I. INTRODUCTION

Cholecystectomy is the surgical removal of the gallbladder. Despite the

development of non-surgical techniques, it is the most common method for treating

symptomatic gallstones, although there are other reasons for having this surgery done.

Each year more than 500,000 Americans have gallbladder surgery. Surgery options

include the standard procedure, called laparoscopic cholecystectomy, and an older more

invasive procedure, called open cholecystectomy. A cholecystectomy is performed when

attempts to treat gallstones with ultrasound to shatter the stones or medications to

dissolve them have not proven feasible.

Gallbladder disease is cured by removal of the gallbladder in a procedure

referred to as a cholecystectomy—the most common surgical procedure performed on the

biliary tract. A cholecystectomy is performed to relieve the gastrointestinal distress

common in patients with acute or chronic cholecystitis (with or without gallstones); it

also removes a source of recurrent sepsis. Persistent infection in the biliary tract may

cause recurrent stones.

Open cholecystectomy is a surgery in which the abdomen is opened to permit

cholecystectomy -- removal of the gallbladder. This operation has been employed for

over 100 years and is a safe and effective method for treating symptomatic gallstones,

ones that are causing significant symptoms. At surgery, direct visualization and palpation

of the gallbladder, bile duct, cystic duct, and blood vessels allow safe and accurate

dissection and removal of the gallbladder. Intra-operative cholangiography has been

variably used as an adjunct to this operation. The rate of common bile duct exploration

for choledocholithiasis (gallstones in the bile duct) varies from 3% in series of patients

having elective operations to 21% in series that include all patients. Major complications

of open cholecystectomy are infrequent and include common duct injury, bleeding,

biloma, and infections.

With an open abdominal cholecystectomy, the gallbladder is usually exposed

through a right subcostal incision (Kocher incision) that may be extended over to the

midline at the level of the xiphoid. The incision should be adequate for good exposure of

the gallbladder and bile ducts. After exploration of the abdominal cavity, laparotomy

packs are used to wall off the surrounding organs for exposure. The bilious contents of

the gallbladder may be aspirated to prevent bile from spilling into the peritoneal cavity - a

potential source of peritonitis, especially if the gallbladder is inflamed and tightly

distended. The cystic duct, cystic artery, hepatic ducts, and common bile duct are

accurately identified.

Open cholecystectomy is the standard against which other treatments must be

compared and remains a safe surgical alternative.

The student chose this case study in the hope of gaining more insights,

realizations and helpful theory to lessen the vivacity of the disease, the surgery and its

post operative management of the patient as well as of imparting basic knowledge on the

disease process of cholecystitis, its medical management, the factors contributing to its

occurrence and the normal anatomy & physiology of the affected system. And lastly, may

this study serve as a comprehensive tool for better understanding of the nurse’s role in the

incidence of such case that may help her develop new skills in rendering holistic nursing

care.

II. OBJECTIVES

GENERAL OBJECTIVE

After 5 days of giving holistic nursing care, the patient and the significant others

will be able to gain knowledge, skills, and attitude in the care of the member who

undergone an open cholecystectomy.

SPECIFIC OBJECTIVES

After 5 days of student nurse - patient interaction, the student nurse will be able

to:

1. make a thorough assessment about the patient’s personal history, family

background, and lifestyle.

2. identify predisposing and precipitating factors that have contributed to the

patient’s present condition.

3. review the normal anatomy and physiology of the gallbladder.

4. discuss the pathophysiology of acute calculous cholecystitis.

5. identify the physiologic problems manifested by the patient.

6. formulate a comprehensive nursing care plan in the care for patient with

acute calculous cholecystitis.

8. implement health teachings for the improvement of the patient’s well being.

2. evaluate patient’s reaction, state or condition after are implementation of

care plan.

After 5 days of student nurse - patient interaction, the patient will be able to:

1. state information about self, family background, and history of condition

2. express feelings, perceptions and fears that cause disturbance.

3. verbalize physiologic, psychologic discomforts and other needs.

4. cooperate on the interventions to be rendered by the student nurse.

5. develop skills in immediate nursing measures on incidences of discomfort

or occurrences of possible complications.

6. develop self-care to the fullest possible level.

7. apply the learned nursing measures in her activities of daily living.

III. NURSING ASSESSMENT

1. PERSONAL HISTORY

1.1 Patient’s Profile

Name: Balansag, Nicolas

Age: 46 years old

Sex: Male

Civil Status: Married

Religion: Roman Catholic

Date of Admission: Aug. 8, 2007

Room No.: 424

Complaints: right upper quadrant pain,

general abdominal pain for 1 month

Diagnosis: Acute Calculous Cholecystitis

Physician: Dr. Bernadette Moscoso

1.2 Family and Individual Information, Social and Health History:

Mr. Balansag is residing at Dona Rita Village 1C Compound, Banilad,

Cebu City with her wife and their 2 daughters. Patient is working as a mechanic at Don

Bosco School. Patient is an occasional alcoholic drinker, a slight smoker which consumes

around 3 sticks per day. He has no known allergy to food and drugs. Patient is known to

be hypertensive at the age of 40. His usual blood pressure is 140/90 and has a highest

blood pressure of 160/100. He has been taking his maintenance drug for his BP which is

the Neobloc.

Patient had an STD during his 20’s. Patient is non-diabetic and non-asthmatic.

Patient complains of general abdominal pain for 1 month now and

that he hasn’t been able to sleep well because of the pain felt in his right upper

quadrant. He seek consult to Dr. Moscoso thus advised to be admitted to Cebu

Doctors’ Hospital on April 7, 2007.

1.3 Level of Growth and Development

1.3.1 Normal Development at Particular Stage

Physical Development

Integumentary system, appropriate distribution of pigmentation, slow

progressive decrease in skin turgor, skin turgor and moisture decrease, subcutaneous fat

decreases and wrinkling occursfatty tissue is redistributed, resulting in fat deposits in the

abdominal area, hair begins to thin, and gray hair appears.

Respiratory system, Anteroposterior diameter increased, respiratory rate

16-21 breaths per minute, normal tactile fremitus, resonance and breath sounds heard

throughout.

Cardiovascular System, Blood vessels lose elasticity and become thicker,

normal heart sounds (systole-S, < S2 at the base; diastole-S, > S2 at the apex), point of

maximal impulse at fifth intercoastal space in the mid-clavicular line and 2cm or less in

diameter, blood pressure: systolic 95 to 140 mmHg, diastolic 60 to 90 mmHg, all pulses

are palpable.

Reproductive System, normal penis and scrotum, prostatic enlargement in

some men, the climacteric (andropause) refers to the change of life in men, when sexual

activity decreases, androgen levels decrease very slowly.

Musculoskeletal System. Thinning of the intervertebral discs causes a

decrease in height of about 1 inch. Calcium loss from bone tissue is more common

among postmenopausal women. Muscle growth continues in proportion to use, decreased

muscle mass, pathologic fractures resulting from osteoporosis, decreased range of joint

motion.

Sensory Changes. Visual acuity declines, often by the late 40s, especially

for near vision (presbyopia),visual acuity by Snellen chart < 20/50, pupillary reaction to

light and accommodation, normal visual fields and extraocular movements, normal retina

structures, auditory acuity for high-frequency sounds decreases (presbycusis), particularly

in men, normal auditory structures and acuity, patent nares and intact sinuses, mouth and

pharynx, trachea at midline, lateral thyroid lobes and nonpalpable, taste senasations

diminish.

Psychosocial Development

Is in the generativity versus stagnation phase of Erikson’s stages of

development. Accept aging body. Feel comfortable and respect self. Enjoy new freedom

to be independent. Self seems more altruistic, and concepts of service to others and love

and compassion gain prominence. Accept changes in family roles (e.g., having teenaged

children and aging parents). Interact well and share companionable activities with life

partner. Expand and renew previous interests. Pursue charitable and altruistic activities.

Have meaningful philosophy of life. These concepts motivate charitable and altruistic

actions, such as church work, social work, political work, community fund raising drives,

and cultural endeavors. The middle-aged person looks older and feels older. People

usually accept the fact that they are aging; however, a few try to defy the years by

changing their dress and even their actions.

Cognitive development

Reaction time during the middle years stays much the same or diminishes

during the later part of the middle adulthood. Memory and problem solving are

maintained through middle adulthood. Learning continues and can be enhanced by

increased motivation at this time in life. Middle-aged adults are able to carry out all the

strategies. Some may use postformal operations strategies to assist them in understanding

the contradictions that exist in both personal and physical aspects of reality. The middle-

aged adult can “ reflect on the past and current experience and can imagine, anticipate,

plan and hope” (Muray and Zentner,2001, p.722)

Spiritual Development

In middle age, people tend to be less dogmatic about religious beliefs, and

religion often offers more comfort to the middle-aged person than it did previously.

People in this stage rely on spiritual beliefs to help them deal with illness, death and

tragedy. At this stage, the individual can view “truth” from a number of viewpoints.

1.3.2 The Ill Person at a Particular Stage of Patient

Physiological concerns for the middle adult include stress, level of

wellness, and formation of positive health habits.

Because middle adults are experiencing physiological changes and

face certain health realities, their perceptions of health and health behaviors

are often important factors in maintaining health.

Attention to risk factors that can be altered to improve the client's

health such as stress, obesity, use of tobacco, excessive alcohol consumption,

poor nutrition, and unsafe sexual practices, can increase the quality of life and

add years to it.

Anxiety is a critical maturational phenomenon related to change,

conflict, and perceived control of the environment. Adults often experience

anxiety in response to the physiological and psychosocial changes of middle

age. Depression that occurs during the middle years is commonly

characterized by moderate-to-high anxiety and physical complaints.

Chronic illnesses such as hypertension, diabetes mellitus, cancer may

affect the roles and responsibilities assumed by the middle adult. Strained

family relationships, modifications in family activities, increased health care

tasks, increased financial stress, the need for housing adaptation, social

isolation, medical concerns, and grieving may also result from chronic illness.

The degree of disability and the client's perception of both the illness and the

disability determine the extent to which lifestyle changes will occur. A few

examples of the problems experienced by clients who develop debilitating

chronic illness during adulthood include role reversal, changes in sexual

behavior, and alterations of self-image.

2. Diagnostic results

Radiology Department:

Operative Cholangiography

Remarks: Calcified galstones

               Persistent filling defects in the common bile duct suggestive of radiolucent

Chest PA

Remarks:  No significant cardiopulmonary finding

 Ultrasound

Remarks: Cholelithiases, biliary tract obstruction secondary to choledocholothiasis

               The rest of abdomen are unremarkable

Surgical Pathology / Cytology Report

 Specimen:

      GALLBLADDER

 Remarks:  Chronic calcolous cholecystitis

Hematology

DIAGNOSTIC TEST NORMAL VALUES PATIENT’S RESULT SIGNIFICANCE

CBC     normal

Hgb 13-18gm/dL 15.1gm/dL normal

Hct 42-52% 44.2% normal

WBC 4.4-11.1x10g/UL 8.43 x 10 g/UL normal

Eosinophil 0-3% 3% normal

Lymphocyte 20-40% 23% normal

Monocyte 2-8% 3% normal

RBC 4.6-6.2x10/L 5.62 x 10/L normal

MCV 84-96cu um 78.7 cu um Decreased, microcytic

anemia

MCH 28-33mm g/cell 26.9mm g/cell Decreased, microcytic

anemia

MCHC 33-35% 34.9% normal

platelet 150,000-450,000/

cumm

293,000/cumm normal

Prothrombin time 12-14 sec 11.4 sec Decreased, prolonged

deficiency of factor

I,II,V,VII,X,fat

metabolism, severe

liver disease.

Conrol 10-14 sec 12.3 sec normal

Glucose blood 65-110mg/g: 94 mg/g normal

Phosphatase alkaline 38-126 U/L 251 U/L Increased, hepatic

disease

SGPT 11-66U/L 291 U/L Increased, hepatic

disease

3. Present Profile of Functional Health Pattern (Pre-operatively)

3.1 Health Perception / Health management

            Before the diagnosis, the patient already complains of on and off tolerable pain

with a scale of 6 from 1-10 pain scale. Felt at the epigastric region radiating to back, that

would last for around 10 to 20 seconds. Pain is described as constant, aggravated usually

after eating relieved by rest and relaxation in bed and pain relievers. The patient has

described his health as poor, due to the known diagnosis at present, since he is aging, he

admits of some limitations in his activities as compared to his past health status.  As of

now, he feels fine except from his experience of pain and reduced activity. Patient says

that he never tried any attempts of dieting or any weight loss programs; he had  an apple

juice therapy. He is not completely immunized.

3.2 Nutritional-Metabolic Pattern

            Prior to admission, patient’s meals usually consist of rice and dried fish, and

often pork during lunch and dinner time and usually eat bread with coffee during

breakfast. For his snacks he eats banana or bread. His fluid intake is about 8 glasses a day

and says that he drinks apple juice and carbonated drinks often. He does not have any

problems with his appetite. The patient takes in Shilintong tab a Chinese medicine as his

daily supplements and he often drinks 4 glasses/day of apple juice. His weight has not

changed for the last six months and he does not have any problems with his ability to eat

such as swallowing or chewing liquids and solids. He is currently on NPO status prior to

scheduled surgery tomorrow.

3.3 Elimination Pattern

            Patient reports of very dark colored urine. He does not make use of any assistive

devices. He used to defecate once a day. He says that the usual characteristics of his

stools are clay colored, hard and well-formed. Patient does not make use any assistive

device.  Patient has a good skin turgor but has jaundice and pruritus.

3.4 Activity / Exercise Pattern

            Patient does not do routine exercises and considers household chores to be one of

his exercises. In addition, he also walks daily. He can ambulate freely.

3.5 Cognitive /   Perceptual Pattern

            Patient says that he has no hearing problems except for his visual acuity, since he

no longer sees fine fonts clearly without his glasses. He said that he used to wear glasses,

but unfortunately his glasses got lost. He does not use any hearing aids and he complains

of dizziness at times.

3.6 Rest /   Sleep Pattern

            He usually sleeps at 11:00 midnight and wakes up at around 7:00 am until now,

that he is hospitalized.  He has problems with sleeping early, so he usually drinks a warm

cup of milk and  some biscuits.

3.7 Self-perception Pattern

            He is concerned about getting well and as much as possible be free of any illness,

but it does not bother him that well.  Being ill has not changed or made him feel different

about himself although for him, aging has indeed led him to be more health conscious.

3.8 Role-relationship Pattern

            He is married, a father of two children and is currently living with his eldest son

and grandchildren.   He makes decisions with the help of his children.

3.9 Sexuality-Reproductive Pattern

           The patient is being open minded to the things with regards to sexuality. He is

already a middle age adult and has no problem about his sexuality and his activities

regarding his life. He knows that he must start practicing good hygiene. Now he has

sexual activities for some time.          

3.10 Coping ?Stress Tolerance Pattern

           He usually sleeps at long hours or watch television when he feels tired. He makes

decisions together with his children. He is already retired, and says that he does not want

to change anything with his life. When is tense or under stress, he seeks help from his

children.

3.11 Value-belief System

            The patient as well as significant others is a Roman Catholic. Patient claims to be

attending masses regularly but is inactive in any spiritual groups or activities.

IV. PATHOPHYSIOLOGY AND RATIONALE

The Normal Anatomy and Physiology of the Organ Affected

The Gallbladder

The gallbladder (or cholecyst, sometimes gall bladder) is a pear-shaped organ that

stores about 50 ml of bile (or "gall") until the body needs it for digestion. The gallbladder

is about 7-10 cm long in humans and appears dark green because of its contents (bile),

rather than its tissue. It is connected to the liver and the duodenum by the biliary tract.The

cystic duct connects the gallbladder to the common hepatic duct to form the common bile

duct. The common bile duct then joins the pancreatic duct, and enters through the

hepatopancreatic ampulla at the major duodenal papilla.

The gallbladder stores about 50ml of bile (1.7 US fluid ounces / 1.8 Imperial fluid

ounces), which is released when food containing fat enters the digestive tract, stimulating

the secretion of cholecystokinin (CCK). The bile, produced in the liver, emulsifies fats

and neutralizes acids in partly digested food.After being stored in the gallbladder, the bile

becomes more concentrated than when it left the liver, increasing its potency and

intensifying its effect on fats. Most digestion occurs in the duodenum.

4.2 DISEASE PROCESS AND ITS EFFECTS ON DEIFFERENT ORGAN/SYSTEM

Cholecystitis is a medical condition, in which gallbladder’s wall becomes inflamed, and

is usually caused by a gallstone in the cystic duct, that results in an attack of abrupt

severe pain. At least 95% of the patients with Cholecystitis have gallstones. In very rare

cases, a bacterial infection results in inflammation. Cholecystitis starts with sudden, sharp

pain in the upper abdomen. In most cases this medical condition is very severe and may

cause perforation of the gallbladder or gangrene. Prompt surgery is needed to remove the

diseased gallbladder. The symptoms of acute cholecystitis include pain in the right upper

area of the abdomen and it is a 1st sign of inflammation of the gallbladder. The pain may

become worse when a patient is breathing deeply and frequently extends to the lower area

of the right shoulder blade. Vomiting and nausea are common. A patient usually

experiences sharp pain when a physician presses the upper right area of the abdomen.

During a several hours, the muscles of the abdomen on the right side can become rigid.

At beginning, the patient can have only slight temperature, but later it tends to become

high. Usually Acute Cholecystitis attack is subsiding in two or three days and fully

disappears in 7 days. If it does not, the individual can have severe complications such as

high fever, gangrene, gallbladder perforation, shivering, and others. Prompt surgery is

required for these conditions. Acute Cholecystitis usually accompanied by jaundice or a

backup of bile into the liver, showing that the common bile duct can be partially

obstructed by inflammation or gallstone. If blood tests determine a higher level of the

enzyme amylase, a patient can have pancreatitis (pancreas inflammation), resulted from

gallstone obstruction of the pancreatic duct. Diagnosis of Acute Cholecystitis depends on

the patient’s symptoms and the results of specific tests. Ultrasound scan may help to

determine the presence of gallstones in the gallbladder and may show thickening of the

wall of gallbladder. The procedure called Hepatobiliary Scintigraphy provides more

accurate diagnosis. In this test, images of liver are taken, as well of galbladder, upper

portion of the small intestine and bile ducts. A patient with Acute Cholesystitis usually is

hospitalized, getting intravenous electrolytes and fluids, and not permitted eat or drink.

Physician can pass a tube through the nose and into the stomach, so that suctioning may

be used to maintain stomach empty and thus reduce gallbladder stimulation. Antibiotics

are given as soon as Acute Cholecystitis is suspected. If the diagnosis of acute

gallbladder inflammation is confirmed and the risk of operation is small, the gallbladder

is usually taken out within 1 or 2 days of the disease, but if a patient has another disease

that increases the surgery’s risk, the operation can be delayed until that illness is treated.

If Acute Cholecystitis attack subsides, the gallbladder can be taken out later approx after

1 1/2 months or more. If such side effects like gangrene, gallbladder perforation, abscess

occur, prompt surgery is usually required. Some individuals have recurring or new

incidences of pain that feel like Acute Cholesystitis attack even though they have no

gallbladder. The cause of these incidences is unknown, but they cab be caused by a

defected function of the sphincter of Oddi - the opening, that releases bile into the small

intestine. Pain is suggested to be caused by increased pressure in the duct resulted from

resistance to the bile flow or secretions of pancreatis. In some individuals, small

gallstones, which are remains after operation, can result in pain. Physician may use an

endoscope to widen the sphincter of Oddi. This procedure generally relieves symptoms in

patients with abnormal sphincter, but does not help people who only experience pain.

4.3 Classical and Clinical/Actual Symptoms (Pre-operatively)

Classical Symptom Clinical Symptom Rationale

Pain and Biliary Colic

Jaundice

Manifested

patient feels the pain

on her right upper

quadrant of her

abdomen

score of 6/10 in a

pain scale

facial grimace noted

pain radiates to the

back

Manifested

The skin of the

patient is slightly

yellowish in color.

Itching on the

extremities

If a gallstone obstructs the

cystic duct, the gallbladder

becomes distended,

inflamed, and eventually

`infected. The patient may

have biliary colic with

excruciating upper right

abdominal pain that radiates

to the back or right

shoulders, is usually

associated with nausea and

vomiting and is noticeable

several hours after a heavy

meal.

Jaundice occurs in a few

patients with gallbladder

disease and usually occurs

with obstruction of the

common bile duct. The bile

which is no longer carried

to the duodenum, is

absorbed by the blood and

gives the skin and mucous

membrane a yellow color.

This is frequently

accompanied by marked

Changes in Urine and Stool

Color

Vitamin Deficiency

Manifested

grayish stools

Tae colored urine

Not Manifested

itching of the skin.

The excretion of bile

pigments by the kidney give

the urine a very dark color.

The feces, no longer

colored with bile pigments,

are grayish, like putty and

usually described as clay-

colored.

Obstruction of the bile flow

also interferes with the

absorption of fat-soluble

vitamins A, D, E, K.

Therefore the patient may

exhibit deficiencies (eg,

bleeding caused by vitamin

K deficiency, which

interferes with normal

blood clotting) of these

vitamins if biliary

obstruction has been

prolonged.

4.4 Schematic Diagram of the of the Pathophysiology of Cholelithiasis

Precipitating Factors Predisposing Factors

- excessive fat ingestion - sex (female)

- decreased bile acid synthesis - age above 40 years old

- increased cholesterol synthesis - fertile women (estrogen)

in the liver - frequent weight changes

- infections in the biliary tract

Bile supersaturated with cholesterol

Bile forms into gallstones

Gallstones acts as an irritant

Inflammatory changes in the gallbladder

Clinical Manifestations

- Pain and Biliary Colic

- Jaundice

- Changes in urine and stool color

- Vitamin deficiency (A,D,E,K)

Medical Management Surgical Management Nursing Management

- NGT insertion- Antibiotic theraphy- Parenteral Fluids-Analgesic- Lithotripsy

-Laparoscopic Cholecystectomy- Open cholecystectomy

- rest for the client-monitoring client’s ability to digest bland diet.-observe for increased pain, shock, or signs of internal bleeding.

Present Profile of Functional Health Pattern (Post-operatively)

1 Health Perception / Health management 

            Patient appears tired as he has slow guarded movements and could only speak minimally. Discomforts of postoperative surgery were evident as the patient felt pain, constipation and feeling of weakness. However, he verbalizes that he is happy for a successful operation, and describes his health better, now that he is slowly recovering.

2 Nutritional-Metabolic Pattern

            He is currently under NPO but is allowed to take sips of water and usually nibbles on some crackers.

3 Elimination Pattern

            Patient is currently using a Foley bag catheter with 50cc urine,JP drain with 20cc of drainage and T tube with 15cc of drainage during the morning shift of her second post operative day. He has not defecated yet. Patient’s skin exhibits good color and turgor, stable temperature and no edema noted.

4 Activity / Exercise Pattern      

            Patient is found lying in bed and still asks assistance from significant others for help. He can change positions, as he complains.  He looks tired.  Before admission he exercises by walking and doing household chores. 

  5 Cognitive /   Perceptual Pattern

            He used to have glasses.  He can read and write. However, as of now, he is tired and rests in bed most of the time

6 Rest /   Sleep Pattern

            Patient was seen sleeping most of the time after the surgical procedure.

7 Self-perception Pattern

            He is much concerned of his health now.  His present health goal is to get well as soon as possible after a successful surgery.

8 Role-relationship Pattern

            His eldest son, who is currently working as a drug representative, helps him in the care and financial aspect of his present health condition.

9 Sexuality-Reproductive Pattern

            He had just undergone Open Cholecystectomy.     

10 Coping-Stress Tolerance Pattern

            He is currently resting since he feels tired after the operation.

11 Value-belief System

            For him, his condition had not changed his faith in God, however it has even

increased his faith since he believes that this is part of God뭩 purpose for him and that he

trusts God in his healing.

Classical and Clinical/Actual Symptoms (Post-operatively)

Classical Symptom Clinical Symptom Rationale

Pain and Biliary Colic

Jaundice

Not manifested

Manifested

Still the skin of the

patient is slightly

yellowish in color.

Itching on the

extremities

If a gallstone obstructs the

cystic duct, the gallbladder

becomes distended,

inflamed, and eventually

`infected. The patient may

have biliary colic with

excruciating upper right

abdominal pain that radiates

to the back or right

shoulders, is usually

associated with nausea and

vomiting and is noticeable

several hours after a heavy

meal.

Jaundice occurs in a few

patients with gallbladder

disease and usually occurs

with obstruction of the

common bile duct. The bile

which is no longer carried

to the duodenum, is

absorbed by the blood and

gives the skin and mucous

membrane a yellow color.

Changes in Urine and Stool

Color

Vitamin Deficiency

Not manifested

Not Manifested

This is frequently

accompanied by marked

itching of the skin.

The excretion of bile

pigments by the kidney give

the urine a very dark color.

The feces, no longer

colored with bile pigments,

are grayish, like putty and

usually described as clay-

colored.

Obstruction of the bile flow

also interferes with the

absorption of fat-soluble

vitamins A, D, E, K.

Therefore the patient may

exhibit deficiencies (eg,

bleeding caused by vitamin

K deficiency, which

interferes with normal

blood clotting) of these

vitamins if biliary

obstruction has been

prolonged.

V. Nursing Intervention

Relieving pain

      The location of the subcostal incision in nonlaparoscopic gallbladder surgery disease

is likely to cause the patient to avoid turning and moving, to splint the affected site, and

to take shallow breaths to prevent pain. Because full exacerbation of the lings and

gradually increased activity are necessary to prevent postoperative complications, the

nurse should administer analgesic agents as prescribed to relieve pain and promote well-

being.

Improving respiratory status

      Patients undergoing biliary tract surgery are prone to pulmonary complications, as are

all abdominal incision. Thus, the nurse remind patient to take deep breaths and cough

every hour to expand the lungs fully and prevent atelectasis.

Monitoring and Managing Potential Complications

      Bleeding may occur as a result of inadvertent puncture or nicking of major blood

vessel. Post-operatively, the nurse closely monitors vital signs and inspects the surgical

incision and drains, if in place, for evidence of bleeding.

Improving Nutritional Status

      The nurse encourages the patient to eat a diet low in fats and high in carbohydrates

and proteins especially after surgery. At the time of hospital discharge, these are usually

no special dietary instructions other than to maintain a nutritious diet and avoid excessive

fats. Fat restriction usually is lifted in 4-6 weeks when the biliary ducts dilate to

accommodate the volume of bile once held by the gallbladder and when the ampulla of

Vater again functions affectively.

Promote Skin and Biliary Drainage

      In patient who have undergone cholecystectomy, the drainage tubes must be

connected immediately to a drainage receptacle. The nurse fasten tubing to the dressing,

with enough leeway for the patient to move without dislodging.

2.1 NURSING CARE PLAN

Problems/needs/ Cues

Nursing diagnosis

Scientific Basis Objectives Of Care

Nursing Actions Rationale

Physiologic Overload

A. Altered comfort

Cues:

-pain

-facial grimace

-guarded movements

-presence of operative wound

-throbbing pain on the abdomen radiating to the lower back lasting for 2-5 minutes that is aggravated by sudden movement but relieved by massage of surrounding areas and pain medication

“sakit man ang gi-operahan dong” as said by the patient

Altered Comfort: Mild Pain related to operation performed

“Most patients experience some degree of pain after a surgical procedure. The degree and severity of postoperative pain and the patient’s tolerance for pain depend on the incision site, the nature of the surgical procedure, the extent of surgical trauma, the type of anesthetic agent and how the agent was administered.”

Source: Medical-Surgical Nursing by Suzanne C. Smeltzer and Brenda G. Bare; 9th edition

p.355

After 2 days of holistic nursing caring care, the client will be able to:

1. minimize discomfort at tolerable level

1. minimize discomfort at tolerable level

1.1 provide comfort measures like therapeutic touch

1.2 perform assessment each time pruritus occurs

1.3 accept client’s description of itching

1.4 encourage adequate rest periods

1.5 perform tepid sponge bath

1.6 modify environment like using electric fan

1.7 review procedures to client like blood transfusion and sponge bath

1.8 advise client to wear loose clothing

1.9 provide diversional activities

1.1 to provide nonpharmacologic relief

(NANDA 9th ed., p.368)

1.2 to monitor progress of condition

(NANDA 9th ed., p.367)

1.3 it is a subjective experience and differs from others

(NANDA 9th ed., p.367)

1.4 to prevent fatigue

(NANDA 9th ed., p.369)

1.5 to prevent further itching and aid in healing process

(Potter and Perry, Fundamentals of Nursing p. 1062)

like social interaction, hanging out in the garden

1.10 administer medications as ordered

1.6 to provide comfort and relaxation

(NANDA 9th ed., p.368)

1.7 to reduce concern of the unknown and stress

(NANDA 9th ed., p.368)

1.8 itching may be initiated by physical substance

(Medical-Surgical Nursing by Black, 7th ed., p. 1394)

1.9 to relieve mind of discomfort

(NANDA 9th ed., p.368)

1.10 to medicate prophylactically as appropriate

(NANDA 9th ed., p.368)

Physiologic deficit

B Impaired Skin Integrity

Cues:

-incision site on abdomen 3-5 cm

Impaired skin integrity: presence of surgical incision related to operative procedure

“Surgery interrupts the integrity of the skin surface providing a potential portal of invasion of bacterial”

Medical-surgical Nursing p.1573 by Lemone and Burke ;10th edition

2. manifest timely wound healing as evidenced by the absence of dehiscence and evisceration

Measures to:

2. promote good wound healing

2.1 monitor site of impaired tissue integrity and determine etiology

2.1 Poor assessment of wound etiology is critical for proper identification of nursing interventions (Source: Nursing Care Plans by Doenges)

2.2 wound assessment is more reliable when

-dressing on site present

-bleeding still present on surgical site

-skin seems a dry and wrinkly

-“bag-o pa man ko gi-operahan dong” as verbalized by the client

2.2 determine size and depth of wound

2. 3.monitor site of impaired tissue integrity

2.4.monitor status of skin around wound, monitor client’s skin, practices, noting type of soap or other cleansing agents used and temperature of water

2.5 avoid massaging around site of impaired tissue integrity and over bony prominences

2.6 assist with general comfort and hygiene measures

2.7 maintain infection control standards

2.8 emphasize need of adequate nutrition or fluid intake of 8 – 10 glasses/day

2.9 reassess signs of infection

3.0 administer medications as ordered

performed by the same caregiver, the client is in the same position and same techniques (Source: Nursing Care Plans by Doenges)

(Source: Nursing Care Plans by Doenges)2.3 identify impending problems easily (Source: Nursing Care Plans by Doenges)(Source: Nursing Care Plans 

2.4 individualize plan according to client’s skin condition, needs and preferences, avoid harsh cleansing agents, hot water and extreme friction. (Source: Nursing Care Plans by Doenges)

2.5 research suggests that massage may lead to deep tissue trauma (Source: Nursing Care Plans by Doenges)

2.6 to promote comfort and sense of well being (Source: Nursing Care Plans by Doenges)

2.7 to decrease risk of infection (Source: Nursing Care Plans by

Doenges)

2.8 to maintain general good health and skin turgor

(NANDA 9th ed., p.467)

2.9 to ensure free of infection(NANDA 9th ed., p.467)

3.0 to provide pharmacologic relief (NANDA 9th ed., p.467)

Physiologic Deficit

C. Activity Intolerance

Cues:

-difficulty in feeding herself

-tired looking eyes

-can’t walk without assistance

-thin looking appearance

-client has undergone surgery

Activity intolerance: difficulty in feeding herself related to weak muscle strength

After surgery, the body needs extra calories and protein for wound healing and recovery. At this time, many people have some pain and fatigue. In addition, they may be unable to eat a normal diet because of surgery-related side effects.

http://www.cancer.org

Perform activities of daily living at a tolerable level

3. Perform activities of daily living at a tolerable level

3.1 assess emotional / psychological factors

3.2 evaluate current limitations/degree of deficit in light of usual

3.3 cluster activities

3.4 increase activities or exercise gradually

3.5 plan care with rest periods between activities

3. 6 assist with activities and monitor use of assistive devices

3.1 stress and/or depression may be increasing the effect of an illness, or depression might be the result of being forced into inactivity

(NANDA 9th ed., p.61)

3.2 provides comparative baseline

(NANDA 9th ed., p.61)

3.3 to prevent overexertion

(NANDA 9th ed., p.61)

3.4 to conserve energy

(NANDA 9th ed., p.62)

3.5 helps to minimize frustration, rechannel

3.7 promote comfort measures and provide relief of pain

3.8 review expectations of client and/or significant others

3.9 assist client to learn and demonstrate appropriate safety measures

3.10 encourage client to maintain positive attitude

energy

(NANDA 9th ed., p.62)

3.6 to protect client from injury

(NANDA 9th ed., p.62)

 3.7 enhance ability to participate in activities

(NANDA 9th ed., p.62)

3.8 to establish individual goals

(NANDA 9th ed., p.62)

3.9 to prevent injuries

(NANDA 9th ed., p.62)

3.10 to enhance sense of well-being

(NANDA 9th ed., p.63

SOAPIE CHARTING

SOAPIE NO.1

DAY 1(Aug 23, 2007)

S- “maayung buntag dong, o ugma na lagi ang schedule sako operation, nakuyawan ko,

unsaon diay ko ana?”as verbalized by the patient

O- seen patient lying on bed awake, conscious. With IV #3 with IVF D5LR 1L @

30gtts/min at the left hand. The patient’s temperature is 36.9 degrees Celsius, respiratory

rate of 20 breaths per minute, pulse rate of 80 beats per minute. The patient appears weak

and anxious as evidenced by frequent asking of questions about his surgery.

A- Knowledge Deficit related to unfamiliarity of the surgical procedure.

P- to encourage verbalizations about the understanding of the surgical procedure

I- introduced self to the patient, established rapport with the patient and significant

others, informed the patient of the surgery to be performed the following day, explained

the nature of the surgery(cholecystectomy), enumerated different preoperative care prior

to the surgery, cited some possible rare complications, explained what will happened

after the surgery, reassured the patient that he is in safe hands that the surgical team will

do their best

E- the patient was able to understand simple information about his operation and was able

to decreased his fear about the operation by saying “salamat dong, nakuhaan gamay

akong kulba”

SOAPIE NO.2

DAY 2(Aug 24, 2007)                          

S- “sakit ang akong samad” as verbalized by the patient

O- received a 46 y.o. male patient with wound dressing at the abdominal area, dry and

intact, with IVF D5LR 1L @ 30gtts/min at the left hand, lying in bed, weak and tired,

complains of throbbing pain felt at surgical site lasting from 2-5 minutes, located in the

right quadrant of the abdomen, sharp throbbing pain, aggrevated by sudden movements,

relieve by rest and proper positioning and pain medication, facial grimace noted

A- Altered Comfort: Mild Pain related to operation performed

P- minimize discomfort at tolerable level 

I- assisted in transferring the patient to the Post Anesthesia care Unit, after care done-

assessed the dressing of the patient for presence of drainage, maintained comfortable and

calm environment, removed any instruments like stethoscope from the patient’s bed,

raised side rails of the bed to protect the patient, placed pillow on the side of the bed to

limit head movement of the patient, regulated IV line, changed patients gown, transferred

patient from the operating table to the stretcher,

E- Noted relief from pain after and experience comfort after interventions are

implemented as evidenced by the verbalization of the client. “ maagwanta na gamay ang

sakit, dili pareha ganiha”

2.4 Health Teaching Plan 

Name of Patient: Mr. Balagtas, Nicolas

Age: 46 years old                                     

Room No. 424

HEALTH TEACHING PLAN

OBJECTIVES CONTENTS METHODOLOGY EVALUATION

General Objectives

After 1 day of nurse-patient interaction the client will be able to gain knowledge, attitude and skills in the care for postoperative patients of Open Cholecystectomy.

Specific Objectives:

After 30 minutes of student nurse-client and significant others interaction, the client and the significant others will be able to:

1. define cholecystitis and cholelithiasis to their level of understanding.

2. cite importance of wound dressing

1.  Definition of cholecystitis and cholecystectomy

Cholecystitis – acute inflammation of gallbladder

Cholelithiasis – calculi or gallstones, usually form in the gallbladder from solid constituents of bile.

2. Importance of wound dressing

2.1. treatment for wounds, ulcers and recalcitrant dermatitis

2.2.create an optimal environment for healing

Informal discussion

Sharing

The patient listened attentively and was able to understand the meaning of wound dressing, shared some importance of wound dressing.He was able to cooperate follow the right procedure of wound dressing, identified bed rest as a comfort measure to relieve pain, asked questions about wound dressing, demonstrated proper breathing techniques.

V. Evalutation and Recommendation

Evaluation:

      The patient responded well to the care being rendered by the health care team. Both

nursing and medical interventions and health teachings contributed to the steady recovery

and improvement of the health condition of the patient. The client and the significant

others have partaken their part in utilizing the health teachings being taught by the

student nurse. The student nurse was able to accomplish all the objectives and health care

plan formulated for the client and thus there was a positive outlook in life by the client.

The prognosis is very good.

Recommendation:

      The student nurse would like to suggest that the patient be consulted regularly by a

gynecologist for check up about the health condition of the client after surgery and

discharge from the health care facility.

      On the other hand, the patient’s family must also be very supportive of her and should

help her meet more of her emotional and psychological needs since she is already old.

Though the family may be in a financial crisis, several non-government organizations

may be able to provide some extent of help.

      Lastly, proper compliance of medication as ordered is also a very vital factor in

restoring the client’s former physiologic state.

VI. Evaluation and Implication of this Case Study To:

Nursing Practice

This case study provides information about chronic calculous cholecystitis and its

treatment which includes surgery. In this case, the surgery performed is open

cholecystectomy. This case study would serve as a help to the nursing practice since it

provides an appropriate plan of care for patients who undergo this operation for efficient

nursing care.

Nursing Education

To the nursing education, this case study would help in sharing data or information about

the disease condition, which is chronic calculous cholecystitis, and its management as

well as the preoperative and postoperative nursing interventions needed for the promotion

of patient’s recovery. With these, the students as well as the teachers would gain

additional information about the disease and patient’s condition so that it would equip

them for an efficient nursing care in the future.

Nursing Education

This case study would help in the nursing research as a source of data for example, in

tracking the population of persons with this condition. With this information, it would

make us aware of its growing incidence rate and the need to treatment and share the

importance of early detection or early prevention of this disease condition.

VII. Referral and follow-up

With proper compliance to medications and treatments prescribed, further complications

would be prevented. In contrast, patient must be alert for complications such as signs of

infection, hemorrhage. If signs occur, patient must refer to surgeon immediately. In

addition, follow-up visits are also recommended for continuous monitoring to ensure a

smooth recovery.  

VIII. Bibliography

Black, Joyce M., et.al. Medical Surgical Nursing. 6th ed. Philadelphia: W.B. Saunders

Company. 2001, pg 991-994

Kozier, Barbara, et.al. Fundamentals of Nursing: Concepts, Process, and Practice. 7th ed.

USA: Pearson Education, Inc. 2004, p.629-636

Smeltzer, Suzanne C., Bare, Brenda G.. Brunner and Suddarth’s textbook of Medical    

Surgical Nursing. 7th ed. USA: J.B. Lippincot Company. 1992. p. 1275, 1989-2006

Wilson, Kathleen J.W., Waugh, Anne. Ross and Wilson Anatomy and Physiology. 8th ed.

London. Churchill Livingstone. 1999. pg.

http://www.medterms.com/script/main/art.asp?articlekey=39742

http://www.healthatoz.com/Atoz/common/standard/transform.jsp?

requestURI=healthatoz/Atoz/ency/cholecystectomy.jsp)

http://www.surgerychannel.com/cholecystectomy/

http://www.consciouschoice.com/1999/cc1201/hmd1201.html

http://en.wikipedia.org