Cholecystitis Repaired)

1

INTRODUCTION

Calculi, or gallstones, usually form in the solid constituent of bile; they vary greatly in size, shape, and composition. They are uncommon in children and young adults but become increasingly prevalent after 40 years of age, especially in women. The incidence of cholelithiasis increases after the age of 40 years, affecting 30% to 40% of the population by the age of 80 years.

There are two major types of gallstones: those composed predominantly of pigment and those composed primarily of cholesterol. Pigments stones probably form when unconjugated pigments in the bile precipitate to form stones. The risk of developing such stones is increased in patients with cirrhosis, hemolysis, and infections of the biliary tract. Pigment stones can not be dissolved and must be removed surgically.

Two to three times more women than men develop cholesterol stones and gallbladder disease; affected women are usually older than 40 years of age, multiparous, and obese. The incidence of stone formation is grater among people who use medications are known to increase biliary cholesterol saturation. The incidence of stone formation increases with age as a result of increased hepatic secretion of cholesterol and decreased bile acid synthesis. The incidence also increases in people with diabetes.

Gallstones may be silent producing no pain and only mild gastrointestinal symptoms. Such stones may be detected incidentally during surgery of evaluation for unrelated problems.

The patient with gallbladder disease resulting from gallstones may develop two types of symptoms: those due to the disease of the gallbladder itself and those due to obstruction of the bile passages by a gallstone. The symptoms may be acute or chronic. Epigastric distress, such as fullness, abdominal distension, and vague pain in the right upper quadrant of the abdomen, may occur. This distress may follow a meal rich in fried or fatty foods.

Standard treatment of acute cholelithiasis is to begin intravenous fluids, antibiotics, pain medication, and to consider immediate surgery during the same hospitalization. Inflammation, edema, and adhesions around the gallbladder increase the likelihood of requiring a cholecystectomy (removal of the gallbladder). However, dramatic changes have occurred in the surgical management of gallbladder disease. There is now widespread use of laparoscopic cholecystectomy (removal of the gallbladder through a small incision through the umbilicus). This procedure requires general anesthesia and decompression of the stomach and urinary bladder with a nasogastric and Foley catheter. Three additional trocars are placed under direct vision one just inferior to the xiphoid (10 mm), and two in the right abdomen (5mm). Grasping instruments are used to retract the gallbladder superiorly and to the right to expose the

2

triangle of Calot through which the cystic duct and artery are identified, clipped, and divided.

In contrast, an open cholecystectomy is performed through a right vertical midline incision of 12 to 20 cm. Under direct vision, the connections between gallbladder, cystic duct, and the common bile duct are identified and separated. As a result, surgical risks have decreased, along recovery period required after standard surgical cholecystectomy.

As with any surgery, there are certain risks, which may include excessive bleeding or blood clots, difficulty with anesthesia, or infection. As a preventive measure, the surgeon may administer antibiotics through I.V. After surgery, most patients will spend several hours recovering at the hospital and then be released either the same day or the next day, barring complications. Once the anesthesia has worn off, the patient may be asked to walk around to help prevent blood clots. The patient may be given a liquid diet for a few hours after surgery, but in most cases, the patient may return to a regular diet the next day and to the regular routine within a few days.

The diet required immediately after an episode is usually limited to low-fat liquids. These can include powdered supplements high in protein and carbohydrate stirred into skim milk. Cooked fruits, rice or tapioca, lean meats, mashed potatoes, non-gas-forming vegetables, bread, coffee, or tea may be tolerated. The patient should avoid eggs, cream, pork, fried foods, cheese, rich dressings, gas-forming vegetables, and alcohol. It is important to remind the patient that fatty foods may bring on an episode of cholecystitis. Dietary management may be the major mode of therapy in patients who have had only dietary intolerance to fatty foods and vague gastrointestinal symptoms.

The Ursodeoxycholic acid (UDCA) and chenodeoxycholic acid (chenodiol or CDCA) have been used to dissolve small, radiolucent gallstones composed primarily of cholesterol. Patient with significant, frequent symptoms; cystic duct occlusion; or pigment stones are not candidates for this therapy. Laparoscopic or open cholecystectomy is more appropriate for symptomatic patients with acceptable operative risk.

http://www.essortment.com/all/laparoscopicgal_riwj.htm

http://www.essortment.com/all/laparoscopicgal_riwj.htm

3

THEORETICAL FRAMEWORK

Virginia Henderson has been called the “First Lady of Nursing” and the “First Truly International Nurse”.

Henderson’s metaparadigm viewed person as a patient. She stated that the person is an individual who requires assistance to achieve health and independence or in some cases, a peaceful death. Then she viewed health as a quality of life and is very basic for a person to function fully. As a vital need, health requires independence and interdependence heath is a multi factor phenomenon. It is influenced by both internal and external factors which play independent and interdependent roles in achieving health. It is important for a healthy individual to control the environment, but as illness occurs, this ability is diminished or affected. She stated that, in caring for the sick, it is the responsibility of the nurse to help the patient manage her surroundings to protect from harm or any mechanical injury. And she viewed nursing that function independently from the physician, but they must promote the treatment plan prescribed by the physician.

The theory involved in Virginia Henderson is the 14 Basic Needs that conceptualizes the 14 fundamental needs of humans. These needs are:

1. Breathing normally2. Eating and drinking adequately3. Eliminating body wastes4. Moving and maintaining a desirable position5. Sleeping and resting 6. Selecting suitable clothes7. Maintaining normal body temperature by adjusting clothing and modifying the

environment8. Keeping the body clean and well groomed to promote integument (skin)9. Avoiding dangers in the environment and avoiding injury to others10.Communication with others in expressing emotions, needs, fears or opinions11.Worshiping according to one’s faith12.Working in such a way that one feel a sense of accomplishment13.Playing or participating in various forms of recreation14.Learning, discovering or satisfying the curiosity that leads to normal development

and health, and using available health facilities

4

We decided to apply in our case the theory of Virgina Henderson, 14 basic needs because it comprises the needs of our client that a health care provider must be knowledgeable and must have the ability to assess in order to meet the needs of our client.

The needs and the interventions that we implement are as follows:

In order to breathe normally, postoperatively we encourage our client to do some deep breathing exercises to promote lung expansion. We also encourage our client to eat nutritious food like vegetables and avoid foods that rich in fats and sodium, we also encourage her to drink plenty of water that may help her in eliminating body wastes and to prevent having constipation. After her operation, we encourage to move and to maintain desirable position in a well- ventilated room and can maintain her body temperature in order for her to rest comfortably, also we encourage her to early ambulate to promote circulation and keep her body clean especially in the operative site to prevent having infection.

And then during stress periods, it is important for her to express her emotions, fear and needs by communicating with others or by participating in various forms of recreation especially with our God Almighty to enlighten her mind.

5

GENERAL INFORMATION

I. BIOGRAPHIC DATA

Name: Mrs. N.D.C. Case no: 87381Address: # 1508 Pastol Muzon San Jose Del Monte BulacanAge: 58 years oldBirthday: December 25, 1957 Birthplace: ManilaSex: Female Marital Status: MarriedOccupation: House wifeReligion: Catholic

II. PRESENTING PROBLEM

Chief Complaint: Abdominal painDate Admitted: September 10, 2010 Time: 5:25 pmDepartment: P2 (Sta. Cecilla)Attending Physician: Dra. C.L.Admitting Diagnosis: to consider Peptic Ulcer Disease, Gallstone SymptomaticAdmitting Vital Signs: BP: 120/70 mmHg RR: 22 cpm

CR: 87 bpm T: 36˚CDate Handled: September 13, 2010 and September 14, 2010Date Discharge: September 14, 2010 Time: 3:30 pmFinal Diagnosis: Gallstone S/P Cholecystectomy S/P Laparoscopic Cholecystectomy, Multiple Duodenal Ulcers

III. HISTORY OF PRESENT ILLNESS

Mrs. N.D.C stated that she experienced bloatedness two weeks before she had check up. Then she experienced frequent burping and hyperacidity with or without meal. Last August 13, 2010, she decided to have a consultation in Mendoza Hospital and ultrasound was done.

The physician suggested an operation but Mrs. N.D.C refused it because she preferred to have a home medication. One day prior to admission, Mrs. N.D.C experienced severe right upper abdominal pain with scale of 8/10 in the afternoon while watching television and her daughter decided to brought her to NCHF at around 5 pm and Dra. C.L. advised her to be confined for further evaluation.

6

IV. RECORD OF OPERATION

Name: N.D.C. Age: 58 years oldDate: September 11, 2010Operation proposed: Esophago Gastro DuodenoscopySurgeon: Dra. C.LPreoperative diagnosis: T/C Peptic ulcer diseaseOperative Diagnosis: Multiple Duodenal Ulcers Operation Performed: EGD with BiopsyAnesthesiologist: Dr. L.TPremedication: Dipenhydramide 50 mg IVAnesthetic: Demerol .5 mg IV Time Began: 1:20 pm

Midazolam 2mg IV Time Operation: 1:23 pmTechnique: IV Sedation Time Operation ended: 1:28 pm

7

Name: N.D.C. Age: 58 years oldFinal Diagnosis: Gallstone S/P cholescystectomy S/P Lap cholecystectomy, Multiple Duodenal UlcerRemarks: ImprovedRoom Bed No: Sta CeciliaHospital No: 87381Surgeon: Dr: F.D.First Assistant: Dr. A.D.Date of Operation: September 11, 2010 Time started: 5:55 pmAnesthesiology: Dr. J.D Time finished: 7:35 pmAnesthetic agent: Propofol 100 mg

Succinylcholine 90 mgDetailed technique: General Intubation Anesthesia Pre-operative Diagnosis: CholecystolithiasisPost-operative Diagnosis: CholecystolithiasisMaterial Forwarded to laboratory for examination: GallbladderOperation Performed: Lap Cholecystectomy S/P EGDDescription of operation:

Patient supine under general anesthesiaAsepsis and antisepsisSterile drapes in place10mm umbilical incision carried down to peritoneumLeft and right anchoring sutures applied at fascia10 mm blunt trochar inserted, abdomen in sulfated with CO2 at 14 mm pressure at high flow rate10 mm, zero degrees laparoscope inserted, abdomen inspected, no bleeding, no injuries to bowel/ vessel notedSkin crease incision done in epigastric, right midclavicular and right anterior axillary10mm, 5mm, 5mm trochars inserted at epigastric, right midclavicular, right anterior axillary respectively under direct visionIntra operative findings: calcolous cholecystitisGall bladder fundus retracted inferiorly and laterallyHart man’s pouch retracted inferiorly and laterally Common bile duct and cystic artery identified; dissected, doubly clip proximally and singly clip distally using titanium clips and dividedGall bladder separated from liver bed using electrocautery with no spillageGall bladder extracted from umbilical partHemostasis, suction, irrigation doneTitanium clips inspected, liver bed, no bile leak, no injury to visceral organs notedTrochars removed under direct visionAbdomen desufflatedTrochar sites closed using chromic 0 at fascia in figure of eight manner, vicryl 4/0 subcuticularly at skin Sterile dressing applied

8

V. PAST HEALTH HISTORY

Childhood Illness: Mrs. N.D.C. had a measles when she was 7 years old and chicken pox when she was 10 years old.

Childhood Immunization: Mrs. N.D.C.was fully immunized.

Allergies: Mrs. N.D.C. has allergies in seafood’s and chicken.

Accidents and Injuries: Mrs. N.D.C. has no history of any accidents and injuries.

Hospitalization for Illness: Mrs. N.D.C. had been hospitalized due to Premature Rupture of Membrane and she was undergone with cesarean section.

Obstetrics history: G3P3 (3004)

Mrs. N.D.C. was 22 years of age when she got pregnant to her first baby, and was delivered NSD at the house by a midwife. Then after two years she had her twin delivery in her second delivery that was delivered NSD by a midwife. When she was 26 years of age, she delivered on a cesarean section because of Premature Rupture of Membrane in Malolos Provincial Hospital.

VI. FAMILY HISTORY OF ILLNESS

Disease Paternal Maternal

1. Hypertension2. Diabetes mellitus3. Cancer4. Heart Disease5. Obesity6. Hepatitis7. Kidney Disease8. Chronic Lung

Disease9. Other Disease

√------√

-√------

9

VII. LIFESTYLE

Diet: Mrs. N.D.C. usually eats 5 times a day and she drinks 4 glasses of water a day. She is the one who is preparing for their foods. And she usually cooks meat and fish.

Personal Habit: Mrs. N.D.C. loves to drink coffee. She usually takes 4 glasses of coffee a day.

Rest and Sleep pattern: Mrs. N.D.C. goes to bed at around 11:00 pm and she wakes up at around 6:00 am. She had difficulties in initiating and maintaining sleep because she cannot sleep when the time she lies on bed. According to her it takes 2 to 3 hours before she attain to sleep.

Recreation and Activities: Mrs. N.D.C. has a small poultry in their backyard. Taking care and feeding of her hens and gardening is a form of her recreation. And also watching T.V. is a form of her relaxation.

VIII. SOCIAL DATA

Family Relationship: Mrs. N.D.C. lives with her husband. She has intact relationship with her family.

Ethnic Affiliations: Mrs. N.D.C. doesn’t believe in any Faith healing or rituals, whenever she got sick she will consult to a doctor.

Educational Attainment: Primary: Rizal Elementary School (1965) Secondary: Rizal National High School (1969) Tertiary: La Salle-Araneta University (1978)(Bachelor of Education Major in Physical Education)

Occupational History: Mrs. N.DC. is a P.E. and Filipino teacher since 1979 in Meycauayan College. She also becomes a P.E. coordinator in Meycauayan College. She retired last 2006.

Economic Status: Mrs. N.D.C. is financially stable. Her husband is the one who is providing for their needs.

IX. PHYSIOLOGIC DATA

Major Stressors: Mrs. N.D.C. had no particular major stressor at this time.Usual Coping Pattern: She is always praying to God for their guidance and safety.Communication Style: Mrs. N.D.C. talks in a clear and good manner.

10

ACTIVITIES OF DAILY LIVING

Activities Pre-confinement(September 9, 2010)

Intra-confinement(September 10-11, 2010)

Post-Confinement(September 20, 2010)

Nutrition Mrs. N.D.C. usually eats meat and fish and drinks 4 glasses of water a day. She eat breakfast at around 7:00 am, lunch at 12:00 noon and dinner at 8:00 pm.

Mrs. N.D.C had Nothing Per Orem before and after operation. After 18 hours on the NPO diet, she had her soft diet at around 1:30 in the afternoon which include lugaw, oatmeal, soft bread, and skyflakes.

Mrs. N.D.C. had low sodium low fat diet. She doesn’t drink coffee and carbonated drinks anymore; instead she drinks 6-8 glasses of water a day. She ate fresh fruits and vegetables.

Bowel Elimination

Mrs. N.D.C. has a regular pattern of defecation at least once a day and she immediately responds to her urge to defecate.

During hospital stays Mrs. N.D.C defecate two times.

Mrs. N.D.C had already adjusted for her regular pattern of defecation since the operation had been done.

Urination According to Mrs. N.D.C, she usually urinates 6 times a day.

Mrs. N.D.C. urinates 7 times a day during in the hospital.

Mrs. N.D.C. urinates 6 times a day with yellowish color of urine.

Hygiene Mrs. N.D.C usually takes a bath once a day and usually in the afternoon. She brush her teeth every after meal.

Sponge bath is a form of her hygiene.

Mrs. N.D.C. takes a bath in the morning. She brush her teeth every after meal.

Exercise Mrs. N.D.C. has no particular means of exercise. Taking care of her plants and feeding her hens is a form of her routine exercise.

Mrs. N.D.C. was advised to sit and walk around after 12 hours of operation.

Mrs. N.D.C. had a simple exercise in the morning like walking and stretching.

11

PHYSICAL ASSESSMENT

A. General Appearance

Area Findings Normal Values Remarks

Height 5’2” feet 4-6 ft or 129-182 cm (Basic Nutrition of

Filipinos By Claudio and Dirige)

Normal

Weight 135 lbs 97.5-122 lbs. (Basic Nutrition of Filipinos

By Claudio and Dirige)

Not normal due to sedentary life style

Posture/gait Stand erect, with coordinated movements

Relaxed, erect, posture; coordinated

movement.(Fundamentals of Nursing by Kozier

and Erbs 8th Edition pg. 572)

Normal

Personal Hygiene Neat and clean Neat and clean(Fundamentals of Nursing by Kozier

and Erbs 8th Edition pg. 572)

Normal

12

B. Physiologic Cues

Vital Signs Normal findings Actual findings Interpretation

TemperatureAxillary: 36.5°C to

37.4°C

Reference: Kozier and Erb’s

Fundamental of Nursing 8th edition

37.4°C Normal

Cardiac rate60-100bpm



85 bpm Normal

Respiratory rate12-20 cpm

Reference: : Kozier and Erb’s


15 cpm Normal

Blood pressure100-130/60-80

mmHg



120/70 mmHg Normal

13

HEAD-TO-TOE ASSESSMENT

Area Normal findings Actual Findings Interpretation

HeadSkull

Size, shape and symmetry

Nodules, masses and depressions

Scalp and Hair

Symmetry of facial movement

INSPECTIONRounded

(Normocephalic and symmetric with frontal

Reference: Health assessment in nursing

3rd edition.

PALPATIONSmooth, uniform,

consistency, absence of nodules or masses


3rd edition.

INSPECTIONEvenly distributed hair, thick, silky,

resilient, no infection or infestation


3rd edition.

INSPECTIONSymmetrical facial

movementReference: Health

assessment in nursing 3rd edition.

Rounded, smooth, skull contour

Smooth, uniform, consistency, absence of nodules or masses

Evenly distributed hair, no presence of

infection

Symmetric facial movements

Normal

Normal

Normal

Normal

EyesEyebrows

(Hair Distribution, alignment, skin

quality and

INSPECTIONEqually distributed,

curled, slightly outward

Equally distributed hair and eyelashes are slightly curled

Normal

14

movements)

Eyelids

Cornea

Pupils

Bulbar conjunctiva

Palpebral Conjunctiva


3rd edition.

INSPECTIONSkin intact; no discharge; no

discoloration; lids closes symmetrically


3rd edition.

INSPECTIONTransparent, shiny

and smooth, details of iris are visible


3rd edition.

INSPECTIONBlack in color, equal in size, round, smooth,

border and reactive to light


3rd edition.

INSPECTIONTransparent, capillary sometimes evident;

sclera appears white(Yellowish in dark skin

clients)Reference: Health

assessment in nursing

INSPECTIONShiny, smooth, and pick or slightly red in

colorReference: Health

assessment in nursing

outside

No discharge, skin intact, no discoloration

Transparent, shiny and smooth details of

iris are visible

Equal in size, black in color and reactive to

light

Sclera appears white

Slightly red in color and shiny

Normal

Normal

Normal

Normal

Normal

15

3rd edition.

EarsAuricles

INSPECTIONColor same as facial skin, mobile, firm, no

tender

Color same as facial skin

Normal

Nose INSPECTIONSymmetric and

straight, no discharge or flaring, uniform

color, air moves freely as the client breaths to

the naresReference: Health


Symmetric and straight, no discharge uniform in color, air moves freely as the client breaths to the

nares

Normal

MouthTeeth and gums INSPECTION

32 adult teeth, smooth, white, shiny tooth enamel, pink gums moist, firm texture to gums


3rd edition.

Upon inspection there were two upper

canine, two incisors and one molar. While

on the lower part there were four molars, two

canine and two incisors.

Normal.

Tongue InspectionCentral Position, pink

in color, raved papillae, moves freely; no

tendernessReference: Health


Central position, pink color moves freely

Normal

16

Neck Inspection, PalpationMuscle equal in size,

Head center coordinated, smooth

movementReference: Kozier and Erb’s Fundamentals of

Nursing 8th Edition

Muscle equal in size, with smooth movement

Normal

Thorax Inspection, Palpation Percussion, Auscultation

Skin intact, uniform in color, no tenderness,

no lesions, quite rhythmic and effortless

respirationReference: Kozier and Erb’s Fundamentals of

Nursing 8th Edition

Quite rhythmic and effortless respiration

Normal

Heart AuscultationNormal heart beat is

60-100 bpm.Reference: Kozier and Erb’s Fundamentals of

Nursing 8th Edition

85 bpm Normal

Abdomen Inspection, Auscultation

Unblemished skin, uniform in color, flat,

rounded, audible bowel sounds, no tendernessReference: Kozier and Erb’s Fundamentals of

Nursing 8th Edition

Upon inspection there are four incision sites. One in the umbilical area, two in the right upper quadrant and one in the right lower quadrant. Dressing is dry and intact. There is also a presence of

Normal

17

cesarean section scar.

Upon auscultation there are three

borbourygmic sounds per minute.

Upper ExtremitiesMuscle Strength

and toneInspection, PalpationNormally firm, equal

strength in each body size

Reference: Kozier and Erb’s Fundamentals of

Nursing 8th Edition

Firm, uniform in color, equal strength on each body sides

Normal

Joint Range of motion

Smooth coordinated movements and joints

moves smoothlyReference: Kozier and Erb’s Fundamentals of

Nursing 8th Edition

Joints move smoothly, no tenderness

Normal

Lower Extremities muscle strength

and tone

Inspection, PalpationNormally firm, equal

strength in each body size

Reference: Kozier and Erb’s Fundamentals of

Nursing 8th Edition

Muscle strength and tone are normally firm

and equal

Normal

18

Joint Range of Motion

Joint moves smoothly, no swelling, no

tendernessReference: Kozier and Erb’s Fundamentals of

Nursing 8th Edition

Joints move smoothly, no tenderness

Normal

Skin

Nails

INSPECTIONInspection reveals evenly colored skin

tone without unusual or prominent

discoloration. No edema.


3rd edition.

INSPECTIONPink tones should be

seen. Some longitudinal ridging is normal. Dark-skinned

client may have freckles or pigmented streaks in their nails.Reference: Health


No prominentdiscoloration, light brown in color, no

edema

Nail bed is vascular, pink in color, no

curvature

Normal

Normal

ANATOMY AND PHYSIOLOGY

19

The gastrointestinal tract is a long pathway that extends from the mouth to the esophagus, stomach, small and large intestines and rectum, to the terminal structure, the anus.

20

Mouth is responsible for the intake of food. It is lined by stratified squamuos oral mucosa with keratin covering those areas subjects to significant abrasion, such as the tongue, hard palate and roof of the mouth. Mastication refers to the mechanical breakdown of food by chewing and chopping action of the teeth. The tongue, a strong muscular organ, manipulates the food bolus to come in contact with the teeth. It is also the sensing organ of the mouth for touch, temperature and taste using its specialized sensors known as papillae.

Esophagus is located in the mediastinum anterior to the spine and posterior to the trachea and heart. This hollow muscular tube passes through the diaphragm at an opening called the diaphragmatic hiatus.

Stomach is situated in the left upper portion of the abdomen under the left bone of the liver and the diaphragm overlying mast of the pancreas. A hollow muscular organ with a capacity of approximately 1500 ml the stomach stores food during eating, secretes, digestive fluids and propels the partially digested food into the small intestine.

The function of the stomach includes:1. The short- term storage of ingested food.2. Mechanical breakdown of food by churning and mixing motions.3. Chemical digestion of proteins by acids and enzymes.4. Stomach acid kills bugs and germs.5. Some absorption of substances such as alcohol.

Liver often start in hepato- or hepatic from the Greek word for liver, hēpar (ἡπαρ). Four pounds of highly efficient chemical-processing tissues, the liver is the largest solid organ in the body. You can locate it by placing your left hand over your right, lowermost ribs; your hand then just about covers the area of the liver. More than any other organ, the liver enables our bodies to benefit from the food we eat. Without it, digestion would be impossible, and the conversion of food into living cells and energy practically nonexistent. Insofar as they affect our body's handling of food—all the many processes that go by the collective name of nutrition—the liver's functions can be roughly divided into those that break down food molecules and those that build up or reconstitute these nutrients into a form that the body can use or store efficiently.

Bile, bitter, neutral, or slightly alkaline fluid secreted by the liver and passed through a duct into the gallbladder, where it is stored and, as necessary, released into the duodenum. As formed in the liver, bile is a thin, watery fluid to which the gallbladder adds a mucous secretion, forming a complex thickened and stringy substance consisting of salts and bile salts, proteins, cholesterol, hormones, and enzymes. The gallbladder returns water containing salts and other materials to the circulation and concentrates the complex further by a tenfold reduction of the bile salts, which the liver synthesizes from cholesterol. Such foods as fats, egg yolk, and foods rich in cholesterol cause concentrated

http://en.wikipedia.org/wiki/Greek_language

21

bile, together with secretions from the pancreas, to be discharged into the duodenum to promote digestion, to stimulate peristalsis and absorption, and to carry off excess cholesterol and the disintegration products of overage red blood cells. The hemoglobin of such disintegrating cells degrades rapidly into reddish-yellow bilirubin, predominant in the bile of carnivorous and omnivorous animals, and biliverdin, a green pigment that appears in the bile of herbivores. Under normal conditions, the liver efficiently clears these pigments.

Gallbladder- The function of the gallbladder is to store bile, secreted by the liver and transmitted from that organ via the cystic and hepatic ducts, until it is needed in the digestive process. The gallbladder, when functioning normally, releases bile through the biliary ducts into the duodenum to aid digestion by promoting peristalsis and absorption, preventing putrefaction, and emulsifying fat.

Bile stored in the gallbladder is much more concentrated and thicker than bile that is fresh from the liver. This allows the three-inch gallbladder to store a great deal of bile components. But the thickening process can also create problems in the form of extremely painful gallstones, which are dried, crystallized bile. Fortunately, the entire gallbladder can be removed with little or no lasting ill effect. All that is missing is a small storage sac for bile.

From 1 to 1.5 fluid ounces. The body (corpus) and neck (collum) of the gallbladder extend backward, upward, and to the left. The wide end (fundus) points downward and forward, sometimes extending slightly beyond the edge of the liver. Structurally, the gallbladder consists of an outer peritoneal coat (tunica serosa); a middle coat of fibrous tissue and unstriped muscle (tunica muscularis); and an inner mucous membrane coat (tunica mucosa).

Small intestine is the largest segment of the GIT, accounting for about two thirds of the total length. It folds back and forth on itself, providing surface area for secretion and absorption of the process by which nutrients enter the bloodstream through the intestinal walls. It has three sections, the duodenum, jejunum and ileum. They terminate at the ileocecal valve which controls the flow of digested material from the ileum into the oecal portion of the large intestine and prevents reflux of bacteria into the small intestine.

Large intestine consists of an ascending, segment, on the right side of the abdomen, a transverse segment that extends from right to left in the upper abdomen and a descending segment on the left of the abdomen completing the terminal portion of the large intestine are the sigmoid colon, the rectum and anus. Regulating the anal outlet is a network of striated muscle that forms both the internal and external anal sphincters.

All cells of the body require nutrients. These nutrients are derived from the intake of food that contains proteins fats, carbohydrates, vitamins, minerals, and cellulose fibers

22

and other vegetable matter, some of which has no nutritional value. Primary functions of the GI tract are the following:

The breakdown of food particles into the molecular form for digestion The absorption into the bloodstream of small nutrient molecules produced

by digestion. The elimination of undigested, unabsorbed food stuffs and other waste

products.

Digestive Process

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. After being chewed and swallowed, the food enters the esophagus. It uses rhythmic, wave-like muscle movements to force food from the throat into the stomach. Food in the stomach that is partly digested and mixed with stomach acids is called chyme.

After being in the stomach, food enters the duodenum in the small intestine, bile, pancreatic enzymes, and other digestive enzymes produced by the inner wall of the small intestine help in the breakdown of food.

After passing through the small intestine, food passes into the large intestine. In the large intestine some of the water and electrolytes are removed from the food. Many microbes in the large intestine help in the digestion process. Solid waste is then stored in the rectum until it is excreted via the anus and end of the process.

PATHOPHYSIOLOGY

Advancing ageAdvancing age LifestyleLifestyle

23

Decrease activityDecrease activity

Decrease burning of fatsDecrease burning of fats

Increase intake of fats and salt

Increase intake of fats and salt

High level cholesterol irritates gallbladder

mucosa

High level cholesterol irritates gallbladder

mucosa

Exceeds bile Cholesterol

Exceeds bile Cholesterol

Inability of the bile to dissolve it

Inability of the bile to dissolve it

Change in bile composition

Change in bile composition

Allow low-solubility bile components to come out of the solution

Allow low-solubility bile components to come out of the solution

Cholesterol precipitate out of the bileCholesterol precipitate out of the bile

Formation of small crystals on the gallbladders mucosal surface

Formation of small crystals on the gallbladders mucosal surface

Blockage in the common hepatic or bile ducts

Blockage in the common hepatic or bile ducts

Epigastric pain

Epigastric pain Abdominal

distention

Abdominal distention

Vague pain in RUQ of

the abdomen

Vague pain in RUQ of

the abdomen

24

DRUG STUDYSeptember 11, 2010

GENERIC NAME

BRAND NAME

MECHANISM OF ACTION

INDICATIONS ADVERSE REACTION

DOSAGE, ROUTE &

FREQUENCY

NURSING CONSIDERATION

Vitamin K Phytonadione An anti- hemorrhagic factor that promotes hepatic formation of active coagulation factors.

Hypoprothrom-binemia caused byVitamin k malabsorption

Hypoprothrom-binemia caused by effect of oral anticoagulants

CNS- dizziness

CV- flushing,transient hypotension, after IV administration rapid and weak pulse

SKIN- diaphoresis, erythema

10 mgIVq8º

-Check label for administration route restrictions

-Explain purpose of drug

-Watch for flushing, weakness, tachycardia and hypotension

25

September 11, 2010

GENERIC NAME

BRAND NAME

MECHANISM OF ACTION

INDICATION ADVERSE REACTION

DOSAGE, ROUTE &

FREQUENCY


Omeprazole Omepron -Proton pump inhibitor that reduces gastric acid secretions and decreases gastric acidity

Gastroesophageal reflus disease(symptomatic)

To eliminate Helicobacter pylori

To reduce the risk of gastric ulcers in patients receiving continuous NSAIDS therapy

CNS- headache

GI- dry mouth, diarrhea, abdominal pain, nausea, flatulence, vomiting, constipation

40 mgIV

q12º

-Give drug at least one hour before meals

-Monitor for rash or signs and symptoms of hypersensitivity

-Tell patient to inform prescribed of worsening sign and symptoms of pain

-Warn patient not to chew or crush drug because this inactivates the drug

26

September 11, 2010

GENERIC NAME

BRAND NAME

MECHANISM OF ACTION


DOSAGE, ROUTE &

FREQUENCY


Cefuroxime Pantrexon -Second generation cephalosporin that inhibits cell wall synthesis promoting osmotic instability, usually bactericidal

-Perioperative prevention

CV- phlebitis, thrombophelebitis,

GI- nausea, vomiting diarrhea, anorexia

SKIN- erythematous rashes

Hematologic- eosionophilia, hemolytic anemia

1gmIV

q12º

-Before giving drugs ask patient if he is allergic to pencillins or cephalosporins

-Obtain specimen for culture and sensitivity test before giving first dose

-Tell patient to notify prescriber about loose stools or diarrhea

-Advise patient receiving drug IV to report discomfort at IV insertion site

27

September 11, 2010

GENERIC NAME

BRAND NAME

MECHANISM OF ACTION


DOSAGE, ROUTE &

FREQUENCY


Tramadolhydrochloride

Tramal -A centrally acting analgesiccompound not chemically related to opioids thought to bind to opiate receptors and inhibit reuptake of norepinephrine and serotonin

-Moderate to moderately severe pain

CNS- dizziness, vertigo, headache, somnolence,confusion

CV- vasodilation

GU- urine retention, urinary frequency, menopausal symptoms

50 mgIVq6º

-Tell patient to take drug as prescribed and not to increase dose or dosage interval unless ordered by prescribed

-Reassess patient’s level of pain at least 30 minutes after administration

-Monitor cardivascular and respiratory status

-Monitor bowel and bladder function

28

September 12, 2010

GENERIC NAME

BRAND NAME

MECHANISM OF ACTION


DOSAGE, ROUTE &

FREQUENCY


Metoclopramidehydrochloride

Plasil -Stimulates motility of upper GI tract, Increases lower esophageal sphincter tone and blocks dopamine receptors at the chemoreceptors trigger zone

-To prevent or reduce postoperative nausea and vomiting

CNS- restlessness, anxiety, fever, depression

GI- nausea, bowel disorders, diarrhea

CV- hypotension, bradycardia

GU-urinary frequency, incontinence

Skin- rash, urticaria

10 mgIV

q8º, RTC

-Tell patient to avoid activities that require alertness for 2 hours after doses

-Urge patient to report persistent or serious disease reactions promptly

-Advise patient not to drink alcohol during therapy

-Monitor bowel sounds

29

September 13, 2010

GENERIC NAME

BRAND NAME

MECHANISM OF ACTION


DOSAGE, ROUTE &

FREQUENCY


Bisacodyl Dulcolax Works by stimulating enteric nerves to cause colonic mass movements. it increases fluid and NaCl secretion. Stimulant laxatives mainly promote evacuation of the colon.

Stimulant laxative. It acts directly on the bowels, stimulating the bowel muscles to cause a bowel movement, relieving occasional constipation and irregularity.

GI: abdominal cramping, abdominal distension, diarrhea,

CNS: faintness

10 mg suppository

stat

-Do not give if the patient had allergy in Dulcolax Suppositories

-Do not give if the patient has severe stomach pain; appendicitis; severe constipation; stomach, intestinal, or rectal bleeding; or intestinal blockage

http://www.drugs.com/cdi/bisacodyl.html

30

LABORATORY RESULTS

Ultra Sound

HEMATOLOGY RESULTSeptember 10, 2010

PARAMETER RESULT NORMAL VALUE SIGNIFICANCE

Hemoglobin 134g/L 120-150g/L Normal Hematocrit 0.399 0.38-0.48 Normal RBC Count 4.29 10^12/L 4.2-5.410^12/L Normal RDW-SD 43.30 fl 37-54 fl Normal RDW-CD 13.10% 11-16% Normal

WBC 7.31 10^12g/L 5-10 10^12g/L NormalNeutrophils 0.486 0.45-0.65 Normal

Lymphocytes 0.404 0.25-0.4 Not normal due to possible infection

Monocyte 0.068 0.02-0.1 Normal Eosinophil 0.031 0.020-0.040 NormalBasophil 0.008 0-0.010 Normal

Platelet Count 386 10^12g/L 150-450 10^12g/L Normal

MVC 93 fl 80-100 fl Normal MCH 31 Pg 27-31 Pg Normal

MCHC 33.60 % 31-36% Normal

Mendoza General HospitalPoblacion Sta. Maria Bulacan

Name: N.C. Date: August 13, 2010Age: 58 years oldSex: Female

Impression:Diffused fatty infiltration of the liver and pancreas suggestClinical correlationNon- obstructing CholelithiasisNormal sonogram of the specimenNon- Dilated ducts

September 10, 2010

Examination: Chest X-ray (PA)Roentgenological Report

Impression: Normal Chest Findings

31

September 10, 2010Prothrombin time

Pt: 13.4 sec.Control: 12.9 secINR: 1.12% activity: 68.7%

September 11, 2010 Fluid Serum

Test Result Normal RangeCreatinine .9 mg/dl .7-1.2Sodium 147 mmol/L 137-145Potassium 4.6 mmol/L 3.5-5.1ALKP 117. u/L 38.-126.

*Increase sodium due to increase intake, either orally or parentally

September 10, 2010Partial Thromboplastin time

Pt: 27.9 sec Control: 34.3 sec

September 10, 2010

Blood Typing

Pt result: “B” Rh (+)

32

September 11, 2010

Fasting Blood Sugar

Test Result Normal RangeGlucose 97mg/dl 74-106

September 14, 2010Fecalysis

Color: BrownConsistency: FormedA . Lymbriocoides: None FoundT Trichiura: None FoundHookworm: None FoundE. Histolytica: None FoundWBC:0-1/hpfRBC: 0-1/hpfMucus: RareYeast cells: RareFat Globules: None FoundOccult Blood: Negative

September 12, 2010Prothrombin time

Pt: 10.2 sec.Control: 13.3 secINR: .55% activity: 101.4%

33

NURSING CARE PLAN: PHYSIOLOGIC

ASSESSMENT NURSING DIAGNOSIS

PLANNING NURSING INTERVENTIONS

RATIONALE EVALUATION

Subjective data:“I usually don’t touch my incision because it might have an infection,” as verbalized by the client.

.

Objective data:

-Warm to touch-Post op pain with the pain scale of 3 out of 10.

Vital signs:BP: 120/70 mmHgCR: 85 bpmRR: 15 cpmT: 37.4°C

Risk for infection related to abdominal incision as manifested by:

-Warm to touch-Post op pain with the pain scale of 3 out of 10.


Laboratory resultsLymphocytes= 0.404Sodium=147 mmol/L

Within 4 hours of effective nursing interventions such as proper hygiene, proper cleaning of incision site and administering antibiotic as ordered, the client will be able to remains free from infection.

INDEPENDENT:1. Monitor vital signs

2. Assess incisions for redness, drainage, swelling and increase pain.

3. Maintain and teach asepsis for dressing changes and wound care.

4. Instruct the client and relatives to wash hands.

5. Encourage coughing and deep breathing exercise

6. Advise the patient to avoid lifting heavy objects for 1 week

1. To obtain baseline data

2. To check for signs of infection

3. To decrease the chances of infection

4. To reduces the risk of infection

5. To reduce stasis of secretions in the lungs and bronchial tree

6. To prevent bleeding of the incision site

After 4 hours of effective nursing interventions such as proper hygiene, proper cleaning of incision site and administering antibiotic as ordered, the client was able to remains free from infection as evidenced by good healing of incision site that is free of redness, swelling, purulent discharge and by normal body temperature.

Latest vital signs:BP:120/70 mmHgCR: 90 bpmRR: 15cpmT: 36.5°C

34

Laboratory results:Lymphocytes= 0.404

7. Instruct the patient to wash the puncture site with mild soap and water

8. Increase fluid intake

9. Advise the patient to comply to her follow up check up

DEPENDENT:1. IVF as ordered

2. Administer antibiotics as ordered

INTERDEPENDENT:1. Monitor WBC

7. To maintain asepsis in the incision site

8. To promote proper hydration

9. To evaluate the patient’s condition after hospitalization

1. To promote proper hydration

2. To prevent infection

1. To monitor risk for infection

35

NURSING CARE PLAN: PSYCHOLOGIC

ASSESSMENT NURSING DIAGNOSIS

PLANNING NURSING INTERVENTIONS

RATIONALE EVALUATION

Subjective data:

“I’m not able to eat my favorite foods,” as verbalized by the client.

Objective data:

-verbalization of inability to cope-fatigue-sleep disturbance


Ineffective coping related to recent change in health status as manifested by:

-verbalization of inability to cope-fatigue-sleep disturbance


Within 6 hours of effective nursing interventions such as therapeutic communication, the client will be able to understand the importance of healthy lifestyle and she will be able to set a goal for her balance diet.

INDEPENDENT:1. Established a

therapeutic relationship

2. Assess level of understanding and readiness to learn needed lifestyle changes

3. Assist patients to accurately evaluate the situation and their own accomplishments

4. Explore attitudes and feelings about required lifestyle changes

1. To let the patient feel secured and comfortable

2. To provide appropriate and accurate information and understanding option

3. To recognize that the patient has the skills and reserves of strength

4. To understand how the client respond to changes

After 6 hours of effective nursing interventions such as therapeutic communication, the client was able to understand the importance of healthy lifestyle and she was able to set a goal for her balance diet as evidenced by verbalization of understanding about her proper diet.

Latest vital signs:BP:120/70 mmHgCR: 90 bpmRR: 15cpmT: 36.5°C

36

5. Encourage the client to set realistic goals like avoiding high fatty foods and restriction of carbonated beverages

6. Encourage the client to communicate feelings with significant others

7. Point out maladaptive behaviors

8. Instruct in need for adequate rest and balanced diet

9. Teach use of relaxation exercise and diversional activities as method to cope with stress

5. To help the client gain control over the situation

6. To decrease stress

7. To help the client to focus on appropriate strategies

8. To promote a healthy lifestyle

9. It can be used toward assisting client to reduce level of stress

37

DISCHARGE PLANNING

MedicationTake full course of medicines in a right time, dosage and frequency to obtain the best result of the drug effect.

Take home medications:

Amoxicillin 500 mg capsule BID for 7 days as antibioticLevofloxacin 500 mg tablet OD for 7 days as antibioticOmeprazole 20 mg capsule BID for 7 days for gastric acidityBetamethasone cream apply 3 times a day for allergyTramadol 50 mg capsule TID PRN for pain

ExerciseEncourage the patient to do simple exercise such as stretching and walking in

the morning.

TherapyStress management to cope up with everyday stressors by having a recreational

activity.

Health Teachings1. Proper hand washing.2. Encourage client to do deep breathing exercises to promote lung expansion.3. Avoid heavy work lifting or straining.4. Instruct the patient and the relatives to wash hands before contact with the

postoperative patient and on changing the dressing. 5. Encourage the client to use binder or pillow at the incision site when coughing.6. Take a complete bed rest to restore energy and stamina.7. Observe proper hygiene to keep the body clean and well groomed.8. Encourage the patient to participate in any various forms of recreation9. Educate the client about the medication she will take at home10.Encourage measures to promote bowel function such as increase fluid intake,

attention to urge to defecate and ambulation

Out-patient follow-up Advice the patient to comply at the schedule time of follow up check up. The follow-up check up is on September 17, 2010.

Diet

Eat well balanced diet low fat, low sodium, high calorie to have a source of energy, to protein to promote immediate healing in the operative site.

38

REFLECTION AND INSIGHTS

Cholecystolithiasis is a disease characterized by the inflammation of gall bladder which extends in forming gallstones. This kind of disease is associated with acute abdominal pain, nausea, vomiting, jaundice, and sometimes low grade fever secondary to inflammation.

We the group I, are able to define and understand this case with all of our best and precious time to study this cholecystolithiasis. We are able to meet our learning objectives by describing the appropriate medical, surgical, and also the Nursing management for the patient with Cholecystolithiasis and then during the recovery phase of our patient, we were given a chance to show our post operative care for Mrs. NDC and explained it well to her and also in our presentation. And lastly we were able to use the Nursing process as a framework in giving care to the patient undergoing Laparascopic Cholecystectomy.

After constructing our case study, we realized Cholecystolithiasis is fatal if the management is not attain immediately and emergency may occur if chronic inflammation had experienced. We learned that lifestyle has a big factor in developing Cholecystolithiasis because of that, we started to modify our lifestyle in order to prevent this disease. And we will be able to share our knowledge and what we had learned to others.

It contributes to our life as a Nursing student by knowing the pathophysiologic changes of this disease, to prevent the occurrence of having gallstones and also giving care to ourselves not only in our patient but also started to us.

39

REFERENCES

Medical –Surgical Nursing Critical Thinking for Collaborative Care Vol.1 5th EditionIgnativicius Workman

Brunner & Suddarth’s Textbook of Medical-Surgical Nursing Vol. 1 10th EditionSuzanne C. Smeltzer

Brenda G. Bare

Nursing Care Plan 6th EditionCulanick/Myers

Understanding Pathophysiology 3rd EditionSue E. Muether, Kathryn L. Mc Cance

Health Assessment in Nursing 3rd Edition

Kozier and Erb’s Fundamentals of Nursing Vol 1 & 2 8th EditionKozier, Erb, Berman and Synder

Theoretical Foundation of Nursing: The Philippine RespectiveCarl E. Balita

Eufemia F. Octaviano

Lippincott’s Drug Handbook 2007

Nurse’s Pocket Guide Diagnose, Prioritized Intervention and RationalesMarilynn E Doengers

Mary Frances MoorhouseAlice C. Murr

Basic Nutrition of FilipinosClaudio and Dirige

Ultimate Learning Guide to Nurses ReviewCarl E. Balita

Documents

Cholecystitis Repaired)