out Patient Diet Spiritual Eliminate consumption of fatty foods, excessive calcium and salty foods. The client is scheduled to visit the hospital on January 27, 2010 Wednesday, JBL-OPD. Encourage early ambulation, deep breathing techniques, ROM exercises and promote proper wound care.

Have trust and faith in God, for God will help her in his trials in life.

X BIBLIOGRAPHY Kozier, Barbara et.al. Fundamentals of Nursing (concepts, process, and practice) 8th edition. pearson prentice hall.2001 Huether and Mccance. Understanding Pathophysiology, 3rd edition. lippincott williams and wilkins, 2007 Text of Medical Surgical Nursing 11th edition by brunner and suddarth nursingscrib.com Lemone,Priscilla et.al. Principle of Medical Surgical Nursing: Critical Thinking in Client Care, 4th edition. pearson prentice hall.2008 Wlkinson, Jdith et.al. Nursing Diagnosis Handbook, 9th edition Nursing Implication of Laboratory test 2nd editon Mcfarland and Marcia Grant Nursing 2007 drug handbook 27th edition, lippincott williams and wilkins PDF nurses drug hand book 2008 edition, george r. spratto and adrienne l woods Pathophysiology for the Health Profession by Barbara Gold Diagnostic clues in abnormal test pattern by Reese and Hobbie Handbook of Pathophysiology 3rd edition by corwin ACP medicine vol 2 david dale ppds nursing drug guide